In Reply. —
The comment by Dr Powers is most appropriate regarding the possible relationship between tumor grade and prognosis for patients with metastatic disease.Our initial analysis did not include tumor grade because there was no centralized pathology review and this raised the potential for significant variability. Nevertheless, we have now reviewed all of the data and found in a univariate analysis that, indeed, tumor grade was prognostic.However, in the multivariate analysis, the addition of tumor grade did not add any significant predictability for prognosis. The four parameters presented in our paper remain the most important within our own study population.