Prognostic value of textbook outcome in resected non-small cell lung cancer after neoadjuvant therapy: a multicenter retrospective study

This study evaluated the prognostic value of textbook outcome (TO) and its association with postoperative adjuvant therapy delivery in patients with non-small cell lung cancer (NSCLC) undergoing resection after neoadjuvant therapy. We also examined whether integrating TO with major pathological response (MPR) could improve postoperative risk stratification. We retrospectively analyzed 347 patients with NSCLC who underwent curative-intent resection after neoadjuvant therapy at six tertiary hospitals between 2015 and 2022. TO required R0 resection, adequate lymph node dissection, and uncomplicated perioperative recovery. Logistic and Cox regression models were used to identify factors associated with failure to achieve TO and to evaluate its associations with postoperative adjuvant therapy, overall survival (OS), and disease-free survival (DFS). The incremental prognostic value of TO beyond MPR was also assessed. TO was achieved in 278 patients (80.1%). A Charlson comorbidity index ≥3 and ypN-positive disease were independently associated with failure to achieve TO. After multivariable adjustment, failure to achieve TO was independently associated with shorter OS (HR, 1.61; 95% CI, 1.02–2.52; P = 0.039), whereas its association with DFS was not statistically significant (HR, 1.33; 95% CI, 0.88–2.01; P = 0.180). Patients who achieved TO were more likely to receive postoperative adjuvant therapy than those who failed to achieve TO (72.3% vs. 46.4%; P < 0.001); failure to achieve TO remained associated with a lower likelihood of receiving adjuvant therapy after adjustment (OR, 0.28; 95% CI, 0.15–0.50; P < 0.001). Combined MPR–TO stratification identified distinct prognostic groups, and adding TO to the MPR-only model significantly improved model fit for both OS and DFS (P = 0.004 and P = 0.029, respectively). TO provides clinically relevant information on perioperative recovery in patients with NSCLC undergoing resection after neoadjuvant therapy. Failure to achieve TO was independently associated with shorter OS and reduced postoperative adjuvant therapy delivery. Combined assessment of TO and MPR may improve postoperative risk stratification by integrating perioperative recovery with pathological response.