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

👉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.


  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.

#Arrangoiz #BreastSurgeon #BreastSurgeon

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