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Blue dye is sufficient for sentinel lymph node biopsy in breast cancer. BJS 2014; 101: 383-389.

Published: 3rd February 2014

Authors: C. H. Ang, M. Y. Tan, C. Teo, D. W. Seah, J. C. Chen, M. Y. P. Chan et al.


Most previous studies have reported superior results when blue dye and radiocolloids were used together for sentinel lymph node (SLN) biopsy in early breast cancer. Blue dye was reported to perform poorly when used alone, although more recent studies have found otherwise. This study reviewed the authors' practice of performing SLN biopsy with blue dye alone.


This was a retrospective review of patients who underwent SLN biopsy using blue dye alone from 2001 to 2005, when SLN biopsy was performed selectively and always followed by axillary lymph node dissection (ALND), and from 2006 to 2010, when SLN biopsy was offered to all suitable patients and ALND done only when the SLN was not identified or positive for metastasis.


Between 2001 and 2005, 170 patients underwent SLN biopsy with blue dye alone. The overall SLN non‐identification rate was 8·4 per cent. The overall false‐negative rate was 34 per cent, but decreased with each subsequent year to 13 per cent in 2005. From 2006 to 2010, 610 patients underwent SLN biopsy with blue dye alone. The SLN was not identified in 12 patients (2·0 per cent) and no significant contributing factor was identified. A median of 2 (range 1–11) SLNs were identified. A non‐SLN was found to be positive for metastasis in two patients with negative SLNs. Axillary nodal recurrence developed in one patient; none developed internal mammary nodal recurrence. Anaphylaxis occurred in one patient.


Blue dye performed well as a single modality for SLN biopsy. Non‐identification, axillary nodal recurrence and serious allergic reactions were uncommon.

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Your comments


Kirsty McFarlane

3 years ago


Ang and co-workers provide us with a comprehensive analysis of the learning curve of surgical techniques of SNB, performed using blue dye alone over a ten-year period. The level of effectiveness is comparable with the still-dominant, dual-modality SNB, a combination of blue dye and radiocolloid. The authors emphasize the simplicity of this procedure compared to the costly and complicated use of radioactive materials.

Most studies on the effectiveness of SNB emphasize that the goal of testing is not only to identify stained or “hot” nodes, but also those which are suspicious (1). Their suspect nature primarily refers to their altered characteristics based on palpation, but may also be related to pre- and intraoperative ultrasound appearance, mammogram abnormalities etc. Ang and colleagues describe two patients from among 470 with negative SLN, with metastasis in a “non-sentinel” node present in the axillary tail of the mastectomy specimen. According to our clinical database, there are positive (up to 0.5% of clinically negative axillas) but preoperatively unpalpable lymph nodes of small dimensions (6-7mm), fully occupied by tumour tissue. There is no lymph flow through these nodes, so they cannot be stained, but they are palpable intraoperatively because of their firmness. We are of the opinion that positive nodes in the mastectomy specimens in this study should have been discovered earlier as they actually represent the true sentinel nodes, by intraoperative palpation or preoperative mammography. In that way the “blue dye alone” technique would present a more effective and recommendable surgical technique.

N Ivanovic
D Zdravkovic
D Radovanovic
D Stamenkovic

University Medical Center "Bezanijska kosa", Belgrade
Faculty of Medicine
University of Belgrade
Bezanijska kosa bb
Belgrade 11000

1. Schuman S, Walker G, Avisar E. Processing sentinel nodes in breast cancer: when and how many? Arch Surg 2011; 146: 389-393.

Kirsty McFarlane

3 years ago

At our institute, mammography and breast ultrasound are part of the routine work-up for patients being investigated for breast cancer. The axillary nodes are specifically assessed on the breast ultrasound and suspicious nodes are biopsied pre-operatively. This also includes nodes which are reported as slightly enlarged, with thickened cortex but no loss of fatty hilum. As such, sentinel node biopsy is only performed in cases where the nodes are sonographically normal or in the absence of malignancy on the nodal biopsy. This has meant that sentinel nodes found to be positive are usually not involved extensively enough to be detectable clinically or sonographically. Although we do not routinely palpate the axilla for abnormal nodes prior to the sentinel node biopsy, note is made of any enlarged nodes found intra-operatively. In the two cases where a positive non-sentinel node was found in the axillary tail, no abnormal nodes were detected on the pre-operative ultrasound or during surgery. We postulate that in those two cases, dissection had occurred at a level higher than the ‘true’ sentinel node such that a non-sentinel node that had been coloured blue by diffusion of the dye was identified instead. Our existing practice of assessing the axilla nodes with breast ultrasound has ensured that a large proportion of involved nodes not detectable by clinical palpation are picked up pre-operatively. As such, patients offered sentinel node biopsy are a highly selected group. Together with familiarity with the technique, missing a ‘true’ sentinel node is uncommon in our practice.

C. H. Ang
M. Y. Tan
C. Teo
D. W. Seah
J. C. Chen
M. Y. P. Chan
E. Y. Tan

Department of General Surgery
Tan Tock Seng Hospital
11 Jalan Tan Tock Seng
Singapore 308433