CONCLUSIONS: In our multi-institutional series, we found thatpatients with pRCC and vena cava thrombus who underwent radicalnephrectomy and tumor thrombectomy had significantly worse cancer-specific outcomes and a higher tumor thrombus level when comparedto patients with other histologic subtypes of RCC. Moreover, we con-firmed that higher TT level and Fuhrman grade were independentlyassociated with reduced CSS.

Source of Funding: None

1831THE NUMBER OF LYMPH NODES REMOVED IN RENAL CELLCARCINOMA DOES AFFECT CANCER SPECIFIC SURVIVAL INSPECIFIC SUBGROUPS OF PATIENTS: RESULTS FROM ASYSTEMATIC ANALYSIS

Umberto Capitanio*, Rayan Matloob, Firas Abdollah,Nazareno Suardi, Paolo Capogrosso, Marco Moschini,Cristina Carenzi, Fabio Castiglione, Andrea Russo, Alberto Briganti,Francesco Montorsi, Roberto Bertini, Milan, Italy

INTRODUCTION AND OBJECTIVES: Although the EORTCprospective trial failed to demonstrate a significant benefit of lymphnode dissection (LND) on renal cell carcinoma specific survival (CSS),some retrospective reports suggested that LND might be beneficial inpresence of unfavourable conditions. We systematically tested theeffect of the number of lymph nodes removed on cancer specificsurvival (CSS).

METHODS: Patient records were prospectively retrieved andyielded 1983 RCC patients treated with partial or radical nephrectomybetween 1987 and 2012 at a single tertiary care institution. TNM stageswere assigned according to the 2009 AJCC/UICC classification. Casesbefore the introduction of the most updated classification were reclas-sified. Univariable and multivariable Cox regression analyses targetedthe effect of the number of lymph nodes removed on CSS. Since thenumber of nodes removed may be influenced by patients and tumorcharacteristics, analyses were further adjusted for number of positivenodes, patient age, pathological T stage, ECOG performance status,metastases at diagnosis, pathological tumor size, Fuhrman grade,presence of necrosis and sarcomatoid features.

RESULTS: Pathological nodal status resulted pN0, pN1 andpNx in 758 (38.0%), 120 (6.1%) and 1109 (55.9%) cases, respectively.When LND was performed, the mean number of nodes removed was7.8 (median 6, range 1-58). Mean follow up was 74.4 months (median54.2). CSS rates at 1, 5 and 10 years resulted 57.9, 22.1 and 15.4% vs.94.3, 78.4 and 70.8% vs. 96.9, 92.3 and 89.1% for pN1 vs. pN0 vs. pNxcases, respectively. At multivariable analyses, after adjusting for all thepotential confounders, the number of nodes removed showed anindependent, protective effect on CSS in patients with larger tumors(pT2a-pT2b, hazard ratio [HR] 0.91, p�0.008), locally advanced dis-ease with extension to vena cava wall or above the diaphragm (pT3c,HR 0.86, p�0.008), tumors invading beyond Gerota fascia (pT4, HR0.84, p�0.007) or when sarcomatoid features were found (HR 0.81,p�0.006).

CONCLUSIONS: When clinically indicated, LND and its extent,namely the number of nodes removed, independently affect survival inspecific subgroups of patients. Specifically, LND extent seems to affectCSS in those cases which show lymph node trophism or with thehighest risk of lymph node invasion (larger tumors, locally advanceddisease with extension to vena cava wall or above the diaphragm,tumors invading beyond Gerota fascia or when sarcomatoid featuresare found).

Source of Funding: None

1832DOES TIMING OF TARGETED THERAPY FOR METASTATICRENAL CELL CARCINOMA IMPACT TREATMENT TOXICITY ANDSURGICAL COMPLICATIONS? A COMPARATIVE ANALYSIS OFPRIMARY AND ADJUVANT APPROACHES

Nishant D Patel*, Kerrin L Palazzi, Ryan P Kopp, Michael Liss, SanDiego, CA; Reza Mehrazin, Memphis, TN; Ramzi Jabaji,Hossein Mirheydar, Seth Cohen, Samuel K Park, San Diego, CA;Anthony Patterson, Memphis, TN; Christopher Kane,Frederick Millard, Ithaar Derweesh, San Diego, CA

INTRODUCTION AND OBJECTIVES: The efficacy of tyrosinekinase inhibitors (TKI) in combination with cytoreductive nephrectomy(CN) has been demonstrated for metastatic renal cell carcinoma(mRCC). TKI therapy carries a unique toxicity profile that may impactthe rate of post-operative complications. We compared surgical com-plications and TKI-toxicities in patients who underwent primary CNfollowed by adjuvant TKI therapy versus those who underwent neoad-juvant TKI therapy prior to planned CN.

METHODS: Multi-center retrospective analysis of 61 mRCCpatients who underwent TKI therapy with sunitinib between 5/2005-6/2011. Patients were divided into three groups: Primary TKI alone (nosurgery, n�13), neoadjuvant TKI prior to CN (n�21), and primary CNfollowed by adjuvant TKI (n�27). TKI-related toxicities were gradedaccording to NIH Common Toxicity Criteria. Surgical complicationswere graded according to the Clavien System. Patient demographics/clinical characteristics, surgical complications, and TKI-toxicities werecompared. Primary outcomes were incidence of high-grade (�3a/b)Clavien surgical complications and overall TKI-toxicity rate.

RESULTS: Between the three treatment groups, no significantdifference was seen in age, gender, BMI, and ECOG status. Significantdifference was seen in mean clinical tumor size between primary TKI,neoadjuvant TKI, and adjuvant TKI groups at 12.8 cm, 8.9 cm and 9.3cm, respectively, p�0.014. Median number of TKI cycles were similarbetween the groups (primary TKI 2.0, neoadjuvant TKI 2.0, and adju-vant TKI 2.4, p�0.337). TKI-related toxicities occurred in 100%, 90.5%,and 88.9% in TKI alone, neoadjuvant TKI and adjuvant TKI groups, p�0.469, and there was no difference in incidence of high grade(p�0.967) and low grade (p�0.380) TKI-toxicities among the groups.The overall surgical complication rate was similar between neoadjuvantTKI (47.6%) and adjuvant TKI (33.3%), p�0.380. However, the neo-adjuvant TKI group saw more high-grade surgical complications(28.6%) compared to the adjuvant TKI group (0%), p�0.004. High-grade complications in the neoadjuvant TKI group included 1 postop-erative bowel leak, 1 fluid collection, and 3 urine leaks.

CONCLUSIONS: Patients receiving neoadjuvant TKI therapyprior to planned CN experienced more high-grade surgical complica-tions. The potential for increased high-grade surgical complicationsrequires further investigation and may impact clinical decision makingand pretreatment counseling.

Source of Funding: None

1833THE BLIND SPOTS IN FOLLOW-UP AFTER NEPHRECTOMY FORLOCALISED RENAL CELL CARCINOMA

Tim van Oostenbrugge*, Stephanie Kroeze, Nieuwegein,Netherlands; Ruud Bosch, Utrecht, Netherlands; Harm van Melick,Nieuwegein, Netherlands

INTRODUCTION AND OBJECTIVES: The rationale for onco-logic follow-up (FU) after nephrectomy for renal cell carcinoma (RCC)is primarily early detection of asymptomatic recurrent disease throughfrequent routine imaging. This early detection is thought to improvesurvival by providing better palliative therapeutic options. The objectiveof this study was to analyze metastases that were found and missed byperforming routine FU imaging. Thereby we aimed to clarify what groupof patients might benefit from enhancements in FU guidelines that haveto be defined in the future.

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METHODS: All patients who underwent radical or partial ne-phrectomy for RCC in two clinics between Jan. 2000 and Dec. 2010were reviewed. Data regarding demographics, initial treatment, char-acteristics, staging, metastasis and FU were recorded. All patients withmetastases were categorized as either being detected by routineguideline FU or being detected outside this scheme (symptomatic atmoment of recurrence).

RESULTS: Overall 398 patients treated for localized RCC werereviewed, of which 20% (81/398) developed metachronous metasta-ses. Initial staging of the 398 patients was 231 T1, 70 T2, 92 T3 and 3T4. The mean time to metastasis in months (range) was 56 (3-142,n�21) for T1, 24 (1-82, n�18) for T2, 20 (2-101, n�39) for T3 and 11(5-17, n�2) for T4 tumours. Symptomatic presentation of recurrenceoccurred in a total of 32% (26/81). 21% (17/81) of metastases pre-sented themselves as symptomatic outside the regular FU periodaccording to the EAU guidelines (p�0,01). Detection of metastaseswithin the first 6 months of FU occurred in 28% (23/81) of all metastaticpatients, of which 65% (15/23) were initially T3 or T4 stage tumours. Ofthe metastases found within the first 6 months, 35% (8/23) weresymptomatic at presentation. Of the low risk tumours, 48% (10/21) T1and 17% (3/18) T2 tumours recurred later than the 5 year standard FUafter nephrectomy. Of these metastases, 69% (9/13) were symptomaticat presentation. Using a Kaplan-Meier survival analysis no significantbenefit in survival was found for asymptomatic patients detected out-side the regular FU period (log-rank 1,0; p � 0,31).

CONCLUSIONS: Of the low stage T1 tumours, almost half ofrecurrences present themselves outside the EAU guideline FU schemeof 5 years. In higher staged RCC a considerable number of metastaseswere detected before the recommended start of FU at 6 months. Thesedata suggest that a more intensive FU in the first 6 months for higherstage disease and a prolonged scheme for T1 disease might improveearly detection of recurrence. Whether this would improve survivalneeds to be further studied.

Source of Funding: None

1834TEMPORAL TRENDS IN UTILIZATION OF CYTOREDUCTIVENEPHRECTOMY AND PATIENT SURVIVAL IN THE TARGETEDTHERAPY ERA

Simon L Conti*, Judith Hagedorn, Benjamin I Chung,Sandhya Srinivas, John Leppert, Stanford, CA

INTRODUCTION AND OBJECTIVES: To analyze the temporaltrends in utilization of cytoreductive nephrectomy (CN) and the effectthis might have on survival of patients with metastatic RCC in thetargeted therapy era.

METHODS: We queried the SEER registry for metastatic RCCcases between 1993 and 2009 using SEER*Stat (version 7.1.0) andStata (version 10.1). We restricted our cohort using the primary sitecode and ICD-0-3 codes for RCC specific histologies resulting in ananalytic cohort of 17,864 patients. The proportion of metastatic patientsundergoing CN was determined by year. This data was analyzed usingJoinPoint (Version 3.4.5) with 5 maximum allowable join-points toidentify years where CN trends changed. We then performed anunadjusted product limit Kaplan Meier survival analysis of patients whoreceived CN stratified by the period prior to and after the join-point year.

RESULTS: The proportion of CN increased between 1993-2004, from 30% in 1993, to 39% in 2004. Following 2004, there was amodest decline in the proportion of patients receiving CN (Figure 1) to36% in 2009. The year 2004 was the primary join point occurring at theintroduction of targeted therapies. Prior to 2004, median overall survivalwas 7 months. After 2004, median overall survival increased to 8months. Patients that received CN had a median survival of 17 months,compared to 4 months for patients not receiving surgery. Patientsreceiving CN after 2004 had improved survival (20 months) whencompared to those prior to 2004 (15 months) (see figure 2).

CONCLUSIONS: With the advent of targeted therapy, the roleof CN remains controversial. These data suggest there is a decreasing

utilization of CN in the targeted therapy era. The 5-month survivalbenefit seen in patients who received CN after 2004 is potentially aproduct of synergism with CN and targeted therapies or the increasedselectivity with which CN is offered.

Source of Funding: None

1835CANCER CONTROL OUTCOMES FOLLOWING PARTIAL VSRADICAL NEPHRECTOMY AMONG PATIENTS WITH HIGH-RISKRENAL CELL CARCINOMA

Hugo Lavigueur-Blouin*, Montreal, Canada; Jens Hansen,Andreas Becker, Hamburg, Germany; Florian Roghmann, Herne,Germany; Malek Meskawi, Zhe Tian, Al’a Abdo, Pierre I Karakiewicz,Quoc-Dien Trinh, Maxine Sun, Montreal, Canada

INTRODUCTION AND OBJECTIVES: To compare cancer-spe-cific mortality after either partial nephrectomy (PN) or radical nephrec-tomy (RN) among patients with high-risk renal cell carcinoma (RCC),defined as tumors �7 cm, lesions extending beyond the kidney (pT3a),or Fuhrman grade III?IV disease.

METHODS: Respectively 4011, 2133, and 4296 PN and RN-treated patients with tumors �7cm, pT3a, or Fuhrman grade III?IVRCC were abstracted from the Surveillance, Epidemiology, and EndResults?Medicare database. Instrumental variable approach was ap-plied to account for measured and unmeasured differences betweentreatment groups. Separate two-stage residual inclusion models wereused to estimate the effect of nephrectomy type on cancer-specificmortality. Covariates comprised of comorbidities, age, race, sex, lymphnode status, laparoscopy, year of diagnosis, tumor stage, tumor size,and Fuhrman grade.

RESULTS: Respectively 55 (1.4%), 88 (4.1%), and 205 (4.8%)individuals with tumors �7cm, pT3a lesions, or Fuhrman grade III?IV

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