How do you decide when to refer a patient with metastatic renal cell carcinoma for cytoreductive nephrectomy?

Although dated, two large randomized trials showed a nearly 6 month OS advantage with debulking nephrectomy in the cytokine era, and thus my opinoin is that debulking nephrectomy is the standard of care in appropriately selected patients. The phase 3 data and modern retrospective analyses in the TKI...