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



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.

This is a preview of subscription content, log in to check access.

Fig. 1


  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.

    Article  Google Scholar 

  2. 2.

    Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg. 1994;220:391.

    CAS  Article  Google 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.

    CAS  Article  Google 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.

    Article  Google Scholar 

  5. 5.

    Rao R, Euhus D, Mayo HG, Balch C. Axillary node interventions in breast cancer: a systematic review. JAMA. 2013;310:1385.

    CAS  Article  Google 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.

    CAS  Article  Google 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.

    Article  Google 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.

    Article  Google 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.

    CAS  Article  Google 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.

    Article  Google Scholar 

  11. 11.

    Sharma AR. Nuclear medicine in India: a historical journey. Indian J Nucl Med. 2018;33:S5–10.

    Article  Google 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.

    CAS  Article  Google 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.

    CAS  Article  Google 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.

    Article  Google 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.

    Article  Google 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.

    Article  Google 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.

    Article  Google 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.

    Article  Google 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.

    Article  Google 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.

    Article  Google 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.

    Article  Google 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.

    CAS  Article  Google 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.

    CAS  Article  Google 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.

    CAS  Article  Google 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.

    Article  Google 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.

    Article  PubMed  PubMed Central  Google 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.

    Article  Google 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.

    Article  PubMed  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to C. Rohit Kumar.

Ethics declarations

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.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Somashekhar, S.P., Rohit Kumar, C., Ashwin, K.R. et al. Indocyanine Green (ICG) Fluorescence Imaging in Sentinel Lymph Node Biopsy (SLNB) for Early Breast Cancer: First Indian Experience. Indian J Gynecol Oncolog 17, 31 (2019).

Download citation


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