To the Editor
Sentinel node biopsy is the standard method for axillary staging of the early stage breast cancer patients [Citation1,Citation2], which is usually performed by the aid of radiotracers and blue dyes in combination or alone [Citation3,Citation4]. With more availability of nuclear medicine facilities, sentinel node biopsy for breast cancer patients is increasing [Citation5–7]. Despite its proven benefit for the patients, sentinel node mapping using blue dyes has some fatal complications; such as anaphylaxis reaction [Citation8].
Case presentation
A 56-year-old woman with early stage breast cancer was referred for breast surgery as well as sentinel node biopsy. 99mTc-Antimony sulfide colloid was injected superficially the day before surgery for sentinel node mapping using gamma probe during operation. After induction of anesthesia, 2 ml methylene blue was injected in the subdermal fashion in the peri-areolar region of the index quadrant of the breast. Two minutes post-blue dye injection the patient developed severe hypotension, tachycardia, bronchospasm, as well as hypoxia. The main surgery was not conducted and resuscitation started with oxygen, epinephrine, mechanical ventilation and intravenous fluid. Histamine receptor blockers as well as high dose corticosteroid were also started. The patient was transferred to ICU. Chest x-ray showed diffuse pulmonary edema. The patient's condition gradually improved and after couple of days she was discharged.
The patient did not have any history of atopic disorders; however she reported history of food allergy (to melon and eggplant) in her family (herself and her father). She was referred for allergy testing and prick tests with diluted anesthetic drugs (which were used for the patient during surgery), latex, and methylene blue were done. Histamine and normal saline were used as positive and negative control respectively. The prick test with methylene blue was positive (20×30 mm wheal was raised) and the patient developed urticaria.
Breast surgery with sentinel node biopsy mapping (using radiotracers and surgical gamma probe) was performed for the patent two months later without blue dye injection.
Discussion
Several kinds of blue dyes are in use for sentinel node mapping of early stage breast cancer patients such as Patent blue V [Citation9], isosulfan blue [Citation10], and methylene blue [Citation11].
Methylene blue is a compound with widespread use in medicine [Citation12]. This dye has been used for sentinel node biopsy mapping since 2001 with favorable results [Citation11,Citation13]. However it has several reported adverse reactions such as interference with pulse oximetry [Citation14], and skin complications (necrosis) [Citation15–17].
It is usually stated that methylene blue is safer and cheaper than other dyes using in sentinel node biopsy [Citation12,Citation18]. Despite its widespread use in medicine, anaphylaxis to methylene blue has been very rarely reported in medical literature [Citation19,Citation20]. To the extent of our knowledge, there is only one report of pulmonary edema after methylene blue injection for sentinel node biopsy [Citation21]. Our case is the second in this regard and underscores the importance of considering the possibility of anaphylactic reaction to methylene blue while performing sentinel node biopsy.
In conclusion, although methylene blue is considered safer than other kinds of blue dye which are currently in use for sentinel node mapping (with almost the same accuracy), anaphylaxis can occur with this compound and facilities to treat this fatal condition should always be in hand.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Related Research Data
References
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