Re: Presence of tumor necrosis is not a significant predictor of survival in clear cell renal cell carcinoma: higher prognostic accuracy of extent based rather than presence/absence classification. T. Klatte, J. W. Said, M. de Martino, J. Larochelle, B. S
Re: Presence of tumor necrosis is not a significant predictor of survival in clear cell renal cell carcinoma: higher prognostic accuracy of extent based rather than presence/absence classification. T. Klatte, J. W. Said, M. de Martino, J. Larochelle, B. S
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回复：肿瘤坏死的存在并不是透明细胞肾细胞癌生存的重要预测因子：基于程度而不是存在/不存在分类的预后准确性更高。
DOI：
10.1016/j.juro.2009.08.066
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发表时间：
2009
期刊：
影响因子：
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通讯作者：
Blute,MichaelL
中科院分区：
文献类型：
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作者：
Breau,RodneyH;Cheville,JohnC;Lohse,ChristineM;Kwon,EugeneD;Blute,MichaelL
0022-5347/09/1826-2979/0第182卷，2979-2985，2009年12月THE JOURNAL OF UROLOGY®美国印刷版权所有© 2009美国泌尿外科协会DOI：10.1016/j. juro。2009.08. 059 www.司法学对于患有透明细胞肾细胞癌（ccRCC）的患者，com 2979信息是令人担忧的。如果不熟悉现有证据的临床医生阅读，这种对无统计学意义结果的解释是误导性的，并且可能有害。对泌尿外科无统计学意义的结果的错误解释是有问题的，因为无意义的结果往往反映了不足的力量，而不一定是缺乏关联。1为了强调这一问题，我们参考了构成研究结论基础的统计数据（文章中的表2）。在多变量模型中，与坏死相关的ccRCC死亡风险无统计学显著性（HR 1.8，95% CI 0.59 - 5.45）。然而，肿瘤分期（HR 1.42，95% CI 0.95 - 2.13）和分级（HR 1.37，95% CI 0.89 - 2.13）同样无统计学显著性。由于缺乏统计学意义，我们是否应该得出结论，肿瘤分期和分级也不重要？显然，第二类错误的概率是本分析中的一个问题。基于这些数据，关于已建立的预后因素无效的权威性声明是未经证实的，并且可能是错误的。应用分期、大小、分级和坏死（SSIGN）评分，2其中包括凝固性肿瘤坏死的存在，证实了这一特征的独立有用性。3凝固性肿瘤坏死是一种明确的显微病理特征，必须与ccRCC中发现的纤维化和纤维蛋白沉积的更常见退行性特征分开。大量的数据集一致显示，凝固性肿瘤坏死的存在携带重要的预后信息，可用于患者咨询和术后监测。4-7坏死程度可能进一步分层患者风险的观察结果增加了我们的理解，尽管在更大的数据集中外部验证这些结果很重要（如作者所指出的）。我们怀疑凝固性肿瘤坏死被病理学家低估了，尽管这一信息很有价值，但泌尿科医生却没有充分利用。鉴于目前的证据，以及有待充分把握的矛盾数据，凝固性肿瘤坏死的存在应被视为ccRCC的一个强有力的不良预后特征。
0022-5347/09/1826-2979/0 Vol. 182, 2979-2985, December 2009 THE JOURNAL OF UROLOGY® Printed in USA Copyright© 2009 by AMERICAN UROLOGICAL ASSOCIATION DOI: 10.1016/j. juro. 2009.08. 059 www. jurology. com 2979 mation for patients with clear cell renal cell carcinoma (ccRCC) is concerning. This interpretation of their nonstatistically significant result is misleading and potentially harmful if read by clinicians unfamiliar with existing evidence. Incorrect interpretation of statistically nonsignificant findings in urology is problematic, since nonsignificant results are often a reflection of inadequate power and not necessarily an absence of association. 1 To highlight this issue, we refer to the statistics that formed the basis of the study conclusions (table 2 in article). In the multivariable model the risk of death from ccRCC associated with the presence of necrosis was not statistically significant (HR 1.8, 95% CI 0.59 to 5.45). However, tumor stage (HR 1.42, 95% CI 0.95 to 2.13) and grade (HR 1.37, 95% CI 0.89 to 2.13) similarly were not statistically significant. Given the lack of statistical significance, should we conclude that tumor stage and grade are also of no importance? Clearly the probability of type II error is a concern in this analysis. Based on these data, authoritative statements about the futility of established prognostic factors are unsubstantiated and likely erroneous.Application of the stage, size, grade and necrosis (SSIGN) score, 2 which incorporates the presence of coagulative tumor necrosis, gives credence to the independent usefulness of this feature. 3 Coagulative tumor necrosis is a well-defined microscopic pathological feature, and must be separated from the more common degenerative features of fibrosis and fibrin deposition found in ccRCC. Large data sets consistently reveal that the presence of coagulative tumor necrosis carries important prognostic information that can be used for patient counseling and postoperative surveillance. 4–7 The observation that the extent of necrosis may further stratify patient risk adds to our understanding, although it will be important (as the authors note) to validate these results externally in larger data sets. We suspect that coagulative tumor necrosis is underreported by pathologists and underused by urologists despite the value of this information. Given the current evidence, and pending adequately powered contradictory data, the presence of coagulative tumor necrosis should be considered a strong adverse prognostic feature of ccRCC.