Isosulfan Blue

Isosulfan blue injection (Lymphazurin) is a blue dye injection that is commonly used to map lymphatics in lymphangiography and sentinel lymph node biopsies. A 75-year-old male with a history of hyperlipidemia presented after excision of multiple lesions with plastic surgery, revealing melanoma in situ on the patient's scalp and superficial spreading melanoma with 4 mm margins on the right posterior axilla. During what was expected to be a routine procedure, anesthesia informed the operating room that the patient had become abruptly hypotensive, but responded to a one-time dose of peripheral vasopressors. The patient's chest and face were noticed to be erythematous and edematous when the patient was turned to begin the wide local excision. Welts and hives were noticed to be originating from the area where isosulfan blue was injected. The patient did fully recover from the incident with no unfortunate sequelae, but given this likely anaphylactic event, the patient should never again be exposed to isosulfan blue without direct physician care. Most reactions to isosulfan blue occur on first exposure and, despite its misnomer, have little to no relation to sulfa allergies. This case report and literature review critique the uses and indications for isosulfan blue, as well as discuss the hazards and prevention of these potentially critical reactions.

To compare the effectiveness of combined (indocyanine green [ICG]+ blue dye) tracing versus blue dye alone in guiding sentinel lymph node biopsy (SLNB) in breast cancer.

A total of 112 female patients (mean ± SD age: 51.9 ± 11.9 years) with clinically node-negative (cN0) early-stage breast cancer were evaluated based on SLN tracing technique including methylene blue + ICG (n = 17), isosulfan blue + ICG (n = 19) and methylene blue alone (n = 76). Mapping patterns of each SLN, the number of total lymph nodes (TLNs) removed, including metastatic and hyperplastic lymph nodes, and the metastatic lymph node detection rate were analyzed for each tracing technique.

SLN detection rate was 100 % with complementary use of ICG. No significant difference was noted between methylene blue + ICG, isosulfan + ICG and methylene blue alone groups in terms of the mean ± SD number of TLNs removed (3.9 ± 2.5, 4.7 ± 3 and 3.7 ± 2.3, respectively) and metastatic lymph node detection rates (16.0 %, 16.25 % and 13.98 %, respectively). Complementary use of ICG revealed the N0 stage for 66.6 % of cases considered as Nx (cannot be detected) on blue dye alone. Also, 20.0 % of N0 and 11.1 % of N1 cases on blue dye were diagnosed with more advance nodal status (N1 and N2 respectively) after complementary use of ICG.

The combined tracing (ICG + blue dye) seems valuable not only in terms of the SLN detection rates and lymph node yield but also has an added value in providing more accurate nodal stating and thus a proper final tumor staging with considerable therapeutic implications.