One of the most important factors in the prognosis of children with ependymoma continues to be the extent of tumor resection provided by the neurosurgeon. In numerous retrospective and prospective publications, children who undergo a gross-total resection have almost double the survival rate compared with those who undergo a subtotal resection. Massimino and collegues2 report the results of 2 multicenter cooperative trials involving 16 participating pediatric oncology centers from the Italian Association for Pediatric Hematology and Oncology, in which the authors assess the impact of second-look surgery with the intent of accomplishing a gross-total resection in children with ependymoma and prior incomplete resections. In the first study, conducted from 1994 to 2001, children with a gross-total resection received hyperfractionated radiotherapy. Those children with partial resections received vincristine, etoposide, and cyclophosphamide (VEC) chemotherapy, were eligible for second-look surgery, and then received the same radiotherapy as the children with grosstotal resections. In this cohort of 63 children, 9 underwent second-look surgery, and 6 of the 9 underwent a gross-total resection with no major complications. The second study enrolled 110 children who were stratified as either “evidence of disease” on postoperative MR imaging or “no evidence of disease,” and also according to histological results as either WHO Grade II or Grade III tumors. Those children with no evidence of disease and Grade II tumors were treated with 3D conformal radiotherapy. Those with no evidence of disease and Grade III tumors received the same radiotherapy in addition to 4 rounds of VEC chemotherapy. Those with residual tumor were given VEC chemotherapy and the option for second-look surgery before receiving radiotherapy. Of 110 children enrolled, 29 underwent secondlook surgery with 2 significant complications. Fourteen of the children attained gross-total resection. In this study, those children who underwent second-look surgery were referred to specialty centers with greater experience in childhood ependymoma surgery. At a mean follow-up of 4 years, the authors report that the overall survival and event-free survival of the children who underwent more than 1 surgery to achieve a gross-total resection was at least as good as those children who underwent a gross-total resection at a single surgery. They found that the complication rate of secondlook surgery in experienced hands was acceptable and that the risk of iatrogenic dissemination of disease was no different in the children having 1 surgery from those who had multiple surgeries. The authors conclude that secondlook surgery is safe, feasible, and leads to improved survival in this population. They state that future studies within their national cooperative group will include centralized review of postoperative MR images and referral to high-volume specialty centers of those children who require further surgeries. The authors are to be complimented on an enlightening review. It is interesting to note that in historical publications in which a minority of patients underwent a grosstotal resection or in whom postoperative radiographic evaluation was performed with noncontrast CT scans, there was controversy over whether or not the histological results were significant in childhood ependymoma. All of the children did equally poorly. More recently, with high quality postoperative MR imaging and a trend towards a gross-total resection in the vast majority of patients, the difference in Grade II and Grade III ependymoma has proven highly significant.3 Secondly, there has been the suggestion in the past that prolonging the time between resection and radiation in order to give chemotherapy may actually be detrimental. We have employed chemotherapy in young children with very vascular ependymomas prior to second-look surgery and have been pleased to find that the chemotherapy dramatically reduces the vascularity of the tumors, thus facilitating the resection of residual disease.5 We are comforted that the authors confirm our bias that those children receiving a couple of rounds of chemotherapy followed by repeat surgery are at no increased risk.4 Finally, the recognition that higher volume centers do a better job at treating complex neurosurgical problems is notable but of little surprise, because 244 245