Textbook Outcome: A Novel Quality Measure for Surgical Management of Neuroblastoma with Image-Defined Risk Factors

"Textbook Outcome" (TO) is a composite surgical quality measure encompassing intraoperative/postoperative complications, length of stay, resection completeness, and perioperative mortality. While established in adult surgical oncology for standardized outcome reporting, TO has not been employed in pediatric surgery. This study evaluated TO for neuroblastoma resections involving image-defined risk factors (IDRFs).

Children with neuroblastoma and IDRFs who underwent resection at our institution from 2012-2022 were included. Textbook Outcome was defined as achieving >90% total resection without intraoperative/postoperative complications, 30-day readmission, length of stay exceeding the 75th percentile, or mortality. Patient data, perioperative information, and postoperative outcomes were extracted from institutional records.

Among 69 patients analyzed, 32 (46.4%) achieved TO. Specific IDRFs negatively impacted TO achievement: duodenopancreatic block infiltration (p < 0.001), porta hepatis infiltration (p = 0.001), vena cava encasement (p = 0.01), and >3 IDRFs (p = 0.007). High-risk neuroblastoma patients showed increased risk of not achieving TO (p = 0.003). The primary barrier to achieving TO was postoperative complications, which affected 81.1% of those who did not achieve TO, with 23% classified as Clavien-Dindo grade 3 and 6.7% as grade 4. Median length of stay was 7 (range 4-73) days; no intraoperative mortality occurred.

Textbook Outcome achievement was <50%, highlighting the complexity of care in this population. Textbook Outcome may provide healthcare providers and families new perspectives on pediatric cancer center quality. As a potentially useful but exploratory quality measure, TO assessment for neuroblastoma requires validation in larger multicenter studies before implementation across institutions to enhance surgical standardization and to improve overall care quality.