Cytoreductive nephrectomy in the elderly: A population-based cohort from the USA

Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada.
BJU International (Impact Factor: 3.53). 09/2011; 109(12):1807-12. DOI: 10.1111/j.1464-410X.2011.10569.x
Source: PubMed


Study Type – Therapy (cohort)
Level of Evidence 2b
What's known on the subject? and What does the study add?
While cytoreductive nephrectomy is associated with a survival benefit in the context of metastatic renal cell carcinoma, the rates of morbidity and perioperative mortality remain non-negligible. For example, perioperative mortality may be as high as 21% in elderly patients.
The study shows that perioperative death amongst the elderly was substantially lower than what was previously reported from a single institutional report. Nonetheless, postoperative adverse outcomes were non-negligible in elderly patients relative to their younger counterparts. In consequence, these rates should be discussed at informed consent and a rigorous patient selection remains essential.

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    ABSTRACT: We reviewed cytoreductive nephrectomy for pT3b-T4 renal cell carcinoma with metastasis and evaluated the prognostic factors for cancer-specific survival. A total of 39 patients who underwent cytoreductive nephrectomy for renal cell carcinoma with pathological T3b-T4 (2009 Union for International Cancer Control consensus) from 1986 to 2011 in our hospital were the participants in this study. Prognostic factors for cancer-specific survival were analyzed. The median patient age was 64 years (range 31-84). Pathological T3b, T3c and T4 were found in 24 (61%), one (3%) and 14 (36%) patients, respectively. The distribution of the histological type was clear cell type in 34 (87%), papillary type in two (5%) and any type of renal cell carcinoma with a sarcomatoid component in three patients (8%). The median overall and cancer-specific survival was 7.5 and 7.6 months, respectively. Low-grade performance status, regional lymph node metastasis, higher pT stage and histological type were prognostic factors for cancer-specific survival on univariate analysis. On multivariate analysis, lymph node metastasis, higher pT stage and histological type (non-clear cell or sarcomatoid component) were significant predictors for cancer-specific survival. With cytoreductive nephrectomy for patients with pT4, lymph node metastasis and non-clear cell histology, we have to be particularly careful in terms of cancer control.
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    ABSTRACT: Two randomized trials published in 2001 established CyNx for patients with metastatic renal carcinoma (mRCC) as a treatment standard in the cytokine era. However, first-line systemic therapy for mRCC changed in 2005 with FDA approval of VEGFR TKIs. We evaluated the patterns of use of CyNx from 2000 to 2008. The National Cancer Database was queried for patients diagnosed with mRCC. Patients who underwent CyNx were identified and were further categorized by pre-VEGFR versus VEGFR TKI era, race, insurance status, and hospital. For these subcategories, prevalence ratios (PRs) were generated using the proportion of patients with mRCC undergoing CyNx versus those not undergoing CyNx. Of the 47,417 patients (pts) identified with mRCC, the prevalence of cytoreductive nephrectomy increased 3% each year from 2000 to 2005 (P < .0001), then decreased 3% each year from 2005 to 2008 (P = .0048), with a significant difference between the eras (0.97 vs. 1.025; P < .0001). Black and Hispanic pts were less likely than Caucasian pts to undergo CyNx. Pts with Medicaid, Medicare, and no insurance were less likely than pts with private insurance to undergo CyNx. Pts diagnosed at community hospitals were significantly less likely than pts at teaching hospitals to undergo CyNx. The use of CyNx has declined in the VEGFR-TKI era. In addition, racial and socioeconomic disparities exist in the use of CyNx. The results of pending randomized trials evaluating the role of CyNx in the VEGFR-TKI era are awaited to optimize use of this modality and address potential disparities.
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    ABSTRACT: BACKGROUND: The risk of in-hospital mortality after cytoreductive nephrectomy (CNT) is non-negligible and may vary widely according to various patient and hospital characteristics and clinical contexts. OBJECTIVE: To better elucidate the mechanisms underlying variability in operative mortality after CNT. DESIGN, SETTING, AND PATIENTS: Using the US-based Nationwide Inpatient Sample registry, a weighted estimate of 16 285 patients with metastatic renal cell carcinoma (mRCC) treated with CNT between 1998 and 2007 was made retrospectively. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Failure to rescue (FTR), defined as the number of deaths in patients who developed an adverse outcome during hospitalization. Univariable and multivariable logistic regression models were used. RESULTS: Of all 16 285 mRCC patients who underwent a CNT, 31% had an occurrence of one complication or more. The overall FTR rate was 5% and differed significantly according to age (≥75 yr vs <75 yr: 7.9% vs 4.3%) and comorbidities (≥3 vs 0: 7.7% vs 4.8%), as well as hospital bed size (small vs large: 7.2% vs 5.3%, all p≤0.03). Patients who had an occurrence of infections (19.3%), cardiac- (15.7%), respiratory- (11.4%), or vascular-related complications (16.5%) had significantly higher FTR rates. It is noteworthy that increasing hospital volume and number of hospital beds also corresponded to lower rates of FTR after adjusting for other covariates. CONCLUSIONS: Following CNT for mRCC, the occurrence of infections, cardiac-, respiratory-, or vascular-related complications resulted in higher FTR rates. Hospitals with greater number of beds and higher annual hospital volume had lower FTR rates, confirming the concepts that support FTR as an indicator for better quality of care following a high-risk surgical procedure.
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