Complementary Value of CEUS-Guided Hookwire Localization Combined with Methylene Blue Staining for Sentinel Lymph Node Detection, and the Predictive Role of Imaging Grade for Nodal Metastasis: A Single-Arm Clinical Study

Why It Matters

Integrating CEUS hookwire localization with methylene blue staining enhances SLN detection reliability and offers a non‑invasive imaging marker to predict nodal metastasis, potentially refining surgical planning and reducing missed disease.

Key Takeaways

• CEUS hookwire + methylene blue yields 96% SLN detection.
• Each method alone identifies ~90% of patients, showing complementarity.
• CEUS grade III predicts 100% SLN metastasis.
• Grade II shows 15% positivity, grade I under 2%.
• Combined approach may reduce missed metastases in surgery.

Pulse Analysis

Sentinel lymph node biopsy remains a cornerstone for accurate cancer staging, yet reliance on a single detection method—whether dye, radiotracer, or imaging—can leave surgeons vulnerable to false negatives. Contrast‑enhanced ultrasound (CEUS) has emerged as a dynamic, real‑time modality that visualizes lymphatic channels and nodal architecture without ionizing radiation. When paired with the traditional methylene blue stain, which provides direct visual confirmation during surgery, clinicians gain both pre‑operative mapping and intra‑operative verification, bridging the gap between imaging and pathology.

The recent single‑arm trial involving 76 patients demonstrated that CEUS‑guided hookwire localization identified sentinel nodes in 93.42% of cases, while methylene blue staining succeeded in 90.79%. Together, they achieved a 96.05% overall detection rate, underscoring their complementary nature. Notably, the study linked CEUS imaging grades to metastatic risk: grade I nodes showed a 1.82% positivity rate, grade II rose to 15%, and grade III reached 100%. This stratification equips surgeons with predictive insight before incision, allowing targeted excision of high‑risk nodes and potentially sparing patients from extensive lymphadenectomy.

For surgical oncology teams, the combined CEUS‑hookwire and methylene blue protocol offers a pragmatic pathway to improve nodal staging precision while minimizing operative time and morbidity. As hospitals adopt portable ultrasound platforms, the barrier to implementation lowers, making the technique scalable across institutions. Future research should explore integration with radiotracer methods and assess long‑term outcomes such as recurrence rates and cost‑effectiveness, positioning CEUS as a pivotal tool in the evolving landscape of minimally invasive cancer surgery.