| Sumario: | Simple Summary: Soft tissue sarcomas (STS) are rare and heterogeneous tumors for which achieving complete tumor resection with negative surgical margins remains the cornerstone of curative treatment and a key predictor of survival. This review presents emerging technologies designed to improve real-time margin assessment, including fluorescence-guided imaging with indocyanine green (ICG), acridine orange (AO), Raman spectroscopy, diffuse reflectance spectroscopy (DRS), rapid evaporative ionization mass spectrometry (REIMS), optical coherence tomography (OCT), and intraoperative ultrasound (IOUS). Each technique offers distinct benefits while facing limitations in sensitivity and feasibility. Among these methods, ICG demonstrates the most clinical evidence for reducing positive margin prevalence along with safety and applicability, while others remain at early investigational stages. Continued research is needed to obtain further clinical validation and clarify their roles in improving intraoperative precision and oncologic outcomes in STS surgery. Soft tissue sarcomas (STS) are rare and heterogeneous tumors for which achieving complete tumor resection with negative surgical margins remains the cornerstone of curative treatment and a key predictor of survival. Current intraoperative resection margin status assessment techniques remain limited, as traditional intraoperative frozen section analysis is of limited accuracy for most STS histological subtypes. This comprehensive review evaluates current and emerging margin assessment techniques used intra-operatively during STS resection. A systematic search of PubMed and PubMed Central databases from 2000 to 2025 identified studies using fluorescence imaging, spectroscopy, and ultrasound-based modalities. Indocyanine green (ICG) fluorescence-guided surgery appeared to be the closest to widespread use, with the most clinical evidence showing potential to reduce positive margins. Use of acridine orange (AO) as a fluorescent dye also showed potential in decreasing local recurrences, but it remains in the experimental stage of research with little clinical data available. Raman spectroscopy has recently shown high accuracy in identifying STS from healthy tissue, but the impact of its use on patient outcomes has not been studied yet. Other techniques, such as diffuse reflectance spectroscopy (DRS), rapid evaporative ionization mass spectrometry (REIMS), optical coherence tomography (OCT), and intraoperative ultrasound (IOUS) yielded encouraging results but still require further prospective studies to validate their safety, reproducibility, and clinical utility in improving surgical precision and patient outcomes.
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