Sentinel lymph node mapping of the canine anal sac using lymphoscintigraphy: A pilot study

Sentinel lymph node mapping and biopsy are important parts of oncologic staging in human medicine. Sentinel lymph node mapping enables identification of the first lymph node to receive lymphatic drainage while avoiding unnecessary lymph node dissection. Anal sac adenocarcinoma is the most common malignant neoplasm of the canine perineal area. For dogs with anal sac adenocarcinoma, lympadenectomy and metastasis to the iliosacral lymphocentrum are negative prognostics indicators. The objectives of this prospective, two by two, crossover pilot study were to establish the feasibility of lymphoscintigraphy using Technetium‐99 sulfur colloid of the canine anal sac of healthy dogs, compare two injection techniques, and the time for identification of sentinel lymph nodes using each technique. We hypothesized that both intramural and perimural injections of the canine anal sac would identify similar sentinel lymph node drainage. The sentinel lymph node was identified in all dogs using either technique. Intramural injection of the canine anal sac showed radiopharmaceutical uptake faster than perimural injection technique (P = 0.040). There was concordance between intramual and perimural techniques for the sentinel lymph node identified in 50% of cases. A sacral lymph node was identified as sentinel in three of eight dogs (37.5%). Lymphoscintigraphy of the canine anal sac is safe and feasible in normal dogs; however, the method of injection technique seems to have a significant effect on the sentinel lymph node identified.     

FEASIBILITY OF CONTRAST‐ENHANCED ULTRASOUND‐GUIDED BIOPSY OF SENTINEL LYMPH NODES IN DOGS

Our goal was to develop and validate a technique to identify the sentinel lymph nodes of the mammary glands of healthy dogs with contrast‐enhanced ultrasound, and evaluate the feasibility of obtaining representative samples of a sentinel lymph node under ultrasound guidance using a new biopsy device. Three healthy intact female adult hounds were anesthetized and each received an injection of octafluoropropane‐filled lipid microspheres and a separate subcutaneous injection of methylene blue dye around a mammary gland. Ultrasound was then used to follow the contrast agent through the lymphatic channel to the sentinel lymph node. Lymph node biopsy was performed under ultrasound guidance, followed by an excisional biopsy of the lymph nodes and a regional mastectomy procedure. Excised tissues were submitted for histopathologic examination and evaluated as to whether they were representative of the node. The ultrasound contrast agent was easily visualized with ultrasound leading up to the sentinel lymph nodes. Eight normal lymph nodes (two inguinal, one axillary in two dogs; two inguinal in one dog) were identified and biopsied. Lymphoid tissue was obtained from all biopsy specimens. Samples from four of eight lymph nodes contained both cortical and medullary lymphoid tissue. Contrast‐enhanced ultrasound can be successfully used to image and guide minimally invasive biopsy of the normal sentinel lymph nodes draining the mammary glands in healthy dogs. Further work is needed to evaluate whether this technique may be applicable in patients with breast cancer or other conditions warranting evaluation of sentinel lymph nodes in animals.     

Comparison of computed tomographic images of normal cranial and upper cervical lymph nodes with corresponding E12 plastinated-embedded sections in the dog

To document normal lymph nodes on computed tomographic images, 102 scans were reviewed of dogs that had computed tomography (CT) of the head and upper cervical region. If lymph nodes were identified, symmetry, density, homogeneity, and size, as well as the relation to the surrounding fat tissue were noted. CT images with distinct asymmetric, enlarged, and obliterated lymph nodes were excluded. To improve the detailed anatomical topography, corresponding E12 plastinated-embedded sections of a dog were used. Compared with muscle tissue, normal lymph nodes were slightly hypodense and had a homogeneous parenchyma. Mandibular and retropharyngeal lymphocentres could be seen consistently and CT proved to be a useful method both to detect their presence and to assess their morphology. It was not possible to identify the parotid lymph node consistently because of the lack of tissue contrast at the lymph node-gland interface.     

Surgical treatment of a mandibular ameloblastic carcinoma with metastases to the mandibular lymph nodes in a pony

A 4-year-old Connemara filly was presented with a rapidly growing oral mass on the right rostrolateral mandible and a right mandibular lymphadenopathy. Radiographs of the rostral mandible revealed a lytic, infiltrative mass consistent with soft tissue and mineralised material, and displacement of tooth 403. A biopsy showed characteristic histopathological features of an ameloblastic carcinoma. Subsequent FNA of the right abnormally firm and enlarged mandibular lymph node confirmed the metastatic spread. Computed tomography of the head was performed for surgical planning, including sentinel lymph node mapping to rule out other lymph node involvement. An aggressive lesion, consistent with soft tissue of the rostral right mandible was identified with intralesional contrast injection showing drainage of contrast within the right mandibular lymph nodes (Sentinel node). Based on the infiltrative and destructive nature reported in ameloblastic carcinoma in humans, a rostral mandibulectomy was performed, along with complete mandibular lymphadenectomy. The horse recovered uneventfully from surgery. In the early post-operative period marked lymphoedema of the ventral mandibular region was observed, which resolved 4–5 days post-operatively. Optimal cosmesis was maintained post-operatively, and no recurrence has been observed to date – 12 months post-surgery.     

Comparison of Computed Tomographic and Radiographic Popliteal Lymphangiography in Normal Dogs

Objective: To (1) describe computed tomographic (CT) popliteal lymphangiography; (2) compare the number of thoracic duct (TD) branches detected by CT and by radiography after popliteal lymphangiography; and (3) to compare the number of branches detected after left and right popliteal lymphangiography. Study Design: Experimental study. Animals: Adult dogs (n=6). Methods: A randomly selected popliteal lymph node was percutaneously injected with 12 mL iodinated contrast medium through a 25‐g butterfly catheter over 4–5 minutes. Lateral and ventrodorsal (VD) thoracic radiograph projections and thoracic CT were performed. The procedure was repeated using the contralateral lymph node after a 48–72 hours washout period. Results: One dog had TD branches visible on CT but not on radiographs. A significantly greater number of TD branches were observed with CT popliteal lymphangiography compared with lateral and VD radiographic popliteal lymphangiography (P=.003 and P<.001, respectively). The number of visible TD branches observed between the 6th thoracic and 1st lumbar vertebrae were not significantly different in these dogs (P=.146). A significant difference in number of TD branches observed was not found after left or right popliteal lymph node injection (P=.097). Conclusions: CT popliteal lymphangiography consistently identified a greater number of TD branches when compared with radiographic popliteal lymphangiography. Injection of either popliteal lymph node resulted in the same number of TD branches being observed.     

Comparison of mesenteric lymphadenography performed via surgical and laparoscopic approaches in dogs

OBJECTIVE: To determine whether injection of a mesenteric lymph node with iodinated aqueous contrast medium results in radiographic delineation of the thoracic duct and its branches, ascertain the ideal interval between injection and radiographic imaging, and evaluate mesenteric lymphadenography performed via laparoscopic and surgical approaches in dogs. ANIMALS: 10 adult dogs. PROCEDURE: In each dog, a right paracostal laparotomy or a right laparoscopic approach was performed to identify a mesenteric lymph node for injection of an iodinated aqueous contrast agent (0.22 mL/kg [81.4 mg of iodine/kg]). Lateral radiographic views were obtained at 60, 120, 180, 240, and 300 seconds after injection. RESULTS: A mesenteric lymph node was identified and injected with contrast medium in each dog. Via paracostal laparotomy, lymph node injection resulted in successful lymphangiographic evaluation in 4 of 5 dogs, whereas via the laparoscopic approach, lymph node injection resulted in successful lymphangio-graphic evaluation in 2 of 5 dogs. In successful radiographic evaluations, injected lymph nodes, mesenteric lymphatics, and the thoracic duct and its branches were delineated. Radiographs obtained at 60 and 120 seconds after injection of contrast medium provided the most detail. CONCLUSIONS AND CLINICAL RELEVANCE: Injection of a mesenteric lymph node directly with contrast medium appears to be a feasible technique for delineation of the thoracic duct and its branches in dogs and might be useful in small animals in which mesenteric lymphatic catheterization can be difficult and lymphangiography is more likely to fail. Refinement of the laparoscopic technique may provide a minimally invasive approach to lymphadenography.     

Sentinel lymph node mapping in canine mast cell tumours using a preoperative radiographic indirect lymphography: Technique description and results in 138 cases

Several sentinel lymph node (SLN) mapping techniques, to detect nodal metastasis in canine tumours have been investigated in the last 10 years in veterinary oncology. The purpose of this prospective study was to describe a reliable, quick, and inexpensive technique for SLN mapping in canine patients affected by cutaneous and subcutaneous mast cell tumours (MCT). Eighty dogs were enrolled in this study for a total of 138 cytologically diagnosed MCTs. Sentinel lymph node mapping was performed by injecting iomeprole peritumorally followed by serial radiographs at 1, 3, 6 and 9-min post injection. A total of 168 SLNs were detected, 90% at first radiograph, 1 min after the peritumoral iomeprole injection, while in the rest of the cases SLN was identified at 3 min. Sentinel lymph nodes detected by the preoperative radiographic indirect lymphography with iomeprole (PRILI) differed from regional lymph nodes in 57% of cases. The PRILI technique detected simultaneously multiple SLNs in the 26% of cases and multiple lymph centers in the 31% of MCTs. To allow the surgical identification of the SLNs, a peritumoral injection of methylene blue was performed at the time of surgery. This study reports a widely available technique for SLN mapping using digital radiographs in combination with a water-soluble medium, representing a cost-effective alternative to other SLN mapping procedures. Based on our results, this technique can be effective for SLNs mapping in dogs with MCTs but further comparative studies are needed to assess its reliability and efficacy in different tumours.     

Lymphography of the thoracic duct by percutaneous injection of iohexol into the popliteal lymph node of dogs: experimental study and clinical application

OBJECTIVE: To evaluate the efficacy of percutaneous administration of iohexol into the popliteal lymph node as a non-invasive technique for thoracic duct lymphangiography in dogs. STUDY DESIGN: Experimental study and clinical report. ANIMALS: Normal adult dogs (n=4) and 1 dog with recurrent chylothorax. METHODS: For the experimental study, 4 dogs (weight, 8.4-12.3 kg) had 5-10 mL iohexol injected percutaneously into 1 popliteal lymph node and then thoracic radiographs were taken. Popliteal lymph nodes were examined by histopathology 8 days later. One 25-kg dog with recurrent chylothorax had 25 mL iohexol injected into the right popliteal lymph node followed by thoracic radiography. RESULTS: In experimental dogs, the thoracic duct was best visualized on thoracic radiographs after administration of 10 mL iohexol. Clinically, no abnormalities were identified in the injected limb and except for 1 dog that had large numbers of siderocytes and erythrophagocytic macrophages in the injected lymph node, the histopathologic findings in the other injected popliteal lymph nodes were not different from contralateral nodes. In the clinical case, the thoracic duct was visualized, but there was leakage of iohexol around the node. CONCLUSION: The thoracic duct in dogs can be visualized by lymphography after percutaneous injection of iohexol (1 mL/kg at 2 mL/min) into the popliteal lymph node. CLINICAL RELEVANCE: Percutaneous popliteal lymph node administration of iohexol should be considered as an alternative to mesenteric lymph node injection for radiographic identification of the thoracic duct in dogs.     

Pilot study to evaluate the efficacy of lymphotropic nanoparticle enhanced MRI for diagnosis of metastatic disease in canine head and neck tumours

This pilot study is designed to determine if lymphotropic nanoparticle enhanced MRI (LNMRI) is a viable technique for staging of naturally occurring canine malignant head and neck tumours. Previous imaging studies in veterinary medicine have shown variable sensitivity and specificity for determining metastasis for local lymph nodes in head and neck tumours. LNMRI utilizes ultra‐small superparamagnetic iron oxide nanoparticles (USPIOs) to help in the detection of metastatic disease in lymph nodes. USPIOs are phagocytized and localized to normal lymph nodes where they assist in evaluation for regions of effacement by cancerous cells. Six dogs underwent LNMRI for the diagnosis of metastatic lymph nodes. A truncated MRI consisting of transverse images of T2, T1 pre‐ and post‐contrast and T2* sequences were evaluated for presence of metastasis. Sentinel lymph nodes and lymph nodes with possible metastatic lesions were surgically excised for histological evaluation. In the initial phase of this study, 24 lymph nodes were included in analysis. Subjective observation by the primary investigator had a calculated sensitivity and specificity of 100% and 88% based on histological results. There were no negative side effects to the USPIOs noted in the limited number of patients in this study. Percentage signal intensity loss was calculated and found to be significantly different between metastatic and non‐metastatic lymph nodes (P‐value = .038). In conclusion, this pilot study shows that LNMRI has the potential to be a sensitive and specific method of diagnosing lymph node metastasis. Further research is warranted to determine if this method is clinically applicable and accurate.     

Retrospective analysis of use of fluorine-18 fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG PET/CT) for detection of metastatic lymph nodes in dogs diagnosed with appendicular osteosarcoma

The purpose of this retrospective analysis was to determine if fluorine-18 fluorodeoxyglucose-positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) could potentially be an accurate staging tool for detecting metastatic lymph nodes in dogs with appendicular osteosarcoma based on the quantitative measurement of the maximum standard uptake value (SUV_max) of lymph nodes. A total of 53 dogs were identified that presented for staging via ¹⁸F-FDG PET/CT for primary appendicular osteosarcoma. Patients were categorized according to lymph node status of having either metastatic or non-metastatic nodes based on cytological or histological analysis. Maximum standard uptake (SUV_max) values of the sampled lymph node(s) were recorded and 3/77 (3.9%) of sampled lymph nodes were confirmed metastatic. A Mann-Whitney test revealed a statistical difference in the SUV_max of the metastatic versus non-metastatic lymph nodes [median: 6.6 to 95% confidence interval (CI): 2.56 to 14.37 versus 2.18 95% CI: 2.32 to 3.17, respectively, P-value = 0.05]. This retrospective analysis revealed a significant difference in the SUV_max as measured on ¹⁸F-FDG PET/CT between metastatic lymph nodes and non-metastatic lymph nodes in canine patients afflicted with appendicular osteosarcoma, in spite of the small numbers analyzed. While these results are promising, they should be interpreted with caution and further studies are justified.     

COMPUTED TOMOGRAPHY CHARACTERISTICS OF CANINE TRACHEOBRONCHIAL LYMPH NODE METASTASIS

Tracheobronchial lymph node evaluation is critical for accurate staging of canine thoracic neoplasia and is more accurately achieved with computed tomography (CT) than radiography. Thoracic CT scans of 18 canine patients with known tracheobronchial lymph node histopathology and 10 clinically normal dogs were compared to establish if enlargement or contrast enhancement pattern correlated with metastatic status. Absolute lymph node size and three anatomically normalized lymph node ratios were significantly correlated with metastasis or severe granulomatous lymphadenitis (P<0.0003). Transverse maximum lymph node diameter of 12 mm or lymph node to thoracic body ratio of 1.05 are proposed cutoffs, above which metastatic involvement is very likely; however, only minimal accuracy was gained with normalized ratios. Lymph node contrast enhancement pattern was also significantly correlated to disease. A heterogenous and/or ring pattern was related to metastatic disease (P=0.03). Recommended protocol for CT examination of the tracheobronchial lymph nodes is 1–1.5 mm slices and intervals, intravenous contrast, and control of respiratory motion.     

Radiographic lymphangiographyin the dog using iodized oil

The objective of this study was to develop a clinically applicable technique to visualize the medial retropharyngeal, superficial cervical, axillary, superficial inguinal and medial iliac lymph nodes on radiographs. Direct and indirect lymphangiographic methods using iodized oil were repeated for a minimum of five times at eight different locations to enhance the various lymph nodes, using 16 healthy research dogs. Direct lymphangiography, although more invasive than indirect lymphangiography, resulted in uniform contrast uptake by an increased number of nodes and increased enhancement of the lymphatic vasculature, and is recommended for imaging the medial iliac and superficial cervical lymph nodes. Side effects were more frequent after indirect lymphangiography (10/20 injection sites) than after direct lymphangiography (3/16 injection sites). The small size of afferent lymphatic vessels did not allow use of direct lymphangiography for the medial retropharyngeal, axillary and superficial inguinal lymph nodes; however, indirect techniques allowed adequate visualization of these nodes.     

Computed Tomographic Lymphography of the Thoracic Duct by Mesenteric Lymph Node Injection

Objective— To document a novel technique to image the thoracic duct and its tributaries by contrast enhanced computed tomography (CT) lymphography.
Study Design— Clinical report.
Animals— Dogs (n=6) idiopathic chylothorax.
Methods— Ultrasonography was used to guide percutaneous injection of intestinal lymph nodes with nonionic iodinated contrast medium for preoperative CT lymphography of the thoracic duct in 6 dogs with chylothorax. Thoracic CT images were acquired immediately after contrast medium injection. All dogs had subtotal pericardectomy and thoracic duct ligation. Postoperative thoracic duct lymphography was performed in 3 dogs. Superficial cervical lymph node lymphography was performed in 2 dogs to determine cervical lymphatic contribution to thoracic effusions.
Results— Preoperative thoracic duct lymphography using this technique was successful in delineating the cisterna chyli, thoracic duct, and associated lymphatic vessels in all dogs. Immediate postoperative lymphography performed in 2 dogs revealed successful duct ligation in 1 dog and persistent lymphatic leakage in the other. A 1-month postoperative thoracic duct lymphogram performed in 1 dog revealed unsuccessful ligation or recannulation of 1 of 3 redundant vessels seen preoperatively.
Conclusion— Percutaneous CT lymphography results in excellent detection of the thoracic duct and abnormal thoracic duct drainage patterns both pre- and postoperatively. The contribution of superficial cervical lymph node drainage to reoccurrence of effusions can be evaluated.
Clinical Relevance— Percutaneous CT lymphography using ultrasound-guided contrast medium injection should be considered as an alternative to conventional open abdominal approaches to radiographic or CT lymphography.     

Incorporation of sentinel lymph node mapping in dogs with mast cell tumours: 20 consecutive procedures

The study hypothesis is that incorporation of sentinel lymph node (SLN) mapping in dogs presenting for mast cell tumour (MCT) removal would impact the recommended adjuvant therapy offered. Nineteen dogs were enrolled having either spontaneously occurring or incompletely excised MCTs. Staging included regional lymph node aspiration. SLN mapping was done with regional lymphoscintigraphy combined with intra‐operative lymphoscintigraphy and blue dye. Twenty MCTs in 19 dogs were excised with SLN mapping. Eight dogs had SLNs different from the closest node. Twelve dogs had metastasis in extirpated SLNs, seven occurred in MCTs with a MI ≤ 5. No correlation was noted between patient stage and the c‐KIT proto‐oncogene. Because of SLN staging, 8 of 19 dogs were offered additional therapy that would have otherwise been excluded. Anatomic sampling of lymph nodes in dogs with MCTs does not accurately reflect which lymph nodes are most likely to be receiving the draining tumour lymph.     

Indirect magnetic resonance lymphography of the head and neck of dogs using Gadofluorine M and a conventional gadolinium contrast agent: A pilot study

The purpose of this pilot study was to evaluate lymph node enhancement with an indirect magnetic resonance (MR) lymphography technique using 2 different contrast agents in the head and neck region of healthy dogs. Five dogs were imaged at various times after intradermal injection of gadoversetamide and Gadofluorine M (minimum of 1 week apart) in the right and left mandibular, temporal, and lateral neck regions. We observed consistent progressive enhancement with time in the mandibular, retropharyngeal, and superficial cervical lymph nodes. The node enhancement was comparable for both contrast agents. Contrast enhancement of the parotid lymph nodes was not seen. We conclude that this technique of indirect MR lymphography using either agent could be used to identify those lymph nodes at highest risk of metastatic disease in dogs with cancer, and to guide staging and treatment.     

COMPARATIVE POPLITEAL AND MESENTERIC COMPUTED TOMOGRAPHY LYMPHANGIOGRAPHY OF THE CANINE THORACIC DUCT

Thoracic duct computed tomography (CT) lymphangiograms were performed on seven clinically normal dogs. The appearance of the thoracic duct system was compared following administration of contrast medium through a mesenteric lymphatic vessel vs. ultrasound guided percutaneous injection into a popliteal lymph node using helical and sequential CT acquisition modes. The number of visible thoracic duct branches and the largest thoracic duct branch cross‐sectional area and mean Hounsfield units (HU) were determined from thoracic vertebra 9 to lumbar vertebra 1. Procedural time and patient discomfort were also assessed. Popliteal administration produced a successful thoracic duct lymphangiogram in eight of 11 dogs (73%) after two attempts, while mesenteric administration was successful in eight of 10 dogs (80%) after a single attempt. Popliteal lymphography required 46% of the time and was associated with less patient discomfort than mesenteric lymphangiography. The number of thoracic duct branches seen was not significantly different for either administration technique (P=0.256) or CT acquisition mode (P=0.417). However, the cross‐sectional area and mean HU of the largest thoracic duct branch were greater with mesenteric administration (P<0.001), and helical image acquisition (P<0.001). The thoracic duct branch number, size, and location were highly variable between dogs. Percutaneous popliteal lymphography appears to be an acceptable alternative to mesenteric lymphangiography for the detection of thoracic duct branches in the dog when using either helical or sequential CT acquisition modes.     

Computed tomographic appearance of masticatory myositis in dogs: 7 cases (1999-2006)

OBJECTIVE: To document computed tomography (CT) features in dogs with masticatory myositis. DESIGN: Retrospective case series. ANIMALS: 7 dogs with an immunologic diagnosis of masticatory myositis and an absence of clinical abnormalities of any skeletal muscles other than the masticatory muscles. PROCEDURES: History; clinical, hematologic, biochemical, immunologic, cytologic, and histologic findings; and pre- and postcontrast CT imaging features of masticatory muscles and head and neck lymph nodes were extracted from medical records. RESULTS: On CT images, changes in size (atrophy or swelling) were common for all masticatory muscles except the digastricus muscles, which were involved only in 1 dog. Pre-contrast attenuation changes, most often hypoattenuation with varied distribution patterns, were seen in masticatory muscles of 4 dogs. Contrast enhancement with a predominantly inhomogeneous distribution pattern was seen in the temporalis, masseter, and pterygoid muscles of all dogs. Head and neck lymph nodes were enlarged in all but 1 dog and had contrast enhancement with predominantly central or homogeneous distribution patterns. Muscle biopsy was performed in 6 dogs, with biopsy specimens obtained from areas that had the most obvious contrast enhancement on CT images. For all 6 dogs, biopsy specimens had histologic features indicative of masticatory myositis. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggested that CT may be a useful adjunct in the diagnosis of masticatory myositis in dogs, including selection of sites for diagnostic muscle biopsy.     

COMPUTED TOMOGRAPHIC CHARACTERISTICS OF PRESUMED NORMAL CANINE ABDOMINAL LYMPH NODES

Though identification of lymph nodes is essential in staging cancer patients, little has been reported about the CT features of canine abdominal lymph nodes. The purpose of this retrospective study was to describe the visibility, location, and characteristics of abdominal lymph nodes in abdominal CT studies of dogs considered unlikely to have lymphadenopathy. The relationship between the number of identified lymph nodes and intraabdominal fat ranking, body weight, and slice thickness was also investigated. A total of 19 dogs were included. At least two jejunal lymph nodes and both left and right medial iliac lymph nodes were identified in all dogs. Colic lymph nodes were not identified in any of the dogs. Visualization of all other lymph nodes varied. There were significantly more lymph nodes visible in dogs with more intraabdominal fat (P < 0.0001). No correlation between the number of identified lymph nodes and body weight (P = 0.64) or slice thickness (P = 0.76) was found. Though most of all identified lymph nodes had an elongated shape, a rounded shape was most common in splenic, pancreaticoduodenal, renal, ileocolic and caudal mesenteric lymph nodes. Most lymph nodes had a homogeneous structure before and following the intravenous administration of contrast medium. Some lymph nodes had a slightly irregular structure or were relatively more hyper attenuating in the periphery than centrally before and/or after contrast administration. Mean attenuation before contrast was 37 Hounsfield Units (HU) (range 20–52 HU), and 109 HU after contrast (range 36–223 HU). Findings indicated that the CT visibility, characteristics of different abdominal lymph nodes may be variable in dogs.