In this large contemporary series involving 376 patients, Onaitis and colleagues [1Onaitis M.W. Petersen R.P. Haney J.C. et al.Prognostic factors for recurrence after pulmonary resection of colorectal cancer metastases.Ann Thorac Surg. 2009; 87: 1684-1689Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar] discuss clinical prognostic factors for recurrence-free survival after pulmonary metastasectomy for colorectal cancer metastases. Because there are only a few large and contemporary studies on recurrent-free survival after pulmonary metastasectomy, the resulting article is of particular value. It has been clearly shown that the prognosis is significantly impaired if the number of pulmonary metastases exceeds two, the disease-free interval is less than 1 year, age is younger than 65 years at time of metastasectomy, and if the patient is of female gender. More than 50% of all patients were enrolled in a treatment concept with neoadjuvant or adjuvant chemotherapy. Thus, this study is an important addition to the literature in regard to our continuing efforts on the best method of incorporating multidisciplinary care in the management of patients with pulmonary metastases. In my opinion, the necessity of this fact is no longer debatable. Prospective randomized trials to evaluate the use of additional chemotherapy have been performed mostly for hepatic metastasectomy [2Mitry E. Fields A.L. Bleiberg H. et al.Adjuvant chemotherapy after potentially curative resection of metastases from colorectal cancer: a pooled analysis of two randomized trials.J Clin Oncol. 2008; 26: 4906-4911Crossref PubMed Scopus (403) Google Scholar], but as thoracic surgeons, we are also encouraged to evaluate this concept through an adequately powered randomized trial. The feasibility of pulmonary metastasectomy through video-assisted thoracic surgery (VATS) has been recognized; some clinical studies find no inferior results on overall survival compared with open thoracotomy [3Nakajima J. Murakawa T. Fukami T. Takamoto S. Is thoracoscopic surgery justified to treat pulmonary metastasis from colorectal cancer?.Interact Cardiovasc Thorac Surg. 2008; 7 (discussion 216–7): 212-216Crossref PubMed Scopus (58) Google Scholar]. According to the data presented here, no recurrence-free survival difference between the two approaches. This may be attributable to the evolvement of modern staging techniques, such as multislice computed tomography and positron-emission tomography. By reducing the slice thickness, the rate of false-positive intrapulmonary nodules can be adversely increased [4Pfannschmidt J. Bischoff M. Muley T. et al.Diagnosis of pulmonary metastases with helical CT: the effect of imaging techniques.Thorac Cardiovasc Surg. 2008; 56: 471-475Crossref PubMed Scopus (31) Google Scholar]; furthermore, if a very small metastasis is missed and resected later, it is unclear whether the effect on long-term survival might be negative. However, factors such as thoracic lymph node involvement, histology, and perhaps the use of different interim chemotherapy may affect the findings [5Pfannschmidt J. Dienemann H. Hoffmann H. Surgical resection of pulmonary metastases from colorectal cancer: a systematic review of published series.Ann Thorac Surg. 2007; 84: 324-338Abstract Full Text Full Text PDF PubMed Scopus (424) Google Scholar]. The former two factors of histology and thoracic lymph node involvement were not addressed in the current study. Intraoperative assessment of the lymph nodes might be considered at the time of pulmonary metastasectomy because 12% to 19% of patients with pulmonary metastases will have positive thoracic lymph nodes [5Pfannschmidt J. Dienemann H. Hoffmann H. Surgical resection of pulmonary metastases from colorectal cancer: a systematic review of published series.Ann Thorac Surg. 2007; 84: 324-338Abstract Full Text Full Text PDF PubMed Scopus (424) Google Scholar]. Unexpected involved thoracic lymph node metastases were not detected in the study by Onaitis and colleagues [1Onaitis M.W. Petersen R.P. Haney J.C. et al.Prognostic factors for recurrence after pulmonary resection of colorectal cancer metastases.Ann Thorac Surg. 2009; 87: 1684-1689Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar], however, because a systematic mediastinal and hilar lymph node dissection was not reported. No doubt, the debate whether systematic mediastinal and hilar lymph node dissection contributes to radicality, or whether it is mostly diagnostic or not, will go on. Although this article does not clearly address the question of whether a VATS approach alters survival, it does suggest that the tumor biology may be far more important for the outcome of these patients than undetected lymph node metastases and residual pulmonary metastases. Surgically amendable metastatic disease develops in a limited number of patients; thus, we are obligated to research the relevant molecular pathways to give us further understanding of the pulmonary metastatic cascade and to evaluate proposals for prospective randomized trials [6Treasure T. Fallowfield L. Farewell V. et al.Pulmonary metastasectomy in colorectal cancer: time for a trial.Eur J Surg Oncol. 2009; ([E-pub ahead of print; doi:10.1016/j.ejso.2008.12.005])PubMed Google Scholar]. Prognostic Factors for Recurrence After Pulmonary Resection of Colorectal Cancer MetastasesThe Annals of Thoracic SurgeryVol. 87Issue 6PreviewThis study was undertaken to review a large series of resections of colorectal pulmonary metastases in the era of modern chemotherapy. Full-Text PDF