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A qualitative framework of non-selection factors for cytoreductive nephrectomy

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Abstract

Purpose

Cytoreductive nephrectomy (CN) benefits a subset of patients with metastatic renal cell carcinoma (mRCC), however proper patient selection remains complex and controversial. We aim to characterize urologists’ reasons for not undertaking a CN at a quaternary cancer center.

Methods

Consecutive patients with mRCC referred to MSKCC urologists for consideration of CN between 2009 and 2019 were included. Baseline clinicopathologic characteristics were used to compare patients selected or rejected for CN. The reasons cited for not operating and the alternative management strategies recommended were extrapolated. Using an iterative thematic analysis, a framework of reasons for rejecting CN was designed. Kaplan–Meier estimates tested for associations between the reasons for not undertaking a CN and overall survival (OS).

Results

Of 297 patients with biopsy-proven mRCC, 217 (73%) underwent CN and 80 (27%) did not. Median follow-up of patients alive at data cut-off was 27.3 months. Non-operative patients were older (p = 0.014), had more sites of metastases (p = 0.008), harbored non-clear cell histology (p = 0.014) and reduced performance status (p < 0.001). The framework comprised seven distinct themes for recommending non-operative management: two patient-fitness considerations and five oncological considerations. These considerations were associated with OS; four of the oncological factors conferred a median OS of less than 12 months (p < 0.001).

Conclusion

We developed a framework of criteria by which patients were deemed unsuitable candidates for CN. These new insights provide a novel perspective on surgical selection, could potentially be applicable to other malignancies and possibly have prognostic implications.

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Code availability

Statistical analyses were completed using R version 3.5.1 (R Core Development Team, Vienna, Austria). Code can be provided upon request.

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Funding

Supported by: the Sidney Kimmel Center for Prostate and Urologic Cancers and the National Institutes of Health/National Cancer Institute to Memorial Sloan Kettering Cancer Center through the Cancer Center Support Grant, award number P30 CA008748.

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Authors and Affiliations

  1. Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA

    Andrew W. Silagy, Kyrollis Attalla, Renzo G. Dinatale, Kate L. Weiss, Stanley Weng, Roy Mano, Skylar Iosepovici, Julian Marcon, Jonathan A. Coleman, A. Ari Hakimi & Paul Russo

  2. Department of Surgery, University of Melbourne, Austin Hospital, Melbourne, Australia

    Andrew W. Silagy

  3. SUNY Downstate College of Medicine and Kings County Hospital Center, New York, NY, USA

    Stanley Weng

  4. Department of Urology, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel

    Roy Mano

  5. Department of Urology, University Hospital of Munich, Munich, Germany

    Julian Marcon

  6. Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Ed Reznik

  7. Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Ritesh R. Kotecha, Robert J. Motzer & Martin H. Voss

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  1. Andrew W. Silagy
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  2. Kyrollis Attalla
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  15. Paul Russo
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Contributions

AWS: Data collection, data analysis, manuscript writing/editing. KA: Data collection, manuscript writing. RGD: Project development, manuscript writing, data analysis. KW: Project development, data collection. SW: Manuscript writing. RM: Project development, manuscript editing. SI: Data collection. JM: Project development, data collection. ER: Project development, data analysis. RRK: Project development, manuscript editing. RJM: Project development, manuscript editing. MHV: Project development, manuscript editing. JAC: Project development, data collection, manuscript editing. AAH: Project development, data collection, manuscript editing. PR: Project development, data collection, manuscript editing.

Corresponding author

Correspondence to Paul Russo.

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Informed consent was obtained from all individual participants included in the study.

Research involving human participants/Ethical approval retrospective studies

This research was conducted after obtaining Institutional Review Board approval.

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Silagy, A.W., Attalla, K., Dinatale, R.G. et al. A qualitative framework of non-selection factors for cytoreductive nephrectomy. World J Urol 39, 3359–3365 (2021). https://doi.org/10.1007/s00345-021-03650-4

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  • DOI: https://doi.org/10.1007/s00345-021-03650-4

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