Use of systemic therapy and factors affecting survival for patients undergoing cytoreductive nephrectomy

OBJECTIVE To present a multi-institutional experience evaluating the use of systemic therapy in patients undergoing cytoreductive nephrectomy (CN), as prospective randomized trials showed a survival benefit for CN in patients with metastatic renal cell carcinoma treated with immunotherapy, and these data have been extrapolated to support CN in the era of targeted therapy, but the likelihood that patients with metastatic kidney cancer who undergo CN will receive systemic treatment afterward remains poorly defined. PATIENTS AND METHODS In all, 141 patients who underwent CN between 1990 and 2008 were identified from our Institutional Kidney Cancer Registries. Kaplan-Meier analyses and Cox regression models were used to assess the effect of clinicopathological and perioperative variables on patients' subsequent receipt of systemic therapy, and survival after CN. RESULTS Overall, 98 of the 141 patients (69.5%) received postoperative systemic treatment, at a median (range) of 2.5 (0.1-61.5) months after CN. In this group, 52 (53%) patients received immunotherapy, 34 (35%) targeted agents, and 12 (12%) other regimens. By contrast, 43 patients (31%) did not receive systemic therapy, because of rapid disease progression (13, 30%), decision for surveillance by medical oncology (nine, 21%), patient refusal (10, 23%), perioperative death (eight, 19%), and unknown reasons in three (7%). The median (range) survival after CN was 16.7 (0-120) months. The risk of death after surgery correlated with the number of metastatic sites (P = 0.012) and symptoms (P = 0.001) at presentation, poor performance status (P = 0.001), high tumour grade (P = 0.006), and presence of sarcomatoid features (P < 0.024). CONCLUSION Nearly a third of patients undergoing CN did not receive systemic treatment. While some were electively observed or declined therapy, others did not receive treatment due to rapidly progressive disease. Further investigation is warranted to identify those patients at highest risk of rapid postoperative disease progression who might benefit instead from an initial approach to treatment with systemic therapy.