Fluorescence imaging in pediatric surgery: State-of-the-art and future perspectives

Abstract

The employment of fluorescence imaging has gained popularity in many fields of adult surgery, such as organ perfusion assessment, intra-operative solid tumor identification and sentinel lymph node mapping. In this respect, it has demonstrated great potential to improve both surgical and oncological outcomes while minimizing anesthetic time and lowering health-care costs.However, the clinical application of Fluorescence-Guided Surgery (FGS) in pediatrics is just at the initial phase.Review of published literature indicates a paucity of clinical studies evaluating FGS in pediatric surgery but huge scope for preclinical investigation and new clinical studies. Great emphasis has been given to the clinical application of FGS for surgical resection of hepatoblastoma and its metastasis and for real-time imaging of the biliary tree. Other current uses of fluorescent imaging in children concern the assessment of blood perfusion and lymphatic flow with the aim to prevent iatrogenic injuries during intestinal and urogenital surgeries. While new and more specific probes are under development, the only fluorescent dyes safely employed in children are currently indocyanine green and fluorescein sodium. Advantages, limitations and potential future development of FGS in pediatrics are systematically discussed and analyzed.

The Use of Indocyanine Green Fluorescence Angiography in Pediatric Surgery: A Systematic Review and Narrative Analysis

“…After Lau and al. 's first overview of ICG applications in Pediatric Surgery in 2009, two other reviews have been published ( 74 , 77 , 88 ). Goldstein et al ( 77 ) focused on the evolving applications in surgical oncology which still seem experimental, but promising for delineating tumor margins, localizing metastases, protecting important structures around the tumor, and assisting reconstruction.…”

“…Goldstein et al ( 77 ) focused on the evolving applications in surgical oncology which still seem experimental, but promising for delineating tumor margins, localizing metastases, protecting important structures around the tumor, and assisting reconstruction. Paraboschi et al ( 88 ) have published a systematic review including 21 studies on fluorescein sodium and indocyanine green imaging in pediatric surgery. Compared to our study, they included fluorescence imaging studies at large, excluded neurosurgical, vascular, ENT, and orthopedic articles, and their last search was in January 2020.…”

Above and Beyond Robotic Surgery and 3D Modelling in Paediatric Cancer Surgery

“…Imaging systems are often calibrated around the excitation and emission spectrum of indocyanine green (ICG), widely applied in surgery. In the paediatric field, ICG has been used safely and efficiently to delineate the biliary flow during laparoscopic cholecystectomies, assess bowel perfusion in neonates with necrotising enterocolitis, map arteries during urogenital surgeries and reconstruct the microvascularity in plastic surgery ( 34 , 35 ). However, it is mainly in the oncological field that FGS has been emerging as a cutting-edge innovation.…”

“…The live visualisation of the 3D tumour anatomy can facilitate the differentiation between the tumour and the normal tissue and lead to more radical tumour resections with improved surgical outcomes ( 34 , 35 ). ICG-optical imaging has been adopted for the surgical treatment of several paediatric cancers, including hepatoblastomas, osteosarcomas, non-rhabdomyosarcomas, rhabdomyosarcomas, neuroblastomas, Ewing sarcoma, germ cells tumours, chondroblastoma, solid pseudopapillary neoplasms of the pancreas, lymphoma, and myoepithelial carcinoma ( 34 , 35 ). Although ICG navigation imaging for paediatric hepatoblastomas is at its initial stages, early results seemed to be very promising ( 34 – 39 ).…”

“…ICG-optical imaging has been adopted for the surgical treatment of several paediatric cancers, including hepatoblastomas, osteosarcomas, non-rhabdomyosarcomas, rhabdomyosarcomas, neuroblastomas, Ewing sarcoma, germ cells tumours, chondroblastoma, solid pseudopapillary neoplasms of the pancreas, lymphoma, and myoepithelial carcinoma ( 34 , 35 ). Although ICG navigation imaging for paediatric hepatoblastomas is at its initial stages, early results seemed to be very promising ( 34 – 39 ). In particular, ICG-angiography has been very helpful to detect the primary tumour and its peritoneal and lung metastases ( 36 , 36 – 39 ).…”