Sentinel lymph node mapping in early breast cancer using methylene blue dye

H T Amar Rao; Rohan Shetty; K C Jalaluddin Akbar; KB Mahesh; Jaganath Dixit; Manavalan Vijayakumar; S Gopinathan; Noor Mohammed

doi:10.4103/oji.oji_36_20

PROSPECTIVE STUDY

Year : 2020 | Volume : 4 | Issue : 3 | Page : 120-123

Sentinel lymph node mapping in early breast cancer using methylene blue dye

H T Amar Rao¹, Rohan Shetty¹, K C Jalaluddin Akbar¹, KB Mahesh², Jaganath Dixit², Manavalan Vijayakumar¹, S Gopinathan³, Noor Mohammed¹
¹ Department of Surgical Oncology, Yenepoya Medical College, Mangalore, Karnataka, India
² Department of Surgical Oncology, HCG Hospital, Bengaluru, Karnataka, India
³ Department of Surgical Oncology, Father Muller Medical College, Mangalore, Karnataka, India

Date of Submission	29-Jul-2020
Date of Decision	26-Aug-2020
Date of Acceptance	08-Sep-2020
Date of Web Publication	26-Nov-2020

Correspondence Address:
Rohan Shetty
Department of Surgical Oncology, Yenepoya Medical College, Mangalore, Karnataka
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/oji.oji_36_20

Abstract

Background: With the introduction of the concept of sentinel lymph node biopsy (SLNB), the surgical management of the axilla has undergone a paradigm change in clinically node-negative early breast cancer, and complete axillary dissection is avoided if the sentinel lymph node (SLN) is negative for metastasis. Aim: The purpose of this study was to identify the reliability, accuracy, and safety of using methylene blue dye (MBD) in SLNB for early-stage carcinoma of the breast. Materials and Methods: A prospective study was conducted among 151 early breast carcinoma patients (T1/2N0M0) from December 2012 to February 2016. Intraoperative identification of the SLN was done by injecting 5 ml of 1% MBD into the subareolar region of the breast. All the blue-stained lymph nodes were then surgically excised and sent for frozen section examination. Results: The mean age of presentation was 54.10 years. Thirty out of 151 cases had SLN metastasis and 115 cases were negative for malignancy on the frozen section. On the final histopathological examination, 36 cases had metastasis and 115 cases were negative for malignancy. The false-negative rate was 5%. No patients developed anaphylactic/allergic or any type of skin reaction following MBD injection. The accuracy, positive predictive value, and negative predictive value of sentinel node identification using MBD were 96.02%, 100%, and 95.04%, respectively. After a mean follow-up of 10 months, no patient was found to be with ipsilateral axillary or supraclavicular recurrence. Conclusion: The use of MBD in SLNB for the diagnosis of axillary metastasis is reliable, accurate, and safe.

Keywords: Accuracy, early breast carcinoma, methylene blue dye, sentinel lymph node biopsy

How to cite this article:
Rao H T, Shetty R, Akbar K C, Mahesh K B, Dixit J, Vijayakumar M, Gopinathan S, Mohammed N. Sentinel lymph node mapping in early breast cancer using methylene blue dye. Oncol J India 2020;4:120-3

How to cite this URL:
Rao H T, Shetty R, Akbar K C, Mahesh K B, Dixit J, Vijayakumar M, Gopinathan S, Mohammed N. Sentinel lymph node mapping in early breast cancer using methylene blue dye. Oncol J India [serial online] 2020 [cited 2021 Jan 20];4:120-3. Available from: https://www.ojionline.org/text.asp?2020/4/3/120/301582

Introduction

A paradigm change has been occurred for the surgical management of the axilla among early breast carcinomas due to the introduction of the concept of lymphatic mapping of the breast way back in 1992 at the John Wayne Cancer Institute, and sentinel lymph node biopsy (SLNB) has replaced axillary lymph node detection (ALND) for the management of the axilla in clinically node-negative early breast cancer.^[1] Moreover, significant morbidity such as lymphedema of the ipsilateral arm (3%–12%), pain, and paresthesia occurs due to ALND affecting the quality of life of the patients.^[2]

Combined technetium and blue dye are recommended to reduce the false negative (FN) rate of SLNB procedure.^[3] Several blue dyes such as isosulfan blue dye (IBD), patent blue (PB), sulfan blue, sulphane blue, PB violet, and methylene blue dye (MBD) have been studied for the SLNB procedure. IBD and PB have a high affinity for lymphatics.^[4] Giuliano et al. in their study on intraoperative lymphatic mapping identified sentinel lymph node (SLN) using IBD.^[5] Unfortunately, many hospitals in developing countries like India do not have the nuclear medicine department to provide radioactive dye or IBD. Furthermore, IBD and BD were associated with a significant number of allergic reactions and also life-threatening reactions may occur.^[6],[7] Published literatures found to be equally effective of MBD in SLN identification than other blue dyes.^[8] MBD is cheaper than isosulfan blue or radio colloid and is easier to obtain in developing countries. Therefore, in a low-cost setup hospital across India, MBD alone can be used to identify SLN. Recently, several studies reported that blue dye alone was sufficient for identifying SLN in breast cancer.^{[9],[10],[11]} However, the safety of using MBD in the SLNB procedure is not clear, although localized reactions have been described.^[8] With this background, we are conducting the study to evaluate the feasibility of using MBD for the identification of SLN in patients with early breast cancer.

Materials and Methods

The present prospective clinical study was conducted on the identification of sentinel node among early breast cancer patients attending to our tertiary care institute during the period from December 2012 to February 2016. The patients of all age groups, both sexes, and biopsy-proven early breast carcinoma (T1 and T2) with clinically node negative (N0) and no distant metastasis (M0) were included in the study. Those patients with clinically palpable nodes, tumor size >5 cm, multicentric tumor, and patients who received neoadjuvant chemotherapy were excluded from the study. The study was approved by the scientific approval committee and central ethical committee (registration number: ECR/386/INST/KA/2013). Completion ALND was done only if SLN was found positive on intraoperative assessment or if SLN was not identified, delayed ALND was done if negative SLN turns out to be positive on the paraffin section.

After induction of anesthesia, 5cc of 1% methylene blue for injection was infiltrated into the subareolar tissue of the affected breast [Figure 1]a and [Figure 1]b. Care was taken to avoid injection into the skin or submammary connective tissue and muscle. After injecting the dye, the breast was massaged for 10 min, and massaging was directed toward the axilla.

Figure 1: Clinical image showing 5cc of 1% methylene blue dye injection site (a), injection into the subareolar area (b), and methylene blue dye-stained sentinel lymph node with lymphatic (c)

Click here to view

A small incision of size 3–4 cm was made in the axilla along the breast crease, axillary tissue carefully dissected, and blue-stained lymphatics carefully traced up to the blue-stained lymph nodes. All the blue nodes found and any node receiving a blue lymphatic channel were SLN [Figure 1]c. All the blue-stained lymph nodes were then surgically excised and sent for further examination. The final histopathological examination (HPE) report after ALND was compared with MBD-stained frozen section report, and results were analyzed in order to draw conclusions. H and E staining method was used for microscopic examination of all the sections. All the pathological examination was done by a well-experienced breast oncopathologist. Data on true positive, FN, true negative, and false positive were recorded. The sensitivity, specificity, and diagnostic accuracy of MBD toward the identification of SLN were calculated.

Results

A total of 151 patients were included in the study. The clinical and demographic characteristics of the patients are mentioned in [Table 1]. The mean age of presentation in our study was 54.10 years. All the patients were female. Majority of the patients were of invasive ductal carcinoma histology (145 cases) and were of clinical T2 tumor status (110 cases). Breast conservative surgery was performed for all the cases, followed by receiving adjuvant chemotherapy and adjuvant radiotherapy.

Table 1: Clinical and demographic characteristics of the patients (n=151)

Click here to view

SLN identification was possible in all the 151 patients. The mean size of nodes harvested was 1.39 cm. The total number of lymph node excised from 151 patients was 370, among that methylene-stained node was 357, whereas the rest were enlarged nodes or suspected. Hence, the mean number of sentinel nodes harvested from 151 patients was 2.36.

Out of the 151 patients, SLN was positive for 30 patients and 115 MBD-stained nodes were negative for malignancy on the frozen section of SLNs. On final HPE after the paraffin section, 36 cases had metastasis and 115 cases were negative for malignancy. Hence, the FN rate for SLN identification using MBD was 5% (6 cases). ALND was performed for these 36 cases. None of the patients who underwent SLNB developed allergic/anaphylactic or skin necrosis following MBD injection. True positive, false positive, true negative, and FN rates toward SLN identification are mentioned in [Table 2]. The rates of sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of using MBD in SLN identification were 83.7%, 100%, 100%, 95.04%, and 96.02%, respectively [Table 2]. Out of 30 cases of metastatic SLN on the frozen section, MBD-stained node was the only metastatic node in 15 (50%) patients, whereas in the rest 15 cases, there were also other metastatic nodes found out during ALND. Patients were followed up for a period of 3–24 months. Ninety-six patients were seen in the outpatient department during this period on a frequent basis of every 3 months. The mean duration of follow-up was 10 months. No cases of ipsilateral axillary or supraclavicular recurrence were detected in our study during the period of follow-up.

Table 2: Diagnostic value of frozen section report of methylene blue-stained node compared to the final histopathological examination

Click here to view

Discussion

SLNB now a day considered as the standard of surgical care worldwide. Patients of early breast cancer with clinically negative axillary status and negative SLN following SLNB procedure may avoid unnecessary ALND. The ALND during breast cancer surgery has resulted in future complications such as lymphedema, pain, numbness, limitation of shoulder movement, seroma collection, and nerve and vascular injuries.^[2]

There are two methods to perform SLNB. In the first method, blue dye such as isosulphane blue or MBD is injected. In the second method, radioactive material is injected and the SLN is identified with a gamma probe. Both the methods can be used in combination.

MBD is a cheaper and easily obtainable dye with a fewer complications as compared to isosulphane blue. In a developing country like India, it gives the opportunity of performing SLNB even in tier 2 and tier 3 cities. Hypersensitivity reactions have been reported at a rate of 0.6%–2.5% of cases following isosulphane blue injection.^[12] Skin necrosis, fat necrosis, and fibrosis are the complications reported for MBD injection. However, we found no complications related to MBD in our study. Several studies revealed the safety use of MBD with high success as an alternative to isosulphane blue.^{[8],[13],[14],[15]}

Several multicenter trials have confirmed the feasibility of SLNB as a staging procedure among clinically node-negative early breast carcinoma. They found an identification rate from 86% to 97% with an accuracy from 96% to 98% and a FN rate from 4% to 9.8%.^{[16],[17],[18]} The identification rate in our study was 100%. Experienced surgeons are extremely successful in accurately identifying the SLN regardless of technique. The experience of the oncopathologist also matters. The mean number of the SLN harvested from our 151 patients is 2.36. We used only the H and E staining method to examine the sections of lymph nodes. We found a sensitivity, specificity, and accuracy of 83.7%, 100%, and 96.2%, respectively, toward the identification of SLN. Therefore, based on these values, the MBD-stained node with the frozen section remains the accurate intraoperative diagnostic method for SLN assessment and accurately predicts the status of the axilla. The FN rate in our study was 5%. FN rate was comparable to other studies which ranged from 4% to 9.8%.^{[16],[17],[18]} NSABP B-32 trial. Compared breast cancer patients assigned to sentinel node resection plus axillary dissection with those assigned to sentinel node resection alone with axillary dissection only if sentinel nodes were positive. Three thousand nine hundred and eighty-six patients had pathologically negative SLN with follow-up information. With a mean follow-up of 95.6 months, there was no significant difference between the two groups with respect to overall survival, disease-free survival, and regional control. NSABP B-32 trial suggests that when SLN is negative, SLN surgery alone without any further ALND is technically feasible, safe, appropriate, and effective therapy for breast cancer patients with clinically negative nodes.^[19]

Many times, it is found that SLN is the only positive node in the axilla. In our study, 30 patients had metastatic SLN out of a total of 151 patients. In 15 (50%) patients, this was the only metastatic node, whereas in the rest 15, there were also other metastatic nodes found out during ALND. With SLN as the only positive lymph node raises the question that whether ALND is a justified in these type of cases. Finding of around 50% of SLN as the only node positive with the rest of the axilla showing no evidence of metastasis indicates that the concept of SLN is biologically valid and is favorable for SLNB.^[5],[20] Our data were supported by Giuliano et al. where metastases in SLN were seen among 42 out of 100 patients identified with SLNs and 28 of these 42 cases (66.7%) had metastases to only SLNs without the involvement of other axillary nodes.^[20]

During a short period of follow-up of 3–24 months, no patient was found to be with ipsilateral axilla/supraclavicular recurrence, 96 patients were seen in the outpatient department during this period on a frequent basis of every 3 months. According to a meta-analysis of the available evidence, the axillary recurrence rate is 0.3% following negative SLNB.^[21] Axillary recurrence following a SLNB is a rare event which further validates the use of SLNB.

Conclusion

SLNB using methylene blue is highly effective and predicts axillary status with high accuracy and safety. Methylene blue may be considered as an alternative to isosulphane blue or radio colloid in hospitals not having access to nuclear medicine or isosulfan blue.

Acknowledgment

The authors would like to acknowledge the contribution from Dr. Nischith D'souza, Dr. Rohan Thomas Mathew, Dr. Ravi Verma, Dr. Nancy Parul Singh, Dr. Jnani Dinesh Reddy, and Dr. Rithik Bansal, Department of Surgical Oncology in preparation of this draft.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Albertini JJ, Lyman GH, Cox C, Yeatman T, Balducci L, Ku N, et al. Lymphatic mapping and sentinel node biopsy in the patient with breast cancer. JAMA 1996;276:1818-22.
2.	Maunsell E, Brisson J, Deshenes L. Arm problem and psychological distress after surgery for breast cancer. Can J Surg 1993;36:315-20.
3.	Cody HS 3^rd, Fey J, Akhurst T, Fazzari M, Mazumdar M, Yeung H, et al. Complementarity of blue dye and isotope in sentinel node localization for breast cancer: Univariate and multivariate analysis of 966 procedures. Ann Surg Oncol 2001;8:13-9.
4.	Masannat Y, Shenoy H, Speirs V, Hanby A, Horgan K. Properties and characteristics of the dyes injected to assist axillary sentinel node localization in breast surgery. Eur J Surg Oncol 2006;32:381-4.
5.	Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg 1994;220:391-8.
6.	Thevarajah S, Huston TL, Simmons RM. A comparison of the adverse reactions associated with isosulfan blue versus methylene blue dye in sentinel lymph node biopsy for breast cancer. Am J Surg 2005;189:236-9.
7.	Dewachter P, Mouton-Faivre C, Benhaijoub A, Abel-Decollogne F, Mertes PM. Anaphylactic reaction to patent blue V after sentinel lymph node biopsy. Acta Anaesthesiol Scand 2006;50:245-7.
8.	Zakaria S, Hoskin TL, Degnim AC. Safety and technical success of methylene blue dye for lymphatic mapping in breast cancer. Am J Surg 2008;196:228-33.
9.	Kantaraksa N, Kongdan Y, Suvikapakornkul R, Wasutit Y, Chirappapha P, Lertsithichai P. The relative false negative rate of isosulfan blue in detecting sentinel lymph nodes in early breast cancer. J Med Assoc Thai 2012;95:181-5.
10.	Eser M, Kement M, Kaptanoglu L, Gecer M, Abamor E, Tutal F, et al. A prospective comparative study to assess the contribution of radioisotope tracer method to dye-only method in the detection of sentinel lymph node in breast cancer. BMC Surg 2013;13:13.
11.	Ang CH, Tan MY, Teo C, Seah DW, Chen JC, Chan MY, et al. Blue dye is sufficient for sentinel lymph node biopsy in breast cancer. Br J Surg 2014;101:383-9.
12.	Altıntoprak F, İǧci A, Asoǧlu O, Gök K, Müslümanoǧlu M, Özmen V, et al. Allergic reaction due to subareolar isosulphane blue dye injection for sentinel lymph node biopsy: Case Report. J Breast Health 2006;2:34-6.
13.	Varghese P, Abdel-Rahman AT, Akberali S, Mostafa A, Gattuso JM, Carpenter R. Methylene blue dye--a safe and effective alternative for sentinel lymph node localization. Breast J 2008;14:61-7.
14.	Golshan M, Nakhlis F. Can methylene blue only be used in sentinel lymph node biopsy for breast cancer? Breast J 2006;12:428-30.
15.	Nour A. Efficacy of methylene blue dye in localization of sentinel lymph node in breast cancer patients. Breast J 2004;10:388-91.
16.	Krag DN, Anderson SJ, Julian TB, Brown AM, Harlow SP, Ashikaga T, et al. Technical outcomes of sentinel-lymph-node resection and conventional axillary-lymph-node dissection in patients with clinically node-negative breast cancer: Results from the NSABP B-32 randomised Phase III trial. Lancet Oncol 2007;8:881-8.
17.	Gill G, SNAC Trial Group of the Royal Australasian College of Surgeons (RACS) and NHMRC Clinical Trials Centre. Sentinel-lymph-node-based management or routine axillary clearance? One-year outcomes of sentinel node biopsy versus axillary clearance (SNAC): A randomized controlled surgical trial. Ann Surg Oncol 2009;16:266-75.
18.	Gupta V, Raju K, Rao TS, Naidu CK, Goel V, Hariharan N, et al. A Randomized trial comparing the efficacy of methylene blue dye alone versus combination of methylene blue dye and radioactive sulfur colloid in sentinel lymph node biopsy for early stage breast cancer patients. Indian J Surg Oncol 2020;11:216-22.
19.	Krag DN, Anderson SJ, Julian TB, Brown AM, Harlow SP, Costantino JP, 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;11:927-33.
20.	Giuliano AE, Jones RC, Brennan M, Statman R. Sentinel lymphadenectomy in breast cancer. J Clin Oncol 1997;15:2345-50.
21.	van der Ploeg IM, Nieweg OE, van Rijk MC, Valdés Olmos RA, Kroon BB. Axillary recurrence after a tumour-negative sentinel node biopsy in breast cancer patients: A systematic review and meta-analysis of the literature. Eur J Surg Oncol 2008;34:1277-84.