Utilization of Indocyanine Green for Augmentation of Pulmonary Metastases Resection in Pediatric, Adolescent, and Young Adult Sarcoma Patients

BACKGROUND: Complete pulmonary metastasectomy is central to curative-intent therapy for sarcoma, but lesion localization can be challenging. Indocyanine green (ICG) near-infrared fluorescence offers real-time intraoperative guidance, though data in pediatric and adolescent/young adult sarcoma patients are limited. METHODS: A retrospective review of patients with metastatic sarcoma who underwent pulmonary metastasectomy was performed. Patients were dosed preoperative ICG (dose: 4 mg/kg, 24 h before surgery) between April 2019 and November 2022. Demographics, tumor histology, operative details, lesion characteristics, and ICG status were analyzed. Sensitivity, positive predictive value (PPV), and the proportion of lesions identified solely by ICG were calculated. RESULTS: Thirty-one patients aged 6-42 years underwent 51 pulmonary metastasectomies. Overall sensitivity of ICG for detecting metastatic lesions was 81.0% with a PPV of 39.0%. ICG identified 17.0% of metastases not palpable or visible on inspection. Patients with prior lung radiation demonstrated lower sensitivity at 64.0% than the overall cohort. No adverse reactions to ICG were observed. CONCLUSION: ICG fluorescence imaging is a safe adjunct to pulmonary metastasectomy in pediatric, adolescent, and young adult sarcoma patients. It facilitates more complete resection by identifying additional lesions not detected with standard techniques without significant adverse effects. These findings support use of ICG as a complement to meticulous surgical exploration. Further multicenter studies are needed to assess its impact on oncologic outcomes.