Impact of cytoreductive nephrectomy on eligibility for systemic treatment and effects on survival: Are surgical complications or disease related factors responsible?

Objective: To understand the impact of cytoreductive nephrectomy on the ability to receive systemic therapy in patients with metastatic renal cell carcinoma. Causes of delayed eligibility and effect on overall survival (OS) were investigated. Methods: Patients with metastatic renal cell carcinoma who underwent cytoreductive nephrectomy between 2002 and 2010 were identified. Those ineligible to receive systemic therapy >2 months after surgery were considered delayed. Reasons for delay and effect on OS were investigated, including a thorough analysis of surgical morbidity. Results: Of 65 patients identified, 28% experienced delayed eligibility for systemic therapy. Reasons for delay were related to surgery in 33%, disease progression in 56%, and both in 11%. Of the entire cohort, pT4 and sarcomatoid disease predicted poor outcomes with median OS of 9.8 and 7.6 months, respectively. Comparison of the delay vs no delay groups revealed more intraoperative complications (P =.01), a trend toward more high-grade postoperative complications (17% vs 4%, P =.09), and a median OS of 4.8 vs 18.9 months. Controlling for grade and stage, delay and sarcomatoid features independently predicted poor OS (HR, 2.61; P =.01 and HR, 2.25; P =.02, respectively). Conclusion: Delay in eligibility for systemic therapy after cytoreductive nephrectomy adversely affects OS and is most commonly caused by disease-related factors, although high-grade complications may contribute. Those with evidence of T4 or sarcomatoid disease features may best be served by systemic therapy followed by cytoreductive nephrectomy only in those exhibiting response.