Sentinel lymph node biopsy mapped with methylene blue dye alone in patients with breast cancer: A systematic review and meta-analysis

Jiyu Li, Xiao Chen, Ming Qi, Yanshuang Li, Jiyu Li, Xiao Chen, Ming Qi, Yanshuang Li

Abstract

Background: Methylene blue dye is easy to obtain in developing countries and can be used in sentinel lymph node mapping for breast cancer. However, the accuracy of methylene blue alone for sentinel lymph node mapping in breast cancer has not been well defined. In this study, we collected data to assess the feasibility and accuracy of sentinel lymph node biopsy mapped with methylene blue alone in patients with breast cancer.

Methods: We searched the PubMed, EMBASE, and Cochrane Library databases from January 1, 1993, to March 31, 2018. Selected studies had to have a defined group of patients with breast cancer in which MBD alone was used as the mapping technique for SNB.

Results: 18 studies were included in this study. The combined identification rate was 91% [95% confidence interval (CI): 88%-94%, I2 = 68.3%], and the false negative rate was 13% (95% CI: 9%-18%, I2 = 36.7%). The pooled sensitivity, negative predictive value, and accuracy rate were 87% (95% CI: 82%-91%, I2 = 37.5%), 91% (95% CI: 87%-93%, I2 = 32.4%) and 94% (95% CI: 92%-96%, I2 = 29%), respectively.

Conclusions: This meta-analysis found that mapping sentinel lymph node locations with methylene blue dye alone results in an acceptable identification rate but an excessive false negative rate according to the American Society of Breast Surgeons' recommendations. Caution is warranted when using methylene blue dye alone as the mapping method for sentinel lymph node biopsy.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. Flow diagram of the literature…
Fig 1. Flow diagram of the literature search and individual studies identified for this systematic review and meta-analysis.
Fig 2. The combined IR and FNR…
Fig 2. The combined IR and FNR of SNBs mapped with MBD alone.
A: A random-effects model was used to estimate the combined IR, with a result of 91% (95% CI: 88%-94%, I2 = 68.3%); B: A fixed-effects model was used to estimate the pooled FNR, with a result of 13% (95% CI: 9%-18%, I2 = 36.7%).
Fig 3. The combined sensitivity, NPV, and…
Fig 3. The combined sensitivity, NPV, and AR of SNBs mapped with MBD alone.
A: The pooled sensitivity was 87% (95% CI: 82%-91%, I2 = 37.5%); B: The combined NPV was 91% (95% CI: 87%-93%, I2 = 32.4%); C: The overall AR was 94% (95% CI: 92%-96%, I2 = 29%).
Fig 4. The combined IR for studies…
Fig 4. The combined IR for studies using peritumoral injection and studies using subareolar injection.
A: The combined IR for studies using peritumoral injection was 89% (95% CI: 83%-93%, I2 = 62.3%); B: The combined IR for studies using subareolar injection was 94% (95% CI: 89%-97%, I2 = 60.3%).
Fig 5. The combined FNR for studies…
Fig 5. The combined FNR for studies using peritumoral injection and studies using subareolar injection.
A: The combined FNR for studies using peritumoral injection was 11% (95% CI: 7%-18%, I2 = 35.9%); B: The combined FNR for studies using subareolar injection was 6% (95% CI: 2%-17%, I2 = 0%).
Fig 6. The combined IR of SNB…
Fig 6. The combined IR of SNB according to different MBD dose.
A: The combined IR for the studies that used a 2-ml injection of MBD was 90% (95% CI: 77%-96%, I2 = 70.3%); B: The combined IR for the studies that used a 5-ml injection of MBD was 92% (95% CI: 87%-95%, I2 = 67.1%).
Fig 7. The combined FNR of SNB…
Fig 7. The combined FNR of SNB according to different MBD dose.
A: The combined FNR for the studies that used a 2-ml injection of MBD was 11% (95% CI: 5%-22%, I2 = 0%); B: The combined FNR for the studies that used a 5-ml injection of MBD was 10% (95% CI: 6%-16%, I2 = 0%).
Fig 8. Funnel plots used to assess…
Fig 8. Funnel plots used to assess the effects of publication bias on the IR and FNR.
A: Funnel plot to assess publication bias effect on the IR; B: Funnel plot to assess publication bias on the FNR. Each dot represents a separate study. The funnel plots revealed no apparent evidence of publication bias.

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