To the Editor We read the article by Altorki et al, reporting that the presence of visceral pleural invasion (VPI) was associated with higher recurrence rates and poorer survival in patients with small (≤2 cm) peripheral non–small cell lung cancer (NSCLC) independent of the extent of resection (lobar vs sublobar). The authors suggested that patients with clinical stage IA NSCLC (≤2 cm) with VPI may be candidates for adjuvant therapy trials. However, we think that these data should be interpreted with caution, as there was no adjustment for conventional tumor-specific pathologic variables predictive of relapse in stage IA NSCLC, including lymphovascular invasion (LVI), high-grade patterns (micropapillary and/or solid subtypes), and tumor spread through air spaces (STAS). In a study by Schuchert et al, although univariate analysis indicated VPI as a significant clinical parameter influencing recurrence in clinical stage I NSCLC after resection, it did not emerge as a statistically significant predictor of inferior survival in multivariable analysis. Therefore, further data on the co-occurrence of additional prognostic pathologic features are needed to accurately assess the exact prognostic impact of VPI in this patient group. If possible, we kindly recommend multivariable analyses incorporating LVI, grade, and STAS to evaluate the generalizability of the study findings.