Comments to the Letter to the Editor by Dr. Ponzone

Abstract

We read the Letter from Dr Riccardo Ponzone with great attention and are grateful to be given the opportunity to contribute to it with some comments. In our opinion, this new concept should be evaluated in the light of two questions. Firstly, is this new technique reproducible and improvable? And secondly, does this technique imply oncologic risks for the patients? First, it is interesting that this method is being reproduced and seems relatively easy to perform. Regarding the improvements of the blue dye technique with injections in the arm, Dr Ponzone presents his experience with four cases, with a detection rate of the blue node of 50%. In our series with 21 patients, we showed that (as in the classical blue dye sentinel node identification published by Armando Giuliano) there was a learning curve to practice the lymphatic arm drainage identification (or axillary reverse mapping) with an identification rate of only 50 % for the first 10 cases (5/10) and 91 % in the last 11 cases (9/ 11). We thus believe that, with Dr Ponzone s further practice of the technique, there will be a higher rate of identification. In fact, the main problem of our series was the risk of blue skin coloration on the arm, which can persist for many months after surgery. Our study was performed during the winter of 2004 and that some 2 years after surgery all patients were reviewed in that regard: in only 10 (47%) patients had the blue color fully disappeared from the arm while for others, the blue color was still slightly visible. This aesthetic problem of blue staining should be taken into consideration, especially in Italy or Florida where patients live with short-sleeved shirts throughout most of the year. This problem of blue staining has induced a change in our method of detection of the lymphatic arm drainage. We now use a technique with isotopes injected in the interdigital space of the ipsilateral arm to visualize the arm drainage. This technique has allowed, in our experience, a much better identification rate of the node in the axilla (unpublished data). Also of interest is that we have improved our technique regarding the issue of visualization of the efferent lymphatic duct from the first identified blue node, which is problematic in Dr Ponzone s series. We would thus suggest that the following technique be pursued. The day before surgery, lymphoscintigraphy of the ipsilateral arm is performed with injection in the interdigital space. During the surgery, the axillary dissection is performed with identification of the second intercostal brachial nerve. During the dissection, one, two, or three radioactive nodes in relation with the lymphatic arm drainage will be identified. The first radioactive node, which is in the lateral pillar of the axillary dissection and above the second intercostal brachial nerve, must be carefully dissected. It is then possible to inject a small amount of blue dye (0.1 ml with a 30.5 G needle) into this node. If the injection is done properly and carefully, an immediate coloration of the efferent ducts will appear, showing Received September 10, 2007; accepted September 11, 2007; published online: November 8, 2007. Address correspondence and reprint requests to: Claude Nos, MD; E-mail: claude.nos@idsein.fr