title: The difficulty in selecting patients for cytoreductive nephrectomy: An evaluation of previously described predictive models.
abstract: To externally evaluate a preoperative points system and a preoperative nomogram, both created to assess time to death after cytoreductive nephrectomy (CN).
  
  
  
  We identified 298 patients who underwent CN at our institution, a tertiary cancer center, between 1989 and 2015. To validate the points system, we compared reported overall survival (OS) for each criterion to observed OS in our cohort. To evaluate the nomogram, we prognosticated risk of death at 6 months after surgery for 280 patients with sufficient follow-up in our cohort and evaluated discrimination using area under the curve (AUC) and calibration. Decision curve analysis was performed to assess clinical utility of the nomogram.
  
  
  
  Significant differences in OS were observed between patients with and without 5 of 7 criteria on univariate analysis: low albumin (P<0.0001), high lactate dehydrogenase (P = 0.002), liver metastasis (P = 0.004), retroperitoneal lymphadenopathy (P = 0.002), and supradiaphragmatic lymphadenopathy (P = 0.019). Discrimination from the preoperative model, predicting death within 6 months of surgery was lower in our cohort (AUC = 0.65, 95% CI: 0.52-0.79) than the original publication (AUC = 0.76). Decision curve analysis demonstrated little benefit for applicability.
  
  
  
  Five previously defined risk factors are predictive of decreased OS after CN in our cohort. We found lower discrimination using the preoperative model and minimal clinical utility according to decision analysis in our study cohort. These findings suggest the need for improved models to aid patient stratification and consequent treatment choice.
authors: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
authors: Brandon J
authors: BJ
authors: Manley
authors: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
authors: Daniel M
authors: DM
authors: Tennenbaum
authors: Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY.
authors: Emily A
authors: EA
authors: Vertosick
authors: Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY.
authors: James J
authors: JJ
authors: Hsieh
authors: Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY.
authors: Daniel D
authors: DD
authors: Sjoberg
authors: Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY.
authors: Melissa
authors: M
authors: Assel
authors: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
authors: Nicole E
authors: NE
authors: Benfante
authors: Division of Urology, Department of Surgery, Washington University in St. Louis, St. Louis, MO.
authors: Seth A
authors: SA
authors: Strope
authors: Division of Urology, Department of Surgery, Washington University in St. Louis, St. Louis, MO.
authors: Eric
authors: E
authors: Kim
authors: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
authors: Jozefina
authors: J
authors: Casuscelli
authors: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
authors: Maria F
authors: MF
authors: Becerra
authors: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
authors: Jonathan A
authors: JA
authors: Coleman
authors: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
authors: Abraham Ari
authors: AA
authors: Hakimi
authors: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY. Electronic address: russop@mskcc.org.
authors: Paul
authors: P
authors: Russo
mesh_terms: D000368:Aged; D002292:Carcinoma, Renal Cell / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D065426:Cytoreduction Surgical Procedures / Q000401:mortality; D003661:Decision Support Techniques; D003964:Diaphragm; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007680:Kidney Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D007770:L-Lactate Dehydrogenase / Q000097:blood; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods / Q000401:mortality; D049451:Nomograms; D018579:Patient Selection; D057234:Preoperative Period; D016016:Proportional Hazards Models; D012187:Retroperitoneal Space; D018570:Risk Assessment / Q000379:methods; D012709:Serum Albumin / Q000378:metabolism; D015996:Survival Rate; D013997:Time Factors
chemical_list: D012709:Serum Albumin; D007770:L-Lactate Dehydrogenase
keywords: Mortality; Neoplasm metastasis; Nephrectomy; Prognosis; Renal cell carcinoma