2025 Pediatric Surgery Update Course - Updates in Oncology

ICG (indocyanine green) is excreted through the liver, so liver tumor cells that don't excrete ICG well will retain the dye and appear fluorescent during surgery.

Pafolacianine (Cytalux) is an FDA-approved targeted fluorescence molecule used in adult cancer patients that binds folate to a fluorescent marker, exploiting the high folate receptor expression in rapidly dividing cancer cells.

Dinutuximab is a monoclonal antibody used in neuroblastoma that can be conjugated with fluorescent markers for intraoperative tumor visualization.

Two ongoing pediatric studies are evaluating pafolacianine safety: one at Lurie Children's Hospital for metastatic patients and one at Mayo Clinic for all solid tumors.

Pafolacianine is currently used off-label at Cleveland Clinic specifically for patients with desmoplastic small round cell tumors.

Pediatric solid tumors have really high folate receptor expression, making them candidates for pafolacianine-based fluorescence-guided surgery.

Subcutaneous tumors do not highlight well with ICG, which is a known limitation of non-targeted fluorescence.

Current near-infrared fluorescence imaging only allows visualization of superficial tumors (approximately one centimeter depth), but newer molecules in development will allow deeper tissue penetration.

The renal tumor biology study (Renal PEC) allows enrollment as soon as a renal mass is identified, before surgery or pathology confirmation, and provides rapid central review for risk assessment.

The COG renal tumor trial AREN2231 requires at least one lymph node for enrollment, though ideally five to seven lymph nodes should be sampled based on retrospective data.

The modified very-low-risk group in AREN2231 includes stage I patients less than four years old (expanded from previous age two cutoff) regardless of tumor size, without adverse biomarkers (LOH 1p/16q, 1q gain, or LOH 11p15), with epithelial predominant Wilms tumor.

The aim of the modified very-low-risk arm is to demonstrate that patients can be treated effectively with nephrectomy only and avoid chemotherapy.

Patients in the modified very-low-risk group must have upfront total nephrectomy without tumor spill; partial nephrectomies are not eligible for this arm.

For right-sided renal tumors, lymph nodes should be sampled from hilar, paracaval, and aortic-caval regions, not including periportal, iliac, or mesenteric nodes.

ICG can be used for partial nephrectomy planning by creating inverse fluorescence where normal kidney lights up and tumor does not, helping identify margins.

ICG injection for lymph node identification in renal tumors requires injection in the perihilar region but often results in dye oozing out, making everything appear green and limiting utility.

Central venous access placement should be delayed in patients under age four without obvious rupture, tumor spill, or stage IV disease, as approximately 50-70% more patients may avoid chemotherapy under the new protocol.

Intraoperative frozen section of suspicious lymph nodes can guide the decision to place a central line at the time of surgery and avoid a subsequent anesthetic.

Patients with negative biomarkers (LOH 1p/16q, 1q gain, or LOH 11p15) have been shown to have increased risk of recurrence and are excluded from the modified very-low-risk group.