Prospective Comparison of Near-Infrared I and II Fluorescence Imaging for Intraoperative Navigation in Pediatric Hepatoblastoma Resection.
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BACKGROUND: Complete resection is critical for cure in hepatoblastoma (HB), but small, superficial, or deep lesions may be missed by conventional intraoperative assessment or near-infrared window I (NIR-I) fluorescence imaging. We prospectively evaluated the feasibility and comparative performance of indocyanine green (ICG)-based near-infrared window II (NIR-II) fluorescence imaging during pediatric hepatoblastoma resection. METHODS: Fourteen children with HB were prospectively enrolled. All patients received preoperative ICG administration and underwent intraoperative paired NIR-I and NIR-II fluorescence imaging using a self-developed multispectral imaging system. In vivo and ex vivo fluorescence findings were correlated with histopathology. In vivo tumor-to-normal ratio (TNR), ex vivo tumor-to-background ratio (TBR), and lesion detection performance were compared between the two modalities. RESULTS: NIR-II imaging showed higher intraoperative TNR than NIR-I imaging (10.11 ± 3.48 vs 6.49 ± 3.48, P < 0.05) and higher ex vivo TBR (16.05 ± 8.43 vs 9.88 ± 5.35, P < 0.05). In specimen-based analysis, NIR-II showed higher sensitivity (88.9% vs 77.8%) and accuracy (84.4% vs 80.0%) than NIR-I imaging. NIR-II also identified additional satellite or metastatic lesions not clearly visualized by NIR-I imaging in representative cases and improved localization of deeply located tumors. CONCLUSION: ICG-based NIR-II fluorescence imaging is feasible in pediatric HB surgery and may provide incremental intraoperative visualization compared with NIR-I imaging, particularly for selected small, deep, or weakly fluorescent lesions. These preliminary findings support the complementary role of NIR-II imaging in intraoperative decision-making but require validation in larger studies with standardized follow-up. LEVEL OF EVIDENCE: Level III.