Name: the application of 1% methylene blue dye as a single technique in breast cancer sentinel node biopsy
Uploaded: 2019-06-01T12:30:00
Description: Watch this Scientific Journal Video about The Application of 1% Methylene Blue Dye As a Single Technique in Breast Cancer Sentinel Node Biopsy at JoVE.com

The authors have nothing to disclose.

All procedures including human subjects have been approved by Dharmais Cancer Hospital Ethics Committee with certificate number of 040/KEPK/VII/2017. All patients signed the consent forms and expressed agreement to participate in this study.
NOTE: The inclusion criteria are patients with diagnosis of early breast cancer, with tumor stage T1-T2 without palpable and ultrasonography lymph nodes enlargement (cNo). The exclusion criteria are locally advanced breast cancer, received neo adjuvant che...

<ol>
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In the modern era of breast cancer surgery, SNB has replaced ALND as the standard of care for axillary staging in early breast cancer and ALND should be abandoned if the SNs are free from metastasis14,15. The lymphatic mapping technique which is commonly used in developed countries is the application of radioisotope tracer and PBD as a combined or single technique16,17. The question on how to perform SNB ...

The status of axillary lymph nodes (ALNs) metastasis is the most important prognostic factor in breast cancer. Axillary lymph node dissection (ALND) was the conventional procedure to assess metastatic status of ALNs1,2. Unfortunately, ALND results in morbidities to the patients which decreases the quality of life, especially by increasing the risk of lymphedema after this procedure3,4. Nowadays, sentinel node biopsy (SNB) has replaced ALND for axillary staging because of its minimal morbidities among patients5. The most common method for performing SNB is using radioisotope tracer and PBD6. In some parts of the world, including in developing countries, these tracer agents could be difficult to procure and searching for an alternative tracer agent is critical to solve the problem.
Initially, MBD was used by Wong et al. as a tracer agent for mapping sentinel nodes (SNs)7. In their study using a feline model, intradermal injection of MBD showed poor lymphatic uptake and isosulfan blue was chosen as the preferred dye for sentinel node (SN) mapping7. Methylene blue dye has been used in breast cancer SNB since the first successful report by Simmons et al.8. Several studies have also reported MBD as the favorable dye for SNs identification, and that the false negative rates of MBD technique were comparable to radioisotope or PBD9,10,11. Fewer allergic reactions and lower price are the other reasons to consider its use in SN mapping12.
Recently, we studied the use of 1% MBD alone for SNB in clinically node negative breast cancer. In early stages, MBD has a favorable identification rate and negative predictive value13. We inject 2 mL of 1% MBD into the subareolar space or peritumoral area if there was an excisional biopsy scar at the upper outer quadrant or nipple areolar complex (NAC) of the breast. The blue nodes and non-blue nodes with lymphatic blue channels are categorized as SNs. The anatomical landmark in the axilla is used as a guidance to find SNs. Intraoperative examination is applied to assess the metastasis and the SNs are sent for histopathology analysis based on American Society of Clinical Oncology (ASCO) Guidelines14.
If the cases are selected carefully and the skills required for this technique are obtained by the surgeons as well as pathologists, many patients could be saved from the harmful effects of ALND while still having favorable survival.

<table border="0" cellpadding="0" cellspacing="0" style="width:1046px;" width="1046">
	<tbody>
		<tr height="40">
			<td height="40" style="height:40px;width:348px;">Metiblo 50mg/5ml</td>
			<td style="width:174px;">Laboratories Sterop NV</td>
			<td style="width:353px;">BE475217</td>
			<td style="width:171px;">Methylene Blue Dye</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;">Disposable syringe with needle - 3mL (Luer Lock Tip)</td>
			<td>Terumo Europe NV</td>
			<td>dvr-3414</td>
			<td>Syringe for Injection</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;">ForceTriad energy platform</td>
			<td>Medtronic</td>
			<td>ForceTriad</td>
			<td>Surgical cautery</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;">Shandon Cryomatrix embedding resin</td>
			<td>Thermo (scientific)</td>
			<td>6769006</td>
			<td rowspan="2">Frozen Section</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;">Cryotome FSE</td>
			<td>Thermo (scientific)</td>
			<td>77210153</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;">HistoStar Embedding Workstation</td>
			<td>Thermo (scientific)</td>
			<td>A81000001</td>
			<td rowspan="3" style="width:171px;">Histopathological Examination</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;">Finesse Me+</td>
			<td>Thermo (scientific)</td>
			<td>A77510272</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;">Gemini AS</td>
			<td>Thermo (scientific)</td>
			<td>A81500002</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;">Benchmark GX</td>
			<td>Ventana Medical Systems</td>
			<td>750-850</td>
			<td rowspan="2">Immunohistochemistry</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;">Benchmark XT</td>
			<td>Ventana Medical Systems</td>
			<td>750-700</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;">Microscope</td>
			<td>Olympus</td>
			<td>Model BX53</td>
			<td></td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;">Ultrasound</td>
			<td>Phillips</td>
			<td>HD 7XE</td>
			<td></td>
		</tr>
	</tbody>
</table>

the application of 1% methylene blue dye as a single technique in breast cancer sentinel node biopsy

In this study, we injected 1% methylene blue dye (MBD) into the subareolar or peritumoral space of the breast. In the case of breast conserving surgery (BCS), a separate incision in the lower axilla hairline was made to find the sentinel nodes (SNs). In mastectomy, the SNs were identified through the same mastectomy incision. The SNs were described as blue nodes or nodes with lymphatic blue channels. An anatomical landmark in the axilla was used to facilitate SNs identification. The SNs metastases were evaluated by intraoperative frozen section analysis and histopathology examination as it is a gold standard. Here, we described the MBD as the lone technique in breast cancer sentinel node biopsy (SNB) which could be useful when radioisotope tracer or patent or isosulfan blue dye (PBD) cannot be provided.

Here, we describe the results from the presented technique. Two milliliters of 1% MBD were injected at the deep subareolar space as the standard technique of injection (Figure 1A). If the peritumoral injection is indicated, it should be performed under ultrasound guidance (Figure 1B). The blue nodes or lymphatic blue tracts were seen after entering the axillary space. Following the lymphatic blue tracts lead to finding the SNs (<...

Watch this Scientific Journal Video about The Application of 1% Methylene Blue Dye As a Single Technique in Breast Cancer Sentinel Node Biopsy at JoVE.com

The Application of 1% Methylene Blue Dye As a Single Technique in Breast Cancer Sentinel Node Biopsy

In Indonesia, sentinel node biopsy (SNB) is not routinely performed for breast cancer surgery because of the limitation to provide radioisotope tracer and isosulfan or patent blue dye (PBD). To overcome this obstacle, we applied 1% methylene blue dye (MBD) as a single agent to map the sentinel nodes (SNs).

In this study, we injected 1% methylene blue dye (MBD) into the subareolar or peritumoral space of the breast. In the case of breast conserving surgery ...

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