Three stage axillary lymphatic massage optimizes sentinel lymph node localisation using blue dye
© Kirby et al; licensee BioMed Central Ltd. 2007
Received: 20 November 2007
Accepted: 22 December 2007
Published: 22 December 2007
This paper describes a simple technique of axillary and breast massage which improves the successful identification of blue sentinel nodes using patent blue dye alone.
Patent blue dye was injected in the subdermal part of the retroaroelar area in 167 patients having surgical treatment for invasive breast cancer. Three stage axillary lymphatic massage was performed prior to making the axillary incision for sentinel lymph node biopsy. All patients had completion axillary sampling or clearance.
A blue lymphatic duct leading to lymph nodes of the first drainage was identified in 163 (97%) of the patients. Results are compared with 168 patients who had sentinel lymph node biopsy using blue dye without axillary massage. Allergic reactions were observed in four patients (1.2%).
Three stage axillary lymphatic massage improves the successful identification of a blue sentinel lymph node in breast cancer patients.
Number of Patients
Number of SLN*
SLN Identification rate (%)
Blue Dye Only
ALMANAC Mansel 2006
Combined Blue Dye and Radiocolloid
Combined Blue Dye and Radiocolloid
Combined Blue Dye and Radiocolloid
We report a technique using a three stage axillary and breast massage after subcutaneous injection of 2 ml of patent blue dye alone. This massage technique applies the principle of manual lymphatic drainage and is based on the physiology of lymphatic flow described originally by Winiwarter (1892) and Vodder (1982). It improves the localisation of a blue lymphatic duct in the axilla and almost always leads to successful identification of the blue sentinel lymph node. 
In 167 patients with three stage axillary lymphatic massage a blue sentinel lymph node was identified in 163 patients thereby achieving a localisation rate of 97%. We compared the results with our previous technique of simple massage from the injection site towards the axilla (Antegrade massage). A blue sentinel lymph node had been identified in 144 of 168 patients with simple antegrade massage alone, a localisation rate of only 85%.
Four patients (1.2%) developed allergic reaction to patent blue dye which manifested in the form of blisters or wheal and blue hives with bluish discolouration of the skin. One of these patients became hypotensive. All reactions occurred within 45 minutes of the injection and were treated by a single intravenous injection of 200 mg of Prednisolone.
The false negative rate was 6% in the antegrade massage group and zero per cent in the three stage axillary lymphatic massage group. The new technique also improved the sensitivity and specificity from 70 and 88 per cent with simple antegrade massage to 84% and 100% with a three stage massage.
Axillary sentinel lymph node biopsy allows a minimal invasion of the axillary area in order to obtain a limited number of axillary lymph nodes to identify patients who do not have nodal metastases. This avoids a more extensive axillary dissection with its associated complications. It is important that techniques used to localise the axillary sentinel lymph node in breast cancer are optimized to achieve a high identification rate. A combined technique using Tc-99 isotope and patent blue dye has been shown to achieve a localisation rate of up to 98% [1, 9, 10].
Of the various dyes used for sentinel node localization patent blue dye is currently recommended for sentinel node biopsy in breast cancer patients in the United Kingdom. When injected subdermally in any area of the breast it binds to proteins and is absorbed by the lymphatics and highlights the lymphatic drainage and the sentinel lymph node in the axilla . Three stage lymphatic massage works by first emptying the "reservoir" in the lymph nodes creating an empty space into which lymphatics containing the blue dye can be emptied easily .
A localisation rate of over 90% is currently recommended to assure quality in breast cancer surgery [7, 12, 13]. We report in this study that a localisation rate of 97% is achievable by using blue dye alone with axillary lymphatic massage in three stages. This technique can be useful for breast surgeons working in breast units where facilities for nuclear medicine are not readily available . A blue dye assisted four node sampling can be performed making it a targeted axillary sampling . A comparison of Methylene blue dye and combined dye and radioactive technique has shown that the blue dye technique with breast massage can be as accurate as the combined isotope dye technique .
We thank all patients who have taken part in this study. Written informed consent was obtained from the patient for publication of images in this paper. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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