The Experiences of Performing Sentinel Lymph Node Biopsies with the Use of Methylene Blue Dye in Patients with Invasive Breast Carcinoma

Hee-Moon Song; Yang-Soo Lim; Min-Hee Jeong; Sun-Mi Paik; Jin-Gu Bong

doi:10.4048/jbc.2007.10.3.223

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Song, Lim, Jeong, Paik, and Bong: The Experiences of Performing Sentinel Lymph Node Biopsies with the Use of Methylene Blue Dye in Patients with Invasive Breast Carcinoma

Original Article

Journal of Breast Cancer

Journal of Breast Cancer 2007; 10(3): 223-229.

Published online: 30 September 2007

DOI: https://doi.org/10.4048/jbc.2007.10.3.223

The Experiences of Performing Sentinel Lymph Node Biopsies with the Use of Methylene Blue Dye in Patients with Invasive Breast Carcinoma

Hee-Moon Song, Yang-Soo Lim, Min-Hee Jeong¹, Sun-Mi Paik², Jin-Gu Bong³

Department of Surgery, Wallace Memorial Baptist Hospital, Busan, Korea.

¹Department of Pathology, Wallace Memorial Baptist Hospital, Busan, Korea.

²Department of Radiology, Wallace Memorial Baptist Hospital, Busan, Korea.

³Department of Surgery, Catholic University of Deagu, Deagu, Korea.

jgbong@cu.ac.kr

Received 9 July 2007 Accepted 16 August 2007

Abstract

Purpose

Isosulfan blue has been traditionally used as a tracer to map the lymphatic system during identification of the sentinel lymph node (SLN). However, this vital dye is difficult to obtain in Korea. Radioisotopes such as technetium-labeled sulfur colloid or albumin colloid are also expensive and complex to use. The purpose of this study is to evaluate usefulness of a sentinel lymph node biopsy (SLNB) using methylene blue dye in breast cancer patients.

Methods

We evaluated the sentinel node mapping experience using methylene blue dye from July 2003 to January 2007. Fifty-eight patients with clinical T1-T2 breast cancer without palpable axillary lymph nodes were enrolled. All SLNs were submitted for intraoperative frozen section and hematoxyline and eosin (H & E) stain analysis. For the negative SLNs, serial sections of each SLN specimen were examined by permanent H & E staining and by immunohistochemical techniques (IHC) using cytokeratin. Regardless of the results of a frozen section for the SLNs, a backup level II or III axillary lymph node dissections (ALND) was performed.

Results

Of the 58 patients that underwent a SLNB using methylene blue dye, an SLN was identified in 56 patients (96.6%), and metastatic SLNs were detected in 14 cases. Axillary lymph node metastasis found in 18 out of 58 patients. Thus, the false negative rate for a SLNB was 22.2% (4/18). Two patients had a micrometastasis (pN1mi) and two patients had clusters of isolated tumor cells (pN0[i+]) that were identified in the SLNs by IHC with the additional use of cytoketatin. The sensitivity, specificity, and accuracy of the SLNBs were 77.8%, 100%, and 92.9%, respectively. The false negative rate improved with the accumulation of experience for performing a SLNB (12.5% vs 30.0%). The sensitivity, specificity, positive predictive value, and accuracy of preoperative ultrasonography (USG) for an axillary lymph node metastsis were 50.0%, 95.5%, 81.8% and 81.0% respectively.

Conclusion

Based on our initial experience, methylene blue dye is safe, inexpensive, and a readily available tracer for the SLN mapping, and it could be an effective alternative to the use of isosulfan blue dye for accurately identifying SLNs in early breast caner patients. We expected that the findings of preoperative USG could serve as useful adjuncts to a SLNB.

Keywords: Methylene blue, Sentinel lymph node, Breast cancer

Figures and Tables

Fig 1

Stained lymphatics and lymph node during sentinel lymph node biopsy.

Fig 2

Ultrasonographic findings of metastatic axillary lymph node. This lymph node was not palpable. But, this round lymph node had increased vascular flow at perinodal area and cortex on doppler examination and did not display hilar structures.

Fig 3

Cytokeratin immunohistochemical staining of sentinel lymph nodes. (A) isolated tumor cells (pN0[i+]) (×400) and (B)1.5 mm sized micrometastasis (pN1mi) (×100).

Table 1

Clinicopathologic characteristics of patients of the study (N=58)

EIC=Extensive intraductal component; LVI=lymphovascular invasion; ER=estrogen receptor; PR=progesterone receptor.

Table 2

Numbers of identified sentinel and axillary lymph nodes

SLNs=sentinel lymph nodes; ALNs=Axillay lymph nodes.

^*Identification rate: 96.6% (56/58).

Table 3

Sentinel and axillary lymph node status on permanent sections (N=56)

ALNs=axillary lymph nodes; SLNs=sentinel lymph nodes.

^*Included 2 cases with clusters of isolated tumor cells (pN0[i+]) in SLN on cytokeratin immunohistochemical stain (IHC); ^†Include 2 cases with micrometastasis(pN1mi) in SLN on IHC.

Sensitivity=14/18 (77.8%); Specificity=38/38 (100%); Positive predictive value=14/14 (100%); Negative predictive value=38/42 (90.5%); False negative rate=4/18 (22.2%); Accuracy=92.9% (52/56).

Table 4

Metastatic lymph nodes found in sentinel and nonsentinel lymph nodes

SLN=sentinel lymph node.

Table 5

Outcomes of sentinel lymph node biopsy in learning periods and after learning periods

^*Sentinel lymph node biopsy experiences of early 25 cases to January, 2005.

Table 6

Correlation^* between USG findings of axillary lymph node and pathologic results

USG=ultrasonography.

^*p-value=0.000; Sensitivity=50.0% (9/18); Specificity=95.0% (38/40); Positive predictive value=81.8% (9/11); Negative predictive value=80.9% (38/47); False positive rate=5.0% (2/40); False negative rate=50.0% (9/18); Accuracy=81.0% (47/58).

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