Sentinel lymph node biopsy for breast cancer using methylene blue: a new anatomical landmark involving intercostobrachial and medial pectoral nodes
BACKGROUND Sentinel lymph node biopsy (SLNB) using blue dye is becoming popular in Indonesia given that knowledge on new anatomical landmarks involving intercostobrachial and medial pectoral nodes have replaced the need for radioisotope tracers. This study aimed to evaluate the utility of the proposed landmark involving intercostobrachial and medial pectoral nodes to determine axillary lymph node status during SLNB.
METHODS A prospective study was conducted involving 55 patients with early-stage breast cancer who had clinically negative lymph nodes (T1T2, cN0) between 2018 and 2019 at Cipto Mangunkusumo Hospital. During SLNB, methylene blue 1% was injected at the subareolar area to identify intercostobrachial and medial pectoral nodes followed by axillary lymph node dissection (ALND). Histopathological results of sentinel nodes (SNs) were then compared to those of other axillary nodes.
RESULTS SNs were identified in 54 patients (98%), 33 (61%) of whom had both intercostobrachial and medial pectoral SNs. Among patients with SNs, there were 1 patient without intercostobrachial SNs, 10 patients without medial pectoral SNs, and 1 patient with medial pectoral SNs but no intercostobrachial SNs. Accordingly, SNs had a negative predictive value (NPV) of 96.77% for axillary metastasis (95% confidence interval = 81.5499.51), with a false negative rate of 4.7%. No serious adverse events was observed.
CONCLUSIONS The high identification rate and NPV, as well as the low false negative rate of the new anatomical landmark involving intercostobrachial and medial pectoral nodes during SLNB, suggest its reliability in determining axillary lymph node status.
Verbelen H, Tjalma W, Meirte J, Gebruers N. Long?term morbidity after a negative sentinel node in breast cancer patients. Eur J Cancer Care. 2019;28(5):e13077. https://doi.org/10.1111/ecc.13077
Li J, Chen X, Qi M, Li Y. Sentinel lymph node biopsy mapped with methylene blue dye alone in patients with breast cancer: a systematic review and meta-analysis. PLoS One. 2018;13(9):e0204364. https://doi.org/10.1371/journal.pone.0204364
Dogan NU, Dogan S, Favero G, Köhler C, Dursun P. The basics of sentinel lymph node biopsy: anatomical and pathophysiological considerations and clinical aspects. J Oncol. 2019;2019:3415630. https://doi.org/10.1155/2019/3415630
National Institute of Health Research and Development, Indonesian Ministry of Health. Basic Health Research; RISKESDAS 2013. Jakarta: National Institute of Health Research and Development, Indonesian Ministry of Health; 2013. p. 110-9. Indonesian.
Brahma B, Putri RI, Karsono R, Andinata B, Gautama W, Sari L, et al. The predictive value of methylene blue dye as a single technique in breast cancer sentinel node biopsy: a study from Dharmais Cancer Hospital. World J Surg Oncol. 2017;15(1):41. https://doi.org/10.1186/s12957-017-1113-8
Li C, Zhang P, Li R, Wu C, Zhang X, Zhu H. Axillary lymph node dissection versus sentinel lymph node biopsy alone for early breast cancer with sentinel node metastasis: a meta-analysis. Eur J Surg Oncol. 2015;41(8):958-66. https://doi.org/10.1016/j.ejso.2015.05.007
Ong KW, Sim YR. Sentinel lymph node biopsy in breast cancer. In: Sobri FB, Azhar Y, Wibisana IGN, Rachman A, editors. Current management of breast cancer. 1st ed. Jakarta: Media Aesculapius; 2017. p. 144-59. Indonesian.
Straver ME, Meijnen P, van Tienhoven G, van de Velde CJ, Mansel RE, Bogaerts J, et al. Sentinel node identification rate and nodal involvement in the EORTC 10981-22023 AMAROS trial. Ann. Surg. Oncol. 2010;17(7):1854-61. https://doi.org/10.1245/s10434-010-0945-z
Sappey M. Injection preparation et Conservation des Vais-Seaux Lyphatics (thes pour le doctorat en medecine, No. 241). Paris: Rignoux Imprimeur de la Faculte de Medecine. 1834. French.
Rodier JF, Velten M, Wilt M, Martel P, Ferron G, Vaini-Elies V, et al. Prospective multicentric randomized study comparing periareolar and peritumoral injection of radiotracer and blue dye for the detection of sentinel lymph node in breast sparing procedures: FRANSENODE. J Clin Oncol. 2007;25(24):3664-9. https://doi.org/10.1200/JCO.2006.08.4228
Whitman GJ, AlHalawani RH, Karbasian N, Krishnamurthy R. Sentinel lymph node evaluation: what the radiologist needs to know. Diagnostics. 2019;9(1):12. https://doi.org/10.3390/diagnostics9010012
Parasuraman M, Giridharan B, Vijaylakshmi. Use of methylene blue for the detection of sentinel lymph node in breast cancer: a systematic review and meta-analysis. Int Surg J. 2018;5(1):1-10. https://doi.org/10.18203/2349-2902.isj20175879
Ushadevi JS, Rajaraman R, Subbaih S. Assessment of sentinel nodes with methylene blue dye in carcinoma breast is feasible? A pilot study. Int J Sci Stud. 2017;5(1):148-52. https://doi.org/10.17354/ijss/2017/177
Bakhtiar N, Jaleel F, Moosa FA, Qureshi NA, Jawaid M. Sentinel lymph node identification by blue dye in patients with breast carcinoma. Pak J Med Sci. 2016;32(2):448-51. https://doi.org/10.12669/pjms.322.9563
Nandu VV, Chaudhari MS. Efficacy of sentinel lymph node biopsy in detecting axillary metastasis in breast cancer using methylene blue. Indian J Surg Oncol. 2017;8:109-12. https://doi.org/10.1007/s13193-016-0616-z
Lyman GH, Temin S, Edge SB, Newman LA, Turner RR, Weaver DL, et al. Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2014;32(13):1365-83. https://doi.org/10.1200/JCO.2013.54.1177
Kim MK, Park HS, Kim JY, Kim S, Nam S, Park S, et al. The clinical implication of the number of lymph nodes harvested during sentinel lymph node biopsy and its effects on survival outcome in patients with node-negative breast cancer. Am J Surg. 2017;214(4):726-32. https://doi.org/10.1016/j.amjsurg.2016.10.019
Dialani V, James DF, Slanetz PJ. A practical approach to imaging the axilla. Insights Imaging. 2015;6:217-29. https://doi.org/10.1007/s13244-014-0367-8
Giuliano AE, Ballman KV, McCall L, Beitsch PD, Brennan MB, Kelemen PR, et al. Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: the ACOSOG Z0011 (Alliance) randomized clinical trial. JAMA. 2017;318(10):918-26. https://doi.org/10.1001/jama.2017.11470
Muñiz-Diaz E, Puig L. Allergic and anaphylactic reactions to methylene-blue-treated plasma in Catalonia in the period 2008-2013. Blood Transfus. 2014;12(4):628-30. https://doi.org/10.2450/2014.0121-14
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(1):61-7. https://doi.org/10.1111/j.1524-4741.2007.00519.x
Colomer R, Saura C, Sánchez?Rovira P, Pascual T, Rubio IT, Burgués O, et al. Neoadjuvant management of early breast cancer: a clinical and investigational position statement. Oncologist. 2019;24(5):603-11. https://doi.org/10.1634/theoncologist.2018-0228
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