Perioperative hypersensitivity reactions to Patent Blue V in sentinel lymph node biopsy for breast cancer and melanoma

BACKGROUND: Patent Blue V (PBV) is widely used for sentinel lymph node biopsy (SLNB) in breast cancer and melanoma, but can rarely cause life-threatening perioperative hypersensitivity reactions (POH).

METHODS: We conducted a retrospective analysis of POH to PBV in SLNBs for breast cancer and melanoma between February 2016 and May 2024, alongside a prospective survey of PBV administration techniques in 60 SLNB procedures for breast cancer and melanoma. The clinical characteristics of five patients with confirmed POH to PBV are also described.

RESULTS: Eight of 2515 breast cancer patients and six of 1621 melanoma patients were referred to the Danish Anaesthesia Allergy Center (DAAC) for suspected POH. POH to PBV was confirmed in five patients with breast cancer (0.2%) and none in patients with melanoma (p = 0.16). Breast surgeons used deeper, higher-volume injections, while plastic surgeons favoured lower-volume intradermal techniques. All confirmed reactions occurred in otherwise healthy women, with onset of symptoms 20-70 min post-injection, predominantly as cutaneous signs and hypotension. Two patients required postoperative transfer to the Intensive Care Unit (ICU).

DISCUSSION: POH to PBV is rare but clinically significant, with a rate of 0.2% in breast cancer SLNBs and 0% in melanoma SLNBs, though this difference was not statistically significant in our study. Variations in PBV administration techniques between breast and plastic surgeons may contribute to the different rates. In five patients with confirmed POH to PBV symptoms consisted mainly of mucocutaneous signs and hypotension. Awareness of these rare but potentially life-threatening reactions, along with prompt management, is essential for both surgeons and anaesthesiologists. This study further underscores the importance of vigilant perioperative monitoring and formal allergy evaluation to guide future care.