Lymphatic drainage on healthy and neoplasic mammary glands in female dogs: can it really be altered?

Risk factor analysis and clinicopathological characteristics of female dogs with mammary tumours from a single-center retrospective study in Poland

This is a comprehensive retrospective study to characterize female dogs with canine mammary tumors (CMTs) using a dataset retrieved from the archives of the Division of Animal Pathology, Institute of Veterinary Medicine in Warsaw, and to identify prognostic factors. Clinical and histopathological data of 1447 dogs with CMTs were included. Malignant tumours were found in 83.3% (n = 1206), benign tumours in 11.7% (n = 169), and non-neoplastic lesions in 5.0% (n = 72) of dogs. Dogs most often had grade II carcinomas (38.2%, 215/562) of a single histological subtype (88.5%, 1281/1447), mostly simple carcinoma (35.3%, 510/1447). Dogs with a median age of 10 years significantly often had larger (≥ 3 cm) and malignant CMTs, whereas intact females had smaller tumours (median size 2.0 cm). However, the threshold value for the age of the dog in the differentiation of malignant and non-neoplastic/benign masses could not be determined. Most females were hormonally active (76.4%, 372/487). Hormonally active dogs significantly more often had multiple tumours. Multiple tumours were significantly smaller (median 2.5 cm) than single ones. Among pedigree dogs, small-breed dogs were mostly recorded (43%, 428/1006). Twelve breeds had an increased risk of CMTs, regardless of tumour behaviour, compared with the theoretical distribution of pedigree dogs in Poland. Four breeds were often affected only by malignant and other four breeds only by non-neoplastic/benign CMT. Large-breed dogs were significantly younger and affected by larger CMT (median 4 cm) compared with small- and medium-breed dogs. Ninety dogs with a malignant CMT and complete records were included in the full analysis of CMT-specific survival (CMT-SS) with a median follow-up time of 20.0 months. We showed that the timing of ovariohysterectomy in relation to mastectomy was significantly associated with grade, CMT-SS, and CMT-related death. We indicated the low diagnostic accuracy of palpation of regional lymph nodes (RLN) in the prediction of their metastatic involvement. By multivariable analysis, dogs with neoplastic emboli, tumour ulceration, and simple or complex carcinoma had a significantly higher risk of local recurrence. Tumour size > 3 cm was as a strong independent predictor of lung metastases. Compared with dogs with an easily separated localized tumour, dogs with a multiple/diffuse malignant CMT pattern had a fivefold higher risk of death. The risk of death was significantly higher in the presence of neoplastic emboli (~ fivefold) and tumour ulceration (~ fourfold). Furthermore, the presence of neoplastic emboli and large tumour size were independent predictors of CMT-related death.

Canine Mammary Cancer: State of the Art and Future Perspectives

Mammary cancer is the most frequently diagnosed neoplasia in women and non-spayed female dogs and is one of the leading causes of death in both species. Canines develop spontaneous mammary tumors that share a significant number of biological, clinical, pathological and molecular characteristics with human breast cancers. This review provides a detailed description of the histological, molecular and clinical aspects of mammary cancer in canines; it discusses risk factors and currently available diagnostic and treatment options, as well as remaining challenges and unanswered questions. The incidence of mammary tumors is highly variable and is impacted by biological, pathological, cultural and socioeconomic factors, including hormonal status, breed, advanced age, obesity and diet. Diagnosis is mainly based on histopathology, although several efforts have been made to establish a molecular classification of canine mammary tumors to widen the spectrum of treatment options, which today rely heavily on surgical removal of tumors. Lastly, standardization of clinical study protocols, development of canine-specific biological tools, establishment of adequate dog-specific disease biomarkers and identification of targets for the development of new therapies that could improve survival and have less adverse effects than chemotherapy are among the remaining challenges.

Mammary Glands of Women, Female Dogs and Female Rats: Similarities and Differences to Be Considered in Breast Cancer Research

Breast cancer is one of the most common and well-known types of cancer among women worldwide and is the most frequent neoplasm in intact female dogs. Female dogs are considered attractive models or studying spontaneous breast cancer, whereas female rats are currently the most widely used animal models for breast cancer research in the laboratory context. Both female dogs and female rats have contributed to the advancement of scientific knowledge in this field, and, in a "One Health" approach, they have allowed broad understanding of specific biopathological pathways, influence of environmental factors and screening/discovery of candidate therapies. This review aims to clearly showcase the similarities and differences among woman, female dog and female rat concerning to anatomical, physiological and histological features of the mammary gland and breast/mammary cancer epidemiology, in order to better portray breast tumorigenesis, and to ensure appropriate conclusions and extrapolation of results among species. We also discuss the major aspects that stand out in these species. The mammary glands of female dogs and women share structural similarities, especially with respect to the lactiferous ducts and lymphatic drainage. In contrast, female rats have only one lactiferous duct per nipple. A comprehensive comparison between humans and dogs is given a special focus, as these species share several aspects in terms of breast/mammary cancer epidemiology, such as age of onset, hormonal etiology, risk factors, and the clinical course of the disease. Holistically, it is clear that each species has advantages and limitations that researchers must consider during the development of experimental designs and data analysis.

Comparison of surgical resection of Axillary Lymph Nodes in Dogs with Mammary Gland Tumors with or without sentinel lymph node visualization with patent blue dye

Introduction

Dogs' axillary lymph node (ALN) is often difficult to locate before surgical resection. The anatomical location of ALN often discourages Veterinarians from surgical lymphadenectomy. Considering the limited literature available, the actual incidence of metastases and the prognostic relevance are poorly understood.

Methods

A non-randomized, prospective clinical study was conducted with female dogs (n = 41) with mammary gland tumor (MGT) in the thoracic or cranial abdominal mammary glands. The study investigated the risks of ALN metastasis based on tumors clinical findings, tumor size, histopathological diagnosis and grade. The main aim of this study was to compare ALN resection with or without patent blue 2.5% (PB) dye injection for sentinel lymph node visualization. A total of 46 mastectomies were performed and five animals underwent two mastectomies. In the first group, 17 patients underwent a mastectomy and lymphadenectomy without PB injection (G1). In contrast, in the second group, 24 patients also received PB injections for sentinel lymph node mapping (G2). The ALN was identified in 38/46 cases (82%). The ALN was identified and excised in only 58% of surgeries in G1(19/46), while in group 2, the lymph node was identified in 92% of the cases and resected in 100% of the cases. The use of PB improves ALN's identification and reduces the surgical resection time in dogs with MGT.

Results and discussion

Surgical time differed between the two groups, as it was significantly shorter in the PB injection group compared to group 1 (80 vs. 45 min) (p < 0.0001). The overall frequency of ALN metastasis was 32%. Macroscopic abnormalities in the lymph nodes, tumor size (>3 cm), and diagnosis of anaplastic carcinoma or grade II/III mammary gland tumors were associated with a higher probability of ALN metastasis. Metastases in the ALNs are more common, in dogs presenting with tumors larger than 3 cm and diagnosed with aggressive histological subtypes. The ALNs should be removed for correct staging, prognostic evaluation, and decision for adjuvant therapy.

Surgical dose and the clinical outcome in the treatment of mammary gland tumours in female dogs: a literature review

Mammary gland tumours are the most frequent tumours in intact female dogs and surgery remains the main treatment modality. Surgery is traditionally performed according to the lymphatic drainage of the mammary glands, but robust evidence is still lacking on what surgical dose is the smallest and results in the best outcome. The objective of the study was to investigate whether choice of surgical dose influences treatment outcome in dogs with mammary tumours and to identify current gaps in research that need to be filled in future studies for identifying the smallest surgical dose with the best possible outcome. Articles for entrance into the study were identified in online databases. Information regarding outcome following use of different surgical doses was extracted for analysis. Also, known prognostic factors were mapped for each study to discuss their impact on treatment outcome. Twelve articles were identified and included. Surgical dose applied ranged from lumpectomy to radical mastectomy. Radical mastectomy was most often analysed [11/12 (92%) articles]. Less invasive surgical doses were used less often in decreasing order of invasiveness. Outcomes analysed were most often survival time [7/12 (58%) articles], frequency of recurrences [5/12 (50%) studies] and time to recurrence [5/12 (42%) studies)]. No studies demonstrated any significant association between surgical dose and outcome. Gaps in the research could be categorised as data that was not available for extraction, for example known prognostic factors. Other factors related to study design were also identified, for example small groups of dogs included into the study. No studies showed a clear benefit of choosing one surgical dose over the other. Choice of surgical dose should be based on known prognostic factors and risks for complications rather than on lymphatic drainage. In future studies all prognostic factors should be included when investigating how choice of surgical dose influences treatment outcome.

Lymphatic Drainage Mapping with Indirect Lymphography for Canine Mammary Tumors

Simple Summary

Mammary gland tumours are the most common canine neoplasms. They account for 25–50% of all tumors diagnosed in bitches. Metastases and recurrences develop in about 35–70% of bitches following excision. The presence of regional lymph node metastases is a relevant factor affecting prognosis and treatment in cases of mammary gland tumors. The sentinel lymph node (SLN) is the first lymph node (or nodes) in the regional lymphatic basin that receives lymphatic flow from the primary neoplasm. As mammary gland tumors mainly spread by lymphatic vessels invasion, conceptually, distant metastasis should not be present if the SLN does not have evidence of a tumor burden. In the present study, an indirect lymphography was used for sentinel lymph node mapping in a cohort of 14 adult female dogs with 24 mammary tumors involving the third to the fifth mammary gland. Contrast was injected around the mammary tumor, and lymph nodes that picked up the contrast were visible after 24 h. The results of this study indicate that the lymph drainage pattern of the neoplastic mammary gland may be different for each tumor. The knowledge of the SLN of the neoplastic mammary glands should be of high importance for the surgeon not only for performing the most adequate surgical excision but also for determining an accurate post-surgical prognosis.

Abstract

Mammary gland tumors are the most common canine neoplasms. They account for 25–50% of all tumors diagnosed in bitches. Metastases and recurrences develop in about 35–70% of bitches following excision. The presence of regional lymph node metastases is a relevant factor affecting prognosis and treatment in cases of mammary gland tumors. The sentinel lymph node (SLN) is the first lymph node (or nodes) in the regional lymphatic basin that receives lymphatic flow from the primary neoplasm. The aim of this study is to investigate the SLN with indirect lymphography for a mammary tumor in dogs. The knowledge of the precise drainage pattern and SLN of the neoplastic mammary glands would provide clinically relevant information to the surgeon and to the oncologist, and it would be of high importance for the surgeon not only for performing the most adequate surgical excision but also for determining an accurate post-surgical prognosis.

Ultrasonographic Algorithm for the Assessment of Sentinel Lymph Nodes That Drain the Mammary Carcinomas in Female Dogs

The status of sentinel lymph nodes (SLNs) is decisive in staging, prognosis, and therapeutic approach. Using an ultrasonographic examination algorithm composed of B-mode, Doppler technique, contrast-enhanced ultrasound (CEUS) and elastography, this study aimed to determine the diagnostic performance of the four techniques compared to histopathological examination. 96 SLNs belonging to 71 female dogs with mammary gland carcinomas were examined. After examinations, mastectomy and lymphadenectomy were performed. Histopathological examination confirmed the presence of metastases in 54 SLNs. The elasticity score had the highest accuracy-89.71%, identifying metastases in SLNs with 88.9.9% sensitivity (SE) and 90.5% specificity (SP), ROC analysis providing excellent results. The S/L (short axis/long axis) ratio showed 83.3% SE and 78.6% SP as a predictor of the presence of metastases in SLN having a good accuracy of 81.2%. On Doppler examination, the resistivity index(RI) showed good accuracy of 80% in characterizing lymph nodes with metastases versus unaffected ones; the same results being obtained by CEUS examination. By assigning to each ultrasonographic parameter a score (0 or 1) and summing up the scores of the four techniques, we obtained the best diagnostic performance in identifying lymph node metastases with 92.2% accuracy. In conclusion, the use of the presented algorithm provides the best identification of metastases in SLNs, helping in mammary carcinoma staging and appropriate therapeutic management.

Decorin concentrations in canine normal and neoplastic mammary gland tissues

In the present study, the concentration of decorin in canine normal and neoplastic mammary gland tissues was examined to understand the potential role of decorin in development and progression of canine mammary tumours. The homogenates of 48 mammary gland tumours (10 benign and 38 malignant) and 10 samples of normal canine mammary gland tissue were used in the study. The presence and quantification of decorin was examined in the homogenates using Western blot and specific canine ELISA. Western blotting confirmed the presence of decorin both in the normal mammary gland tissues and in the mammary gland tumours. The concentration of decorin was significantly higher (p < .05) in the benign tumours and non-metastatic malignant tumours than in the normal mammary gland. The concentration of decorin was significantly lower (p < .05) in the malignant tumours with metastasis to regional lymph nodes compared with benign tumours and non-metastatic malignant tumours. No significant differences were found in the level of decorin between the benign and the non-metastatic malignant tumours. Both the histological type of malignant tumours and the histological grade did not significantly affect the concentration of decorin. These findings suggest that neoplastic transformation in the canine mammary gland leads to increase in the decorin protein synthesis. The reducing decorin concentration in canine malignant mammary tumours appears to facilitate the metastatic spread of these tumours.

Lymphatic Vessel Network Structure and Physiology

The lymphatic system is comprised of a network of vessels interrelated with lymphoid tissue, which has the holistic function to maintain the local physiologic environment for every cell in all tissues of the body. The lymphatic system maintains extracellular fluid homeostasis favorable for optimal tissue function, removing substances that arise due to metabolism or cell death, and optimizing immunity against bacteria, viruses, parasites, and other antigens. This article provides a comprehensive review of important findings over the past century along with recent advances in the understanding of the anatomy and physiology of lymphatic vessels, including tissue/organ specificity, development, mechanisms of lymph formation and transport, lymphangiogenesis, and the roles of lymphatics in disease. © 2019 American Physiological Society. Compr Physiol 9:207-299, 2019.

Sentinel lymph node mapping by near-infrared fluorescence imaging and contrast-enhanced ultrasound in healthy dogs

Sentinel lymph node (SLN) mapping is a valuable and crucial diagnostic procedure in staging malignancies. We compared two non-invasive techniques, near-infrared (NIR) fluorescence imaging and contrast-enhanced ultrasound (CEUS), to identify the SLNs in three superficial anatomical regions in an animal model. Six healthy laboratory dogs were included in a proof-of-concept trial. A NIR fluorescent dye (Indocyanine Green) and microbubbles (Sonovue) were consecutively injected subdermally in the Inguinal, axillary and popliteal region to map the SLNs. Transcutaneous NIR fluorescence imaging identified SLNs in 17 out of a total of 18 occasions. CEUS identified SLNs in all regions (18/18). Whereas NIR fluorescence imaging performed better in the visualization of the afferent lymphatic tract, CEUS demonstrated different filling patterns of the SLNs, a feature potentially critical for the concept of SLN mapping in cancer patients. Both NIR fluorescence imaging and CEUS are safe, non-invasive, practical and accurate methods to perform real-time transcutaneous SLN mapping with potential in a clinical setting.

B-mode and contrast-enhanced ultrasonography of the mammary gland during the estrous cycle of dogs

Pathology of the mammary gland is a common health issue in dogs and includes neoplasia, cysts, inflammation and infection. The use of the B-mode (US) and contrast-enhanced (CEUS) ultrasonography may aid in the diagnosis. Previous studies are currently lacking of the ultrasonic images of the mammary gland of healthy bitches in different stages of the estrous cycle and associated normal blood perfusion patterns. The purpose, therefore, was to describe the normal B-mode US and CEUS images of the mammary gland and inguinal lymph node, in six intact female beagles during five different stages of the estrous cycle (proestrus, estrus, early and late diestrus and anestrus). Within the same stage of the estrous cycle, the size (thickness) of the caudal mammary glands increased. During early and late diestrus, all mammary glands increased in thickness and had an increased heterogeneous B-mode ultrasonic appearance. The mammary glands had a heterogeneous, disorganized perfusion pattern when assessed using CEUS. For the cranial abdominal mammary gland, the area under the curve and the mean transit time increased between estrus and late diestrus and decreased between late diestrus and anestrus. For the inguinal mammary gland, only the time to peak was longer during the periods of anestrus compared to estrus whereas all the other contrast parameters did not change during the estrous cycle. In conclusion, hormonal influences cause major changes in the size, appearance and blood perfusion of mammary glands during the estrous cycle and should be considered when evaluating pathological changes of mammary glands.

Canine mammary tumours, an overview

Canine mammary tumours (CMTs) are the most common neoplasms in intact female dogs. Although the prevalence of these tumours decreases in regions where preventive ovari(ohyster)ectomy is performed, it remains an important disease entity in veterinary medicine. Moreover, treatment options are limited in comparison with human breast cancer. Nevertheless, recent human treatment protocols might have potential in bitches suffering from CMTs.

Prognostic value of regional lymph node status in canine mammary carcinomas

In this study, we have determined the prognostic value of the presence of the micrometastases and metastases greater than 2 mm in the regional lymph nodes for bitches with mammary carcinomas. The study involved 51 dogs diagnosed with a single malignant epithelial tumour in the 4th or 5th mammary gland. All animals underwent regional mastectomy; the 4th and 5th mammary glands were removed together with the inguinal lymph node. The lymph nodes were examined immunohistochemically using the anti-cytokeratin antibody, clone AE1/AE3. The bitches were followed up every 6 months for 2 years after surgery to determine the disease-free survival (DFS) and overall survival (OS). The Kaplan-Meier analysis showed a statistically significant difference in DFS and OS only between the group of bitches without metastases and the group with lymph node metastases greater than 2 mm. No significant differences between these two groups versus bitches with lymph node micrometastases were found.

Development, anatomy, histology, lymphatic drainage, clinical features, and cell differentiation markers of canine mammary gland neoplasms

Mammary neoplasms are the most common neoplasm in female dogs. This article describes the embryologic development, normal anatomy, and histology of the canine mammary gland from the onset of first estrous and the changes that occur in the mammary gland during the estrus cycle. The clinical features of canine mammary gland tumors and their relation to prognosis are discussed, including age, hormones, breed, diet, and obesity. Additional clinical prognostic factors including clinical presentation, tumor size, and lymph node status at the time of presentation are discussed in relation to diagnosis and tumor staging. Immunohistochemical evaluation of the cell differentiation markers of the normal and neoplastic canine mammary gland is described and compared with similar studies in humans; the ways these markers may be used to assist with the prognosis of canine mammary neoplasms are discussed.

Role of lymphatic vessels in tumor immunity: passive conduits or active participants?

Research in lymphatic biology and cancer immunology may soon intersect as emerging evidence implicates the lymphatics in the progression of chronic inflammation and autoimmunity as well as in tumor metastasis and immune escape. Like the blood vasculature, the lymphatic system comprises a highly dynamic conduit system that regulates fluid homeostasis, antigen transport and immune cell trafficking, which all play important roles in the progression and resolution of inflammation, autoimmune diseases, and cancer. This review presents emerging evidence that lymphatic vessels are active modulators of immunity, perhaps fine-tuning the response to adjust the balance between peripheral tolerance and immunity. This suggests that the tumor-associated lymphatic vessels and draining lymph node may be important in tumor immunity which in turn governs metastasis.

Influence of Catechol-O-Methyltransferase (COMT) Genotypes on the Prognosis of Canine Mammary Tumors

Catechol-O-methyltransferase (COMT) is an important enzyme involved in inactivation of catechol estrogens, which are metabolites with carcinogenic properties. Some investigations in human breast cancer associate a genetic polymorphism in the COMT gene (COMT val158met) with an increased risk and poor clinical progression of the disease. In dogs, there are 2 recognized single nucleotide polymorphisms in the COMT gene (COMTG216A and COMTG482A); however, their influence on the outcome of mammary neoplasms has never been investigated. The purpose of this study is to investigate the influence of COMT in the clinical progression of canine mammary tumors, namely in recurrence, metastasis and survival by testing 2 SNPs (G216A and G482A), and 2 genotypes of the COMT gene. A case series was conducted analyzing genomic DNA samples by polymerase chain reaction-restriction fragment length polymorphism from 80 bitches with mammary tumors. Animals were submitted to an active follow-up study for a period of 24 months after surgery. We observed that bitches carrying both genetic variations simultaneously are more likely to develop recurrence of mammary lesions. Our results demonstrate a possible role for COMT genotypes in the outcome of mammary neoplasms in the dog. Identifying a genetic factor predictive of recurrence may be useful in selecting the most effective surgical approach for canine mammary neoplasms.

The Lymph Drainage of the Neoplastic Mammary Glands in the Bitch: A Lymphographic Study

The purpose of this investigation was to study the lymph drainage of the neoplastic mammary glands in the bitch using indirect lymphography. The main conclusions drawn from the study of 41 natural cases were as follows: the first or cranial thoracic and second or caudal thoracic neoplastic mammary glands usually drain into the ipsilateral axillary lymph nodes and rarely into the ipsilateral axillary and sternal lymph nodes, simultaneously. The third or cranial abdominal neoplastic mammary gland usually drains into the ipsilateral axillary and superficial inguinal lymph nodes simultaneously, but sometimes only cranially into the ipsilateral axillary lymph nodes. Rarely, it drains only caudally into the ipsilateral superficial inguinal and medial iliac lymph nodes, simultaneously. The fourth or caudal abdominal neoplastic mammary gland usually drains only caudally into the ipsilateral superficial inguinal lymph nodes. Rarely, it drains into the ipsilateral axillary and superficial inguinal lymph nodes simultaneously. The fifth or inguinal neoplastic mammary gland usually drains into the ipsilateral superficial inguinal lymph nodes but rarely, does it also drain into the ipsilateral popliteal lymph node and into a lymphatic plexus at the medial aspect of the ipsilateral thigh. Lymphatic connections between the neoplastic and adjacent normal mammary glands were demonstrated in only one case. The lymph drainage pattern of the neoplastic mammary glands is slightly different to that described in normal glands using the same radiographic method.

Lymph drainage of the mammary glands in female cats

The mammary gland is a common site of neoplasms in the female cat. All the malignant tumors metastasize to a lesser or a greater extent through the lymphatic system. However, the anatomical knowledge of this system is not sufficiently well known in cats to develop a reasoned model for the extirpation of these glands in case of malignant tumors. A study of the lymph drainage in 50 female cats was done by indirect injection in vivo of India ink inside the mammary parenchyma. After a waiting interval, mammary glands were extracted and the thoracic cavity opened. All the lymph nodes were examined after clearing. The success rate of the colorations of lymph nodes and lymph vessels was 91.8%. Out of the 100 observed mammary chains, the two intermediate mammary glands (T2, A1) may drain caudally to the superficial inguinal lymph center and/or cranially to the axillary lymph center. The T1 gland always drains exclusively cranially and A2 exclusively caudally. The two mammary glands (T1 and A1) often drain towards the sternal cranial lymph nodes, but 100% of the T2 drain towards it. This research assumes that the limit between the two directions of drainage can exist only between glands T2 and A1. The results obtained with the study of the 1st, 2nd, 3rd, and 4th mammary glands permit production of new and more complete data of functional significance that will eventually aid block dissection surgical technique in the removal of malignant tumors in cats.