Preoperative systemic therapy does not lead to worse outcomes after deferred cytoreductive nephrectomy in patients with metastatic renal cell carcinoma, according to study findings presented at American Society of Clinical Oncology’s 2023 Genitourinary Cancers Symposium in San Francisco, California.
Using the 2019-2020 American College of Surgeons NSQIP Participant Use Data File, investigators identified 505 patients who underwent cytoreductive nephrectomy, of whom 115 (23%) received preoperative systemic therapy.
The groups with and without preoperative systemic therapy did not differ significantly in the rates of 30-day mortality, readmission, or return to the operating room, Shawn Dason, MD, of The Ohio State University in Columbus, reported on behalf of his team. Mean operative time, mean hospital stay, and the proportions of patients converted to open surgery or with prolonged hospital stay also were comparable. Nearly all patients in both groups were discharged to their homes.
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Patients receiving preoperative systemic therapy were significantly more likely to take steroids (23% vs 7%) and develop urinary tract infections (4.3% vs 0.5%). Rates of complications, such as surgical site infections, wound dehiscence, sepsis, septic shock, pneumonia, cardiovascular complications, preoperative hypertension, and preoperative diabetes, did not differ between groups.
“We did not find any overt differences in perioperative outcomes between immediate and deferred cytoreductive nephrectomy,” Dr Dason said in an interview. “Those who undergo deferred cytoreductive nephrectomy are unlikely to experience delayed time to surgery or perioperative complications from their systemic therapy. Factors other than perioperative outcomes are more relevant in the decision to perform immediate vs deferred cytoreductive nephrectomy.”
According to Dr Dason, immediate cytoreductive nephrectomy is best suited for patients with:
- Limited metastatic disease amenable to active surveillance following cytoreductive nephrectomy
- Limited metastatic disease that can be controlled completely with metastasis-directed therapy following cytoreductive nephrectomy
- 1 IMDC risk factor with the majority of tumor burden located in the kidney
- Oligoprogressive disease within the kidney following upfront systemic therapy
- Significant local symptoms, particularly those that require hospitalization and prevent receipt of systemic therapy
- an IVC thrombus warrant additional considerations
Dr Dason said upfront systemic therapy with consideration of deferred cytoreductive nephrectomy is best suited for patients with:
- Significant extrarenal disease
- Excessive surgical morbidity
- Poor performance status and/or multiple IMDC risk factors
“Any patient [who] starts systemic therapy and does not receive upfront cytoreductive nephrectomy can be considered for a deferred cytoreductive nephrectomy down the line,” Dr Dason noted.
He added, “Given the genuine equipoise in this topic and our need for prospective data I would encourage consideration of clinical trial enrollment for any patient being considered for cytoreductive nephrectomy. Clinical trials that we hope will inform us on this topic include Cyto-Kik, PROBE, and NORDIC-SUN.”
Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Reference
Dason S, Sheetz T, Ray S, et al. Impact of systemic therapy (ST) on deferred cytoreductive nephrectomy (CN) perioperative outcomes: A National Surgical Quality Improvement Program (NSQIP) analysis. ASCO GU 2023, San Francisco, California, February 16-18. Abstract 650.
