Prior to the advent of targeted therapies, investigators found that subtractive nephrectomy improved overall survival by 6 months in patients with metastatic renal cell carcinoma. With the advent of new and more effective treatments in this field, the rationale for the use of subtractive nephrectomy has been questioned. A study from the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) provides some guidance on which populations of patients with metastatic renal cell carcinoma in the era of targeted therapies may derive a survival benefit from subtractive nephrectomy. The IMDC trial showed that patients with synchronous metastatic renal cell carcinoma with a life expectancy of at least 1 year may benefit from both targeted therapy and subtractive nephrectomy, while patients with shorter life expectancies do not. This study was reported at the 2014 Gastrointestinal Cancer Symposium in San Fransisco. Patient Choice Not all patients with metastatic renal cell carcinoma need to undergo subtractive nephrectomy, according to Daniel Y. C. Heng, associate professor at the University of Calgary, Canada. Patients with a long survival expectancy may benefit, while those with at least four risk factors and a limited life expectancy should not undergo this surgical treatment. There are, of course, exceptions to this rule, and this is an interesting treatment pathway for patients to follow. Two prospective phase III trials, CARMENA and SURTIME, evaluated the efficacy of subtractive nephrectomy, and the results should be more credible than a retrospective analysis. The investigators based their analysis on data from 20 international cancer centers of consecutive patients with metastatic renal cell carcinoma treated with targeted therapies (N = 3,245; of which 2,569 underwent nephrectomy). After excluding patients who had undergone nephrectomy prior to metastasis, the final number analyzed was 982 patients who underwent nephrectomy and 676 patients who did not undergo nephrectomy. More patients in the subtractive nephrectomy group benefited (63% vs. 45% who did not undergo nephrectomy). This is not surprising, according to the investigators, and we can correct the results based on patient baseline characteristics using patient surgical selection criteria. Key Findings In a univariate analysis of overall survival, survival was found to be longer in the subtractive nephrectomy group: 20.6 vs. 9.5 months. After correcting for IMDC criteria, a multivariate analysis found that the benefit in the subtractive nephrectomy group increased with increasing patient survival, with little benefit for patients with shorter survival expectations. hyperplasia. The number of patients with all six prognostic factors included in the trial comparing subtotal nephrectomy vs no nephrectomy was not sufficient, but a significant survival benefit was observed in the subgroup of patients with 0 to 3 prognostic factors, according to the investigators. The investigators stated that the median overall survival improvement after subtractive nephrectomy was 8 months if the patient had 1 prognostic factor, 10 months if the patient had 2 prognostic factors, and 6 months if the patient had 3 prognostic factors.