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Lymphatic mapping in breast cancer Palpable mass at site of injection 10 Varghese et al 1described safely injecting MBD in the subdermal plane in the subareolar region with Their only reported complication was temporary tattooing from MBD, which was also seen on Goavert et al series Stradling et al 5 was the first to describe local skin reactions to MBD injection for SLN mapping, including skin necrosis in 5 of 24 patients.
Zakaria et al 4 and Salhab et al 6 both reported skin and fat necrosis in a small percentage of patients who received MBD injections for SLN mapping. Komenaka et al 13 described a palpable mass at the site of injection of MBD.
Nearly all of the masses resolved by one year, however, one resolved after 18 months.
None of the aforementioned patients required surgical debridement. Singh-Ranger et al 14 did report a complication that required surgical revision.
They reported capsular contraction associated with MBD, after immediate reconstruction using breast prosthesis. In their case they attributed local inflammatory reaction from the MBD as the main cause of the capsular contraction.
Pathological Considerations One of our patients Case 1 presented with a well-developed region of fat necrosis with cavity formation.
Fat necrosis is an important diagnostic consideration as it may persist and can clinically mimic carcinoma. Early in its development, fat necrosis is composed of disrupted fat cells and hemorrhage with an influx of histiocytes, some becoming multinucleate as they ingest debris.
After several weeks the affected area develops peripheral fibrosis, often with calcification and forming a tumor-like lesion which may clinically mimic carcinoma Attachment to the skin, dimpling and retraction are often evident.
Central cystic degeneration may also occur with resultant cavity formation. This type of fat necrosis differs from fat necrosis caused by electrocautery. Electrocautery has evident thermal effect around the edges and involved areas and does not cause such extensive destruction beyond the local tissue perimeter, with several centimeters of fat necrosis, as in the case of our patient.
We are aware of 1 report of MBD contamination with Mycobacteria chelonae that caused infections in patients who had undergone facelifts To our knowledge, our case represents the initial report of contaminated MBD in breast surgery patients.
This is of particular concern due to the impact that contaminated MBD had on the surgical and adjuvant management of breast cancer for our patients. Our 2 case reports confirm the findings of previous publications that complications of MBD are capable of causing tissue necrosis.
Of note, both of our patients required extensive surgical debridements, revealing that MBD does indeed have side effects not considered in the previously published literature.
In our Case Report 2, the discovery of a complicating Mycobacterial infection led to delayed adjuvant treatment and had a significant impact on our choice for systemic treatment.
The site of injection of blue dyes is still controversial. Historically, Giuliano et al 16described using blue dye as peritumoral injection with good results; peritumoral injection of blue dye is the most common approach to lymphatic mapping with vital blue dyes.
Veronesi et al 17 injected blue dyes subdermally. Intradermal, periareolar or subareolar sites have also been described 18 There are a limited number of studies indicating high success rates of identifying SLNs using subareolar injection of blue dye 20 - Rodier et al 23using both blue dye and radiolabelled isotope, found that using periareolar injection was equivalent to using peritumoral injection in identifying SLN.
There are several studies supporting the different sites of injection for blue dye, but subareolar and dermal injections have been proven to cause more local side effects, like discoloration of the breast, that can last several months In our case it caused more than just discoloration but led to substantial tissue loss due to necrosis.
Lymphazurin had long been held as the standard for sentinel lymph node mapping in breast cancer However, MBD has demonstrated equivalent efficacy in lymphatic mapping compared to Lymphazurin 326 - 28is less expensive, more readily available and is not associated with the potentially deleterious side effects of severe allergic reaction, including anaphylaxis 3829 as has been reported with Lymphazurin.
Raut et al reported an incidence of severe anaphylactoid reaction to lymphazurin of 1. Blue urticaria and facial edema were the reactions observed after preoperative prophylaxis in that study. As described in the above cases and table, MBD is not without its own potential for complications.
The risk for complications of MBD should be taken into consideration when selecting a blue dye for lymphatic mapping. Both MBD and Lymphazurin are vital blue dyes.Essay Valentino Case Study. your hobby/project to briefly describe the ways in which the computer would be used (you are not to use more than words for this).
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How to cite this article: Reyes F, Noelck M, Valentino C, Grasso-LeBeau L, Lang J. Complications of Methylene Blue Dye in Breast Surgery: Case Reports and Review of the Literature. Essay Valentino Case Study. VALENTINOS PERSONAL INTRODUCTIONS AGENCY 1.
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