*2.6.3 Blue dye and ICG*

The prospective cohort study by Holloway et al. [31] combining blue dye with ICG achieved a significant increase in the detection rate (87.8% with blue-ICG vs. 76% for blue alone), bilaterality (83.9% with blue-ICG vs. 40% for blue alone; p < 0.001) and detection of lymphatic metastases (21.1% with blue-ICG vs. 13.5% for blue alone; p = 0.056) versus the isolated injection of blue dye. In the study by Jewell et al. [62], lymphatic mapping with ICG detected the SLN in 95% of cases, with bilaterality of 79% and no statistically significant differences versus the combined use with isosulfan blue (detection rate of 93%, p = 0.64; bilaterality of 77%, p = 0.8). Other authors have reached the same conclusion as Jewell: the high effectiveness in the identification with fluorescence is not increased by blue dye. The combination therefore appears unnecessary, which would avoid an increased risk of adverse effects [54].
