Systemic blue hue after isosulfan use for lymphatic mapping in a case of metastatic melanoma excision
Injection of isosulfan blue (lymphazurin) to delineate lymph vessels during lymphaticovenous anastomosis (LVA) is becoming more common as lymphedema surgeries are gaining popularity (Schwarz et al. 2019) Transient discoloration of skin injection sites and urine that may last for several hours to weeks is a well known side effect of isosulfan blue. Adverse reactions such as hives, urticaria, periorbital edema, hypotension requiring vasopressors, and anaphylaxis were reported in up to 1.8% of patients who were injected with isosulfan blue for sentinel lymph node biopsy (King et al. 2004) The incidence of diffuse skin staining is not known. In this letter, we would like to report a generalized blue green skin discoloration following isosulfan blue injection during axillary reverse mapping (ARM) for prophylactic LVA. The patient is a 61 year old female who was diagnosed with nodular melanoma on the upper back (Breslow thickness 3.7 mm, pT3a) Metastatic workup revealed right axillary lymphadenopathy and a left pulmonary nodule. The patient underwent excision of the back lesion, axillary lymph node dissection, and prophylactic LVA. ARM was performed using isosulfan blue, as previously described by our institution (Schwarz et al. 2019) Initially, a total of 3 ml of indocyanine green was injected 1 ml in three interdigital webspaces, and 2 ml in the upper medial arm. Immediately prior to LVA, a total of 5 ml isosulfan blue was injected into the upper medial arm. LVA was performed using the intussusception technique (Schwarz et al. 2019) At the conclusion of the case, the patient was awakened from general anesthesia and it was noticed that there was diffuse blue green discoloration of the face and shoulders (Figure 1) Throughout the postoperative course the patient remained hemodynamically stable with a normal oxygen saturation. The following day, the skin pigment change resolved and the patient was back to baseline and discharged. The patient has been followed with routine multidisciplinary care and has had no residual side effects from the transient skin discoloration. Isosulfan blue in systemic circulation may cause factitious hypoxemia as the maximal absorption wavelength for isosulfan blue is near that of deoxyhemoglobin (Wear et al. 2003) Postoperative oxygen saturation, arterial blood gas measurements and methemoglobin level were normal in this patient during the transient skin discoloration. This is not the only report of systemic skin reaction with the use of isosulfan blue dye. This reaction has been described with use of this dye primarily in breast cancer management but also in other cancers, likely due to inadvertent venous injection (Finkelstein Narayanan, 2019; Haque Nossaman, 2012) To our knowledge this
Microsurgery