In our cohort, adherent tumors contained high levels of MMP9, and elevated circulating MMP9 in VS may reflect ongoing ECM remodeling resulting in “leakage” of tumor-secreted proteins.16,51 MMP9 is an independent factor in predicting the development of adherent tumors apart from tumor size, and our data provides an additional tool for preoperative planning, predicting the intraoperative difficulty of tumor dissection, and patient counseling. The gene discussed is MMP9; the disease is neoplasm.