A Review of Fluorophores for Fluorescence-Guided Surgery in Breast Cancer

Imprecision in breast-conserving surgery results in re-excision in 20% of cases, delaying adjuvant therapy and increasing patient anxiety and financial burden. Fluorescence-guided surgery (FGS) enables real-time tumor visualization and may improve surgical precision. This systematic review evaluates fluorophores investigated for intraoperative navigation in breast cancer. Medline, Embase, Scopus, and Web of Science were searched using "breast cancer," "surgery," "fluorophore," and "near-infrared." Eligible studies investigated in vivo fluorophores for invasive breast cancer in animals or humans. Of 1946 studies, 65 met the inclusion criteria. Extracted data included fluorophore administration, mechanism, optical properties, imaging systems, safety, and diagnostic accuracy. Dual-modality studies were excluded. 58 fluorophores were evaluated across 761 human and 520 animal subjects. Most agents emitted within the near-infrared-I (NIR-I) window (74.1%), while 11 utilized NIR-II imaging for deeper penetration. Indocyanine green (ICG) was the most widely studied fluorophore, demonstrating a pooled clinical tumor-to-background ratio (TBR) of 2.25 ± 0.74 (95% CI 2.10-2.39); sensitivity 80.8% (95% CI 72.5-89.2%); specificity 93.3% (95% CI 88.1-98.6%). IRDye800CW-trastuzumab demonstrated higher pooled TBRs of 4.83 ± 1.77 (95% CI 4.27-5.40). Nanoparticle-based fluorophores showed high contrast but remained preclinical. FGS is rapidly evolving, but no fluorophore has demonstrated optimal performance across translational endpoints; standardized reporting remains essential.