Background: Sentinel lymph node biopsy is currently standard of care in node negative early breast cancer. There are various tracers for detecting sentinel lymph nodes in breast cancer. Sentinel lymph node biopsy (SLNB) using Technetium tagged Sulphur colloid is a convenient and safe method to assess lymph node status. However, sulphur colloid is radioactive and its use needs gamma camera which is very costly and available in very few centers in India. Methylene blue dye is an economical alternative for sulphur colloid having identification rate similar to the isotope. However, it may react with hemoglobin forming meth-hemoglobin resulting in difficulty in pulse oximetry during operation and causes skin eruptions and necrosis. Hence, there is a need to identify a sensitive, inexpensive and safe dye for sentinel node biopsy. In this study we have investigated the effectiveness and safety of fluorescein in sentinel node biopsy in a cross-sectional analytical study compared to Methylene Blue and Technitium Sulphar colloid.
Methods: This trial was conducted at two centers : Tata Memorial Centre, Mumbai and All India Institute of Medical Sciences New Delhi in India.We examined 86 patients of early breast cancer with no palpable axillary nodes undergoing SLNB with three tracers (Sulphur colloid /Methylene blue / Sodium Fluorescein). Patients underwent complete axillary dissection after identification of sentinel node for validation of sentinel node biopsy. Hot nodes were identified using hand held gamma probe and fluorescent nodes were identified using Ultra Violet lamp. All nodes were examined with Haematoxylin and Eosin staining. Since this study is first with use of fluorescein for sentinel node biopsy in breast, we injected fluorescein at decreasing time interval from 12 hours to 5 minutes to ascertain the most appropriate time for injection of fluorescein in first 15 patients. The sentinel nodes were visualized only when fluorescein was injected 5 minutes before incision.
Results: Sentinel nodes could be identified in eighty out of eighty six patients by combined tracers. In 72 out of 86 patients hot nodes could be identified (83.7%) while in 54 out of 86 patients fluorescent nodes could be identified (62.8%). Blue nodes were identified in 64 out of 86 patients(74.4%). Fluorescein delineated the lymphatic pathway going from breast to axilla in most patients. No side effects of Fluoroscein were observed. Of 86 cases, histologically positive sentinel lymph node were found in 15 patients. False negative with combined three tracers was in 3/18 (16.6%) patients. False negative rate with individual tracers was sulphur colloid- 3/16 (18.8%), Fluorescein – 2/15(13.3%) and with Methylene blue – 2/17(11.8%).
Conclusions: Fluorescein can be used as a low cost and effective alternative in sentinel lymph node biopsy for carcinoma breast without the risk of radiation exposure. Moreover, excellent visualisation of lymphatic pathway during procedure can act as a guide to trace the sentinel node.
Citation Format: Anurag Srivastava, Rajendra A Badwe, Amar Prem, Vani Parmar, Vuthaluru Seenu, Anita Dhar, Nita S Nair, Rohini Hawaldar, Vaibhav Sanmali. Sentinel node mapping with fluorescein and comparison with methylene blue and technitium sulphur colloid in early breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-01-31.