Radiographic indirect lymphography using liposoluble contrast for sentinel lymph node mapping of dogs with cutanoeus mast cell tumor
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Data
2022-07-04
Autores
Albernaz, Vinicius Gonzalez Peres [UNESP]
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Universidade Estadual Paulista (Unesp)
Resumo
O mastocitoma cutâneo (MCTc) é uma das neoplasias cutâneas mais comuns em cães. Metástase para o linfonodo (LN) drenante é a principal rota de disseminação sistêmica do MCTc. A detecção precoce de metástases em LNs é crucial no estadiamento e tratamento correto de cães com MCTc. O LN sentinela é amplamente variado entre indivíduos. O objetivo desta tese é realizar uma revisão descritiva do sistema linfático canino aplicado ao mapeamento de LNs sentinelas de cães com MCTc. Simultaneamente, foi conduzido um estudo clínico de cães com ocorrência natural de MCTc para avaliar se o papel da linfografia indireta (LI) com óleo iodado (OI) combinado com o método colorimétrico com azul patente (AP) na detecção do LN sentinela. A principal hipótese era que a LI ajudaria o cirurgião a detectar LNs intracavitários e mais LNs que a técnica do AP. Vinte e três cães fizeram parte do estudo prospectivo. LI OI detectou 29 LNs sentinelas em 19 cães, enquanto 4 não exibiram opacificação em LNs. O AP detectou 26 LNs em 19 cães, com 4 cães não demonstrando coloração azulada em LNs. Trinta e um LNs foram resseccionados, sendo que 10 estavam metastáticos. Laparotomia foi necessária para remover LNs ilíacos opacificados em 26% dos cães. A taxa de concordância entre a LI OI e LN regionais e AP e LNs regionais foi de 82,6%. A taxa foi de 78.2% quando comparando a LI com o AP. Somente um cão apresentou o LN sentinela drenante diferente do LN regional detectado pela LI. Em um contexto clínico, a LI com OI foi responsável por aumentar o número de LNs ressecionado em 41% (29% dos LNs removidos). Não houve diferença estatística quando comparando AP e a LI no cenário base do estudo (p=0.01855), contudo em um cenário clínico houve diferença significativa favorecendo a LI (p=0.0081). A opacificação desigual dos LNs sentinelas não teve associação significativa com a presença de metástase (p=0.2264). O mesmo ocorreu com a coloração azul clara do LN (p=0.6673). Contudo, o tamanho dos LNs metastáticos foi significativamente maior que os normais (p=0.0456). LNs aumentados de tamanho apresente 4.6 mais riscos de estarem metastáticos que os LNs não-palpáveis ou normais (p=0.0374). Locais de alto risco, limites de 3cm no tamanho, invasão profunda e sinal de Darier não estavam associados com metástase locorregional (p>0.05). Os resultados provenientes do mapeamento de LNs sentinelas foram responsáveis por 62,5% das indicações para quimioterapia adjuvante pós-operatória, mas somente um caso teve indicação alterada somente pela LI. Contudo, 60% dos cães com doença metastática apresentaram um LN sentinela metastático intracavitário que só pode ser detectado no pré-operatório pela LI. A LI com OI pré-operatória associada com o AP é um método eficiente de detectar LNs sentinelas em MCTc realizando cirurgia curativa. LI aumenta a taxa de detecção de LNs sentinelas em um contexto clínico. O padrão de opacificação do LN sentinela não deve ser utilizado para predizer metástases.
Cutaneous mast cell tumor (cMCT) is one of the most common skin cancers in dogs. Metastasis to draining lymph nodes is the main route to systemic dissemination of cMCT. Early detection of lymph node metastasis is crucial to correctly stage and treat dogs with cMCT. The sentinel lymph node (SLN) is widely variable among individuals. The objective of this thesis was to make a descriptive review of the canine lymphatic system applied to SLN mapping of dogs bearing cMCT. Simultaneously a clinical study of dogs with naturally occurring cMCT was conducted to evaluate the role of iodized oil (IO) indirect lymphography (IL) combined with patent blue colorimetric method in detecting SLN. The main hypothesis was that IL would aid the surgeon to detect intracavitary or more lymph nodes than the patent blue technique. Twenty-three dogs were enrolled in the prospective study. IO IL detected 29 contrasted SLN in 19 dogs, while 4 dogs did not exhibit lymph node opacification. Patent blue detected 26 SLN in 19 dogs and 4 dogs did not have blue-colored nodes. Thirty-one lymph nodes were resected, of which 10 were metastatic. Laparotomy was necessary to remove opacified iliac lymph nodes in 26% of the dogs. The rate of agreement between IO IL and patent blue with regional lymph nodes was 82.6%. The rate was 78.2% when comparing IL and patent blue. Only one dog had a draining SLN different from the regional lymph node as detected by IL. In a clinical setting, IO IL was responsible to increase the number of resected lymph nodes by 41% (29% of the resected SLN). There was no difference in detected SLN by PB and IO IL in the base scenario (p=0.1855), however, in a clinical scenario, there was a significant difference favoring IL (p=0.0081). Unequally opacified SLN could not be significatively associated with metastasis (p=.2264). The same occurred with light-blue color SLN (p=.6673). However, tumor size was significatively higher in dogs with lymph node metastasis (p=.0456). Enlarged lymph nodes had 4.6-fold more risk of being metastatic than non-palpable/normal-sized nodes (p=.0374). High-risk sites, 3cm size cut-off, deep invasion, and Darier’s sign could not be associated with locoregional metastasis (p>.05). The SLN mapping was responsible for 62.5% of the postoperative indications of adjuvant chemotherapy, however, only one case was indicated solely by the IL. However, 60% of dogs with metastatic disease had an intracavitary metastatic SLN that could only be detected preoperatively by IL. Preoperative IO IL associated with patent blue is an efficient method to detect SLN in cMCT undergoing curative surgery. IL increases the rate of SLN detected in a clinical setting. The pattern of SLN opacification should not be used to predict metastasis.
Cutaneous mast cell tumor (cMCT) is one of the most common skin cancers in dogs. Metastasis to draining lymph nodes is the main route to systemic dissemination of cMCT. Early detection of lymph node metastasis is crucial to correctly stage and treat dogs with cMCT. The sentinel lymph node (SLN) is widely variable among individuals. The objective of this thesis was to make a descriptive review of the canine lymphatic system applied to SLN mapping of dogs bearing cMCT. Simultaneously a clinical study of dogs with naturally occurring cMCT was conducted to evaluate the role of iodized oil (IO) indirect lymphography (IL) combined with patent blue colorimetric method in detecting SLN. The main hypothesis was that IL would aid the surgeon to detect intracavitary or more lymph nodes than the patent blue technique. Twenty-three dogs were enrolled in the prospective study. IO IL detected 29 contrasted SLN in 19 dogs, while 4 dogs did not exhibit lymph node opacification. Patent blue detected 26 SLN in 19 dogs and 4 dogs did not have blue-colored nodes. Thirty-one lymph nodes were resected, of which 10 were metastatic. Laparotomy was necessary to remove opacified iliac lymph nodes in 26% of the dogs. The rate of agreement between IO IL and patent blue with regional lymph nodes was 82.6%. The rate was 78.2% when comparing IL and patent blue. Only one dog had a draining SLN different from the regional lymph node as detected by IL. In a clinical setting, IO IL was responsible to increase the number of resected lymph nodes by 41% (29% of the resected SLN). There was no difference in detected SLN by PB and IO IL in the base scenario (p=0.1855), however, in a clinical scenario, there was a significant difference favoring IL (p=0.0081). Unequally opacified SLN could not be significatively associated with metastasis (p=.2264). The same occurred with light-blue color SLN (p=.6673). However, tumor size was significatively higher in dogs with lymph node metastasis (p=.0456). Enlarged lymph nodes had 4.6-fold more risk of being metastatic than non-palpable/normal-sized nodes (p=.0374). High-risk sites, 3cm size cut-off, deep invasion, and Darier’s sign could not be associated with locoregional metastasis (p>.05). The SLN mapping was responsible for 62.5% of the postoperative indications of adjuvant chemotherapy, however, only one case was indicated solely by the IL. However, 60% of dogs with metastatic disease had an intracavitary metastatic SLN that could only be detected preoperatively by IL. Preoperative IO IL associated with patent blue is an efficient method to detect SLN in cMCT undergoing curative surgery. IL increases the rate of SLN detected in a clinical setting. The pattern of SLN opacification should not be used to predict metastasis.
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Palavras-chave
Lymphatic, Metastasis, Mastocytoma, Iodized oil, Radiographic, Linfático, Metástases, Mastocitoma, Óleo Iodado, Radiografia