# Fluorescence-Guided Surgery in Pediatric Oncology: Current Practice and Future Directions

## TL;DR

Fluorescence-guided surgery helps surgeons see tumors and vital structures during operations, potentially improving precision in pediatric cancer surgery.

## Contribution

This review highlights the unique challenges and current evidence for fluorescence-guided surgery in pediatric oncology and proposes strategies for clinical translation.

## Key findings

- Indocyanine green aids in lymph node mapping and visualization of vascular structures in pediatric surgeries.
- Non-specific imaging agents like ICG lack histopathological validation, limiting their diagnostic precision for tumors.
- Tissue-specific agents are being tested in first-in-human trials to improve imaging accuracy for nerves and ureters.

## Abstract

Surgical removal of tumors in children is often difficult because their tumors can grow into nearby healthy tissues and lie close to vital structures. Surgeons must balance removing as much tumor as possible while preserving healthy anatomy. Fluorescence-guided surgery is an emerging technique that uses (non-)specific imaging agents and imaging systems to visualize tumors, blood flow, and vital structures during an operation, potentially improving surgical precision. Although this approach has been widely studied in adults, its use in pediatric oncology is still limited. This review outlines current evidence on how fluorescence guidance is being applied in children, including its benefits and limitations, and discusses the unique challenges of developing more specific imaging agents for pediatric tumors. It also explores strategies to advance this technology toward routine clinical use. If these efforts are successful, fluorescence-guided surgery may enhance surgical accuracy, reduce recurrence risk, and improve long-term outcomes for children with cancer.

Background/Objectives: Achieving complete, yet safe tumor resections are particularly challenging in pediatric oncology due to infiltrative tumor growth patterns, small patient size, and the close proximity to critical structures. Fluorescence-guided surgery (FGS) enhances visualization of anatomy, tissue perfusion, and tumor tissue in real time, potentially improving surgical precision. While widely explored in adults, its application in pediatric oncology remains limited. This review summarizes current evidence on FGS in pediatric oncology, with emphasis on the unique challenges inherent to this field. Finally, strategies to accelerate clinical translation and assess the potential clinical value are proposed. Methods: A narrative review of the literature was conducted using PubMed and Embase to identify English-language publications on FGS in pediatric oncology up to September 2025. Search terms included Fluorescence, Pediatrics, Neoplasms, and Surgery. Results: Studies commonly reported that indocyanine green (ICG) aids in lymph node mapping, hepatoblastoma resection, and visualization of vascular structures and tissue perfusion. However, its non-specific nature and lack of histopathological validation limits diagnostic precision in tumor imaging. Tissue-specific agents are being investigated in first-in-humans trials to improve sensitivity and specificity, and to identify ureters and nerves. Conclusions: In this review, the challenging roadmap for advancing FGS in pediatric oncology is presented. Closing current gaps will require coordinated efforts in target discovery, agent design, and clinical validation. If successful, FGS can evolve from a promising tool into an indispensable clinical technique that enhances surgical precision, reduces recurrence, and ultimately improves long-term outcomes for children with cancer.