Intravascular Tumor Extension Research Articles

Close margin of adverse histologic factors with a negative primary tumor margin is not associated with increased locoregional recurrence in colon cancer

PurposeLocoregional recurrence after resection of colon cancer is increased when primary tumor margin is positive (<1 ​mm). Data is limited regarding the risk of locoregional recurrence with close margin (<1 ​mm) of histologic factors, such as intravascular tumor, intranodal tumor, tumor deposits, or extranodal extension. We hypothesized that close margin of these factors doesn't affect locoregional recurrence. MethodsA retrospective review of all colon cancer surgical resections for adenocarcinoma from 2007 to 2020 was performed. Inclusion criteria were specimens with a negative primary tumor margin but a close margin of adverse histologic factors, defined as intravascular tumor, intranodal tumor, tumor deposits, or extranodal extension within 1 ​mm of a mesenteric or circumferential margin. ResultsAmong 4435 pathology reports reviewed, 45 (1 ​%) of cases met inclusion criteria. Average follow-up was 38 months. The adverse histologic factor was identified as intranodal tumor in 24 (53 ​%) cases, intravascular tumor in 8 (17.8 ​%), tumor deposits in 5 (11.1 ​%), and more than one pathologic feature in 6 (13.3 ​%). There were 9 (20 ​%) recurrences; 6 (13 ​%) had distant recurrences only, 2 (4 ​%) patients had locoregional recurrences only, and 1 (2 ​%) patient had both locoregional and distant recurrence. The adverse histologic factor in these three patients was intravascular in two and both intravascular and intranodal in one. ConclusionBased on our results, we do not have evidence that the presence of intravascular tumor, intranodal tumor, tumor deposits, or extranodal extension within 1 ​mm of a mesenteric or circumferential margin is associated with increased risk of locoregional recurrence.

Renal Cell Carcinoma With Tumor Thrombus: A Case Series in Puerto Rico.

Renal cell carcinoma (RCC) is one of the most common types of kidney cancer. While RCC tends to present as a localized tumor, a notable proportion may present with distant metastasis. In some instances, RCC may also present with intravascular tumor extension, often called tumor thrombus (TT). Its presence confers a worse prognosis and has important implications for the tumor's staging and treatment. Despite extensive documentation of RCC TT in the US, limited data exists regarding its presentation, management, and outcomes in Puerto Rico(PR). This study aims to broaden the available information on RCC TT, emphasizing surgical management and outcomes. We also provide descriptive data on patient demographics and clinical presentation to improve decision-making among clinicians caring for Puerto Rican men and women. In this single-center, retrospective study, we evaluated patients who underwent partial or total nephrectomy at Saint Luke's Episcopal Medical Center between 2018 and 2022. Data was abstracted from electronic health records (EHR). Patients without documented evidence of TT during the peri-operative period were excluded from the study. A total of 220 patient records were evaluated, of which 12met the inclusion criteria for the study. Caseswere categorized using the latestRCCTT guidelines. Central tendency measurements were used to describe the sample distribution. The mean was considered to make assumptions regarding the prevalent observations, and the median was considered to rule out possible outliers.Categorical data were evaluated using proportion analyses, including TT extension level and BMI variables. Fisher's exact test evaluated the association between the World Health Organization/International Society of Urological Pathology(WHO/ISUP) grade and TT extension level. Most patients lacked TT-related symptoms. Themost severe presenting symptom was a pulmonary embolism (8.3%). Hypertension (83.3%), BMIgreater than 25 at the time of diagnosis (75%), and type 2 diabetes mellitus (66.7%) were the most common comorbid conditions within our cohort. Nearly 75% ofpatients underwent laparoscopic radical nephrectomy with TT resection. One left-sided level III case was managed by laparoscopic-assisted open radical nephrectomy with a right subcostal incision. There were zero intraoperative complications and two postoperative complications. The histopathological reports of all cases were consistent with clear cell carcinoma, and half of the cases (n=6) were WHO/ISUP G4. All patients are alive and free of disease. RCCis a common renal neoplasm in PRthatcanpresent withintravascular tumor extension.Our findings do not establish a definitive association between BMI, tumor size, WHO/ISUP grading, and TT extension level. Our study shows that laparoscopic removal of RCC TT is a safe and effective approach. However, the generalizability of our findings is limited by the study's design and sample size. Future research should focus on identifying predictive markers, establishing effective screening protocols, and determining if our hybrid approach has comparable outcomes to the standard open approach.

Intravascular Tumor Extension and Pulmonary Tumor Embolism in Children With Solid Malignancies: Is There a Role for Inferior Vena Cava Filters?

Intravascular tumor extension is an uncommon complication of solid malignancies that, when present in the inferior vena cava (IVC), can result in fatal pulmonary tumor embolism. Currently, neoadjuvant chemotherapy and surgery are the mainstays of treatment; however, there are no consensus guidelines for management. We describe three cases of pediatric solid malignancies with associated IVC extension and pulmonary tumor embolism. We hypothesize that there is scope for IVC filter placement in such cases to mitigate the risk of fatal pulmonary tumor embolism.

Nephron sparing surgery and surgical management of intravascular extension of Wilms tumor.

Although general treatment approaches for Wilms tumor differ between Children's Oncology Group and Société Internationale d'Oncologie Pédiatrique-Renal Tumors Study Group protocols, complex tumors that may be candidates for nephron sparing surgery (NSS) and those with intravascular tumor extension represent a management challenge. In both of these scenarios, anatomic considerations are important in guiding management, making these areas of significant similarities in management between the international groups. This paper aims to explore the current approaches to NSS and intravascular tumor extension by both international groups, with attention to the evidence supporting these approaches and current knowledge gaps.

A Case Report of a Thrombectomy of Internal Jugular Vein Tumoral Thrombus of Follicular Thyroid Cancer Origin

Intravascular tumor extension of a thyroid cancer is a rare but life-threatening condition. We report herein the case of a 66-year-old female patient with follicular thyroid carcinoma and an internal jugular vein (IJV) tumor thrombus. The patient had undergone a thyroidectomy at our institution and presented with left-sided swelling of face and neck. An MRI showed a thrombus within the left IJV, a finding confirmed by US. During surgery, a left IJV tumor thrombus was identified and excised followed by venous reconstruction. The pathological examination confirmed a follicular thyroid carcinoma. The patient received postoperative treatment with 150 mCi of 131I, followed by thyroid-stimulating hormone suppression therapy with thyroxine. Although the fibrous capsule prevents the tumor’s invasion into the surrounding structures, the presence of a tumor thrombus carries a poor prognosis.

Does Renal Mass with Venous Thrombosis always Indicate Renal Cell Carcinoma? A Case Series.

Intravascular tumor extension in the major renal veins or their tributaries, as ararebut importantclinical entitythat can change the disease stage, prognosis, and approach to treatment. There is limited literature on the obstruction of renal vein and IVC by tumor thrombus in other types of renal tumors that are not of RCC type. We presented four different renal tumor cases with the presence of gross renal vein or IVC thrombosis. Although the incidence of renal vein and IVC tumor thrombus might be suggestive of (often diagnosed as) RCC, the possibility of other non-RCC renal tumors should be included in the differential diagnosis.

Renal spindle cell tumor with thrombus extension into the inferior vena cava and the right atrium depicted by positron emission tomography/computerized tomography scan

Tumor thrombus (also called intravascular tumor extension) can be defined as tumor extending into the vessel, typically a vein; it occurs in a lot of malignancies such as hepatocellular carcinoma and Wilms tumor. Tumor thrombus has been reported to demonstrate increase in fluorodeoxyglucose (FDG) uptake that would differentiate it from the benign bland thrombus, which would not take up FDG on positron emission tomography/computerized tomography (PET/CT) scan. We present a case of spindle cell sarcoma of the right kidney whose baseline contrast-enhanced CT revealed a mass replacing the right kidney and right renal vein and associated with thrombus in the inferior vena cava (IVC). Fluorine-18 FDG PET/CT imaging was done and revealed an FDG-avid hypermetabolic malignant right renal mass with hypermetabolic IVC thrombus extending to the right atrium.

Follicular Variant of Papillary Carcinoma Thyroid with Massive Angioinvasion of the Internal Jugular Vein: Our Approach

Follicular variant of papillary carcinoma thyroid is an aggressive variant of papillary carcinoma thyroid. It is more commonly associated with extrathyroidal extension and regional lymphadenopathy. It can rarely be associated with microscopic vascular invasion but tumor thrombus into great veins is a rare phenomenon. We present a case of 60-year-old male with follicular variant of papillary carcinoma thyroid with tumor thrombosis in superior thyroid vein and internal jugular vein (IJV). We report a case of a 60-year-old male who presented with a large swelling in the lower part of left side of neck for 4 months. Clinical examination revealed a hard swelling of 12x8 cm in left side of neck. Ultrasonography showed a solitary thyroid mass of the left lobe and a dilated left superior thyroid vein and ipsilateral IJV. Fine-needle aspiration cytology revealed follicular variant of PTC cells. Total thyroidectomy was done. A tumor thrombus was discovered in the superior thyroid vein and left IJV was found to be dilated. The left IJV with superior thyroid vein was ligated and excised. The patient recovered well after the operation with no local or distant metastasis detected. Follicular variant of PTC commonly spreads to the lymph nodes. Vascular spread via direct intravascular extension through superior thyroid vein is extremely rare. On palpation cord like IJV is felt on the involved side. Neck ultrasound play important role in the diagnosis. Aggressive surgical treatment with IJV ligation above and below the tumor thrombus is recommended to minimize the risk of potentially fatal complications of the intraluminal masses. Intravascular tumor extension into IJV of neck in follicular variant of PTC is rare and can be associated with serious consequences. Total thyroidectomy with thrombectomy with ligation of IJV must be done.

Prostate specific membrane antigen (PSMA) expression in vena cava tumour thrombi of clear cell renal cell carcinoma suggests a role for PSMA-driven tumour neoangiogenesis.

Clear cell renal cell carcinoma (ccRCC) is a malignant renal neoplasm with a peculiar propensity to propagate as a contiguous tumor extension via the renal vein and inferior vena cava, occasionally reaching the right atrium. This intravascular tumor extension, often referred to as a tumor thrombus, represents the active growing front of the cancer. Prostate specific membrane antigen (PSMA), a glycoprotein that is extensively used in prostate cancer diagnostics, is a useful vascular marker for a variety of solid tumors. It is expressed in renal carcinomas. The aim of the current investigation was to analyse and compare the expression of PSMA at the growing front of the vena cava tumor extension with that found in the primary renal lesion. Immunohistochemical (IHC) analysis of PSMA and CD34 was performed on archived paraffin embedded vena cava tumour thrombus tissue and matching renal tumours. These specimens were collected from radical nephrectomies of 10 patients with vena cava invasive (pT3b) ccRCC in a large tertiary hospital in Australia. Quantitative and qualitative morphometric analysis of PSMA IHC expression was performed with Aperio ImageScope morphometry using intensity and positive pixel counts of CD34 and PSMA from the IVC tumour slides and the corresponding renal tumour mass. PSMA and CD34 immunostaining were noted in the neovasculature of IVC tumour and renal tumour tissue. There was a higher PSMA/CD34 positive pixel count ratio noted in IVC tumour tissue when compared to renal tumour tissue. PSMA showed consistently increased expression in vena cava tumour, in comparison with the renal tumour mass. Intravascular venous tumour extension expresses PSMA more intensely compared to intrarenal tumour tissue neovasculature. Our data suggest a possible mechanism for PSMA in neoangiogenesis and local progression of ccRCC and therefore its usefulness as a biomarker of neoangiogenesis for future diagnostic and therapeutic advancements.

Tumor thrombus: incidence, imaging, prognosis and treatment.

Intravascular tumor extension, also known as tumor thrombus, can occur in many different types of cancer. Those with the highest proclivity include Wilm's tumor, renal cell carcinoma (RCC), adrenal cortical carcinoma (ACC) and hepatocellular carcinoma (HCC). The presence of tumor thrombus markedly worsens prognosis and impacts treatment approach. Imaging plays a key role in its diagnosis. Endovascular methods also play a large role in treatment.

Alveolar soft part sarcoma: a clinicopathologic analysis of 48 cases

To study the clinicopathologic features and differential diagnosis of alveolar soft part sarcoma (ASPS). The clinical data and pathologic features of 48 cases of ASPS were evaluated. Immunohistochemical study, PAS staining and fluorescence in-situ hybridization (FISH) were carried out in selected examples. Relevant literature was reviewed. Amongst the 48 cases studied, there were 17 males and 31 females, with male-to-female ratio of 1.0∶1.8. The age of patients ranged from 2 to 60 years (median=26 years). The tumor was most commonly located in deep soft tissue, especially that of lower extremities. Histologically, the tumor cells were arranged in alveolar or solid patterns and separated by sinusoidal vessels. They were large and contained abundant eosinophilic granules or crystals in cytoplasm. The nuclei were round to polygonal and vesicular, often with prominent nucleoli. Intravascular tumor extension was common. Some cases showed necrosis, hemorrhage and cystic changes. Immunohistochemical study showed that the tumor cells were positive for TFE3 (100%, 33/33). FISH assay was carried out in 4 cases and all of them had TFE3-ASPL gene fusion. ASPS is a rare malignant neoplasm, often occurs in young patients. TFE3 is a useful immunohistochemical marker for diagnosis. The diagnosis is further confirmed by other markers.

A rare case of hepatocellular carcinoma with right atrial invasion

An elderly male came with h/o loss of appetite and weight loss since 3 months. On evaluation, prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) values were high. Hepatitis B surface antigen (HbSAg) screening was reactive and serum alfa-fetoprotein (AFP) was raised. Ultrasound examination revealed a hepatic mass with inferior vena caval extension and direct invasion of the right atrium. Computed tomography (CT) scan of the lower thorax and abdomen was performed, which confirmed the ultrasound diagnosis. The patient had a brief stay in the hospital and got discharged against medical advice; he was not available for follow-up. Hepatocellular carcinomas (HCCs) commonly metastasizes to the lung, bone, brain, and adrenal glands. About 70% of the patients with HCCs have hepatic and portal vein invasions but encroachment into the right atrium is very rare. The most common symptoms of cardiac metastasis include asymptomatic cases, bilateral lower leg edema, and exertional dyspnea in that order. Typical complications of intravascular tumor extension lead to secondary Budd-Chiari syndrome, right heart insufficiency, or massive pulmonary embolism. The prognosis of HCC with atrial invasion is poor, with median survival ranging from 1 month to 4 months. HCC in these cases may be more aggressive, with a shorter doubling time. The risk for cardiopulmonary collapse is higher, with heart failure or sudden death. Surgical interventions as well as nonsurgical approaches have been used in the treatment of patients with symptomatic inferior vena cava (IVC)/right atrial tumor thrombi. There are few reports of en bloc hepatectomy and resection of the right atrial thrombus under cardiopulmonary bypass. Routine screening in patients with HCC, such as including chest imaging as part of surveillance computed tomographic scans, may facilitate earlier detection and treatment.

Intraoperative Echocardiographic Diagnosis of Inferior Vena Cava Stenosis After Cardiopulmonary Bypass

THE INFERIOR VENA CAVA (IVC) is responsible for about two thirds of the total venous return to the right atrium (RA). Obstruction of the IVC can be due to chronic disease or an acute insult. The etiology of chronic IVC obstruction includes congenital abnormalities, indirect compression of the IVC (retroperitoneal tumors, hepatic tumors, giant left atrium), or intravascular tumor extension (metastatic renal tumors). Chronic obstruction of the IVC is associated with findings of hepatic congestion, ascites, lower extremity edema, and venous thrombosis. The slow progression of disease results in collateral venous return to the superior vena cava (SVC) via the azygos, intrathoracic, and vertebral veins. In contrast, acute stenosis of the IVC can result in hepatic and renal dysfunction, severe hemodynamic instability, and cardiovascular collapse if left untreated. Acute IVC obstruction is rare and has been reported as a complication of operative procedures, including bicaval heart transplantation, orthotopic liver transplantation, mitral valve replacement, and extrinsic compression from implantation of a Nuss bar for repair of pectum excavatum. The authors describe a case of acute IVC stenosis at the RA junction that was diagnosed by intraoperative transesophageal echocardiography after cardiopulmonary bypass (CPB). The intraoperative echocardiographic findings included a localized area of narrowing at the IVC-RA cannulation site, turbulent flow into the RA, underfilled cardiac chambers with hyperdynamic biventricular activity, and dilated hepatic veins. The echocardiographic findings were correlated with invasive hemodynamic measurements, and a therapeutic intervention with return to CPB was performed. The authors recommend the routine examination of the IVC at the IVC-RA junction with color-flow Doppler and spectral Doppler interrogation of flow after cardiac surgery cases, especially in the case of a bicaval venous cannulation technique.

Intravenous leiomyomatosis presenting as acute Budd-Chiari syndrome

Intravenous leiomyomatosis is a rare condition that has been described as being associated with venous occlusion by direct intravascular tumor extension, typically from a pelvic organ. We report an exceedingly rare case of intravenous leiomyomatosis extending into the inferior vena cava, leading to pulmonary embolism, hepatic venous outflow obstruction, and an acute Budd-Chiari syndrome. This is the second reported patient with intravenous leiomyomatosis with Budd-Chiari syndrome and, to our knowledge, the first reported patient who survived with surgery. Correlative images, illustrating computed tomography and magnetic resonance imaging findings characteristic of intravenous leiomyomatosis with secondary Budd-Chiari syndrome, are presented and discussed.

EUS FNA of Distant Extra-Vascular Migratory Metastasis (EVMM) and Tumor Thrombosis

Background: Vascular invasion impacts cancer staging, prognosis, and therapy. Malignant infiltration usually results from direct and gross extension from a primary tumor and is readily identified by CT. Cancers may also migrate to remote sites along vascular channels, a process termed angiotropism or EVMM. Sometimes this pattern of spread can be seen with CT. Surgical and autopsy studies also demonstrate microscopic or diminutive (1-3 mm thick) spread not seen with CT. Additionally, a tumor thrombus may only be recognized at surgery or autopsy. We report the EUS FNA diagnosis of malignant perivascular cuffing and tumor thrombosis occurring distant from a primary tumor, including microinvasion with negative helical CT. Aims: To examine the capability and safety of EUS FNA for diagnosing distant perivascular tumor infiltration and tumor thrombus in CT positive and negative (i.e. microinvasion) patients. Methods: Using a prospectively maintained EUS database, we identified all examinations from 09/04 to 11/08 in which FNA was performed of a vascular wall or intravascular thrombus. We abstracted and analyzed date regarding demographic, radiology and EUS features, cytology results, and follow up data. Results: EUS FNA was performed from 31 vascular sites [vascular wall (n=27), intravascular thrombus (n=4)] during 29 exams in 27 patients [15 male, age 55±11 years]. Cancer was diagnosed in 24/27 (89%) patients of whom 20 had pancreatic cancer. For diagnosis of vascular involvement remote from cancer (EVMM), a median of 3 FNAs (range 2-9) was obtained from wall of the celiac artery (n=12), SMA (n=6), hepatic artery (n=5), splenic artery (n=2), SMV (n=1), aorta (n=1); and intravascular FNA of portal vein (n=4). FNA cytology was positive (n=17) or suspicious (n=2) among cancer patients. EUS FNA detected and confirmed microinvasion in 3 patients with negative helical CT. CT and EUS identified indeterminate peri- and intravascular findings in 3 patients ultimately diagnosed with benign disorders after a median follow-up of 3 (0.4-7) months. EUS FNA was negative in each of these patients. Conclusion: CT and EUS can identify peri- and intravascular tumor extension remote from the primary tumor and not resulting from gross infiltration. EUS can detect microinvasion (1-3mm) not seen on helical CT. Further study is needed to determine the prevalence, to establish the safety and accuracy of EUS FNA, and impact on prognosis, clinical care, and outcomes.

Leiomyosarcoma of the Uterus with Intravascular Tumor Extension and Pulmonary Tumor Embolism

We report the case of a 48-year-old woman presenting with recurrent uterine leiomyosarcoma (LMS) associated with right iliac vein and inferior vena cava (IVC) invasion and left lower lobe pulmonary tumor embolus. Because the prognosis and treatment differ from that of thrombotic pulmonary emboli, the differentiating imaging characteristics of intravascular tumor embolism are reviewed. To our knowledge, only two other cases of intravenous uterine leiomyosarcomatosis have been described in the existing literature, and this is the first reported case of the entity with associated intravascular tumor embolism.

Wilms' tumour with persistent intravascular extension: A review of the surgical aspects of management

Aim To review the surgical management of Wilms' tumour with persistent intravascular (vena caval +/− atrial) tumour extension. Patients and methods Data were collected regarding operative details, tumour and ‘thrombus’ histology, and long-term outcome for patients with Wilms' tumour with cavo-artial extension. Result From 1988 to 2004, 13 patients underwent treatment for Wilms' tumour with persistent intravascular extension. Preoperative chemotherapy was administered in 11/13 patients and postoperative radiotherapy in eight patients. Intravascular involvement was upto IVC (5), and right atrium (8) patients. Techniques employed for excision of intra-vascular component were: local cavotomy (3), extensive infra-diaphragmatic cavotomy without cardiopulmonary bypass (CPB) (1), and excision of cavo-atrial tumour with CPB (+/− hypothermia and cardiac arrest) (9). Mean time on CPB was 90 min. Caval repair was accomplished by primary repair (6) and pericardial graft in (7) patients. There were no intraoperative deaths and few major complications. Tumour thrombus contained malignant cells in 10/13 cases. Mean follow up has been for 55.4 months. To date, seven patients remain disease-free (one lost to follow up), disease recurred in five patients, three of whom have died. There were no symptoms related to the graft. Conclusions Surgery for Wilms' tumour with persistent intravascular extension despite chemotherapy is technically challenging. CPB +/− hypothermia and cardiac arrest and extensive caval repair with a graft is safe and reliable in the long term.

Large Adrenocortical Carcinoma Extending into the Inferior Vena Cava and Right Atrium

A case of large adrenocortical carcinoma extending into the inferior vena cava and right atrium is reported. Computed tomography showed a large mass displacing the left kidney inferiorly with an intravascular tumour thrombus extending into the inferior vena cava and right atrium. Radical surgery under hypothermia and cardiopulmonary bypass was performed and the tumour mass, together with the tumour thrombus, was successfully removed. The presence of intravascular tumour extension alone should not be a contraindication to radical surgical therapy, as it is the best hope for prolonged survival.

Three-dimensional volume-rendered CT angiography of the renal arteries and veins: normal anatomy, variants, and clinical applications.

Three-dimensional volume-rendered computed tomographic (CT) angiography represents an increasingly important clinical tool that, in many institutions, is replacing conventional angiography in the depiction of normal vascular anatomy and the diagnosis of vascular disorders. Evaluation of conditions affecting the renal vasculature constitutes a major focus of volume-rendered CT angiography, which has documented utility for demonstrating both arterial and venous disease. Arterial disorders include renal artery stenosis, renal artery aneurysms, and dissection. Venous disorders include splenorenal shunts, thrombosis, and intravascular tumor extension. In addition, volume-rendered CT angiography accurately displays the normal and variant renal vascular anatomy, which is crucial to detect before surgery, especially partial nephrectomy and laparoscopic nephrectomy. CT angiography is also useful in the evaluation of the renal vasculature following renal transplantation. Familiarity with proper CT protocols and data acquisition techniques are crucial for accurate diagnosis.

Pericolonic tumor deposits in patients with T3N+M0 colon adenocarcinomas

A pericolonic tumor deposit (PTD) is a grossly palpated adenocarcinomas within pericolonic adipose tissue not within a lymph node. The source and prognostic significance of PTDs has not been well defined.The authors studied 418 T3N+M0 colon adenocarcinomas to determine the frequency and significance of PTDs. They also step-sectioned 30 PTDs to determine their origin and assist in their optimum TNM classification.Seventy-one (18%) of 400 consecutively examined cases had PTDs. The actuarial 1-, 2-, and 5-year disease free survival rates were significantly lower among patients with a PTD. PTDs, regardless of size, significantly impacted disease free survival. Increasing numbers of PTDs was associated with shorter disease free survival. Adenocarcinoma grade, a PTD, increasing numbers of PTDs, and number of lymph node metastases were independently associated with shorter disease free survival. The likelihood of extrahepatic abdominal failure was proportionally greater with increasing numbers of PTDs. Adenocarcinoma was observed in perineural, peri-large vessel, or intravascular locations in step-sectioned PTDs.A PTD is a perineural, perivascular, or intravascular tumor extension beyond the muscularis propria. They are distinct from lymph node metastases and should not be considered their prognostic equivalent. The disease free survival impact of even small PTDs was significant, suggesting that PTDs of all sizes should be considered a single entity. TNM classification of PTDs as lymph node metastases or discontinuous tumor extension is probably not accurate. The number and greatest dimension of PTDs should be reported separately from lymph node metastases.