BJU International (2002), 89, 523525

Cytoreductive nephrectomy: is it a realistic option in patients

with renal cancer?
E . B R O M W I C H , D . H E N D R Y and M . A I T C H I S O N
Department of Urology, Gartnavel General Hospital, Glasgow, UK

Objective To evaluate the role of cytoreductive nephrectomy (CRN) in improving survival in patients with
renal cell cancer.
Patients and methods The case-notes of 268 consecutive
patients who presented to our specialized renal cancer
clinic between 1998 and 2001 were reviewed. All
patients with metastatic disease were assessed for
CRN. If their primary tumour was considered operable, they were assessed further using the European
Cooperative Oncology Group performance score; only
patients with a performance score of 0 or 1 were
considered for surgery.
Results In all, 168 patients underwent nephrectomy
with curative intent for M0 disease and 11 were
treated conservatively. Ninety-four patients with M+

Introduction
Two recent multicentre trials [1,2] showed a survival
advantage for patients with metastatic RCC who
undergo nephrectomy before treatment with a-interferon
compared with those treated with interferon alone.
We reviewed all patients who had attended our
specialized renal cancer clinic since it began in 1998,
where there is an active policy of considering every
patient for cytoreductive surgery. In the present study
we analysed the effect on survival of cytoreductive
nephrectomy (CRN) in these patients with RCC.

disease (mean age 65 years, range 3880) were

considered for CRN. Thirty-eight patients had an
inoperable primary. Of the remaining 56 patients,
20 had a performance status of 0 or 1 and were
offered CRN.
Conclusion Metastatic disease at presentation occurred
in 34% of all patients referred; 40% patients had an
inoperable primary and 38% had a performance
score of o2. With an active policy of considering all
patients for CRN, only 7% of those with renal cancer
were suitable for this procedure. CRN is unlikely to
have a significant effect on overall survival within a
population of patients with renal cancer.
Keywords renal cell carcinoma, cytoreductive nephrectomy, metastasis, survival

All patients were assessed for operability of their

primary tumour and the presence of metastatic disease,
using CT with or without MRI of the chest and
abdomen. Operability was defined in each case by one
surgeon. Invasion of adjacent tissues or organs with
an associated confluent nodal mass involving the great
vessels was considered inoperable, but renal vein and
caval extension was considered operable. An ECOG
performance score was then calculated; only patients
with a score of <2 were considered for surgery.

Result
Patients and methods
The specialized renal cancer clinic was started in 1998
to provide a joint urological and oncological approach
to complex patients with RCC. The clinic takes referrals
from the West of Scotland region; there have been
268 referrals (196 men and 72 women, mean age
62.9 years, range 2190) to date. Five patients had
Von Hippel-Lindau disease and were excluded from
further analysis.
Accepted for publication 27 November 2001
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2002 BJU International

In all, 163 patients presented with M0 disease and

underwent nephrectomy with curative intent. Eleven
patients with M0 disease were treated conservatively,
10 because of associated comorbidity excluding operative intervention and one through patient preference.
CRN was considered in 94 patients presenting with
M+ disease (mean age 65 years, range 3880). Of
these 94 patients, 38 (40%) were considered to have
an inoperable primary. The ECOG score was assessed
in the 56 patients with an operable primary in the
presence of metastatic disease; 36 had a score of
>1. CRN was offered to the 20 patients (22%) with
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E. BROMW ICH et al.

Table 1 Metastatic sites and final pathological stage of 19 patients

undergoing CRN
Site/stage
Site
Lung
Bone
Para-aortic nodes
Liver
Para-aortic nodes and bone
Bone and lung
Pathological stage
T1
T2
T3a
T3b
T4

No. of patients

9
6
1
1
1
1
5
4
5
4
1

an ECOG score of 0 or 1, and performed in 19 (mean

age 54 years, range 3861); one patient declined
surgery. The metastatic sites and pathological stage
of the patients undergoing nephrectomy are shown
in Table 1.
Of the 19 patients 13 began a course of immunotherapy (interferon) after surgery, with only two
completing 3 months of treatment. Seven patients had
the treatment withdrawn because of toxicity, with four
progressing during treatment. The six patients with
bone metastasis underwent bony excision plus or minus
radiotherapy; they were subsequently considered to be
disease-free and did not receive immunotherapy. Four
of the 19 patients undergoing CRN are alive (mean
follow-up 8 months, range 316) and 15 have died
(mean time to death after surgery 9.5 months, range
328).

Discussion
Two published randomized controlled trials (RCTs)
[1,2] showed that CRN confers a survival benefit on
patients with metastatic disease if undertaken before
a course of a-interferon. The present study reviewed
the effect that CRN had in patients with RCC outside a
clinical trial. Notably, within the large cohort of patients
with RCC, only a small proportion (20 of 268, 7%) were
considered appropriate for CRN.
The authors specialist renal cancer clinic attracts
tertiary referrals from urologists and oncologists
within the region, and so the cohort of patients may
not be representative. Cancer registration statistics for
Scotland in 1995 show a mean age of diagnosis of RCC as
65 years [3]; the present cohort compares favourably
with this.

Although the two RCTs of CRN [1,2] and immunotherapy showed increased mean survival times of
4 and 10 months, respectively, there was no difference
in response to immunotherapy. Importantly, when
counselling patients about the value of CRN, the modest
increase in survival which may be achieved should be
weighed against the postoperative recovery time from
surgery.
The toxicity of interferon is widely recognized and in
the present study only two of 13 patients completed
3 months of treatment. Patients must be assessed
adequately for associated comorbidity, and performance
scored at presentation, to decide if they will tolerate not
only the surgery, but the subsequent course of immunotherapy. In reality, this favours younger patients with
low-volume asymptomatic metastatic disease. Although
there is evidence to support surgery before immunotherapy, the present series suggests that surgery
reduces the patients ability to tolerate a course of
interferon. A large RCT [4] showed a 24% dose-reduction
requirement, whereas in the present study half the
patients had to stop treatment.
Patients and their relatives are becoming more
educated about their conditions; two of the present
patients requested CRN. From a professional and ethical
perspective it is important that there is adequate
assessment and discussion with the patient. Information obtained from Internet sources that are not
validated or peer-reviewed may inform patients of
the benefits of CRN without emphasising the moderate
increase in the mean survival of 410 months, or the
requirement for a major operation with associated
morbidity and mortality, and a potentially toxic course
of adjuvant treatment.
We do not dispute that CRN has a role in treating
metastatic RCC in a carefully selected group of
younger patients who have an operable tumour and
low-volume asymptomatic metastatic disease. CRN was
undertaken in only 7% of the present cohort and in
real terms was of benefit to only two patients (0.7%) who
completed a postoperative course of immunotherapy.
The effect on these two patients of CRN cannot be
underestimated.
In conclusion, we suggest that the cumulative effect of
CRN on future treatment and survival from metastatic
RCC is unlikely to be significant, because so few patients
fulfil the criteria for cytoreductive surgery.

References
1 Flannigan RC, Blumenstein BA, Salmon S, Crawford ED.
Cytoreductive nephrectomy in metastatic renal cancer.
The results of Southwest Oncology Group Trial 8949.
Proc Am Soc Oncol 2000; 19: 2 (Abstract 3)
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CYTOREDUCTIVE NEPHRECTOMY FOR RENAL CANCER

2 Mickisch GH, Garin A, Madej M, de Prijck L, Sylvester R.
Value of cytoreductive tumour nephrectomy in conjunction
with immunotherapy in metastatic renal cell carcinoma.
Results of a randomised phase III Trial (EORTC 30947).
Eur Urol 2000; 37 (Suppl. 2): 55
3 Scottish Cancer Intelligence Unit. Cancer Registration
Statistics Scotland 198695: 124. Edinburgh: ISD Scotland
Publications, 1998
4 Medical Research Council Renal Cancer Collaborators.
Interferon alpha and survival in metastatic renal carcinoma:
early results of a randomised controlled trial. Lancet 1999;
353: 14 7

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Authors
E. Bromwich, MRCS, Research Registrar.
D. Hendry, FRCS(Urol), Specialist Registrar.
M. Aitchison, MD, FRCS(Urol), Consultant Urologist.
Correspondence: E. Bromwich, 4 Dalnair Place, Milngavie,
Glasgow G62 7RD, UK.
e-mail: emma.bromwich@virgin.net

Abbreviations: CRN, cytoreductive nephrectomy;

RCT, randomized controlled trial.