© 2007 THE AUTHORS JOURNAL COMPILATION © 2 0 0 7 B J U I N T E R N A T I O N A L | 1 0 0 , 7 5 5 – 7 5 9 | doi:10.1111/j.1464-410X.2007.07108.x 755 Urological Oncology FPTV REMOVED PREDICTS OUTCOME AFTER CYTOREDUCTIVE NEPHRECTOMY FOR METASTATIC RCC PIERORAZIO et al. Outcome after cytoreductive nephrectomy for metastatic renal cell carcinoma is predicted by fractional percentage of tumour volume removed Phillip M. Pierorazio, James M. McKiernan, Tara R. McCann, Supriya Mohile*, Daniel Petrylak* and Mitchell C. Benson Departments of Urology and *Medicine-Oncology, Columbia University Medical Center, New York, NY, USA Accepted for publication 19 April 2007 was determined using pathological and imaging reports. The patients were stratified as having a > or <90% FPTV. Kaplan–Meier analysis with log-rank test was used to determine survival advantage between groups. A Cox proportional hazard model was used for FPTV in both univariate and multivariate analyses. Secondary analyses were conducted to determine if the size of the primary tumour or volume of metastases affected outcome and if the FPTV affected hospitalization time. RESULTS In all, 55 patients had their FPTV calculated exactly; 45 had a > 90% FPTV. The median DSS times were 11.6 and 2.9 months for patients with > 90% and < 90% FPTV removed ( P = 0.002). The hazard ratio for death was 0.24 for patients with a > 90% FPTV in a univariate model ( P = 0.016) and 0.29 in multivariate analysis ( P = 0.02). Patients with a < 90% FPTV spent a greater percentage of time hospitalized before death, 21.2% vs 6.5% ( P = 0.03). CONCLUSION For patients with (M + )RCC, overall survival is limited, but can be extended by cytoreductive nephrectomy. The FPTV expected to be removed is a simple and available method to counsel patients regarding the benefits of surgical intervention. KEYWORDS renal cell carcinoma, kidney neoplasm, neoplasm metastasis, cytoreductive, outcomes Study Type – Prognosis (case series) Level of Evidence 4 OBJECTIVE To determine if the fractional percentage of tumour volume (FPTV) removed at cytoreductive nephrectomy predicts disease- specific survival (DSS), as metastatic renal cell carcinoma ((M + )RCC) is associated with poor overall survival with only a 10–20% patient survival at 2 years. PATIENTS AND METHODS The Columbia Urologic Oncology Database was reviewed; 1016 patients had renal surgery from 1988 to 2005, 78 patients with (M + )RCC underwent nephrectomy. The FPTV removed INTRODUCTION In a study of the natural history of metastatic RCC ((M + )RCC) in 1978, Patel and Lavengood [1] reported a survival rate of 24% at 1 year and 2% at 5 years, when treatment was limited to nephrectomy, hemi-nephrectomy and radiotherapy. As medical knowledge and treatment techniques have advanced, cytokine-based immunotherapy [2] and now, anti-angiogenic and tyrosine kinase-based therapies [3] have shown survival benefits for patients with (M + )RCC, becoming the basis of treatment for systemic disease. Before these therapies, nephrectomy was the only option for patients with (M + )RCC, offering relief to symptomatic patients and in the few patients with a solitary, resectable, metastatic focus, nephrectomy offered a 30% 5-year survival rate [4]. Nevertheless, spontaneous regression of cancer with nephrectomy occurred in < 1% of patients and the associated morbidity and mortality made nephrectomy a less than desirable first-line therapy [5]. Even with the advent of immunotherapy, survival still remains at < 10% at 5 years for patients with distant metastases and complete response rates to immunotherapy reach only 10–20% with limited durability in selected populations [6]. The combination of cytoreductive surgery before or after immunotherapy was proposed to improve the outcomes associated with the treatment. Recent prospective randomized trials (Southwest Oncology Group, SWOG; and the European Organisation for Research and Treatment of Cancer, EORTC) showed a clear survival advantage of cytoreductive nephrectomy for metastatic disease [7–9]. Many studies have investigated potential prognostic indicators before cytoreductive nephrectomy including performance status, site(s) of metastases, histological subtype of RCC and node-positive disease [10–13]. However, an ideal model of practical patient-selection criteria for cytoreductive nephrectomy remains difficult to determine. The hypothesis for the present study was that clinical response in (M + )RCC is dependent on the interaction between primary and metastatic cancer burden, i.e. the fractional percentage of tumour volume (FPTV) removed. Furthermore, the failure of initial studies to report beneficial response rates of cytoreductive surgery with immunotherapy and the substantial morbidity and mortality reported might be related to poor selection of patients [12,14–16]. By contrast, the success of recent studies might be attributed to improved methods and selection of patients for cytoreductive surgery. Therefore, this study was designed to investigate the FPTV as a contributor to the