Cytoreductive Nephrectomy in Metastatic Renal Cell Carcinoma

Building on the theme of appropriate use of procedures and treatments, a new study suggests that cytoreductive nephrectomy (CN) will not alter survival of patients with metastatic renal cell carcinoma (mRCC) with a short life expectancy (<1 year) and poor prognostic factors. The study was conducted to determine whether CN had a survival benefit in the era of newer targeted therapies for mRCC.

Patients with synchronous mRCC with a life expectancy of 1 year appear to have a survival benefit if treated with targeted therapy and CN, whereas those with a shorter life expectancy will probably have no benefit, the study found.

“Not all patients with metastatic renal cell carcinoma should undergo cytoreductive nephrectomy. Patients with longer estimated survival may benefit, but those with 4 or more risk factors [as indentified by International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) criteria] and limited life expectancy should not have this surgery. Of course there may be exceptions to this rule, but this is an interesting approach to patient selection,” said Daniel Y. C. Heng, MD, MPH, Tom Baker Cancer Centre, University of Calgary, Canada.

The retrospective analysis was based on data from consecutive patients treated at 20 international cancer centers with targeted therapy for mRCC (total number: 3245; 2569 treated with CN). After exclusions for patients undergoing CN before metastasis occurred (about 49%), the study was based on 676 patients who did not have nephrectomy and 982 who had CN.

The CN group had more favorable-risk patients (63% vs 45% in the no CN group). The analysis of the study was adjusted for this baseline difference, Heng said.

In a univariate analysis of overall survival, the CN group lived longer: 20.6 months versus 9.5 months (adjusted hazard ratio: 0.60; 95% confidence interval, 0.52-0.69; P <.0001).

A multifactorial analysis adjusted for IMDC criteria found an incremental benefit for CN as survival lengthened but not much benefit for patients with a shorter life expectancy.

IMDC poor prognostic factors include Karnofsky performance status <80%, time from diagnosis to treatment of <1 year, and 4 lab tests for anemia, hypercalcemia, neutrophilia, and thrombocytosis. No comparison could be made between CN or no CN in patients with all 6 prognostic factors because of insufficient numbers, but those with 0-3 prognostic factors had a significant survival benefit with CN, Heng said.

Reference
Heng DYC, Rini BI, Beuselinck B, et al. Cytoreductive nephrectomy (CN) in patients with synchronous metastases from renal cell carcinoma: results from the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC). J Clin Oncol. 2014;32(suppl 4). Abstract 396. Presented at: 2014 Genitourinary Cancers Symposium; February 1, 2014; San Francisco, CA.