Role of 5-Aminolevulinic Acids in Brain Tumor Surgeries in Pediatrics: A Systematic Review of Case Reports and Series

Pediatric brain tumors remain a leading cause of cancer-related mortality in children, and achieving complete tumor resection is critical for improving survival and neurological outcomes. Fluorescence-guided surgery using 5-aminolevulinic acid (5-ALA) has emerged as a promising adjunct to enhance intraoperative visualization of tumor margins and improve surgical precision in pediatric patients. This systematic review evaluates the safety and efficacy of 5-ALA-guided surgery in pediatric brain tumors, with emphasis on fluorescence visibility, extent of resection, surgical morbidity, and oncological outcomes. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive literature search was conducted across PubMed, Embase, Medline, and Web of Science, identifying 19 studies reporting pediatric cases undergoing 5-ALA-assisted tumor resection. Data regarding patient demographics, tumor characteristics, surgical outcomes, recurrence rates, and complications were extracted and analyzed. A total of 282 pediatric patients with a mean age of 13 years were included, with glioblastomas, medulloblastomas, astrocytomas, and ependymomas being the most common tumor types. Intraoperative fluorescence was observed in 72% of cases, contributing to improved tumor delineation and facilitating more complete resections. Gross total resection was achieved in 77% of patients, of whom 85% demonstrated no tumor recurrence during follow-up periods ranging from three months to five years. Surgical complications occurred in approximately 10% of cases and were predominantly transient neurological deficits. Tumor recurrence was reported in 8% of patients, while overall mortality was 5%, largely associated with aggressive tumor subtypes. Overall, 5-ALA was well tolerated with minimal adverse effects. These findings suggest that 5-ALA fluorescence-guided surgery is a safe and effective adjunct in pediatric brain tumor surgery, enhancing tumor visualization and the extent of resection. Further prospective studies are warranted to establish pediatric-specific protocols and to optimize long-term surgical and oncological outcomes in this vulnerable population.