Minimally invasive surgery reduces intraoperative blood loss and accelerates postoperative recovery without compromising the completeness of tumor resection in children with neuroblastoma: a prospective cohort study

Neuroblastoma (NB) is a common extracranial solid malignancy in children, and surgical resection is an important component of multimodal treatment. Although minimally invasive surgery (MIS) may reduce perioperative trauma, its effects on resection completeness, perioperative outcomes, and long-term oncological safety in pediatric NB require further evaluation. This study aims to compare the clinical efficacy and prognosis of MIS and open surgery (OPEN) for thoracoabdominal NB in children, and to provide evidence for surgical decision-making.

A prospective cohort study was conducted on 289 children with thoracoabdominal NB who underwent surgical resection in Department of Surgical Oncology and Department of Thoracic and Cardiovascular Surgery at Children’s Hospital of Chongqing Medical University between January 2015 and June 2023. OPEN was preferentially selected for patients with large tumors or tumors with obvious invasion or encasement of major vessels or adjacent organs; the remaining patients were randomly allocated to the MIS group or OPEN group. Propensity score matching (PSM) was performed at a 1:1 ratio based on age, maximum tumor diameter, tumor location, preoperative International Neuroblastoma Risk Group Staging System (INRGSS) stage, histopathological type and MYCN amplification status. The 2 groups were compared with respect to tumor location, image-defined risk factors (IDRFs) type, perioperative parameters, gross total resection (GTR) rate of the primary tumor, intraoperative conversion to OPEN, postoperative complications, and event-free survival (EFS) outcomes. Survival analysis was performed using the Kaplan-Meier method, and 60-month restricted mean EFS time was used as a supplementary endpoint.

After PSM, 70 patients were included, with 35 patients in the MIS group and 35 in the OPEN group. The distribution of tumor locations was comparable between the 2 groups, with 27 abdominal and 8 thoracic cases in each. Perioperative outcomes showed that compared with the OPEN group, the MIS group had less intraoperative blood loss [5.0 (5.0, 15.0) vs 20.0 (7.5, 37.5) mL, P=0.006], longer operative time [122.0 (85.5, 162.5) vs 88.0 (71.0, 110.0) min, P=0.008], and shorter time to postoperative oral intake [1.0 (1.0, 1.0) vs 2.0 (1.0, 3.0) d, P<0.001]. The GTR rate of the primary tumor was 94.3% in the MIS group and 100.0% in the OPEN group, with no statistically significant difference. The 1-year EFS rate was 100.0% in both groups, and the 5-year EFS rates were 93.1% in the MIS group and 97.1% in the OPEN group. Kaplan-Meier analysis showed no significant difference in EFS between the 2 groups (Log-rank P=0.536). Cox regression analysis also showed no statistically significant difference in EFS outcomes between groups (HR= 2.10,95%CI: 0.19 to 23.18, P=0.545). The 60-month restricted mean EFS time was 58.16 months in the MIS group and 58.71 months in the OPEN group, with no statistically significant difference. IDRFs types in both groups included involvement of the ipsilateral renal pedicle, compression of the ipsilateral main bronchus, encasement of major vessels, and simultaneous tumor involvement of the thoracic cavity and the cervical or abdominal region.

With appropriate patient selection, MIS for resection of the primary tumor is safe and feasible for children with thoracoabdominal NB. MIS may reduce intraoperative blood loss and facilitate postoperative recovery without substantially compromising resection completeness. The indications for MIS should be determined comprehensively according to risk stratification, IDRFs types, tumor size, tumor location, and surgeon experience.