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

Cancers, vol. 18, pp. 149

Abstract

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.

Authors 7

1. Dominique C. Simons

   Princess Máxima Center

   Affiliation as printed

   Princess Maxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands

2. Lia Schalkwijk

   Princess Máxima Center

   Affiliation as printed

   Princess Maxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands

3. Michiel A. J. van de Sande Aachen Department of Orthopedic Surgery

   Leiden University Medical Center · Princess Máxima Center

   Affiliation as printed

   Department of Orthopedic Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands

   Princess Maxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands

4. Alexander L. Vahrmeijer Aachen Department of Surgery, Leiden University Medical Center

   Leiden University Medical Center

   Affiliation as printed

   Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands

5. Marc H. W. A. Wijnen

   Princess Máxima Center

   Affiliation as printed

   Princess Maxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands

6. Alida F. W. van der Steeg

   Princess Máxima Center

   Affiliation as printed

   Princess Maxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands

7. Willemieke S. F. J. Tummers Aachen Department of Surgery, Leiden University Medical Center

   Leiden University Medical Center · Princess Máxima Center

   Affiliation as printed

   Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands

   Princess Maxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands