Guildford, UK
EditorWe were interested to read the report from Dr Stefanutto and colleagues1 concerning a patient who experienced an anaphylactic reaction to isosulphan blue during a sentinel lymph node biopsy (SNLB) associated with breast tumour surgery. We reported a similar case2 of a lady undergoing breast tumour surgery who developed cardiovascular collapse about 30 min after peritumoural injection of blue dye for SNLB. She developed profound hypotension, associated with large red coloured trunkal wealds. As in Dr Stefanuttos patient, epinephrine, initially as i.v. increments of 0.1 mg followed by an infusion, was successful in reversing the hypotension and the patient recovered uneventfully. Serum tryptase and urinary methylhistamine levels were both significantly raised, indicating an immune mechanism. Skin testing was positive to the blue dye at 1:10 and 1:5 concentrations.
Dr Stefanutto and colleagues emphasize the need to alert anaesthetic personnel to this potential reaction. We would also like to emphasize the delay between initial injection of blue dye and the onset of symptoms (about 25 min in our case). We would agree that full resuscitation equipment should be available whenever anaesthesia is carried out. We do not think, however, that the occurrence of these two cases should preclude the use of this technique in the day-case setting.
The patient we had been treating was part of the UK Axillary Lymphatic Mapping Against Nodal Axillary Clearance (ALMANAC) trial which aims to recruit 1200 patients, randomized to two arms. So far we have treated over 500 patients for SLNB using blue dye. Unlike Dr Stefanutto and colleagues, the UK ALMANAC trial does not use isosulphan blue but instead uses Patent Blue V dye manufactured by Laboratoire Guerbet (Aulnay-Sous-Bois, France). This drug is available world wide with the exception of the USA. It is the dye of choice for SNLB in the UK and throughout Europe. To date, five other cases of anaphylactic reaction have been described with this dye.37
We have also noted two other cutaneous reactions that we believe are related to the use of Patent Blue V dye during SNLB. The first reaction is the development of skin wealds, usually across the trunk of the patient. The wealds are not typically red, but often strongly blue in colour. These wealds, although unsightly, usually disappear over 612 h. This reaction is not associated with any other systemic signs of anaphylaxis such as hypotension or bronchospasm.2 8 Empirical treatment with i.v. steroids and antihistamine has been used successfully in these patients.
In the second type of reaction, the patients are noted (usually in the postanaesthetic recovery area) to be extremely pale or white. The initial reaction is to assume that the patients are very anaemic or hypotensive. However, all cardiovascular and respiratory signs are within normal limits and the patients are not anaemic. On a number of occasions, nurses, concerned at the appearance of the patients, have called us urgently to the postanaesthetic recovery area! All patients who have developed this reaction have recovered uneventfully over the next 46 h.
We concur with Dr Stefanutto and colleagues that the demand for SLNB is likely to increase. It allows identification of those patients with breast cancer who need further lymph node clearance and allows those who need no further surgery to avoid the morbidity associated with extended axillary lymph node clearance. It is likely that once the UK ALMANAC trial has been published, SLNB will become one of the standard treatments in the management of early primary breast cancer. Anaesthetic and surgical personnel should be aware of these different reactions that may be associated with the use of Patent Blue V dye and isosulphan blue dye.
N. F. Quiney
M. W. Kissin
I. Tytler
Guildford, UK
References
1 Stefanutto TB, Shapiro WA, Wright PMC. Anaphylactic reaction to isosulphan blue. Br J Anaesth 2002; 89: 5278
2 Mullan MH, Deacock SJ, Quiney NF, Kissin MW. Anaphylaxis to patent blue dye during sentinel lymph node biopsy for breast cancer. Eur J Sur Oncol 2001; 27: 21819[CrossRef][ISI][Medline]
3 Barber CJ. Case report: serious adverse reaction to patent blue violet at lymphography. Clin Radiol 1989; 40: 631[ISI][Medline]
4 Quiliquini A, Hogendijk S, Hauser C. Anaphylaxis to patent blue. Dermatology 1998; 197: 400[CrossRef][ISI][Medline]
5 Salvat J, Margonari H, Hardelin D. Choc anaphylactique au blue patenté lors de la recherche du ganglion sentinelle. J Gynecol Obstet Biol Reprod 1999; 28: 3934[Medline]
6 Woltsche-Kahr I, Komericki P, Kranke B, et al. Anaphylactic shock following peritumoral injection of patent blue in sentinel lymph node biopsy procedure. Eur J Surg Oncol 2000; 26: 31314[CrossRef][ISI][Medline]
7 Vrancken Peeters M, Boutkan H, Lagaay M, Agsteribbe M, Breslau P. Anaphylaxis to patent blue during sentinel node biopsy. Eur J Surg Oncol 2000; 26: 4312
8 Mullan MH, Kissin MW, Deacock SJ, Quiney NF. Minerva. Br Med J 2000; 321: 460