Nodal status is a major prognostic factor in breast cancer and defines the surgical and oncological care. In invasive breast cancer with clinically negative axillary lymph nodes or in high risk carcinoma in situ, sentinel lymph node (SLN) procedure has replaced axillary lymphadenectomy [1,2]. It allows to reliably determine nodal status without lymphadenectomy related morbidity [3].

Different techniques are used to locate the SLN. The standard procedure comprises the combination of radioisotope, usually 99m Technetium (99mTc), and blue dye [4]. However, the use of a radiotracer induces several constraints. Indeed, it requires a nuclear physician, not available in all hospitals, and the time window of the tracer is short. Moreover, radiotracers do not provide real time visual information. The other option, blue dye is easy to use and gives visual but limited information as lymphatic vessels cannot be seen through skin and fatty tissues. Besides, blue can contaminate the surgical field and skin tattoos can be seen for several months [5]. Above all, it can be responsible for allergic reactions, particularly with patent blue [6].

These limits led to the development of other tracers, particularly Indocyanine Green (ICG) which has been used in alternative or in addition to conventional mapping since 2005 [7]. ICG is a fluorescent contrast agent that can be detected by near-infrared (NIR) fluorescence imaging systems. This agent, injected around the areola, retroareolarly or peritumorally, travels to the axilla within a few minutes [8]. Fluorescence detection range from millimetre to centimetre, which allows to follow the migration of ICG in superficial lymphatic channels through the skin up to the SLN in real time with NIR camera [9]. Safety profile of this component, which is rapidly eliminated into the bile, is proven [10].

Several meta-analyses have documented ICG breast cancer SLN detection rate, which is significantly higher than blue dye [11], [12], [13]. Regarding 99mTc, similar detection rates have been reported [11], [12], [13], [14] with a trend towards a non-significant ICG superiority [15,16]. An isolated study comparing ICG to the standard 99mTc-blue dye confirmed this trend [17].

Despite its potential superiority, ICG has only been approved in breast cancer SLN identification in Japan, Germany and China. In August 2021 in France, the Agence Française de sécurité sanitaire des produits de santé (French Agency for the Safety of Health Products ANSM) approved the therapeutic indication for Infracyanin™ (SERB) for the intraoperative identification of the sentinel node and visualization of the lymphatic pathways in early breast cancer. To the best of our knowledge, this is the first marketing authorization in Europe.

Following the recent drug approval of Infracyanin© in this indication, we aimed to draw up an inventory of the use of this technique on the French territory and to collect the opinion of French breast surgeons on this topic through a web-based survey.