Patent Blue Dye Research Articles

Kounis syndrome after patent blue dye injection for sentinel lymph node biopsy

Kounis syndrome (KS) has been described as an acute coronary syndrome (ACS) associated with an anaphylactic reaction. Several triggers have been identified and the diagnostic and treatment process can be challenging. A 58-year-old, female patient diagnosed with breast cancer and no history of allergies had subcutaneous injection of patent blue V dye for sentinel lymph node biopsy (SLNB). Intraoperatively, she developed anaphylactic shock and was transferred to the intensive care unit (ICU). A few hours later, electrocardiographic alterations and elevation of blood troponin were observed. Emergency coronary angiography revealed no occlusive lesions in coronary vessels. Further investigation in the allergy department set the diagnosis of KS. There are just ten cases of perioperative KS in the literature so far and here we present the first one triggered by patent blue V dye for sentinel node biopsy.

Sentinel lymph node biopsy using indocyanine green in penile cancer.

Detection of positive nodes in men with moderate-risk to high-risk penile cancer and impalpable inguinal nodes is an important step in the therapeutic pathway. Detection using dynamic sentinel node biopsy with patent blue dye and radioisotope is associated with false negatives; indocyanine green might offer an alternative adjunct to improve detection rates.

P092: A pilot study to compare magnetic tracer and patent blue dye as an alternative technique to assess the axillary sentinel lymph node

Introduction: Sentinel lymph node biopsy is now the recognised technique for staging of the axilla in early breast cancer. NICE guidelines advise the use of a dual technique in identifying the sentinel lymph node. However national restrictions in supply of Technetium99 have created a real problem in delivering this gold standard. We piloted an alternative magnetic tracer, both Sienna and Magtrace, to use as an adjunct to Patent blue dye in identifying sentinel node.

Analysis of disease free survival in cutaneous melanoma patients subject to sentinel lymph node biopsy.

<b>Introduction:</b> Cutaneous melanoma is estimated for 2% of malignant neoplasms occurring in humans. It is characterized by a high level of malignancy and low sensitivity to cytostatic drugs. The incidence of cutaneous melanoma is increasing in Poland. The lymphatic system is the most common route of dissemination of this neoplasm. The appearance of a sentinel node biopsy technique has made it possible to identify patients with a regionally advanced disease. It is a minimally invasive method with a small percentage of complications. <br><b>Aim: </b>Analysis of disease free survival (DFS) in cutaneous melanoma patients with sentinel lymph node biopsy. <br><b>Material and methods:</b> The analysis included 222 patients with cutaneous melanoma treated in the Department of Oncological Surgery in 2010-2015, who underwent a sentinel node biopsy. The study group consisted of 136 women and 86 men, the average age of patients was 59 years. Patients were qualified for sentinel node biopsy based on clinical evaluation and ultrasound of regional lymph nodes. The average follow-up was 25.1 months. About 2 hours before surgery, patients received a radioisotope, then lymphoscintigraphy SPECT was performed. Additionally, they were administered the Patent Blue dye in the operating room. <br><b>Results:</b> The sentinel node was identified in 217 patients (98%), and the average sentinel nodes were 2.25. Twenty-seven patients (12%) had a metastasis in sentinel nodes. In this group, the duration of symptom free survival was significantly shorter. Sentinel node status and age of the patient were independent factors affecting the prognosis of disease free survival. <br><b>Conclusions:</b> Sentinel node biopsy is a precise method to identify patients with cutaneous melanoma who have metastasis to regional lymph nodes, as well as the most important prognostic factor.

Comparison between sentinel lymph node hybrid scintigraphy and blue dye technique in breast cancer patients: An institutional experience.

To compare the detection efficacy of radionuclide lymphoscintigraphy (LS) versus patent blue dye (PBD) technique for hidden sentinel lymph node (SLN) in breast cancer patients and to determine which modality is better for SLN detection. One hundred and thirty-four early stage breast cancer female patients with clinically negative axilla who underwent post technetium-99m nanocolloid injection single photon emission computed tomography (SPECT-CT) for negative SLN on planar imaging were studied prospectively between 2015 and 2017. Following SPECT-CT, patients underwent peroperative gamma probe count detection GP-CD and PBD technique. Visually, blue stained ± hot nodes were surgically removed and subjected to histopathological analysis. The detection rate by individual method was calculated. Kappa statistics were applied to calculate overall agreement between radioisotope and PBD techniques for diagnostic value assessment. One hundred and thirty-four patients underwent SPECT-CT LS and PBD injection. Mean age: 47 ± 7.6 years (range: 26–82 years). Forty-nine (36.6%) had T1 and 85 (63.4%) T2. SPECT-CT LS detected SLN in 105/134 cases (success rate: 78.4%), later GP-CD localized “hot nodes” in additional 20 cases (success rate: 93.3%). The PBD successfully localized SLN in 131/134 (97.8%) cases. Three cases remained negative on both radioisotope and PBD localization, which on subsequent nodal dissection had metastatic disease. All SLNs detected on SPECT-CT showed blue dye uptake. In 112 cases, more than one SLN was surgically removed. Frozen section analysis of excised SLNs showed metastasis in 31%. Overall moderate agreement (k = 0.56) was calculated. No statistically significant difference was seen between isotope detection and PBD. Radionuclide sentinel mapping has good detection rate particularly combined with peroperative GP-CD. The PBD has added value to reduce false-negative rate of SLN mapping and can substitute radionuclide imaging with negative results.

Allergic reaction to patent blue in breast surgery: case report

Introduction: The evaluation of the sentinel lymph node in the surgical treatment of initial breast cancer has been widely used. To identify the lymph node, patent blue dye or technetium radiopharmaceutical can be used. However, there have been reports of IgE-mediated hypersensitivity reactions to the blue patent dye (mean incidence of 1.8%), in some cases, severe, with severe hemodynamic repercussions that require vasoactive drugs. This frequency is higher than that of hypersensitivity reactions observed during anesthetic procedures. Therefore, we reported a case of allergic reaction to patent blue in the intraoperative period after periareolar subcutaneous injection. Case description: Female, 56-year old patient. Four months before, she presented with pleomorphic grouped calcifications in the upper quadrants of the left breast (Category 4) in mammography and ultrasound, increasing in the past 2 years. A stereotactic biopsy was performed, and showed a lesion compatible with carcinoma in situ, G3, G3 nuclear grade. She underwent a segmental resection of the left breast, with search for sentinel lymph node under general anesthesia induced by fentanyl, propofol and atracurium, maintained with sevoflurane, 50% of O2 and 50% of Ar. About 15 minutes after the patent blue injection, the patient had sudden tachycardia (HR=122bmp) and arterial hypotension (BP 80x40), simultaneously with the appearance of erythematous papules with bluish core in the trunk, abdomen and limbs. She was treated with volume replacement (500ml of Ringer’s Lactate solution) and vasopressor (Ephedrine, 15 micrograms). Ranitidine, diphenhydramine and hydrocortisone were administered. She was hemodynamically stable. Five hours after the end of the surgery, she was on complete remission. The anatomopathological examination showed carcinoma in situ, sentinel lymph node and free margins, tumor measuring 1.5x0.6 cm. Immunohistochemical test showed invasive ductal carcinoma with extensive intraductal component, 80% ER, negative HER-2, and 40% ki67 – Luminal B. She is still undergoing radiotherapy and hormone therapy. Conclusions: The reaction was manifested by tachycardia, hypotension and skin changes. She presented good response to volume replacement and vasopressor, and was in full remission after 5 hours.

A simple and efficient method to perform preoperative pulmonary nodule localization: CT-guided patent blue dye injection

ObjectiveTo assess the efficacy of computed tomography (CT)-guided localization with the injection of a low dose of patent blue dye (PBD) for the thoracoscopic resection of pulmonary nodules. Materials and methodsOverall, 125 consecutive patients underwent CT-guided localization with injection of a lower dose of PBD between June 2015 and June 2016. The total injection dose relative to the distance between nodules and the visceral pleura was recorded. The clinical and radiological characteristics, technical details, pathological results and procedure-related complications were reviewed. ResultsA total of 137 indeterminate pulmonary nodules were identified. The mean nodule size was 9.5 (3.0–22.0) mm. The mean injection dose of PBD relative to the distance between nodules and the visceral pleura was classified as follows: 0.07 ml: <1 cm, 0.1 ml: 1–2 cm and 0.18 ml: >2 cm. The mean time of CT-guided localization was 16.5 (10–50) min. The mean time interval from localization to surgery was 188 (24–1440) min. Pneumothorax developed in 50 patients (40%), and focal parenchymal hemorrhage occurred in 16 patients (12.8%) after localization. No patient required chest tube placement or emergent resuscitation. The success rate of dye marking was 98.5% (135/137). Malignancies, including 82 lung cancers, were diagnosed in 97 nodules (70.8%). ConclusionThe injection of a lower dose PBD based on the distance to the visceral pleura can be successful with nodular localization and may facilitate thoracoscopic surgery, even in cases with a long interval from localization to surgery.

Peri-Operative Anaphylaxis-An Investigational Challenge.

Patients with suspected peri-operative anaphylaxis (POP) require thorough investigation to identify underlying trigger(s) and enable safe anesthesia for subsequent surgery. The changing epidemiology of POP has been striking. Previous estimates of the incidence of POP have ranged between 1:6,000 and1:20,000 anesthetics, but more recent data from France and the United Kingdom suggest an estimated incidence of 1:10,000. Other important changes include a change in the hierarchy of well-recognized triggers, with antibiotics (beta-lactams) supplanting neuromuscular blockers (NMB) as the leading cause of POP. The emergence of chlorhexidine, patent blue dye, and teicoplanin as important triggers have also been noteworthy findings. The mainstay of investigation revolves around critical analysis of the time-line of events leading up to anaphylaxis coupled with judicious skin testing. Skin tests have limitations with respect to unknown predictive values for most drugs/agents and therefore, knowledge of background positivity in healthy controls, test characteristics of individual drugs and the use of non-irritant concentrations is essential to avoid both false-positive and false-negative results. Specific IgE assays for individual drugs are available only for a limited number of agents and are not a substitute for skin testing. Acute serum total tryptase has a high specificity and positive predictive value in IgE-mediated POP anaphylaxis but is limited by its moderate sensitivity and negative predictive value. Planning for safe anesthesia in this group of patients is particularly challenging and consequently anesthetists need to be alert to the possibility of repeat episodes of anaphylaxis. Because of the limitations of current investigations for POP, collecting systematic data on the outcome of repeat anesthesia is valuable in validating current investigatory approaches. This paper reviews the changing epidemiology of POP with reference to the main triggers, and the investigation and outcome of subsequent anesthesia.

Electromagnetic Navigation Bronchoscopy Localization Versus Percutaneous CT-Guided Localization for Lung Resection via Video-Assisted Thoracoscopic Surgery: A Propensity-Matched Study.

Background: An ideal preoperative localization method is essential for the resection of small and deep-seated pulmonary nodules by video-assisted thoracoscopic surgery (VATS) in the era of low-dose computed tomography (CT) screening. This study describes a new localization method using electromagnetic navigation bronchoscopy (ENB) and compares it against conventional percutaneous CT-guided methods. Methods: Between January 2016 and May 2018, 18 consecutive patients with a total of 27 pulmonary nodules underwent ENB localization using patent blue vital dye before thoracoscopy for lung resection at the National Taiwan University Hospital. Over the same period, 268 patients had a total of 325 pulmonary nodules localized by a CT-guided method. Propensity analysis was applied to minimize bias during comparison. Results: Patients were selected using a propensity-score based process, matched for potential risk factors for localization failure, to ensure equal potential prognostic factors in both groups. After matching, the ENB group had 15 patients with a total of 24 pulmonary nodules, and the CT group had 30 patients with 48 pulmonary nodules. No major procedure-related complications occurred in either group. The target pulmonary nodule was not successfully localized for one patient in the ENB group and three in the CT group. The lesions were fully excised after conversion to mini-thoracotomy. Pathological examination confirmed the accuracy of the dye staining. Analysis found a non-significant difference in the success rate of these two localization methods. However, the following parameters were significantly different: interval between localization to surgery, global time, and rate of pneumothorax (p < 0.05). Conclusions: In the era of minimally invasive surgery, surgeons need an efficient one-step way to manage pulmonary nodules. Patent blue vital injection with ENB guidance in the operating room is a new, effective approach to localize small, deep-seated and non-palpable pulmonary lesions, comparable with CT-guided localization.

Computed tomography-guided dual localization with microcoil and patent blue vital dye for deep-seated pulmonary nodules in thoracoscopic surgery

In video-assisted thoracic surgery (VATS) resection of small lung nodules, preoperative dye marking around the visceral pleura provides surface localization to help initiate resection, while implantation of a fiducial marker such as a microcoil can provide inner localization to aid nodule resection under fluoroscopic guidance. We aimed to determine whether dual localization with microcoil placement and dye marking is safe and useful for guiding the resection of small deep-seated lung nodules. We retrospectively evaluated data pertaining to 39 consecutive patients (40 nodules) managed between January 2016 and December 2017 in our hospital. Dual localization with patent blue V dye and microcoil was performed preoperatively because the pulmonary nodules were expected to be difficult to visualize or palpate intraoperatively. The patients underwent computed tomography-guided dual localization in a single puncture and were then transferred to the operation room. Intraoperative fluoroscopy was used to ensure that the lung tissue resected included the microcoil. All 40 lesions were successfully resected using the dual localization technique followed by fluoroscopy-assisted thoracoscopic surgery. The median lesion diameter and depth were 0.9 and 1.7cm, respectively, while the median margin/diameter ratio in the first resected specimen was 1.25. One patient had failure of localization due to partial release of the microcoil into the chest wall. Localization-related pneumothorax was detected in six of 39 patients (15.4%) and was always self-limited. Dual localization with microcoil placement and dye marking is safe and supports successful VATS resection of small deep-seated lung nodules.

Intraoperative Detection of Efferent Lymphatic Vessels Emerging from Lymph Node during Lymphatic Microsurgery.

Although the usefulness of efferent lymphaticovenular anastomosis (ELVA) in lymphatic microsurgery has been reported, the optimal method to distinguish efferent from afferent lymphatics is not yet established. We propose a novel technique to detect efferent lymphatics appropriate for anastomosis. In total, 62 groin lymph nodes (LNs) of 46 limbs were divided into four groups based on the findings of indocyanine green lymphography: n = 15 in normal, 15 in dermal backflow stage 0, 18 in stage I, and 14 in stage II groups. The target LN and afferent lymphatic connecting it were preoperatively detected using ultrasonography. Intraoperatively, 0.05 mL patent blue dye was slowly manually injected from the afferent lymphatic; the lymphatic(s) subsequently stained was diagnosed as the efferent lymphatic(s) emerging from the node. The success rates of efferent lymphatic detection, sizes of LN, and diameter of efferent lymphatics were compared among the groups. Both LN size and diameter of efferent lymphatic were significantly larger in the stage 0 and I groups than the other groups (p < 0.01). Efferent lymphatic could be stained in 13, 13, 18, and 9 LNs in the normal and stage 0, I, and II groups, respectively. A significant difference was observed between the stage I and II groups regarding the success rate of efferent lymphatic detection (p = 0.04). Efferent lymphatics could be detected using patent blue dye in 85.5% of the cases. The patients in early-stage lymphostasis might be the most appropriate candidates for ELVA.

Use of the Patent Blue and Air in the Preoperative Marking of Impalpable Breast Lesions.

The goal of this study is to analyze the applicability of the patent blue dye and air in the preoperative marking of impalpable mammary lesions with indication of surgical resection. A prospective cohort study was performed. We selected 49 patients with detection of impalpable lesions on a breast mammography or breast ultrasonography. The patients received the dye injection as close to their surgery time as possible. The criteria analyzed included: 1) complete marking and identification of the lesion; 2) complete removal of the lesion; 3) in cases of malignant lesions, presence of free margins for successful surgery; 4) occurrence of allergic events; 5) necessity of reoperation; and 6) difficulty in locating lesions. All lesions were marked, and they were successfully excised. In cases of malignancy, free margins were obtained in 100% of the cases. There were no allergic events or reoperations. Only 8.9% of the lesions were difficult to locate. The marking with patent blue and air is an effective alternative for the labeling of impalpable breast lesions, and it has satisfactory surgical oncology results. All lesions were resected, 91.1% of them were performed with no difficulties, and free margins were obtained in 100% of cases of malignancy.

Diagnostic application of patent blue V in sentinel lymph node biopsy for breast cancer - Is it time for a change?

Sentinel lymph node biopsy (SLNB) was introduced in the 1990s, as a minimally invasive procedure for staging the axilla with less morbidity to the traditional axillary lymph node dissection and is now standard management of the axilla in the early breast cancer. SLNB using the combined technique of blue dye and radioisotope is currently the recommended method for lymphatic mapping, and studies have shown high identification rates (IR) (>95%) and low false-negative rates (FNR) 5-10%. However, there are several reports raising awareness regarding patent blue V dye-induced peri-operative anaphylaxis. The main aim of this article is to highlight the emergence of patent blue dye as a new allergen and present evidence regarding the utility of alternative safer methods of evaluation of early breast cancer without compromising IR.

Feasibility of pedicled vascularized inguinal lymph node transfer in a mouse model: A preliminary study.

Vascularized lymph node transfer is becoming more common in the treatment of lymphedema, but suitable small animal models for research are lacking. Here, we evaluated the feasibility of pedicled vascularized inguinal lymph node transfer in mice. Twenty-five mice were used in the study. An inguinal lymph node-bearing flap with a vascular pedicle containing the superficial caudal epigastric vessels was transferred into the ipsilateral popliteal fossa after excision of the popliteal lymph node. Indocyanine green (ICG) angiography was used to confirm vascularity of the flap. ICG lymphography was performed to evaluate lymphatic flow at 3 and 4 weeks postoperatively. Patent blue dye was injected into the ipsilateral hind paw to observe staining of the transferred lymph node at 4 weeks postoperatively. All transferred lymph nodes were then harvested and histologically evaluated by hematoxylin and eosin staining. In 16 of the 25 mice, ICG lymphography showed reconnection between the transferred lymph node and the afferent lymphatic vessels, as confirmed by patent blue staining. Histologically, these transferred lymph nodes with afferent lymphatic reconnection significantly regressed in size (0.37 ± 0.24 mm2 ) and showed clear follicle formation, whereas those without afferent lymphatic reconnection showed less size regression (1.31 ± 1.17 mm2 ); the cell population was too dense to allow identification of follicles. We established a mouse model of vascularized lymph node transfer with predictable afferent lymphatic reconnection. Both the vascularization and reconnection might be necessary for functional regeneration of the transferred lymph node.

Low Saturation Readings in a Patient with Congenital Methemoglobinemia Exposed to Patent Blue Dye: A Case Report

Low Saturation Readings in a Patient with Congenital Methemoglobinemia Exposed to Patent Blue Dye: A Case Report

Perioperative anaphylaxis — Time for a NAP… 6!

Perioperative anaphylaxis — Time for a <scp>NAP</scp>… 6!

A Case of Intra-Operative Anaphylaxis to Patent Blue Dye during Sentinel Lymph Node Biopsy

Patent Blue Violet dye is commonly used for selective localization of the lymphatic system before sentinel lymph node biopsy. This procedure is routinely recommended for staging the axilla in early breast cancer. However, it has long been recognized that such dye is associated with anaphylaxis. Here, we present a case of an intraoperative grade 2 anaphylaxis which commenced 20 minutes following the subcutaneous periareolar injection of patent blue for sentinel lymph node detection during segmental mastectomy. The timing of the reaction, clinical signs, and results of skin testing confirm patent blue to be the triggering agent.

Removal of Patent Blue (V) Dye Using Indian Bael Shell Biochar: Characterization, Application and Kinetic Studies

The prospective utilization of bael shell (Aegle marmelos) as an agro-waste for the production of biochar was investigated along with its characterization and application for the abatement of hazardous aqueous Patent Blue (PB) dye solution. The sorptive removal of PB on bael shell biochar (BSB) was investigated under the following operational conditions: (pH, 2.7–10.4; biochar dosage, 2–12 g/L; and contact time, 0–60 min). The removal efficiency of PB by BSB in a batch adsorption experiment was 74% (pH 2.7 and 30 ± 5 °C). In addition, a clear relationship between the adsorption and pH of the solution was noticed and the proposed material recorded a maximum sorption capacity of 3.7 mg/g at a pH of 2.7. The adsorption of PB onto BSB was best explained by the pseudo-second order kinetic model (R2 = 0.972), thereby asserting the predominant role of chemisorption. The active role of multiple surface-active functionalities present on BSB during PB sorption was elucidated with the help of Freundlich isotherm (R2 = 0.968). Further, an adsorption mechanism was proposed by utilizing Fourier transform infrared spectroscopy (FTIR).

Characterizing an ideal experimental canine model for penile sentinel lymph node identification

Objective: Develop and evaluate a canine experimental model of penile sentinel lymph node (SLN) detection using a combination of patent blue dye (PB) and technetium99m phytate (99mTc). Methods: The experiment sampled healthy adult male mongrel dogs (N=19; 10-20 kg). After approval by the local ethics committee, we injected99mTc in the glans penis along the midline raphe. After 10 min, PB was injected in the same region. Ten minutes later, we identified hot spots within the inguinals and iliac artery areausing a gamma probe. We dissected identified sites to quantify the radiation at the SLN in vivo and ex vivo and accounted for the stained and unstained nodes. We analyzed the results for statistical significance and determined the level of agreement between the two methods. Results: SLNs were detected in 94.76% of the cases using PB and 99mTc. There was no difference (p&gt;0.05) between the SLNs-count on the left and the right side. However, PB and 99mTc correlated well on the right side (kappa index: 0.642) and perfectly on the left side (kappa index: 1), indicating a high level of consistency. Conclusion: The experimental canine model of penile SLN, in our study, was shown to be feasible.

Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features of perioperative anaphylaxis in the 6th National Audit Project (NAP6)

BackgroundAnaphylaxis during anaesthesia is a serious complication for patients and anaesthetists. MethodsThe 6th National Audit Project (NAP6) on perioperative anaphylaxis collected and reviewed 266 reports of Grades 3–5 anaphylaxis over 1 yr from all NHS hospitals in the UK. ResultsThe estimated incidence was ≈1:10 000 anaesthetics. Case exclusion because of reporting delays or incomplete data means true incidence might be ≈70% higher. The distribution of 199 identified culprit agents included antibiotics (94), neuromuscular blocking agents (65), chlorhexidine (18), and Patent Blue dye (9). Teicoplanin comprised 12% of antibiotic exposures, but caused 38% of antibiotic-induced anaphylaxis. Eighteen patients reacted to an antibiotic test dose. Succinylcholine-induced anaphylaxis, mainly presenting with bronchospasm, was two-fold more likely than other neuromuscular blocking agents. Atracurium-induced anaphylaxis mainly presented with hypotension. Non-depolarising neuromuscular blocking agents had similar incidences to each other. There were no reports of local anaesthetic or latex-induced anaphylaxis. The commonest presenting features were hypotension (46%), bronchospasm (18%), tachycardia (9.8%), oxygen desaturation (4.7%), bradycardia (3%), and reduced/absent capnography trace (2.3%). All patients were hypotensive during the episode. Onset was rapid for neuromuscular blocking agents and antibiotics, but delayed with chlorhexidine and Patent Blue dye. There were 10 deaths and 40 cardiac arrests. Pulseless electrical activity was the usual type of cardiac arrest, often with bradycardia. Poor outcomes were associated with increased ASA, obesity, beta blocker, and angiotensin-converting enzyme inhibitor medication. Seventy per cent of cases were reported to the hospital incident reporting system, and only 24% to Medicines and Healthcare products Regulatory Agency via the Yellow Card Scheme. ConclusionsThe overall incidence of perioperative anaphylaxis was estimated to be 1 in 10 000 anaesthetics.