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Lymphoscintigraphy, lymphangiography, magnetic resonance imaging
Published in Peter Gloviczki, Michael C. Dalsing, Bo Eklöf, Fedor Lurie, Thomas W. Wakefield, Monika L. Gloviczki, Handbook of Venous and Lymphatic Disorders, 2017
Patrick J. Peller, Jeremy L. Friese, Elizabeth A. Lindgren, Claire E. Bender, Peter Gloviczki
The sentinel lymph node is the first lymph node that filters lymph draining from the tumor site. Lymphatic drainage varies greatly in each individual. Lymphoscintigraphy maps the drainage pattern in each patient. The Tc-fSC particles injected adjacent to the tumor site are trapped in the sentinel node. Pre-operative lymphoscintigraphy is valuable for identifying lymphatic drainage and sentinel node location. A hand-held γ-probe is then used intra-operatively to identify the lymph nodes where radioactivity has accumulated. Tracer injections in the dermis, subcutaneous tissue, and peri-tumor locations have all been used with reasonable results. Most reports have agreed that a combination of radioactive tracer with a visible dye (isosulfan blue) yields the best results. Investigators have reported the identification of a sentinel node in well over 90% of patients. The utility and long-term impact of sentinel node mapping and examination in the management of melanoma and breast cancer are well established, but are beyond the scope of this chapter.20–23
Modalities of detection of sentinel nodes in lymphatic mapping
Published in Charles F. Levenback, Ate G.J. van der Zee, Robert L. Coleman, Clinical Lymphatic Mapping in Gynecologic Cancers, 2022
Blanca Segarra, Nuria Agusti, Pedro T. Ramirez
The two substances most commonly used as blue dyes are methylene blue and isosulfan blue (sometimes referred to as patent blue). The substances are functionally interchangeable when used as biotracers and with equal efficacy; however, their different chemical structures explain critical differences between the elements. Methylene blue is an organic chloride salt with a molecular mass of 319.8 g/mol. It may not be an ideal tracer because it is very poorly absorbed when injected intradermally and easily diffuses into the surrounding tissue, causing substantial tissue stain without specific targeting of the sentinel node. However, some claim that among its benefits is the fact that it is cheaper, more readily available, and has a better side effect profile than isosulfan blue. It should be noted that methylene blue has been associated with higher rates of anaphylaxis. Another mapping agent in this category is isosulfan blue. It has a molecular mass of 566.7 g/mol and is a 2,5-disulfonic acid isomer of patent blue. Approximately 50% of isosulfan blue is weakly bound to serum proteins, and it is rapidly transported through the lymphatics after intradermal injection, making it less likely to diffuse into the surrounding tissue. The structure of both blue dyes contains both hydro-phobic and hydrophilic regions. The hydrophilic areas allow for intravenous administration, as the substances dissolve in water and blood. The hydrophobic regions serve as high-affinity binding sites for oncotic proteins that circulate throughout the lymphovascular system. Blue dyes can only be seen in the visible light spectrum. This difference contributes to the overall accessibility and low cost of blue dye technology.
Clipping inguinal lymphatics decreases lymphorrhoea after lymphadenectomy following cancer treatment: results from a randomized clinical trial
Published in Scandinavian Journal of Urology, 2021
Palaniappan Ravisankar, Kanuj Malik, Anand Raja, Kathiresan Narayanaswamy
The concept of intraoperative mapping of identifying lymphatic leak has been applied by few researchers previously. Indocyanine green is being increasingly used to visualise lymphatic channels and assessment of lymphedema status. Bernier et al. in their review concluded that ICG increases the sentinel node detection sensitivity rate when used along with radiotracer [13]. However, when Mistry et al. used indocyanine green to identify transected lymphatics in breast axillary dissection, 70% of the patients still developed seroma [14]. Patent Blue V has been used to identify groin lymph leaks [15,16]. Isosulfan blue has been used extensively for identification of sentinel nodes in cutaneous melanoma, squamous cell carcinoma, merkel cell carcinoma and breast malignancy. Nakamura et al. performed a similar study by injecting isosulfan blue circumferentially around the inguinal dissection wound. In their study, the mean number of lymphatics identified and clipped were 3 (Range: 0−6), which is comparatively less than those in our study. They also found a significant decrease in the mean number of days of suction catheter insertion along with a reduction in the mean drain output [17].
Cutaneous adverse effects of methylene blue in an animal skin-flap model
Published in Acta Chirurgica Belgica, 2020
Sertaç Ata Güler, Sertaç Kırnaz, Turgay Şimşek, Can İlker Demir, Abdullah Güneş, Tonguç İşken, Nuh Zafer Cantürk, Nihat Zafer Utkan
Several different methods are used to perform an SLNB. The use of radiocolloids for SLNB provide many benefits [3,5,6] such as better identification rates compared with using any of the blue dyes alone [7,8]. However, radiocolloid use exposes the patient to additional risks associated with radioactive material [3]. Historically isosulfan blue was the first blue dye used to perform an SLNB [9]. However, isosulfan blue may cause a range of allergic reactions from relatively mild urticaria, rash, blue hives and pruritus to severe reactions such as life-threatening anaphylaxis and hypotension [2,10–12]. Patent blue V, originally a food coloring agent but now banned for human consumption in many countries [3,13], was also used for SLNB but again was associated with allergic reactions, including life-threatening anaphylactic shock. Methylene blue (MB) has replaced the use of isosulfan blue and patent blue V because of better SLN identification rates and a lower risk of allergic reactions [2,14]. However some studies have highlighted a concern that skin necrosis might be observed as a complication of MB injection [13]. Several publications recommend the use of blue dye in combination with radiocolloids and this method has the highest reported identification rates [7,8]. Therefore, if surgeons are to use this combined blue dye/radiocolloid method for mapping of SLN it is important that the possible adverse effects of the most commonly used dye, MB, are better understood.
Study on enhanced lymphatic tracing of isosulfan blue injection by influence of osmotic pressure on lymphatic exposure
Published in Drug Development and Industrial Pharmacy, 2018
Tiantian Ye, Rui He, Yue Wu, Lei Shang, Shujun Wang
Isosulfan blue (IB) is a kind of the triphenylmethane dye. IB is the first dye-type lymphatic tracer approved by the FDA for lymphangiography. It is an inert physiological dye and has no pharmacological action. After subcutaneous (s.c.) administration, IB is selectively picked up by the lymph node and weakly binds to interstitial proteins, thus the lymph nodes are distinguishable from the surrounding tissue by the bright blue color [9,10]. Due to quick localization and precise biopsy of the sentinel lymph node biopsy (SLNB), IB is currently used the most extensive dyes for of breast cancer in Europe and the United States [11]. After the determination of the tumor staging by SLNB, the patients at high risk, who may benefit from lymphadenectomy, are able to be implemented the further the elective lymph node dissection (ELND). However, SLNB and ELND have different imaging requirements for lymphatic tracers. ELND requires complete imaging capabilities for tumor-related lymph nodes at all levels, which need IB injection to have better lymphatic exposure capacity for step-by-step lymphatic tracing [12].