Janice Dutcher, MD, states that in metastatic renal cell carcinoma (RCC), the bulk of the disease process is in the kidney, and many patients will fare better with treatment after kidney removal. To determine who should undergo a nephrectomy, clinicians often evaluate the aggressiveness of the disease by looking at symptoms and the presence of paraneoplastic syndromes, leukocytosis, and/or thrombocytosis.

For aggressive-disease patients with a large kidney tumor and centimeter size lung nodules, Dutcher recommends nephrectomy even if they are asymptomatic. Charles Henderson, MD, adds that he has seen several patients with oligometastatic disease achieve prolonged remission with surgery and focused radiation alone. But for patients presenting with hypercalcemia, kidney mass, and liver, lung, and bone involvement, Dutcher notes that most oncologists would not routinely advise nephrectomy, as they would want to immediately initiate therapies that stabilize disease.

Oncologists may question whether cytoreductive nephrectomy is still needed in an age of targeted therapy. Daniel Heng, MD, explains 2 recent New England Journal of Medicine articles that demonstrated the benefit of cytoreductive nephrectomy. The articles evaluated patients who received surgery versus those who did not receive surgery. The results demonstrated an overall survival benefit even after controlling for prognostic factors.

Not everyone with RCC should receive cytoreductive nephrectomy, however, and considering an individuals’ survival and prognostic factors is advisable, according to Heng. Studies have shown that patients with an estimated overall survival of less than 12 months and patients with a poor risk profile (those with at least 4 of the International metastatic RCC Database Consortium [IMDC] risk factors) would not benefit from a cytoreductive nephrectomy. While there are exceptions to these findings, Heng comments that these criteria can serve as a guide in determining whether someone is a candidate for cytoreductive nephrectomy.