title: Can we better select patients with metastatic renal cell carcinoma for cytoreductive nephrectomy?
abstract: BACKGROUND
  The benefits of cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) should outweigh surgical morbidity. Even when the generally agreed upon selection criteria for CN are met, some patients do poorly after surgery. The objective of this study was to identify preoperative factors that were prognostic of outcome in patients who were being considered for CN.
  
  
  METHODS
  The authors conducted a retrospective study to investigate the overall survival (OS) of patients who underwent CN using the OS of patients with mRCC who did not undergo CN as a referent group. Patients who underwent CN were divided into 2 groups based on when their OS diverged from that of nonsurgical patients. Chi-square analysis was used to identify variables that differed between the 2 surgical groups. Multivariate Cox proportional hazards regression was used to analyze those variables for the entire CN cohort. Risk factors were defined as preoperative variables that remained significant on multivariate analysis. The median OS and the overall risk of death were calculated based on the number of risk factors.
  
  
  RESULTS
  From 1991 to 2007, 566 patients who were eligible for or received systemic therapy underwent CN, and 110 patients received medical therapy alone. On multivariate analysis, independent preoperative predictors of inferior OS in surgical patients included a lactate dehydrogenase level greater than the upper limit of normal, an albumin level less than the lower limit of normal, symptoms at presentation caused by a metastatic site, liver metastasis, retroperitoneal adenopathy, supradiaphragmatic adenopathy, and clinical tumor classification>or=T3. Inferior OS and an increased risk of death were correlated positively with the number of risk factors. Surgical patients who had >or=4 risk factors did not appear to benefit from CN.
  
  
  CONCLUSIONS
  The authors of this report identified 7 preoperative variables that permitted them to identify patients who were unlikely to benefit from CN.
authors.affiliation: Department of Urology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
authors.forename: Stephen H
authors.initials: SH
authors.lastname: Culp
authors.forename: Nizar M
authors.initials: NM
authors.lastname: Tannir
authors.forename: E Jason
authors.initials: EJ
authors.lastname: Abel
authors.forename: Vitaly
authors.initials: V
authors.lastname: Margulis
authors.forename: Pheroze
authors.initials: P
authors.lastname: Tamboli
authors.forename: Surena F
authors.initials: SF
authors.lastname: Matin
authors.forename: Christopher G
authors.initials: CG
authors.lastname: Wood
mesh_terms: D000368:Aged; D002292:Carcinoma, Renal Cell / Q000097:blood / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000097:blood / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis; D009392:Nephrectomy / Q000379:methods*; D018579:Patient Selection; D012189:Retrospective Studies; D012307:Risk Factors