Precise Intraoperative Lymph Node Identification by Isosulfan Blue of Occult Neck Lymph Node Metastases for Decision to Convert from Supraomohyoid Neck Dissection to Comprehensive Neck Dissection in Early-Stage Oral Cancer

Objective: To study the sensitivity and specificity of peritumoral isosulfan blue dye injection for localization of suspected metastatic lymph nodes. Materials and methods: The study included all patients diagnosed with early-stage oral cancer between January 2018 and March 2020. After elevation of the skin flap, the primary site was injected peritumorally with isosulfan blue 0.3-0.5 cc at 1 cm intervals and massaged. The time at which any draining nodes turned blue was recorded and the node was then excised for frozen section. After which supraomohyoid neck dissection was performed. The frozen sections were stained with H&E and analyzed for presence of metastases. Negative sections were further analyzed using immunohistochemistry stains. Sensitivity, specificity and time of identification suspected metastatic lymph node were analyzed . Results: Nineteen patients with early-stage oral cancer were included. The majority (78.4%) presented with tongue lesions. The mean injection amount administered was 3.62±0.83 cc, and the number of injections around the tumor were 10.26±2.31. Mean duration from time of injection to the identification of a blue node was 19.26±15.99 min. Nodes at Level I of the neck were the most common identified as blue nodes (57.8%). Statistical analysis comparing pathological findings with blue node identification revealed this technique has a sensitivity of 71.4% with specificity of 91.7% and an overall accuracy of 84.2% in identify metastasis lymph node. Conclusion: Isosulfan blue injection of primary oral tumors demonstrated a high level of efficiency in identifying metastatic lesions in draining lymph nodes. This technique may be helpful in deciding intraoperatively whether to convert from supraomohyoid neck dissection to comprehensive neck dissection .

A study on the feasibility of axillary reverse mapping with blue dye only in breast cancer patients

Background: Axillary reverse mapping is (ARM) the concept of visualization of the nodes in axilla that drain the arm and preserving them. Literature describes this procedure being done with blue dye (methylene blue) and 99mTC technetium sulphur colloid. This study was undertaken to look for the feasibility of axillary reverse mapping using blue dye alone as there is lack of availability of the radio colloid in many centres in India.Methods: 30 breast cancer patients who underwent axillary dissection as part of their surgery were included in the study. 2.5–5 ml of methylene blue was injected in the medial upper arm in the intermuscular groove region. The number of blue nodes identified, their location, pathological status and procedure related complications were analysed.Results: The ARM blue node was identified only in 7 out of the 30 patients (sensitivity– 23%) and none had a pathologically positive blue node. In those 7 patients, only 1 blue node was identified. All the nodes were in level 1 and the largest node measured 2cm in largest dimension. The complications associated with the procedure included pain, pigmentation, induration and skin necrosis. 16 (53.3%) had pain, 10 (33.3%) had induration, 6 (20%) had pigmentation and 1 (3.33%) had skin necrosis.Conclusions: The feasibility of ARM being done using blue dye alone needs to be questioned in view of its poor sensitivity. Added to this, the complication rates are higher. However, larger studies are needed to validate the same or otherwise.

Extensive Nodal Disease May Impair Axillary Reverse Mapping in Patients With Breast Cancer

Purpose The aim of axillary reverse mapping (ARM) is to preserve arm lymphatics in patients with breast cancer who underwent surgical axillary staging. Patients and Methods From June 2007 to December 2008, 49 patients who required axillary dissection (AD) underwent ARM. One milliliter of patent blue dye was injected in the ipsilateral arm, and all blue nodes identified during AD were sent separately for pathologic examination. Main variables associated with the detection rates of blue lymphatics, the pathologic status of blue and nonblue nodes, and the complications of the procedure were analyzed. Results Identification rates of blue lymphatics and blue nodes were 73.5% and 55.1%, respectively. Blue node identification was influenced by the time elapsed between injection of blue dye and surgery (P = .002) but not by the learning curve of the procedure. Although the blue node was clear of metastases in 24 of 27 patients, three patients with extensive nodal metastatic involvement (ie, pN2a and pN3a) showed breast cancer metastatic cells in the blue nodes as well. The only adverse effect of the procedure was skin tattooing at the injection site, which disappeared within 4 months in almost 80% of the procedures. Conclusion In patients with clinically negative axillary nodes, additional study is warranted to assess whether ARM may be used to spare the lymphatics from the arm. In the presence of extensive nodal disease, this technique may identify metastatic blue nodes, which demonstrates that there is not reliable separation of arm and breast lymphatic pathways.