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EDITORIAL COMMENT

This nomogram is another in a now large number of predictivetools for cancer, and one of several for prostate cancer developed byScardino et al. I have had some conceptual problems with prostatecancer nomograms and other predictive instruments which giveprobabilities for pathological stage or PSA recurrence.

While the information gleaned from these tools will provide moreprecise information about risk stratification and, thus, facilitate thedesign and conduct of clinical trials, I am not sure how they help the

patient or the physician treating him. For a patient or surgeon toknow specifically that the risk of extracapsular extension or PSArecurrence is 50% or 20% may give the participants a sense ofcontrol, but it does not really help in the decision regarding choice oftherapy because the appropriate clinical trials have not been com-pleted. Thus, even if the probability of extracapsular extension isclose to certain by a nomogram, clinical trials have yet to enlightenus as to whether radiation or surgery with or without adjuvanttherapies is better. Nor do these nomograms sufficiently help thesurgeon (or arguably the radiotherapist) in planning the approach.Parenthetically this relative lack of completed clinical trials in local-ized prostate cancer compared to other solid tumors is a stigma thatmust be erased if genitourinary surgical oncology is to remain influ-ential in developing the future care pathways of cancers. Thus Iwould urge the leaders in genitourinary surgical oncology to supportand/or participate in the SPIRIT trial, a randomized study of brachy-therapy vs radical prostatectomy for low risk prostate cancer(www.acosog.org).

However this nomogram I immediately liked! Using their usualcareful approach and data sets accumulated from Baylor and Sloan-Kettering, the authors analyzed the value of certain clinical andpresurgical pathological parameters (eg clinical stage, highestGleason sum, percent positive cores) and the individual and col-lective value in predicting extracapsular extension on an individ-ual side of the prostate as verified by pathological analysis afterradical prostatectomy. They then constructed 3 of their now wellrecognized “Kattan nomograms:” 1) if only PSA level, clinicalstage and highest Gleason grade on each side are known, 2) ifpercent positive cores on biopsy are also known and 3) (and thebest) if percent cancer in all cores on each side are also available.Such information can help the surgeon (possibly with patientinput) to plan whether to save the nerve bundle on a particularside or even to preplan for sural nerve grafting.

How exactly this sided extracapsular extension prediction shouldbe used of course can be individualized. The authors suggest that ifthe chances of extracapsular extension on a side are greater than10%, the surgeon should be careful (eg go a little wider while pre-serving the bundle, be compulsive about frozen sections around theneurovascular bundle) and if the side has a nodule and greater than50% calculated chance of extracapsular extension, that side (and thebundle) should be widely resected.

Of course there are problems with this nomogram, a caveat theauthors nicely express. Thus one does not know exactly where on aside the extracapsular extension might occur. Also this nomogrammust be validated externally and with larger data sets. Finally thereare those who still believe that surgical margins caused because of anerve sparing approach make little difference in outcome. I vigor-ously disagree and congratulate the authors on developing a verysignificant and practical tool.

Paul H. LangeDepartment of UrologyUniversity of WashingtonSeattle, Washington

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