Hemotropic Mycoplasmas (Hemoplasmas) in Free-Ranging Azara's Agoutis (Dasyprocta azarae) from an Urban Area of Southern Brazil.

Hemotropic mycoplasmas (hemoplasmas) are opportunistic bacteria that attach to the erythrocyte surface, causing infectious anemia in several mammalian species, including rodents. Studies surveying native Azara's agoutis (Dasyprocta azarae) in Brazil are lacking. Accordingly, the present study aimed to assess hemoplasmas infection in free-ranging agoutis from an urban environmental conservation area in Curitiba, southern Brazil. Overall, 11/35 (31.43%) agoutis were positive to hemoplasmas by quantitative PCR (cycle threshold≤34.4). Sequencing of the 16S ribosomal RNA gene indicated Mycoplasma haemomuris infection, closely related to M. haemomuris subsp. ratti, suggesting hemoplasma transmission from urban rats to agoutis. Because the main route of M. haemomuris transmission has been direct rodent-to-rodent infection, the relatively lower positivity that we detected may be the result of low intraspecies contact due to the smaller social units of agoutis, generally consisting of two to four individuals, and low interspecies contact due to only sporadic agouti-rat interactions in urban settings, compared with other rodent species interactions. Further studies should be conducted to determine whether the hemoplasma infection that we found can cause clinical onset and life-threatening anemia in agoutis.

Complete Blood Counts and Blood Smear Analyses in 312 Diabetic Dogs (2007-2017).

Diabetes mellitus is a common endocrinopathy in dogs that has been associated with various biochemical changes and comorbid diseases, but hematologic abnormalities have been rarely reported. The aim of this retrospective study was to evaluate complete blood count and blood smear alterations and to describe their relationship with, and incidence of comorbid diseases in, diabetic dogs. Three-hundred twelve diabetic dogs, 286 dogs diagnosed with systemic, nondiabetic illnesses, and 506 healthy dogs were identified during the study period. Groups were compared using contingency tables and logistic regression. Associations between statistically significant complete blood count and blood smear alterations and comorbidities were evaluated using multivariable analysis. High-grade codocytosis and anisocytosis were identified more frequently in diabetic dogs, whereas high-grade reactive lymphocytosis and keratocytosis were identified less frequently (P < .001). Diabetic dogs with high-grade codocytosis had lower red blood cell, hemoglobin, hematocrit and higher white blood cell counts (P < .001). Diabetic ketoacidosis was diagnosed more frequently in diabetic dogs with high-grade codocytosis when compared with those with low-grade codocytosis (P < .001) or when compared with any other cell morphologic alterations. This study suggests that blood smear analysis should be a routine part of the evaluation of diabetic dogs.

Atypical multiple myeloma in 3 young dogs.

Three dogs under 12 months old were diagnosed with atypical multiple myeloma (MM), having an aggressive multifocal anaplastic round cell sarcoma in bone marrow, viscera, and/or peripheral blood, which were confirmed by cytology and immunohistochemistry to be of plasma cell origin. The intramedullary sarcomas caused myelophthisis, osteolysis, and hypercalcemia. Complete or free light chain monoclonal gammopathy in the serum and/or urine was demonstrated by protein electrophoresis and immunofixation. The polymerase chain reaction for antigen receptor rearrangement assay performed on 2 cases identified a clonally rearranged immunoglobulin gene. Neoplastic cells lacked expression of CD45, CD3, CD18, CD21, CD34, and MHCII by flow cytometry. Immunohistochemistry revealed MUM1 immunoreactivity of the neoplastic cells. Combining all data, the diagnosis was MM. An aggressive form of MM in young dogs should be a differential diagnosis for patients with an immunoglobulin-productive, B cell-clonal, CD45-negative, MUM1-positive discrete cell neoplasm arising from the bone marrow.

Hemophagocytic syndrome associated with large granular lymphoma in an adult dog.

Hemophagocytic syndrome (HPS) is a rare disorder characterized by dysregulation of the immune response resulting in uncontrolled activation of macrophages with exacerbated phagocytosis of host cells. In dogs, the criteria for diagnosis include the presence of pancytopenia or bicytopenia in the peripheral blood and >2% hemophagocytic macrophages in bone marrow aspirates. When HPS is associated with lymphoma, it is called lymphoma-associated hemophagocytic syndrome (LAHS). Here, we present a case of a 4 ½-year-old female spayed Old English Mastiff that presented with severe thrombocytopenia, mild anemia, mild to moderate leukopenia, and large granular lymphocytes (LGLs) in the peripheral blood. The patient had enlarged lymph nodes with many LGLs seen cytologically, leading to the interpretation of LGL lymphoma. Bone marrow displayed numerous LGLs that stained strongly for CD3 but did not show immunoreactivity to CD4 or CD8, and PCR for antigen receptor rearrangement analysis confirmed a clonal T-cell receptor gamma gene rearrangement. The presence of ~3.5% hemophagocytes present on the bone marrow evaluation raised concern for HPS and, more specifically, LAHS. HPS and LAHS are challenging to diagnose and require many criteria to be fulfilled before a definitive diagnosis can be made; the low number of cases in the literature makes this even more challenging in dogs. This case represents secondary LAHS due to LGL lymphoma in a dog.

A case of acute monocytic leukemia (AMoL or AML-M5) in an adult FeLV/FIV-positive cat.

A 7-year-old castrated male domestic shorthair cat was presented for evaluation of decreased appetite and respiratory signs. A CBC run on presentation revealed severe nonregenerative anemia, thrombocytopenia, and leukocytosis characterized by a prominent population of blasts, having morphologic features suggestive of a monocytic lineage. The cat tested positive for FIV, FeLV, Mycoplasma haemominutum, and only mild abnormalities were identified on the chemistry panel. Bone marrow biopsies were obtained to investigate the bicytopenia and the possibility of a hematopoietic neoplasm. Although the bone marrow aspirate was nondiagnostic, the core biopsy was markedly hypercellular with a population of blasts, largely replacing the normal hematopoietic tissue. Immunohistochemical staining revealed that the blasts were CD3-negative, Pax5-negative, dimly CD18-positive, and moderately positive for Iba1. These findings, in addition to the prominent monocytic differentiation seen in peripheral blood, supported a diagnosis of acute monocytic leukemia. Palliative antiviral and antibiotic treatment and blood transfusion were performed. The patient was discharged on his fourth day of hospitalization. However, 15 days following discharge, the cat was euthanized due to the worsening of his systemic signs. This report discusses the classifications of myeloid leukemias, implications of infectious diseases in the pathogenesis of neoplasia in cats, and the use of Iba1, a "pan-monocytic/histiocytic" marker, in the diagnosis of acute leukemia.

Genomic profile of Brazilian methicillin-resistant Staphylococcus aureus resembles clones dispersed worldwide.

PURPOSE: Comparative genomic analysis of strains may help us to better understand the wide diversity of their genetic profiles. The aim of this study was to analyse the genomic features of the resistome and virulome of Brazilian first methicillin-resistant Staphylococcus aureus (MRSA) isolates and their relationship to other Brazilian and international MRSA strains. METHODOLOGY: The whole genomes of three MRSA strains previously isolated in Vitória da Conquista were sequenced, assembled, annotated and compared with other MRSA genomes. A phylogenetic tree was constructed and the pan-genome and accessory and core genomes were constructed. The resistomes and virulomes of all strains were identified.Results/Key findings. Phylogenetic analysis of all 49 strains indicated different clones showing high similarity. The pan-genome of the analysed strains consisted of 4484 genes, with 31 % comprising the gene portion of the core genome, 47 % comprising the accessory genome and 22 % being singletons. Most strains showed at least one gene related to virulence factors associated with immune system evasion, followed by enterotoxins. The strains showed multiresistance, with the most recurrent genes conferring resistance to beta-lactams, fluoroquinolones, aminoglycosides and macrolides. CONCLUSIONS: Our comparative genomic analysis showed that there is no pattern of virulence gene distribution among the clones analysed in the different regions. The Brazilian strains showed similarity with clones from several continents.

RNA-Seq based transcriptome of whole blood from immunocompetent pigs (Sus scrofa) experimentally infected with Mycoplasma suis strain Illinois.

Pigs are popular animal models in biomedical research. RNA-Seq is becoming the predominant tool to investigate transcriptional changes of the pig's response to infection. The high sensitivity of this tool requires a strict control of the study design beginning with the selection of healthy animals to provide accurate interpretation of research data. Pigs chronically infected with Mycoplasma suis often show no obvious clinical signs, however the infection may affect the validity of animal research. The goal of this study was to investigate whether or not this silent infection is also silent at the host transcriptional level. Therefore, immunocompetent pigs were experimentally infected with M. suis and transcriptional profiles of whole blood, generated by RNA-Seq, were analyzed and compared to non-infected animals. RNA-Seq showed 55 differentially expressed (DE) genes in the M. suis infected pigs. Down-regulation of genes related to innate immunity (tlr8, chemokines, chemokines receptors) and genes containing IFN gamma-activated sequence (gbp1, gbp2, il15, cxcl10, casp1, cd274) suggests a general suppression of the immune response in the infected animals. Sixteen (29.09%) of the DE genes were involved in two protein interaction networks: one involving chemokines, chemokine receptors and interleukin-15 and another involving the complement cascade. Genes related to vascular permeability, blood coagulation, and endothelium integrity were also DE in infected pigs. These findings suggest that M. suis subclinical infection causes significant alterations in blood mRNA levels, which could impact data interpretation of research using pigs. Screening of pigs for M. suis infection before initiating animal studies is strongly recommended.

Draft Genome Sequence of Methicillin-Resistant Staphylococcus aureus Strain LC33 Isolated from Human Breast Milk.

Here, we report the draft genome sequence of Staphylococcus aureus strain LC33, isolated from human breast milk in Brazil. This microorganism has been typed as ST1/t127/sccmecV. To our knowledge, this is the first draft genome sequence of a methicillin-resistant S. aureus strain isolated from human breast milk.

Draft Genome Sequences of Two Clinical Methicillin-Resistant Staphylococcus aureus Strains Isolated from Healthy Children in Brazil.

We report here the draft genome sequences of two community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) strains, C18 and C80, isolated from healthy children from day care centers. To our knowledge, these are the first draft genome sequences of CA-MRSA ST398/CC398/SccmecV and CA-MRSA ST5/CC5/SccmecIVa isolated from healthy children in Brazil.

Ureaplasma diversum Genome Provides New Insights about the Interaction of the Surface Molecules of This Bacterium with the Host.

Whole genome sequencing and analyses of Ureaplasma diversum ATCC 49782 was undertaken as a step towards understanding U. diversum biology and pathogenicity. The complete genome showed 973,501 bp in a single circular chromosome, with 28.2% of G+C content. A total of 782 coding DNA sequences (CDSs), and 6 rRNA and 32 tRNA genes were predicted and annotated. The metabolic pathways are identical to other human ureaplasmas, including the production of ATP via hydrolysis of the urea. Genes related to pathogenicity, such as urease, phospholipase, hemolysin, and a Mycoplasma Ig binding protein (MIB)-Mycoplasma Ig protease (MIP) system were identified. More interestingly, a large number of genes (n = 40) encoding surface molecules were annotated in the genome (lipoproteins, multiple-banded antigen like protein, membrane nuclease lipoprotein and variable surface antigens lipoprotein). In addition, a gene encoding glycosyltransferase was also found. This enzyme has been associated with the production of capsule in mycoplasmas and ureaplasma. We then sought to detect the presence of a capsule in this organism. A polysaccharide capsule from 11 to 17 nm of U. diversum was observed trough electron microscopy and using specific dyes. This structure contained arabinose, xylose, mannose, galactose and glucose. In order to understand the inflammatory response against these surface molecules, we evaluated the response of murine macrophages J774 against viable and non-viable U. diversum. As with viable bacteria, non-viable bacteria were capable of promoting a significant inflammatory response by activation of Toll like receptor 2 (TLR2), indicating that surface molecules are important for the activation of inflammatory response. Furthermore, a cascade of genes related to the inflammasome pathway of macrophages was also up-regulated during infection with viable organisms when compared to non-infected cells. In conclusion, U. diversum has a typical ureaplasma genome and metabolism, and its surface molecules, including the identified capsular material, represent major components of the organism immunopathogenesis.

Detection of hemoplasma infection of goats by use of a quantitative polymerase chain reaction assay and risk factor analysis for infection.

OBJECTIVE To develop and validate a real-time quantitative PCR (qPCR) assay for the detection and quantification of Mycoplasma ovis in goats and investigate the prevalence and risk factors for hemoplasma infection of goats located in Indiana. ANIMALS 362 adult female goats on 61 farms. PROCEDURES Primers were designed for amplification of a fragment of the dnaK gene of M ovis by use of a qPCR assay. Blood samples were collected into EDTA-containing tubes for use in total DNA extraction, blood film evaluation, and determination of PCV. Limit of detection, intra-assay variability, interassay variability, and specificity of the assay were determined. RESULTS Reaction efficiency of the qPCR assay was 94.45% (R(2), 0.99; slope, -3.4623), and the assay consistently detected as few as 10 copies of plasmid/reaction. Prevalence of infection in goats on the basis of results for the qPCR assay was 18.0% (95% confidence interval, 14% to 22%), with infected goats ranging from 1 to 14 years old, whereby 61% (95% confidence interval, 47% to 73%) of the farms had at least 1 infected goat. Bacterial load in goats infected with M ovis ranged from 1.05 × 10(3) target copies/mL of blood to 1.85 × 10(5) target copies/mL of blood; however, no bacteria were observed on blood films. Production use of a goat was the only risk factor significantly associated with hemoplasma infection. CONCLUSIONS AND CLINICAL RELEVANCE The qPCR assay was more sensitive for detecting hemoplasma infection than was evaluation of a blood film, and production use of a goat was a risk factor for infection.

A cross sectional study evaluating the prevalence of Coxiella burnetii, potential risk factors for infection, and agreement between diagnostic methods in goats in Indiana.

Coxiella burnetii is the etiologic agent of the zoonotic disease Q fever and is considered to be endemic in domestic ruminants. Small ruminants in particular are important reservoirs for human infection. Serologic and molecular methods are both available for diagnosis of infection with C. burnetii, but there has been little research evaluating the prevalence of this organism in small ruminants outside of the context of clinical disease outbreaks. The objectives of this study were to estimate seroprevalence of C. burnetii and the prevalence of shedding of C. burnetii DNA in milk by goats in Indiana, USA, to evaluate potential risk factors for association with C. burnetii exposure and shedding, and to assess the level of agreement between the enzyme-linked immunosorbent assay (ELISA) and real-time polymerase chain reaction (PCR) tests used to estimate prevalence. A total of 649 does over 1 year of age and not pregnant at the time of sampling were included in the study. Serum samples were collected from 608 does representing 89 farms. Milk samples were collected from 387 does representing 85 farms. Both milk and serum samples were collected from 356 does representing 80 farms. The estimated individual seroprevalence and shedding prevalence in milk adjusted for clustering were 3.1% (n=23/608, 95% CI: 1.2-7.0%) and 2.5% (n=9/387, 9.5% CI: 1.0-5.6%) respectively. Estimated adjusted herd level C. burnetii seroprevalence and herd level shedding prevalence were 11.5% (n=10/89, 95% CI: 6.4-20.1%) and 7.0% (n=6/85, 95% CI: 3.3-14.6%) respectively. Based on a generalized estimating equation model (GEE), meat breeds of goat had 7.0 times increased odds of shedding C. burnetii DNA in milk samples as compared to dairy breeds. Agreement between tests as determined by Cohen's kappa was poor at both the individual (kappa=0.04, 95% CI: -0.1 to 0.2) and herd (kappa=0.2, 95% CI: -0.1 to 0.5) levels. This indicates that serologic screening alone is unlikely to prevent the introduction of does shedding C. burnetii into herds.

Genome Sequence of Ureaplasma diversum Strain ATCC 49782.

Here, we report the complete genome sequence of Ureaplasma diversum strain ATCC 49782. This species is of bovine origin, having an association with reproductive disorders in cattle, including placentitis, fetal alveolitis, abortion, and birth of weak calves. It has a small circular chromosome of 975,425 bp.

Microscopy and genomic analysis of Mycoplasma parvum strain Indiana.

Mycoplasma parvum [Eperythrozoon parvum] is the second hemotrophic mycoplasma (hemoplasma) described in pigs. Unlike M. suis, its closest phylogenetic relative, M. parvum, is considered a non-pathogenic bacterium in this host species. Natural infection of a domestic, 6-month-old splenectomized pig with M. parvum strain Indiana is described herein. Light and scanning electron microscopy of the bacteria were performed in addition to whole genome sequencing, analysis, and comparison to the genome of M. suis strain Illinois. Neither clinical signs nor anemia were observed during the infection. Microscopy analyses revealed coccoid to rod- shaped organisms varying from 0.2 to 0.5 µm; they were observed individually or in short chains by both light and electron microscopy, however less than 30% of the red blood cells were infected at peak bacteremia. The single circular chromosome of M. parvum was only 564 395 bp, smaller than M. genitalium, previously considered the tiniest member of the Mollicutes. Its general genomic features were similar to others in this class and species circumscription was verified by phylogenomic analysis. A gene-by-gene comparison between M. suis and M. parvum revealed all protein coding sequences (CDS) with assigned functions were shared, including metabolic functions, transporters and putative virulence factors. However, the number of CDS in paralogous gene families was remarkably different with about half as many paralogs in M. parvum. The differences in paralogous genes may be implicated in the different pathogenic potential of these two species, however variable gene expression may also play a role. Both are areas of ongoing investigation.

Identification, occurrence and clinical findings of canine hemoplasmas in southern Brazil.

Hemoplasmas are ubiquitous pleomorphic and epicellular bacteria detected in erythrocytes in several species. In Brazil, studies on hemoplasmas have not included information on occurrence, clinical signs, and risk factors in dogs. This paper investigates the occurrence of hemoplasmas in dogs, focusing on risk factors and clinical status. Conventional PCR for the four types of canine hemoplasmas was performed in 331 blood samples collected from dogs clinically treated at a teaching veterinary hospital. Of all samples, 17/331 (5.1%) were positive for Mycoplasma haemocanis and 6/331 (1.8%) were positive for a 'Candidatus Mycoplasma haemominutum-like' organism. Risk factors included the presence of vectors, old age, dog bite wounds, and neoplastic diseases. In the multivariate analysis, a 4.40 odds ratio in dogs with vector-borne diseases indicated risk for hemoplasmosis. There was correlation between hemoplasma infection and neoplastic disease, suggesting that neoplastic conditions are a risk factor for hemoplasma infection in dogs.

Comparative genomics and phylogenomics of hemotrophic mycoplasmas.

Hemotrophic mycoplasmas (hemoplasmas) are a group of animal pathogens of the Mollicutes class. Recently, the genomes of 8 hemoplasmas have been completely sequenced. The aim of this study was to gain a better understanding of their genomic features and relationship to other Mycoplasma species. The genome structure and dynamics of hemoplasmas were analyzed by evaluating gene synteny, adaptive evolution of paralogous gene families (PGF) and horizontal gene transfer (HGT). The Mollicutes class was then phylogenetically analyzed by constructing a distance matrix of the 16S rRNA genes and a phylogenetic tree with 32 conserved, concatenated proteins. Our results suggest that the hemoplasmas have dynamic genomes. The genome size variation (from 547 to 1,545 genes) indicates substantial gene gain/loss throughout evolution. Poorly conserved gene syntenies among hemoplasmas, positional shuffling of paralogous genes between strains, HGT, and codons under positive selection in PGFs were also observed. When compared to other Mollicutes species, the hemoplasmas experienced further metabolic reduction, and the 16S rRNA gene distance matrix of the available mollicutes suggests that these organisms presently constitute the most divergent clade within its class. Our phylogenetic tree of concatenated proteins showed some differences when compared to the 16S rRNA gene tree, but non-mycoplasma organisms, such as Ureaplasma spp. and Mesoplasma spp., continue to branch within Mycoplasma clades. In conclusion, while the hemoplasmas experienced further metabolic shrinkage through gene loss, PGFs with positively selected codons are likely beneficial to these species. Phylogeny of the mollicutes based on 16S rRNA genes or concatenated proteins do not obey the current taxonomy. The metabolism and genetic diversity of the mollicutes, the presence of HGT, and lack of standard for genus circumscription are likely to hinder attempts to classify these organisms based on phylogenetic analyses.

Complete Genome Sequence of Mycoplasma ovis Strain Michigan, a Hemoplasma of Sheep with Two Distinct 16S rRNA Genes.

We report the complete genome sequence of Mycoplasma ovis strain Michigan. Its single circular chromosome has 702,511 bp and contains 2 copies of the 16S rRNA gene, one corresponding to M. ovis and the other to "Candidatus Mycoplasma haemovis." All housekeeping genes and the 5S-23S rRNA genes are present in single copies.

Identification of Mycoplasma suis antigens and development of a multiplex microbead immunoassay.

The aims of the current study were to identify Mycoplasma suis antigens and develop a multiplex microbead immunoassay (MIA). A M. suis-expression library was screened for immunogens using sera from infected pigs. Based on bioinformatics, putative antigens were identified within positive inserts; gene fragments were expressed and purified as polyhistidine fusion proteins, and immunoreactivity was confirmed by Western blot. Selected antigens were used to develop a MIA. Sera from noninfected and infected pigs were used to set the median fluorescent intensity (MFI) cutoffs and as positive controls, respectively. Assay specificity was tested using sera from pigs seropositive for other pathogens (2 different pigs seropositive for each pathogen). Samples from 51 field pigs and 2 pigs during the course of acute (pig 1) and chronic (pig 2) infections were tested using MIA, indirect hemagglutination assay (IHA), and quantitative polymerase chain reaction (qPCR). Sixteen reactive plaques (52 genes) were detected. A heat-shock protein (GrpE), a nicotinamide adenine dinucleotide-dependent glyceraldehyde 3-phosphate dehydrogenase (GAPN), and 4 proteins from paralogous gene families (PGFs) were identified as antigens by Western blot. While GrpE, GAPN, and 1 PGF protein were strong antigens, the others were not suitable as MIA targets. A MIA using GrpE, GAPN, and the strongly reactive PGF protein was developed. Cross-reactivity with sera from pigs infected with Mycoplasma hyopneumoniae, Porcine circovirus-2, Porcine parvovirus, Porcine reproductive and respiratory syndrome virus, and Porcine respiratory coronavirus with this MIA was not observed. Pig 2 was consistently positive by MIA and qPCR, whereas pig 1, initially negative, seroconverted before becoming qPCR positive. Only 2 samples (from pig 1) were IHA positive. Five (9.8%) field samples were qPCR positive and 40 (78.43%) were positive for all 3 MIA antigens; however, all were IHA negative. In summary, the MIA is specific and more sensitive than qPCR and IHA, providing simultaneous evaluation of antibody response to M. suis antigens.

Genome Sequence of Mycoplasma parvum (Formerly Eperythrozoon parvum), a Diminutive Hemoplasma of the Pig.

We report the complete genome sequence of Mycoplasma parvum strain Indiana. Its circular chromosome is 564,395 bp, which is smaller than that of Mycoplasma genitalium, which was previously considered the smallest member of the Mollicutes. Comparative analyses of the genomes of M. parvum and Mycoplasma suis will provide novel insights into the molecular basis of their virulence.

Multiple joint metastasis of a transitional cell carcinoma in a dog.

An 8-year-old castrated male hound mix was referred to the Purdue University Veterinary Teaching Hospital for severe lameness, pollakiuria, and dyschezia. On presentation, the dog was nonweight bearing on the right rear limb and the right carpus was diffusely swollen. Synovial fluid analysis from the right carpus revealed a population of epithelial cells displaying marked anisocytosis, anisokaryosis, multinucleation, and prominent, variably sized nucleoli. A metastatic carcinoma with presumed prostatic or urothelial origin was diagnosed based on cytomorphology. Subsequent cytologic evaluation of peripheral lymph nodes revealed the presence of a similar neoplastic population. The dog was euthanized and synovial fluid from both stifle joints, as well as impression smears of the prostate gland, were collected. Carcinoma cells were identified in each stifle joint and in the prostate gland. Immunocytochemistry was performed on synovial fluid smears from 2 of the joints (right stifle and right carpus) and on impression smears of the prostate gland. The neoplastic population in the joints and prostate gland showed strong immunoreactivity to uroplakin III, a urothelial marker, indicating metastasis of a transitional cell carcinoma to multiple joints. In addition, evidence for epithelial to mesenchymal transition was identified using cytokeratin, an epithelial marker, and vimentin, a mesenchymal marker. A necropsy was performed and histopathology confirmed the presence of metastatic transitional cell carcinoma in various tissues. This case illustrates the importance of considering metastatic disease when a patient is presented with severe lameness and joint pain, and the clinical utility of synovial fluid cytology for diagnosis of metastasis in these cases.