Safety and surgical outcomes of sodium fluorescein-guided pediatric brain tumor surgery: a retrospective before-and-after single-center cohort study.

Abstract

Purpose: Sodium fluorescein (SF) used with a YELLOW 560-nm filter may improve intraoperative visualization of contrast-enhancing brain tumors, but pediatric evidence remains limited. We assessed the feasibility, safety, and surgical outcomes of SF-guided resection in a single-center pediatric cohort.

Methods: We retrospectively analyzed pediatric brain tumor resections performed between 2015 and 2023 using a before-and-after design based on the institutional introduction of SF. SF-guided procedures were compared with historical white-light controls. Inclusion required a contrast-enhancing intracranial tumor considered amenable to gross total resection (GTR). SF was administered intravenously at 2 mg/kg. The primary endpoint was radiographically confirmed GTR within 72 h; operative duration, postoperative course, complications, and follow-up outcomes were secondary exploratory endpoints. Exploratory multivariable logistic regression for GTR included SF use, age, sex, and supra- vs. infratentorial location. Operative duration was compared using a two-sided Mann-Whitney U-test.

Results: Among 60 procedures in 50 patients, 32 were performed with SF and 28 without SF. GTR was achieved in 93.8% of SF-guided and 71.4% of non-SF procedures (absolute difference, 22.4 percentage points; Fisher's exact p = 0.035). In exploratory multivariable analysis, SF use was associated with GTR (adjusted odds ratio 5.890, 95% confidence interval 1.091-31.080; p = 0.039). In an unadjusted exploratory analysis, operative duration was lower with SF [median 191.5 min (IQR 148.25-264.25) vs. 249.5 min (IQR 184.00-306.75); U = 303, p = 0.032]. No SF-related adverse reactions occurred. Fluorescence was documented in 20/32 SF-guided procedures and was positive in 17/20 of those cases.

Conclusion: Low-dose SF was safe and feasible and was associated with higher GTR rates and lower operative duration. However, the historical-control design, limited number of non-GTR outcomes, heterogeneous tumors, baseline differences, unequal follow-up, and residual confounding preclude causal or long-term oncological conclusions. Prospective validation is required.