Unenhanced Chest Computerized Tomography Assisted Sentinel Lymph Node Biopsy Could be a Highly Reliable Option for Only Methylene Blue Available Breast Cancer Patients

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Background: Blue dye and radioisotope (RI) combined SLNB is the “best” protocol. However, RI is not available worldwide. This study is to evaluate the feasibility of unenhanced chest Computerized Tomography (CT) with three criteria for suspicious nodal metastasis assisted SLNB using only methylene blue (MB) as an alternative reliable option.

Patients and Methods: A total of 1771 consecutive patients with clinically node negative breast cancer were enrolled. For limiting FNR and surgical complications, the number of removed Sentinel Lymph Nodes (SLNs) was suggested to be 3~5. Unenhanced chest CT is mandatory to locate SLNs, which were graded from 1 to 3 according to suspicious criteria for metastasis. Three doctors adopted three SLNB methods. Periareolar sub-dermal injection using 4ml of 0.5% MB alone or in combination with a radioisotope was individually employed by two doctors. The third doctor used 2ml of 1% MB to inject into parenchyma to map SLNs.

Results: Both FNR and outcomes of patients showed no difference between three methods. We also confirmed that Lymph Vascular Invasion (LVI) and CT grade were both significantly correlated with SLN status (coefficients were0.68 and 0.25, p<0.001). Although there was no difference found in complications, but parenchymal injection did never cause skin necrosis.

Conclusion: Unenhanced chest CT could be are liable assistance to improve SLNB using only MB via parenchymal injection. This technique might be the safest and convenient option for SLNB in the study and RI could be safely spared.

Keywords: Breast cancer; Sentinel lymph node biopsy; Methylene blue; Computerized tomography