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Additional Supporting Information may be found in the
online version of this article at the publisher’s web-site:
Figure S1. Nomogram predicting 10-year CSM-free rate in
pN1 PCa patients in the original study population.
point values are calculated and then applied to the desired
probability scale at the bottom of the ﬁgure.
Editorial Comment to Evaluating the predictive accuracy and the clinical beneﬁt of a
nomogram aimed to predict survival in node-positive prostate cancer patients:
External validation on a multi-institutional database
The paper by Bianchi et al. is an interesting study testing, by
using a multi-institutional database, the predictive accuracy of
a previously published nomogram predicting survival in
patients harboring pathological nodes after radical prostatec-
At the same time, the authors tested the clinical bene-
ﬁt of the above-mentioned nomogram.
Patients with pathological nodes at radical prostatectomy
are currently classiﬁed as harboring a high-risk disease,
regardless of the number, percentage, size or side of nodal
metastases. Effectively, a more extensive evaluation of “quan-
tity” of nodal metastases could explain the heterogeneous
prognosis of such a high-risk population and why up to a
third of patients remain disease-free in the long term without
the need of any adjuvant treatment.
As for other predictive tools or nomograms,
nomogram of Abdollah et al.
was created by using a well-
deﬁned population, within which it received an internal vali-
dation. The “success” in terms of acceptance and expendabil-
ity comes from external validation, which eventually showed
that the nomogram can be replicated by uro-oncologists in
other samples, times and settings. As its original purpose was
to predict cancer-speciﬁc mortality-free survival in patients
harboring lymph node metastases at radical prostatectomy, its
clinical importance in the postoperative decision-making pro-
cess is pivotal.
The external validation showed that the nomogram
revealed inferior predictive accuracy as referred to the origi-
nal population. As scientists and physicians, this is what we
usually experience in real-life practice; that is, certain differ-
ences between an ideal setting (such as accurate clinical tri-
als) and current clinical practice, which is usually
characterized by different surgical approaches and extension
of lymph node dissection, pathology review, timing and type
of adjuvant therapy, and follow up. All these factors com-
monly explain the inferior predictive accuracy in an external
validation setting in contrast to an original validation setting,
as Bianchi et al. correctly suggested. However, the real-life
practice is essential to better understand and eventually
improve the original, admirable idea of Abdollah et al.
Despite this, and conﬁrming the importance of the nomo-
gram, the results coming from the “decision curve analysis”
showed a clinical beneﬁt by improving the postoperative
management of such complex and heterogeneous patients. It
is another step towards a tailored medicine.
Urology Department, USL 2, Umbria, Italy
© 2018 The Japanese Urological Association
Prediction of survival in pN1 PCa