Indocyanine Green (ICG) Fluorescence Imaging in Sentinel Lymph Node Biopsy (SLNB) for Early Breast Cancer: First Indian Experience

  • S. P. Somashekhar
  • C. Rohit KumarEmail author
  • K. R. Ashwin
  • Sushmita Rakshith
  • Anil Jampani
  • Y. Ramya
Original Article



To explore the utility and safety of indocyanine green (ICG) for the fluorescence-guided detection of sentinel lymph nodes (SLNs) during sentinel lymph node biopsy (SLNB) in patients with early breast cancer.


Patients diagnosed with early breast cancer with clinically negative axilla were involved in the study. ICG dye was injected as per protocol. Sentinel lymph node (SLN) was harvested and axillary clearance was done in all patients irrespective of SLN status. SLN identification rate, sensitivity, specificity, positive predictive value, negative predictive value and false negative rate were calculated.


Forty patients were involved in the study, with most of the patients being in their fifth decade. Median BMI of patient was 24 (range 19–34). SLN was identified in all the patients, total of 110 nodes were detected, with mean being 2.75 (1–6). Seventeen of 40 patients had positive nodes on axilla, of which 16 were detected by SLN and one patient had isolated tumour cells which were detected on final grossing and histopathology report. The sensitivity, specificity, positive predictive value, negative predictive value and false negative rate were 94.1%, 100%, 100%, 95.8% and 5.8%, respectively. None of the patients had any complications with ICG injection.


ICG-based fluorescence technique is easy and safe for SLNB in early breast cancer and is ready for clinical application. A well-designed study comparing the standard dual dye technique with ICG needs to be done to explore if it can replace the existing standard.


Indo-Cyanine green Fluroscence imaging SLNB Early breast cancer Validation Irillic 


Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.


  1. 1.
    Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394–424.CrossRefGoogle Scholar
  2. 2.
    Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg. 1994;220:391.CrossRefGoogle Scholar
  3. 3.
    Krag DN, Weaver DL, Alex JC, Fairbank JT. Surgical resection and radio localization of the sentinel lymph node in breast cancer using a gamma probe. Surg Oncol. 1993;2:335.CrossRefGoogle Scholar
  4. 4.
    Lyman GH, Somerfield MR, Bosserman LD, et al. Sentinel lymph node biopsy for patients with early-stage breast cancer: American society of clinical oncology clinical practice guideline update. J Clin Oncol 2017;35(5):561–564.CrossRefGoogle Scholar
  5. 5.
    Rao R, Euhus D, Mayo HG, Balch C. Axillary node interventions in breast cancer: a systematic review. JAMA. 2013;310:1385.CrossRefGoogle Scholar
  6. 6.
    Somashekhar SP, Shabber SZ, Venkatesh KU, Venkatachala K, Vasan Thirumalai MM. Sentinel lymphnode biopsy in early breast cancer using methylene blue dye and radioactive sulphur colloid: a single institution Indian experience. Indian J Surg. 2008;70:111–9.CrossRefGoogle Scholar
  7. 7.
    Cody HS 3rd, Fey J, Akhurst T, et al. Complementarity of blue dye and isotope in sentinel node localization for breast cancer: univariate and multivariate analysis of 966 procedures. Ann Surg Oncol. 2001;8(1):13–9.CrossRefGoogle Scholar
  8. 8.
    James TA, Coffman AR, Chagpar AB, et al. Troubleshooting sentinel lymph node biopsy in breast cancer surgery. Ann Surg Oncol. 2016;23:3459.CrossRefGoogle Scholar
  9. 9.
    Ang CH, Tan MY, Teo C, Seah DW, Chen JC, Chan MYP, et al. Blue dye is sufficient for sentinel lymph node biopsy in breast cancer. Br J Surg. 2014;101:383–99.CrossRefGoogle Scholar
  10. 10.
    Ahmed M, Purushotham AD, Douek M. Novel techniques for sentinel lymph node biopsy in breast cancer: a systematic review. Lancet Oncol. 2014;15:e351.CrossRefGoogle Scholar
  11. 11.
    Sharma AR. Nuclear medicine in India: a historical journey. Indian J Nucl Med. 2018;33:S5–10.CrossRefGoogle Scholar
  12. 12.
    Krag DN, Anderson SJ, Julian TB, Brown AM, Harlow SP, Ashikaga T, et al. Technical outcomes of sentinel-lymph-node resection and conventional axillary-lymph-node dissection in patients with clinically node-negative breast cancer: results from the NSABP B-32 randomized phase III trial. Lancet Oncol. 2007;8:881–8.CrossRefGoogle Scholar
  13. 13.
    Mansel RE, MacNeill F, Horgan K, et al. Results of a national training programmer in sentinel lymph node biopsy for breast cancer. Br J Surg. 2013;100:654–61.CrossRefGoogle Scholar
  14. 14.
    Sugie T, Kassim KA, Takeuchi M, et al. A novel method for sentinel lymph node biopsy by indocyanine green fluorescence technique in breast cancer. Cancers. 2010;2:713–20.CrossRefGoogle Scholar
  15. 15.
    Qiua Si-Qi, Zhangc Guo-Jun, et al. Evolution in sentinel lymph node biopsy in breast cancer. Crit Rev Oncol Hematol. 2018;123:83–94.CrossRefGoogle Scholar
  16. 16.
    Aoyama K, Kamio T, Ohchi T, Nishizawa M, Kameoka S. Sentinel lymph node biopsy for breast cancer patients using fl uorescence navigation with indocyanine green. World J Surg Oncol. 2011;9:157.CrossRefGoogle Scholar
  17. 17.
    Hirche C, Mohr Z, Kneif S, Murawa D, Hünerbein M. High rate of solitary sentinel node metastases identification by fluorescence guided lymphatic imaging in breast cancer. J Surg Oncol. 2012;105:162–6.CrossRefGoogle Scholar
  18. 18.
    Chi C, Ye J, Ding H, He D, Huang W, Zhang GJ, et al. Use of indocyaninegreen for detecting the sentinel lymph node in breast cancer patients: from preclinical evaluation to clinical validation. PLoS ONE. 2013;8:24–8.Google Scholar
  19. 19.
    Tong M, Guo W, Gao W. Use of fluorescence imaging in combination with patent blue dye versus patent blue dye alone in sentinel lymph node biopsy in breast cancer. J Breast Cancer. 2014;17:250–5.CrossRefGoogle Scholar
  20. 20.
    Chagpar A, Martin RC III, Chao C, Wong SL, Edwards MJ, Tuttle T, McMasters KM. Validation of subareolar and periareolar injection techniques for breast sentinel lymph node biopsy. Arch Surg. 2004;139:614–8.CrossRefGoogle Scholar
  21. 21.
    Noguchi M, Inokuchi M, Zen Y. Complement of peritumonal and subareolar injection in breast cancer sentinel lymph node biopsy. J Surg Oncol. 2009;100:100–5.CrossRefGoogle Scholar
  22. 22.
    Gawlick U, Mone MC, Nelson ED, Hansen HJ, Nelson EW. Success in sentinel lymph node procedures in obese patients with breast cancer. Am J Surg. 2010;200:707–11.CrossRefGoogle Scholar
  23. 23.
    Gioux S, Choi HS, Frangioni JV. Image-guided surgery using invisible near-infrared light: fundamentals of clinical translation. Mol Imaging. 2010;9:237–55.CrossRefGoogle Scholar
  24. 24.
    Obana A, Miki T, Hayashi K, Takeda M, Kawamura A, Mutoh T, et al. Survey of complications of indocyanine green angiography in Japan. Am J Ophthalmol. 1994;118:749–53.CrossRefGoogle Scholar
  25. 25.
    Speich R, Saesseli B, Hoffmann U, Neftel KA, Reichen J. Anaphylactoid reactions after indocyanine-green administration. Ann Intern Med. 1988;109:345–6.CrossRefGoogle Scholar
  26. 26.
    Goyal A, Newcombe RG, Chhabra A, Mansel RE, Group AT. Factors affecting failed localisation and false-negative rates of sentinel node biopsy in breast cancer—results of the ALMANAC validation phase. Breast Cancer Res Treat. 2006;99:203–8.CrossRefGoogle Scholar
  27. 27.
    Zhang X, Li Y, Zhou Y, Mao F, Lin Y, Guan J, et al. Diagnostic performance of indocyanine green-guided sentinel lymph node biopsy in breast cancer: a meta-analysis. PLoS ONE. 2016;11(6):e0155597. Scholar
  28. 28.
    Sorrentino L, Sartani A, Pietropaolo G, Bossi D, Mazzucchelli S, Truffi M, Foschi D, Corsi F. A novel indocyanine green fluorescence-guided video-assisted technique for sentinel node biopsy in breast cancer. World J Surg. 2018;42(9):2815–24.CrossRefGoogle Scholar
  29. 29.
    Senkus E, Kyriakides S, Ohno S, Penault-Llorca F, Poortmans P, Rutgers E, et al. Primary breast cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2015;26:v8–30. Scholar

Copyright information

© Association of Gynecologic Oncologists of India 2019

Authors and Affiliations

  1. 1.Manipal Comprehensive Cancer Center, Department of Surgical OncologyManipal Hospital BangaloreBangaloreIndia
  2. 2.Manipal Comprehensive Cancer Center, Department of PathologyManipal Hospital BangaloreBangaloreIndia

Personalised recommendations