Which mapping agent(s) produces the highest sentinel lymph node (SLN) identification rate?

Rodrigo Arrangoiz MS, MD, FACS, FSSO

👉Krag et al. first described using technetium-99m sulfur colloid in sentinel node (SN) mapping and noted that he attained an SN identification rate of 98%, with a false-negative rate of 11%.

👉Technetium-99m sulfur colloid is the most widely used radioisotope for lymphatic mapping in the United States.

👉In Europe, technetium-99m colloid albumin is used most often.

👉Similarly, Giuliano et al. described the use of isosulfan blue dye, with a SN detection rate of 98%, without false-negative nodes.

👉Anaphylaxis and hypotension also have been reported as adverse events when using isosulfan blue dye.

👉Overall, isosulfan blue dye is the most commonly used dye for the lymphatic mapping of breast cancer.

👉The SN detection rate using methylene blue has been described as 93%, and concordance with radioisotope was described in 95% of patients.

👉Although methylene blue is available at a lower cost when compared to isosulfan blue, it must be injected carefully into the subcutaneous tissues.

👉Injection into the dermis may lead to epidermolysis and necrosis.

👉Therefore when used, methylene blue should be diluted with saline to minimize these complications (eg, 1 ml of 1% methylene blue diluted with 2 to 3 ml of injectable saline) and injected in the subareolar breast parenchyma deep to the skin.

👉The combination of blue dye and radioisotope improves the SN detection rate as first described by Albertini and colleagues.

👉As a result, several other studies have demonstrated similar findings and, thus, dual-agent lymphatic mapping has been accepted universally as a better method in the detection of the SN.

👉The National Surgical Adjuvant Breast and Bowel Project (NSABP) B-32 used radioisotope and blue dye for the detection of SLNs.

👉Sentinel nodes were identified by blue dye alone in 5.1%, by radioisotope alone in 24.3% and by both tracers in 65.1% of patients.

👉The reported SLN identification rate was 97% with a 9.8% false-negative rate.

The most common adverse events were allergic reactions.

👉Anaphylaxis was also reported as an adverse event.

REFERENCES

  1. Albertini JJ, Lyman GH, Cox C, et al. Lymphatic mapping and sentinel node biopsy in the patient with breast cancer. JAMA. 1996;276:1818-1822.
  2. Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg. 1994;220:391-401.
  3. Kim T, Giuliano AE, Lyman GH. Lymphatic mapping and sentinel lymph node sampling in breast cancer: a meta-analysis. Cancer. 2006;106:4-16.
  4. Krag DN, Anderson SJ, Julian TB, et al. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 2010;11:927-933.
  5. Krag DN, Weaver DL, Alex JC, Fairbank JT. Surgical resection and radiolocalization of the sentinel lymph node in breast cancer using a gamma probe. Surg Oncol. 1993;2:335-339.
  6. Newman LA, Newman EA. Lymphatic mapping techniques and sentinel lymph node biopsy. Surg Clin N Am. 2007;87:353-364.
  7. Simmons RM, Smith SM, Osborne MP. Methylene blue dye as an alternative to isosulfan blue dye for sentinel lymph node localization. Breast J. 2001;7:181-183.
  8. Simmons R, Thevarajah S, Brennan M, Christos P, Osborne M. Methylene blue dye as an alternative to isosulfan blue dye for sentinel node localization. Ann Surg Oncol. 2003;10:242-247.
  9. Zakaria S, Hoskin TL, Degnim AC. Safety and technical success of methylene blue dye for lymphatic mapping in breast cancer. Am J Surg. 2008;196:228-233.

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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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