In cooperation with
Pathology in Practice
Figure 1—Photographs of a mass found in a 2-year-old Cocker Spaniel during an ovariohysterectomy. Resection and anastomosis of the jejunum was performed to remove the mass. A—Gross image of the excised mass. The mass (asterisk) is attached to the jejunum (J). A ruler (in centimeters) is shown for scale. B—Gross image of a cut section of the excised mass (asterisk) and jejunum (J). The mass has a thin capsule, which is contiguous with the muscularis and serosa of the jejunum. The contents of the mass were firm, sticky, and gelatinous. A communication between the mass and jejunum is not evident.
History A 2-year-old 13.4-kg (29.5-lb) Cocker Spaniel with no veterinary medical history or clinical signs that was adopted from a breeder underwent ovariohysterectomy. During the surgery, an approximately 1 X 5-cm intestinal mass was discovered attached to the jejunum. Resection and anastomosis of the affected jejunum was performed. The tissue was fixed in neuThis report was submitted by Brent E. Walling, DVM, PhD, and Travis M. Arndt, DVM; from the Department of Pathobiology and Veterinary Diagnostic Laboratory, College of Veterinary Medicine, University of Illinois, Urbana, IL 61802 (Walling); and the Animal Medical Center of Mid-America, 1201 Macklind Ave, St Louis, MO 63110 (Arndt). Dr. Walling’s present address is Pathology, WIL Research, 1407 George Rd, Ashland, OH 44805. Address correspondence to Dr. Walling (brent.walling@wilresearch. com). JAVMA, Vol 246, No. 12, June 15, 2015
tral-buffered 10% formalin and the mass submitted to the University of Illinois Veterinary Diagnostic Laboratory for evaluation. Gross Findings Examination of the fixed specimen revealed an oblong, lobular mass approximately 5.5 cm in length with a maximum diameter of 2.75 cm, which was firmly attached to the serosa of the jejunum (Figure 1). On cut surface, the mass had a distinct, variably thick capsule and contained a mixture of gelatinous, sticky, and occasionally firm material and small foci of hemorrhage. No communication between the mass and the intestinal lumen was observed. Formulate differential diagnoses from the history, clinical findings, and Figure 1—then turn the page → Vet Med Today: Pathology in Practice
1297
Histopathologic Findings
Figure 2—Photomicrograph of a section of the cyst and jejunum (J) from the dog in Figure 1. The lumen of the cyst (asterisk) contains abundant necrotic debris and hemorrhage. The wall of the cyst is contiguous with the jejunal muscularis and serosa (arrowhead). H&E stain; bar = 2 mm.
Focally arising from the outer layer of the tunica muscularis of the jejunum was a large cyst-like structure filled with necrotic debris, amorphous material, a small number of leukocytes, and few cholesterol clefts. The cyst wall adjacent to the jejunum was composed of smooth muscle and fibrous connective tissue, which narrowed into a thin fibrous capsule at the apex of the cyst (Figure 2). The internal surface of the cyst wall was lined by a single layer of cuboidal to columnar epithelial cells and goblet cells supported by a thin submucosa which, toward the apex, gradually attenuated (Figure 3). Multifocally, the lamina propria between the crypts contained small numbers of lymphocytes and plasma cells as well as 5 to 10 eosinophils/40X field. The leukocytes also extended down and undermined the crypts approximately 2 to 5 cells deep. Alcian blue staining of additional sections of the cyst resulted in bright blue staining of the cytoplasm of the goblet cells lining the cyst wall, the material in the cyst, and the cytoplasm of goblet cells in the jejunum. Immunohistochemical staining for smooth muscle actin resulted in strong staining of the cyst wall, which blended in with the smooth muscle of the wall of the jejunum (Figure 4). Morphologic Diagnosis and Case Summary Morphologic diagnosis and case summary: jejunal duplication cyst, with minimal segmental lymphoplasmacytic and eosinophilic jejunitis in a dog. Comments
Cystic enteric duplication is a rare congenital malformation that has been dechildren), Figure 3—Photomicrographs of sections of the cyst from the dog in Figure 1. A—The scribed in humans (most often 1–12 Typically, epithelium lining the cyst capsule is composed of both goblet cells and columnar dogs, cats, goats, and horses. epithelial cells with a brush border (arrow). H&E stain; bar = 20 µm. B—Following Al- duplication cysts consist of a blind pouch or cian blue staining, intensely blue material, interpreted as mucus, is evident within the cyst attached to the alimentary tract. They goblet cells lining the cyst capsule. Faint blue material (mucus) is also present within are most commonly associated with the ilthe adjacent cyst lumen. Alcian blue stain; bar = 50 µm. eum1 but may be located anywhere along the entire alimentary tract, including the esophagus,3,10 stomFigure 4—Immuno12 4,5,8,9 and colon.6,7 Although duplication h i s t o ch e m i c a l l y ach, small intestine, stained section of the cysts may be subclinical in animals (as in this case) and hucyst from the dog in mans,2,3,8 affected individuals frequently have nonspecific Figure 1. Immunohistochemically labeled clinical signs associated with the location of the cyst. Clinical smooth muscle is signs include choking or respiratory distress (usually obpresent beneath the served with esophageal duplication cysts),10 signs of epigasepithelium and cyst lumen (asterisk) as tric pain, emesis, diarrhea, constipation, signs of depression, well as in the walls abdominal distension, peritonitis, tenesmus, rectal prolapse, of adjacent vessels. or signs of back pain.2,5–7,9,12 Because duplication cysts may Anti-smooth muscle actin antibody-based develop anywhere along the alimentary tract and clinical signs are nonspecific, diagnosis can be difficult and usually stain; bar = 200 µm. 1298
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JAVMA, Vol 246, No. 12, June 15, 2015
requires surgical exploration and histologic examination of appropriate specimens. Prior to surgical exploration, specialized imaging techniques may provide a preliminary diagnosis. Plain radiographic views are of limited use because they often reveal only a vague radiopaque intraabdominal mass, often with poor detail.7 Computed tomography and MRI have been useful in identifying duplication cysts,13 and barium enemas in conjunction with radiography may also provide diagnostic information when a patent communication between the intestine and cyst is present.6,13 Abdominal ultrasonography is the preferred technique and can be diagnostic by delineating the layers of the cyst wall similar to those of the intestinal wall,5 although this type of imaging may only reveal a variably delineated fluid-filled structure, and other cystic masses such as enteric diverticula, hematomas, or abscesses should be considered.7 Histologic assessment of the abnormal tissue provides a definitive diagnosis. The wall of the duplication cyst contains smooth muscle, which typically blends into the adjacent tunica muscularis and may also include a muscularis mucosa and epithelium. The epithelium may be similar to that of the adjacent intestine, with mucosal epithelium and goblet cells, or may be attenuated, flattened, or absent. In cases of esophageal duplication cysts, the epithelium is composed of stratified and pseudostratified epithelial tissues. The presence of a wall containing smooth muscle that is lined by intestinal epithelium and attachment of the cyst to the alimentary tract (as seen in the case described in the present report) are the criteria for diagnosis of a gastrointestinal duplication cyst.14 The smooth muscle wall distinguishes duplication cysts from false diverticula, which are outpouchings of the intestine that lack smooth muscle.15 A Meckel diverticulum is a true diverticulum that contains all 4 layers of the intestine and, in humans, is found on the antimesenteric border of the ileum approximately 60 cm from the ileocecal junction.16 It results from failure of the vitelline duct to completely close during gestation. These diverticula are most common in humans, pigs, and horses and rare in other species.17 A duplication cyst that communicates with the ileum and is located close to the ileocecal junction may resemble a Meckel diverticulum both on gross and histologic examination. Technetium Tc 99m pertechnetate scintigraphy, the diagnostic technique of choice, can identify the gastric mucosa usually found in Meckel diverticula, but this finding may result in an inaccurate diagnosis because duplication cysts may also contain ectopic gastric mucosa.18 Treatment of humans with clinical signs related to a Meckel diverticulum or duplication cyst at a similar location usually requires complete surgical excision, and the prognosis is typically favorable.16 The cause of intestinal duplication cysts remains elusive to researchers and practitioners; the histologic similarity between embryological diverticula and congenital duplication cysts has led to some researchers using the terms interchangeably.19 The digestive tract initially develops from yolk sac endoderm, which eventually becomes the intestinal epithelium, followed by rearrangement and coalescing of epithelial vacuoles to form the lumen.7 However, much remains unknown JAVMA, Vol 246, No. 12, June 15, 2015
about embryological development of the alimentary tract and multiple theories exist regarding the origin of enteric duplication cysts with no theory adequately explaining the cause of all intestinal duplication cysts. Surgical resection and repair is the preferred treatment for humans and other animals with enteric duplication cysts, even in individuals without associated clinical signs, to avoid potential future complications including obstruction, perforation, or potential malignant transformation of the cyst.12 Successful surgical removal of duplication cysts involving the esophagus,3,10 jejunum,4,8,9 and colon6,7 has been performed in dogs, cats, and a horse; however, euthanasia is often selected in complicated cases that have other congenital malformations.11 Surgery is usually successful and the animals fully recover without any further clinical signs. The dog of the present report remained healthy at follow-up 12 months following surgery. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.
17. 18. 19.
O’Donnell PL, Morrow JB, Fitzgerald TL. Adult gastric duplication cysts: a case report and review of literature. Am Surg 2005;71:522–525. Kuo HC, Lee HC, Shin CH, et al. Clinical spectrum of alimentary tract duplication in children. Acta Paediatr Taiwan 2004;45:85–88. Gabor LJ, Walshaw R. Esophageal duplication cyst in a dog. Vet Pathol 2008;45:61–62. Haziroglu R, Atasever A, Gulbahar MY. Duplication of the jejunum in a dog. J Vet Med Sci 1995;57:143–145. Spaulding KA, Cohn LA, Miller RT, et al. Enteric duplication in two dogs. Vet Radiol 1990;31:83–88. Landon BP, Abraham LA, Charles JA, et al. Recurrent rectal prolapse caused by colonic duplication in a dog. Aust Vet J 2007;85:381–385. Arthur EG, Fox DB, Stephanie CE, et al. Surgical treatment of noncommunicating duplication of the colon in a dog. J Am Vet Med Assoc 2003;223:210–214. Radlinsky MA, Biller DS, Nietfeld J, et al. Subclinical intestinal duplication in a cat. J Feline Med Surg 2005;7:223–226. Kershaw O, Deppenmeier S, Gruber AD. Multiple cystic intestinal duplications in a cat. Vet Pathol 2008;45:188–190. Orsini JA, Sepsey L, Donawick WJ, et al. Esophageal duplication cyst as a cause of choke in the horse. J Am Vet Med Assoc 1988; 193:474–476. Otiang’a-Owiti GE, Oduor-Okelo D, Kamau GK, et al. Morphology of a six-legged goat with duplication of the intestinal, lower urinary, and genital tracts. Anat Rec 1997;247:432–438. Kuraoka K, Nakayama H, Kagawa T, et al. Adenocarcinoma arising from a gastric duplication cyst with invasion to the stomach: a case report with literature review. J Clin Pathol 2004;57:428–431. Olajide A-RL, Yisau AA, Abdulraseed NA, et al. Gastrointestinal duplications: experience in seven children and a review of the literature. Saudi J Gastroenterol 2010;16:105–109. Berrocal T, Lamas M, Guiteerrez J, et al. Congenital anomalies of the small intestine, colon, and rectum. Radiographics 1999;19:1219–1236. Benson RE, Dixon CF, Waugh JM. Nonmeckelian diverticula of the jejunum and ileum. Ann Surg 1943;118:377–393. Kahn E, Daum F. Anatomy, histology, embryology, and developmental anomalies. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran’s gastrointestinal and liver disease. Vol 2. 9th ed. Philadelphia: Saunders Elsevier, 2010;1628–1630. Brown CC, Baker DC, Barker IK. Alimentary system. In: Maxie MG, ed. Pathology of domestic animals. Vol 2. 5th ed. Philadelphia: Elsevier Ltd, 2007;85–86. Alenizi EK, Alfeeli MA. Intestinal duplication mimicking Meckel diverticulum. Clin Nucl Med 2008;33:189–190. Bentley JFR, Smith JR. Developmental posterior enteric remnants and spinal malformations. Arch Dis Child 1960;35:76–86. Vet Med Today: Pathology in Practice
1299
Pathology in Practice
Figure 1—Photographs of a mass found in a 2-year-old Cocker Spaniel during an ovariohysterectomy. Resection and anastomosis of the jejunum was performed to remove the mass. A—Gross image of the excised mass. The mass (asterisk) is attached to the jejunum (J). A ruler (in centimeters) is shown for scale. B—Gross image of a cut section of the excised mass (asterisk) and jejunum (J). The mass has a thin capsule, which is contiguous with the muscularis and serosa of the jejunum. The contents of the mass were firm, sticky, and gelatinous. A communication between the mass and jejunum is not evident.
History A 2-year-old 13.4-kg (29.5-lb) Cocker Spaniel with no veterinary medical history or clinical signs that was adopted from a breeder underwent ovariohysterectomy. During the surgery, an approximately 1 X 5-cm intestinal mass was discovered attached to the jejunum. Resection and anastomosis of the affected jejunum was performed. The tissue was fixed in neuThis report was submitted by Brent E. Walling, DVM, PhD, and Travis M. Arndt, DVM; from the Department of Pathobiology and Veterinary Diagnostic Laboratory, College of Veterinary Medicine, University of Illinois, Urbana, IL 61802 (Walling); and the Animal Medical Center of Mid-America, 1201 Macklind Ave, St Louis, MO 63110 (Arndt). Dr. Walling’s present address is Pathology, WIL Research, 1407 George Rd, Ashland, OH 44805. Address correspondence to Dr. Walling (brent.walling@wilresearch. com). JAVMA, Vol 246, No. 12, June 15, 2015
tral-buffered 10% formalin and the mass submitted to the University of Illinois Veterinary Diagnostic Laboratory for evaluation. Gross Findings Examination of the fixed specimen revealed an oblong, lobular mass approximately 5.5 cm in length with a maximum diameter of 2.75 cm, which was firmly attached to the serosa of the jejunum (Figure 1). On cut surface, the mass had a distinct, variably thick capsule and contained a mixture of gelatinous, sticky, and occasionally firm material and small foci of hemorrhage. No communication between the mass and the intestinal lumen was observed. Formulate differential diagnoses from the history, clinical findings, and Figure 1—then turn the page → Vet Med Today: Pathology in Practice
1297
Histopathologic Findings
Figure 2—Photomicrograph of a section of the cyst and jejunum (J) from the dog in Figure 1. The lumen of the cyst (asterisk) contains abundant necrotic debris and hemorrhage. The wall of the cyst is contiguous with the jejunal muscularis and serosa (arrowhead). H&E stain; bar = 2 mm.
Focally arising from the outer layer of the tunica muscularis of the jejunum was a large cyst-like structure filled with necrotic debris, amorphous material, a small number of leukocytes, and few cholesterol clefts. The cyst wall adjacent to the jejunum was composed of smooth muscle and fibrous connective tissue, which narrowed into a thin fibrous capsule at the apex of the cyst (Figure 2). The internal surface of the cyst wall was lined by a single layer of cuboidal to columnar epithelial cells and goblet cells supported by a thin submucosa which, toward the apex, gradually attenuated (Figure 3). Multifocally, the lamina propria between the crypts contained small numbers of lymphocytes and plasma cells as well as 5 to 10 eosinophils/40X field. The leukocytes also extended down and undermined the crypts approximately 2 to 5 cells deep. Alcian blue staining of additional sections of the cyst resulted in bright blue staining of the cytoplasm of the goblet cells lining the cyst wall, the material in the cyst, and the cytoplasm of goblet cells in the jejunum. Immunohistochemical staining for smooth muscle actin resulted in strong staining of the cyst wall, which blended in with the smooth muscle of the wall of the jejunum (Figure 4). Morphologic Diagnosis and Case Summary Morphologic diagnosis and case summary: jejunal duplication cyst, with minimal segmental lymphoplasmacytic and eosinophilic jejunitis in a dog. Comments
Cystic enteric duplication is a rare congenital malformation that has been dechildren), Figure 3—Photomicrographs of sections of the cyst from the dog in Figure 1. A—The scribed in humans (most often 1–12 Typically, epithelium lining the cyst capsule is composed of both goblet cells and columnar dogs, cats, goats, and horses. epithelial cells with a brush border (arrow). H&E stain; bar = 20 µm. B—Following Al- duplication cysts consist of a blind pouch or cian blue staining, intensely blue material, interpreted as mucus, is evident within the cyst attached to the alimentary tract. They goblet cells lining the cyst capsule. Faint blue material (mucus) is also present within are most commonly associated with the ilthe adjacent cyst lumen. Alcian blue stain; bar = 50 µm. eum1 but may be located anywhere along the entire alimentary tract, including the esophagus,3,10 stomFigure 4—Immuno12 4,5,8,9 and colon.6,7 Although duplication h i s t o ch e m i c a l l y ach, small intestine, stained section of the cysts may be subclinical in animals (as in this case) and hucyst from the dog in mans,2,3,8 affected individuals frequently have nonspecific Figure 1. Immunohistochemically labeled clinical signs associated with the location of the cyst. Clinical smooth muscle is signs include choking or respiratory distress (usually obpresent beneath the served with esophageal duplication cysts),10 signs of epigasepithelium and cyst lumen (asterisk) as tric pain, emesis, diarrhea, constipation, signs of depression, well as in the walls abdominal distension, peritonitis, tenesmus, rectal prolapse, of adjacent vessels. or signs of back pain.2,5–7,9,12 Because duplication cysts may Anti-smooth muscle actin antibody-based develop anywhere along the alimentary tract and clinical signs are nonspecific, diagnosis can be difficult and usually stain; bar = 200 µm. 1298
Vet Med Today: Pathology in Practice
JAVMA, Vol 246, No. 12, June 15, 2015
requires surgical exploration and histologic examination of appropriate specimens. Prior to surgical exploration, specialized imaging techniques may provide a preliminary diagnosis. Plain radiographic views are of limited use because they often reveal only a vague radiopaque intraabdominal mass, often with poor detail.7 Computed tomography and MRI have been useful in identifying duplication cysts,13 and barium enemas in conjunction with radiography may also provide diagnostic information when a patent communication between the intestine and cyst is present.6,13 Abdominal ultrasonography is the preferred technique and can be diagnostic by delineating the layers of the cyst wall similar to those of the intestinal wall,5 although this type of imaging may only reveal a variably delineated fluid-filled structure, and other cystic masses such as enteric diverticula, hematomas, or abscesses should be considered.7 Histologic assessment of the abnormal tissue provides a definitive diagnosis. The wall of the duplication cyst contains smooth muscle, which typically blends into the adjacent tunica muscularis and may also include a muscularis mucosa and epithelium. The epithelium may be similar to that of the adjacent intestine, with mucosal epithelium and goblet cells, or may be attenuated, flattened, or absent. In cases of esophageal duplication cysts, the epithelium is composed of stratified and pseudostratified epithelial tissues. The presence of a wall containing smooth muscle that is lined by intestinal epithelium and attachment of the cyst to the alimentary tract (as seen in the case described in the present report) are the criteria for diagnosis of a gastrointestinal duplication cyst.14 The smooth muscle wall distinguishes duplication cysts from false diverticula, which are outpouchings of the intestine that lack smooth muscle.15 A Meckel diverticulum is a true diverticulum that contains all 4 layers of the intestine and, in humans, is found on the antimesenteric border of the ileum approximately 60 cm from the ileocecal junction.16 It results from failure of the vitelline duct to completely close during gestation. These diverticula are most common in humans, pigs, and horses and rare in other species.17 A duplication cyst that communicates with the ileum and is located close to the ileocecal junction may resemble a Meckel diverticulum both on gross and histologic examination. Technetium Tc 99m pertechnetate scintigraphy, the diagnostic technique of choice, can identify the gastric mucosa usually found in Meckel diverticula, but this finding may result in an inaccurate diagnosis because duplication cysts may also contain ectopic gastric mucosa.18 Treatment of humans with clinical signs related to a Meckel diverticulum or duplication cyst at a similar location usually requires complete surgical excision, and the prognosis is typically favorable.16 The cause of intestinal duplication cysts remains elusive to researchers and practitioners; the histologic similarity between embryological diverticula and congenital duplication cysts has led to some researchers using the terms interchangeably.19 The digestive tract initially develops from yolk sac endoderm, which eventually becomes the intestinal epithelium, followed by rearrangement and coalescing of epithelial vacuoles to form the lumen.7 However, much remains unknown JAVMA, Vol 246, No. 12, June 15, 2015
about embryological development of the alimentary tract and multiple theories exist regarding the origin of enteric duplication cysts with no theory adequately explaining the cause of all intestinal duplication cysts. Surgical resection and repair is the preferred treatment for humans and other animals with enteric duplication cysts, even in individuals without associated clinical signs, to avoid potential future complications including obstruction, perforation, or potential malignant transformation of the cyst.12 Successful surgical removal of duplication cysts involving the esophagus,3,10 jejunum,4,8,9 and colon6,7 has been performed in dogs, cats, and a horse; however, euthanasia is often selected in complicated cases that have other congenital malformations.11 Surgery is usually successful and the animals fully recover without any further clinical signs. The dog of the present report remained healthy at follow-up 12 months following surgery. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.
17. 18. 19.
O’Donnell PL, Morrow JB, Fitzgerald TL. Adult gastric duplication cysts: a case report and review of literature. Am Surg 2005;71:522–525. Kuo HC, Lee HC, Shin CH, et al. Clinical spectrum of alimentary tract duplication in children. Acta Paediatr Taiwan 2004;45:85–88. Gabor LJ, Walshaw R. Esophageal duplication cyst in a dog. Vet Pathol 2008;45:61–62. Haziroglu R, Atasever A, Gulbahar MY. Duplication of the jejunum in a dog. J Vet Med Sci 1995;57:143–145. Spaulding KA, Cohn LA, Miller RT, et al. Enteric duplication in two dogs. Vet Radiol 1990;31:83–88. Landon BP, Abraham LA, Charles JA, et al. Recurrent rectal prolapse caused by colonic duplication in a dog. Aust Vet J 2007;85:381–385. Arthur EG, Fox DB, Stephanie CE, et al. Surgical treatment of noncommunicating duplication of the colon in a dog. J Am Vet Med Assoc 2003;223:210–214. Radlinsky MA, Biller DS, Nietfeld J, et al. Subclinical intestinal duplication in a cat. J Feline Med Surg 2005;7:223–226. Kershaw O, Deppenmeier S, Gruber AD. Multiple cystic intestinal duplications in a cat. Vet Pathol 2008;45:188–190. Orsini JA, Sepsey L, Donawick WJ, et al. Esophageal duplication cyst as a cause of choke in the horse. J Am Vet Med Assoc 1988; 193:474–476. Otiang’a-Owiti GE, Oduor-Okelo D, Kamau GK, et al. Morphology of a six-legged goat with duplication of the intestinal, lower urinary, and genital tracts. Anat Rec 1997;247:432–438. Kuraoka K, Nakayama H, Kagawa T, et al. Adenocarcinoma arising from a gastric duplication cyst with invasion to the stomach: a case report with literature review. J Clin Pathol 2004;57:428–431. Olajide A-RL, Yisau AA, Abdulraseed NA, et al. Gastrointestinal duplications: experience in seven children and a review of the literature. Saudi J Gastroenterol 2010;16:105–109. Berrocal T, Lamas M, Guiteerrez J, et al. Congenital anomalies of the small intestine, colon, and rectum. Radiographics 1999;19:1219–1236. Benson RE, Dixon CF, Waugh JM. Nonmeckelian diverticula of the jejunum and ileum. Ann Surg 1943;118:377–393. Kahn E, Daum F. Anatomy, histology, embryology, and developmental anomalies. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran’s gastrointestinal and liver disease. Vol 2. 9th ed. Philadelphia: Saunders Elsevier, 2010;1628–1630. Brown CC, Baker DC, Barker IK. Alimentary system. In: Maxie MG, ed. Pathology of domestic animals. Vol 2. 5th ed. Philadelphia: Elsevier Ltd, 2007;85–86. Alenizi EK, Alfeeli MA. Intestinal duplication mimicking Meckel diverticulum. Clin Nucl Med 2008;33:189–190. Bentley JFR, Smith JR. Developmental posterior enteric remnants and spinal malformations. Arch Dis Child 1960;35:76–86. Vet Med Today: Pathology in Practice
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