Breast surgery visitors from Carlisle & Whitehaven: A New Technique

Andrew Pieri Breast Surgery Carlisle learning how to use ICG sentinel node biopsy

It was our pleasure to host some of the breast surgery team from Carlisle & Whitehaven Hospitals. Our Cumbrian neighbours came to observe Mr Pieri performing a new method of sentinel lymph node detection.

For breast surgery in Newcastle, Mr Pieri has introduced an improved method of performing “dual localisation” sentinel lymph node biopsy surgery, utilising state-of-the-art technology made by a medical device company called Stryker. Their device is called the Spy-PHI (Spy Portable Handheld Imaging) System. 

What is a Sentinel Lymph Node Biopsy?
A Sentinel Lymph Node Biopsy is the most commonly performed axilla procedure in breast cancer patients in the UK. In the majority of patients with a new diagnosis of breast cancer, the ultrasound scan of their axilla is normal, suggesting that there is no clear evidence of cancer in the lymph nodes.

However, the ultrasound is not always a reliable test for confirming cancer spread to lymph nodes. In a sentinel lymph node biopsy procedure, the surgeon uses a radioactive and/or blue coloured dye to highlight the nodes that cancer would theoretically spread to first. These lymph nodes (usually 2-4 nodes) are surgically removed via a small incision under the arm. They are then sent off to the lab for analysis to confirm whether there is any evidence of cancer spread to the lymph nodes.

breast surgery newcastle - Sentinel node biopsy with ICG
Stryker SPY-PHI ICG SLNB Newcastle
So how does Stryker SPY-PHI work with ICG?

Traditionally, a blue dye is injected into the patient’s breast in order to perform a “dual localisation” sentinel lymph node biopsy procedure. There are a number of drawbacks to using blue dye. Firstly, it stains the skin on the breast, leaving a blue semi-permanent tattoo. This can take up to a year to fade. More significantly, although very uncommon patients can be allergic to the blue dye and anaphylactic reactions have led to fatalities in the past. Blue dye is also not as good  at clearly highlighting the sentinel nodes compared to other described methods i.e. technesium99m (Tc99m) or ICG. 

With the Stryker system, blue dye is not used at all. Instead, a substance called ICG (indocyanine green) is injected. ICG has a much better safety profile and does not cause staining like blue dye. 

The SPY-PHI system (pictured above) emits a near ultraviolet light which causes the ICG in the patient to fluoresce. This fluorescence is then detected by the SPY-PHI device and transmitted to the screen. The surgeon can then clearly see the ICG moving in the lymphatic system in the breast, towards the lymph nodes. When an incision is made in the armpit, the ICG causes the sentinel nodes to fluoresce, indicating to the surgeon which nodes should be removed for lab assessment.

The video shows fluorescing ICG travelling in the lymphatic system in the right breast, from the injection site next to the nipple, towards the axilla (armpit)

Andrew Pieri breast surgery carlisle

Left to right: Becky Moore (Advanced Clinical Practitioner), Ellen Newlands (Breast Theatre Team Lead), Anna Cahill (Advanced Clinical Practitioner), Andrew Pieri (Breast Surgeon Newcastle), Jane Ralph (Breast Surgeon Carlisle)

We very much enjoyed having the Cumbrian breast surgery team over to observe and discuss this exciting new sentinel lymph node biopsy technique. We hope you have success with implementing it at your institutions!


For further information about this sentinel lymph node biopsy technique and whether it is suitable for you, contact us


For more information on the SPY-PHI system, click here


To see a meta-analysis comparing the efficacy and risk profiles of Tc99m, blue dye and ICG, click here 


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