Fluorescence imaging with indocyanine green during breast cancer surgery and postmastectomy breast reconstruction: A double systematic review and cost analysis

Background: Level I evidence argues that indocyanine green fluorescence imaging, used alone, is either noninferior or superior to current gold standards of technetium Tc 99m ± blue dye for detecting sentinel lymph nodes during breast cancer surgery. Extensive literature also shows that perfusion assessments using indocyanine green fluorescence angiography reduce the rates of perfusion-related complications, including flap necrosis and necessary reoperations during breast reconstruction after mastectomy. Our objective was to examine the relative costs of using indocyanine green fluorescence imaging for breast cancer resection and breast reconstruction. Methods: A multidisciplinary team performed an extensive review of published literature spanning PubMed, EMBASE, and Scopus. Cost analysis was conducted for studies meeting stringent eligibility criteria that included the need for detailed data on both variable and fixed costs, both of the procedures and potential complications. Study quality was assessed using the modified Downs and Black Quality Assessment tool. Results: Overall, 2,095 and 993 abstracts were screened for sentinel lymph node detection and postmastectomy breast reconstruction, respectively, leading to 5 studies with 1,484 indocyanine green fluorescence imaging patients and 1,697 control patients for sentinel lymph node detection and 5 studies with 1,446 indocyanine green fluorescence angiography patients and 1,339 control patients for breast reconstruction. For sentinel lymph node detection, per-patient savings using indocyanine green fluorescence imaging ranged from US $175 to US $1,241 (mean = US $474). For breast reconstruction, per-patient costs of indocyanine green fluorescence angiography ranged from a mean US $3 loss to US $1,160 savings (mean = US $553 saved). Conclusion: Although further studies remain necessary, using indocyanine green fluorescence imaging during breast cancer surgery and breast reconstruction appears to appreciably lower costs, both by eliminating the need for technetium Tc 99m and by reducing perfusion-related complications.