PURPOSE: Identifying which patients are likely to benefit from cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma (mRCC) is important. We tested the association between preoperative serum De Ritis ratio (DRR, Aspartate Aminotransferase/Alanine Aminotransferase) and overall survival (OS) as well as cancer-specific survival (CSS) in mRCC patients treated with CN. MATERIAL AND METHODS: mRCC patients treated with CN at different institutions were included. After assessing for the optimal pretreatment DRR cut-off value, we found 1.2 to have the maximum Youden index value. The overall population was therefore divided into 2 DRR groups using this cut-off (low, <1.2 vs. high, ≥1.2). Univariable and multivariable Cox regression analyses tested the association between DRR and OS as well as CSS. The discrimination of the model was evaluated with the Harrel's concordance index (C-index). The clinical value of the DRR was evaluated with decision curve analysis. RESULTS: Among 613 mRCC patients, 239 (39%) patients had a DRR ≥1.2. Median follow-up was 31 (IQR 16-58) months. On univariable analysis, high DRR was significantly associated with OS (hazard ratios [HR]: 1.22, 95% confidence interval [CI]: 1.01-1.46, P = 0.04) and CSS (HR: 1.23, 95% CI: 1.02-1.47, P = 0.03). On multivariable analysis, which adjusted for the effect of established clinicopathologic features, high DRR remained significantly associated with both OS (HR: 1.26, 95% CI: 1.04-1.52, P = 0.02) and CSS (HR: 1.26, 95% CI: 1.05-1.53, P = 0.01). The addition of DRR only minimally improved the discrimination of a base model that included established clinicopathologic features (C-index = 0.633 vs. C-index = 0.629). On decision curve analysis, the inclusion of DRR did not improve the net-benefit beyond that obtained by established subgroup analyses stratified by IMDC risk groups, type of systemic therapy, body mass index and sarcomatoid features, did not reveal any prognostic value to DRR. CONCLUSION: Despite the statistically significant association between DRR and OS as well as CSS in mRCC patients treated with CN, DRR does not seem to add any further prognostic value beyond that obtained by currently available features.

Cancer Prognostics and Health Outcomes Unit Division of Urology University of Montreal Health Center Montreal Canada

Cancer Prognostics and Health Outcomes Unit Division of Urology University of Montreal Health Center Montreal Canada; Department of Urology European Institute of Oncology IRCCS Milan Italy

Cancer Prognostics and Health Outcomes Unit Division of Urology University of Montreal Health Center Montreal Canada; Department of Urology San Luigi Gonzaga Hospital University of Turin Turin Italy

Cancer Prognostics and Health Outcomes Unit Division of Urology University of Montreal Health Center Montreal Canada; Division of Experimental OncologyDepartment of Urology Urological Research Institute IRCCS San Raffaele Scientific Institute Milan Italy

Cancer Prognostics and Health Outcomes Unit Division of Urology University of Montreal Health Center Montreal Canada; Martini Klinik Prostate Cancer Center University Hospital Hamburg Eppendorf Hamburg Germany

Cancer Prognostics and Health Outcomes Unit Division of Urology University of Montreal Health Center Montreal Canada; Urology Unit Department of Medical and Surgical Specialties ASST Spedali Civili of Brescia Radiological Science and Public Health University of Brescia Brescia Italy

Department of Urology Comprehensive Cancer Center Medical University of Vienna Vienna Austria

Department of Urology Comprehensive Cancer Center Medical University of Vienna Vienna Austria; Department of Urology King Fahad Specialist Hospital Dammam Saudi Arabia

Department of Urology Comprehensive Cancer Center Medical University of Vienna Vienna Austria; Department of Urology The Jikei University School of Medicine Tokyo Japan

Department of Urology Comprehensive Cancer Center Medical University of Vienna Vienna Austria; Department of Urology University Hospital of Tours Tours France

Department of Urology Comprehensive Cancer Center Medical University of Vienna Vienna Austria; Institute for Urology and Reproductive Health Sechenov University Moscow Russia

Department of Urology Comprehensive Cancer Center Medical University of Vienna Vienna Austria; Institute for Urology and Reproductive Health Sechenov University Moscow Russia; Department of Urology Weill Cornell Medical College New York NY; Department of Urology University of Texas Southwestern Dallas TX; Department of Urology 2nd Faculty of Medicine Charles University Prague Czech Republic; Karl Landsteiner Institute of Urology and Andrology Vienna Austria; Division of Urology Department of Special Surgery Jordan University Hospital The University of Jordan Amman Jordan; European Association of Urology Research Foundation Arnhem Netherlands

Department of Urology Comprehensive Cancer Center Medical University of Vienna Vienna Austria; Research Center for Evidence Based Medicine Tabriz University of Medical Sciences Tabriz Iran

Department of Urology The Jikei University School of Medicine Tokyo Japan

Department of Urology University of Texas Southwestern Medical Center Dallas TX

Institute for Urology and Reproductive Health Sechenov University Moscow Russia

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