Cytoreductive nephrectomy is a standard of care for metastatic renal cell carcinoma (RCC). There is, however, a subset of patients who derive no benefit from this procedure. Until now, tools with which to identify these patients have been lacking.

Christopher Wood and colleagues from the University of Texas retrospectively investigated the overall survival of almost 700 patients with metastatic RCC who had received medical therapy; that is, immunotherapy, systemic targeted therapy, and/or chemotherapy. In addition to medical therapy, 566 patients underwent cytoreductive nephrectomy. The surgery cohort was subdivided into two groups, based on when their overall survival diverged from that of the nonsurgery patients.

Multivariate analysis showed seven preoperative variables to be independent predictors of inferior overall survival after surgery. The risk factors are greater than normal lactate dehydrogenase level, lower than normal albumin level, metastatic site symptoms at presentation (for example, bone pain or neurologic symptoms), liver metastasis, retroperitoneal adenopathy, supradiaphragmatic adenopathy, and clinical stage ≥T3.

There was a positive correlation between the number of risk factors and increased likelihood of death after cytoreductive nephrectomy. The postsurgery survival of patients with four or more risk factors was equivalent to that of those who had received medical therapy only.

Incorporating the seven predictive variables into initial evaluation of people with metastatic RCC will help identify those unlikely to benefit from surgery. According to the authors “treatment of these patients can be directed toward upfront systemic therapy, helping them to avoid the unnecessary morbidity of surgical intervention.”