The tumors in the IASLC analysis of additional nodules may have been a mixed group (ie, lepidic adenocarcinomas, solid nodules, SPLCs, isolated pulmonary metastases) defined and treated differently in different institutions. A mixed cohort of patients could still yield survival differences among the nodule categories (same lobe, ipsilateral, and contralateral), with consistent trends across continents and histologic and database types. Furthermore, the observed outcomes may reflect our biases more than differences in biology. The IASLC analysis noted 5-year survival by clinical stage of 29%, 25%, and 3% for same-lobe, ipsilateral, and contralateral nodules, respectively.8 However, the majority of same-lobe (96%) and ipsilateral (88%) nodules underwent surgery, whereas the majority (98%) of contralateral nodules did not.1,3 Whether this finding represents selection bias or serendipity, it limits the ability to define the biologic nature of these lesions. Therefore, we must be careful in how we approach patients with additional nodules. If we think too rigidly (eg, isolated metastasis, SPLCs only if histologically different, candidacy for a particular treatment), we easily may be misled and thereby perpetuate suboptimal treatment emanating from a fallacy. The stage classification nomenclature does not address the fundamental issue, which is the nature of the lesions.