Reinforced across multiple analyses: independent studies using different methods – cost-utility (US$4,044/QALY, 80% probability cost-effective vs methylene blue) and pathway costing – consistently favour ICG once full logistics are accounted for.⁵,⁶
ECONOMIC EVIDENCE Case for ICG in Breast SLN Detection
BEYOND THE TRACER
Beyond clinical performance
The cost of sentinel lymph node detection
Sentinel lymph node biopsy (SLNB) is the standard of care for clinically and radiologically node-negative breast cancer, and its clinical performance is well established. As adoption decisions increasingly involve hospital finance and procurement teams alongside surgeons, a second question has become just as important as detection accuracy: does the tracer used deliver value for the hospital as a whole?
The conventional gold standard, radioisotope technetium-99m (Tc-99m), often combined with blue dye, carries costs that extend well beyond the tracer itself. Dependence on a nuclear medicine department, pre-operative lymphoscintigraphy appointments, radio-pharmacy handling and regulatory compliance, occupational radiation exposure monitoring, and management of blue-dye adverse events all add to the total cost of the care pathway, alongside the burden they place on patients and staff scheduling.
Indocyanine green (ICG) fluorescence imaging removes many of these cost drivers at source. A growing body of published health-economic evidence – including a formal cost analysis, a hospital-based Health Technology Assessment (HB-HTA), and a large noninferiority trial – now quantifies the resulting savings.
THE EVIDENCE
ICG economic evidence at a glance
$474 per-patient
Mean per-patient saving of US$474 (range US$175–$1,241) using ICG-FI vs conventional tracers for SLN detection.¹
18% reduction
Approximately 18% reduction in total care-pathway cost with ICG vs Tc-99m, based on Time-Driven Activity-Based Costing (TDABC).²
5x less expensive
ICG-fluorescence SLNB reported as at least 5 times less expensive than Tc-99m.³
PUBLISHED EVIDENCE
Quantifying the savings
A systematic review and cost analysis
A multidisciplinary team of surgeons, physicians, an epidemiologist/biostatistician and health-economics database specialists conducted a double systematic review of the published literature (PubMed, EMBASE and Scopus) to assess the costs and savings associated with intraoperative ICG fluorescence imaging (ICG-FI), including its use for breast sentinel lymph node detection and, separately, for postmastectomy breast reconstruction.¹
For sentinel lymph node detection, five studies meeting stringent eligibility criteria were identified, covering 1,484 patients undergoing ICG-FI and 1,697 control patients undergoing conventional tracer techniques.¹
Supporting this, the 102-patient INFLUENCE noninferiority trial – comparing ICG-fluorescence directly against Tc-99m within the same patients – reported that ICG is an inexpensive pharmaceutical, that the near-infrared camera can be reused across other surgical indications, and that, unlike Tc-99m, ICG requires no special storage, handling procedures, or legal permits – making SLNB with ICG accessible even in hospitals without a nuclear medicine department.³
| Metric | Result |
|---|---|
| Studies included | 5 studies |
| Patients analysed | 1,484 ICG-FI vs 1,697 control |
| Per-patient saving range | US$175 – US$1,241* |
| Mean per-patient saving | US$474* |
Table 1. Cost analysis of ICG-FI vs conventional tracers for breast SLN detection.¹
The authors concluded that, the use of ICG-FI during breast cancer surgery appreciably lowers costs – both by eliminating the need for Tc-99m and by reducing perfusion- and complication-related costs.¹
* These estimates were derived from studies conducted in different healthcare systems and should be interpreted as evidence of potential savings rather than a universal saving per patient
THE ECONOMIC EVIDENCE
Further published economic evidence
The cost analysis and HB-HTA above are reinforced by a growing set of independent economic evaluations published across different healthcare systems, using different methodologies – cost-utility analysis, prospective pathway costing, and multi-tracer micro-costing. Together, they point to the same underlying conclusion: ICG’s economic value comes primarily from simplifying the care pathway.
| Finding | Detail | |
|---|---|---|
 |
US$4,044 per QALY gained | A 2026 cost-utility analysis comparing ICG with methylene blue estimated an incremental cost- effectiveness ratio of US$4,044 per QALY gained; probabilistic analysis found an 80% likelihood that ICG was the more cost-effective strategy.⁵ |
|
Cost-effective once logistics are priced in | A prospective pathway-costing study estimated total costs of €322.29 for Tc-99m without an on-site nuclear medicine department, €308.29 for Tc-99m with nuclear medicine available and €61.35 for ICG. The findings illustrate the potential economic impact of radioisotope logistics, although local costs and infrastructure will affect transferability.⁶ |
|
Multi-tracer micro-costing | A micro-costing and cost-effectiveness analysis compared Patent Blue, Tc-99m, and ICG for SLNB, calculating direct medical and non-medical costs across approximately 100 procedures – adding institution-level costing data to the tracer cost-effectiveness literature. Absolute costs varied by institution and healthcare setting.⁷ |
|
Lower pre-hospitalisation costs | The HB-HTA synthesised 22 breast-cancer studies (2002–2020) and 19 gynaecologic-cancer studies (2014–2020), finding ICG pre-hospitalisation costs lower than Tc-99m, driven by avoiding the nuclear medicine department for the pre-operative injection; no safety issues or significant reactions to ICG were identified across the reviewed literature.² |
Table 2. Additional published economic evidence for ICG in breast SLN detection.
HOSPITAL-BASED HTA
Value beyond the cost of the dye
Cost-of-tracer comparisons capture only part of the picture. A Hospital-Based Health Technology Assessment (HB-HTA), led by Professor Emanuele Lettieri and colleagues at Politecnico di Milano, evaluated ICG against conventional Tc-99m/blue dye tracers across the full spectrum of hospital delivery – clinical, organisational, economic, ethical and patient-centred outcomes – using real-world data from two Italian hospitals that transitioned from Tc-99m to ICG.²
Adopting ICG simplified the patient pathway by eliminating dependence on nuclear medicine scheduling, avoiding pre-operative lymphoscintigraphy, reducing unnecessary patient movement through the hospital, and improving operating theatre scheduling flexibility.²
Using Time-Driven Activity-Based Costing (TDABC) together with Budget Impact Analysis (BIA), the investigators evaluated the complete patient pathway rather than acquisition cost alone. Replacing Tc-99m with ICG reduced overall pathway costs by approximately 18% per patient, driven largely by elimination of nuclear medicine procedures, removal of pre-operative hospital activity, fewer staff interactions, and simplified patient flow.²
Patients benefited from fewer pre-operative appointments, less time spent in hospital, avoidance of radioactive tracers, and a simpler overall treatment pathway – outcomes increasingly recognised by HTA agencies as important contributors to healthcare value alongside traditional clinical endpoints.²
These findings were first presented at the ISPOR Europe 2023 meeting and subsequently published as a peer-reviewed multidisciplinary evaluation in PLOS ONE (2024), reinforcing a principle increasingly recognised within HTA: technologies that simplify care pathways can generate meaningful savings even when device acquisition costs appear similar.²,⁴
PREPARATION & WORKFLOW
Presentation format matters: vial versus glass ampoule
The economic assessment of a tracer should consider not only its acquisition cost, but also its presentation and the preparation steps required before administration.
Verdye is supplied as a lyophilised powder in a stoppered vial. The vial is accessed through its rubber stopper and does not require glass to be snapped open. By comparison, some conventional tracers used in sentinel lymph-node procedures-including certain Patent Blue V presentations-are supplied in glass ampoules.⁸
Opening a glass ampoule creates an open container and carries a recognised risk of microscopic glass particles entering the solution. Published medication-safety literature has therefore examined the use of filter needles or filter straws when withdrawing injectable medicines from ampoules. Local policies vary, but filtering can add a preparation step and an additional consumable.9-11 Breaking an ampoule can also create a risk of cuts or sharps injury for healthcare professionals.
These differences can affect preparation time, consumable use and staff workflow when repeated across a high-volume surgical service. Their economic significance should be assessed according to local protocols and product presentations.
| Preparation Consideration | ICG Vial | Glass Ampoule |
|---|---|---|
| Accessing the container | Rubber stopper is punctured | Glass neck is snapped open |
| Breaking glass required | No | No |
| Glass particles created by opening | Not applicable | Recognised risk in published literature9-11 |
| Filter needle or straw | Not required to address glass created when opening the container | May be recommended under local medication-preparation policy |
| Staff handling | No broken ampoule neck | Appropriate precautions are required when opening and disposing of broken glass |
| Potential workflow effect | Standard vial reconstitution and withdrawal | Opening, possible filtration and glass disposal may add preparation steps |
Table 3. Vial vs glass ampoule: safety and workflow comparison.8,9,10,11
WHY SURGEONS ARE SWITCHING
Significant economic benefits of using ICG
Lower per-patient cost: mean saving of US$474 (range US$175–$1,241) versus conventional tracers for SLN detection.¹
Simplified care pathway: ~18% reduction in total pathway cost by removing pre-operative lymphoscintigraphy and reducing hospitalisation.²
Reduced resource utilisation: fewer staff interactions and less dependence on nuclear medicine infrastructure.²
Improved theatre efficiency: greater flexibility in surgical scheduling, no requirement to coordinate with nuclear medicine.²
Avoided complication costs: reduced costs associated with managing blue-dye adverse events and radiopharmaceutical handling/regulatory compliance.¹
Improved patient experience: fewer pre-operative appointments and less time in hospital, recognised by HTA agencies as a contributor to healthcare value.²
Broader hospital access: no special storage, handling, or legal permits required, unlike Tc-99m – making ICG-based SLNB feasible even without an on-site nuclear medicine department.³
Safer, more flexible preparation: a vial’s septum can be re-accessed for a further draw if re-injection is needed for the same patient, without breaking open a new container, avoiding the glass-particulate and sharps risks associated with ampoules.⁸
THE BOTTOM LINE
Summary
Together, the published evidence indicates that ICG-based SLN detection can be economically attractive, particularly where it reduces dependence on nuclear medicine, removes separate pre-operative activity and simplifies patient flow. The scale of benefit will depend on the comparator, existing hospital infrastructure, procedure volume and utilisation of the fluorescence imaging platform.
REFERENCES
1. Goldhawk-White P, White KP, Doeksen A, McGoldrick C, Neligan PC, Newman MI, Pitsinis V, Schols RM. Fluorescence imaging with indocyanine green during breast cancer surgery and postmastectomy breast reconstruction: A double systematic review and cost analysis. Surgery. 2026 Apr 1;192:110052. 10.1016/j.surg.2025.110052
2. Pinelli M, Gerardi C, Lettieri E, Maioru M, Marone L, Bertoldi L, et al. Comparison of Indocyanine Green with conventional tracers for sentinel lymph node biopsy in breast cancer: A multidisciplinary evaluation of clinical effectiveness, safety, organizational and economic impact. PLOS ONE. 2024;19(8):e0309336.
3. Bargon CA, Huibers A, Young-Afat DA, Jansen BAM, Borel-Rinkes IHM, Lavalaye J, et al. Sentinel Lymph Node Mapping in Breast Cancer Patients Through Fluorescent Imaging Using Indocyanine Green: The INFLUENCE Trial. Ann Surg. 2022;276(5):913–920.
4. Lettieri E, Sosa M, Tariq L, et al. Hospital-Based Health Technology Assessment of Near-Infrared Fluorescence Using Indocyanine Green for Sentinel Lymph Node Mapping for Breast Cancer and Gynecologic Cancer. Value in Health (ISPOR Europe Abstract). 2023;26(11 Suppl):S2.
5. Lee SH, Kohler A, Tingen J, King CA, et al. Cost-Utility Analysis of Indocyanine Green Versus Methylene Blue for Sentinel Lymph Node Biopsy in Breast Cancer. J Surg Oncol. 2026;134(1):41–53. 10.1002/jso.70278
6. Borisova Boyanova IM, Blay Aulina L, de la Iglésia M, López-Cano D, Serra-Serra C, Ruiz-Edo N, Salcedo-Pujantell M, Ibañéz JJ, López Gordo S, et al. Cost Analysis of Technetium-99m versus Indocyanine Green for Sentinel Lymph Node Biopsy in Breast Cancer. Clin Breast Cancer. 2026 Feb;26(2):50–58. 10.1016/j.clbc.2025.12.005
7. Denardi D, Oliveira-Junior ID, Ferigatto JL, Buexm LA, Pereira AC, Vazquez FL. Cost-effectiveness analysis of different tracers (Patent Blue, Technetium-99m, and Indocyanine Green) for Sentinel Lymph Node Biopsy procedure in breast cancer. Cost Eff Resour Alloc. 2026;24:11.
8. Patent Blue V Sodium Guerbet 2.5%, solution for injection. Product information. Supplied in a 2 mL Type I colourless glass ampoule.
8. Kalemci S, et al. Particulate matter contamination from glass ampoules and vials in intravenous therapy. J Surg Med. 2021.
9. Sabon RL, et al. Glass particle contamination: influence of aspiration methods and filter needles. Am J Hosp Pharm. 1989.
10. Preston ST, et al. Particulate contamination from ampoules. Anaesthesia. 1985.
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