Elsevier

Surgery

Volume 130, Issue 3, September 2001, Pages 439-442
Surgery

Original Communications
Allergic reactions to isosulfan blue during sentinel node biopsy—a common event*

https://doi.org/10.1067/msy.2001.116407Get rights and content

Abstract

Background. Sentinel lymph node (SLN) dissection in the management of high-risk melanoma and other cancers, such as breast cancer, has recently increased in use. The procedure identifies an SLN by intradermal or intraparenchymal injection of an isosulfan blue dye, a radiocolloid, or both around the primary malignancy. Methods. At the time of selective SLN mapping, 3 to 5 mL of isosulfan blue was injected either intradermally or intraparenchymally around the primary malignancy. From October 1997 to May 2000, 267 patients underwent intraoperative lymphatic mapping with the use of both isosulfan 1% blue dye and radiocolloid injection. Five cases with adverse reactions to isosulfan blue were reviewed. Results. We report 2 cases of anaphylaxis and 3 cases of “blue hives” after injection with isosulfan blue of 267 patients who had intraoperative lymphatic mapping by the procedure described above. The 2 patients with anaphylaxis experienced cardiovascular collapse, erythema, perioral edema, urticaria, and uvular edema. The blue hives in 3 patients resolved and transformed to blue patches during the course of the procedures. Conclusions. The incidence of allergic reactions in our series was 2.0%. As physicians expand the role of SLN mapping, they should consider the use of histamine blockers as prophylaxis and have emergency treatment readily available to treat the life- threatening complication of anaphylactic reaction. (Surgery 2001;130:439-42.)

Section snippets

Patient 1

A 22-year-old woman with a melanoma of the right shoulder had an uncomplicated general anesthesia induced with use of a laryngeal mask airway, followed by intradermal injection of 3 mL of 1% Lymphazurin blue dye. Ten minutes later, the patient became hypotensive (blood pressure = 60/40 mm Hg) associated with diffuse erythema and facial and uvular edema. Decreasing the depth of anesthesia failed to improve her blood pressure, until large volumes of crystalloid and colloid had been infused. The

Patient 2

A 72-year-old man, with no known allergies and a melanoma on his back, had an uncomplicated endotracheal intubation, followed by injection of 3 mL of 1% Lymphazurin blue dye. Eight minutes later, he became hypotensive and mottled with facial and uvular edema. Decreasing the depth of anesthesia failed to improve his blood pressure. Because of a positive cardiac history, blood was drawn for determination of appropriate enzyme levels, and a transesophageal echocardiogram was performed. The

Patient 3

A 50-year-old woman with a diagnosis of invasive lobular carcinoma underwent a successful endotracheal intubation, followed by injection of 3 mL of 1% Lymphazurin blue dye intraparenchymally around the old biopsy site. About 40 minutes later, hypotension and bradycardia developed. Hypotension and bradycardia did not respond to ephedrine and epinephrine initially but were reversed with the addition of diphenhydramine, famotidine, and methylprednisolone. She had been given cefazolin but had no

Patients 4 and 5

Two 47-year-old women with breast carcinomas underwent breast conserving lumpectomy and sentinel node mapping and biopsy. Both patients were injected with 5 mL of 1% Lymphazurin blue dye subcutaneously near the previous biopsy site. “Blue hives,” involving the entire upper trunk and upper extremities without a decrease in blood pressure or other manifestations of allergic reaction, developed in both the patients 30 to 40 minutes after injection of the dye. In these patients, blue hives can be

Discussion

The use of Lymphazurin 1% became popular in lymphography through the 1970s, when it was replaced by new techniques. Patent Blue Violet is a triphenylmethane dye virtually identical to Lymphazurin 1%. Lymphazurin 1% (isosulfan blue) is the first dye of its type to be approved by the Food and Drug Administration for lymphangiography. Triphenylmethane dyes are used extensively in textile industries for dying nylon, wool, silk, and cotton.6 They have further use as medicines and biologic stains in

Conclusion

As physicians expand the role of sentinel lymph node mapping in the management of high-risk malignancies, they should be reminded of the potential for triphenylmethane dyes to produce allergic reactions. Emergency treatment must be readily available during procedures involving these dyes (eg, Lymphazurin 1%), and health care personnel working with these compounds should be aware that a negative history of drug allergy before exposure does not preclude the possibility of a life-threatening

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    *

    Reprint requests: Vincent M. Cimmino, MD, 1500 E Medical Center Dr, 3214 Cancer Center, Ann Arbor, MI 48109-0932.

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