Case Study

03_00186 Thumper S Hepatocellular carcinoma

An 11-year-old FS Golden retriever mix with a history of elevated liver enzyme, was presented due to a possible seizure, which was described by the owner as a collapsing episode with the patient taking several minutes to stand up. On physical examination tachypnea, grade II-III/VI heart murmur, and bilateral nuclear sclerosis was present. Abnormalities on liver profile were elevated ALT and ALP activity.

An 11-year-old FS Golden retriever mix with a history of elevated liver enzyme, was presented due to a possible seizure, which was described by the owner as a collapsing episode with the patient taking several minutes to stand up. On physical examination tachypnea, grade II-III/VI heart murmur, and bilateral nuclear sclerosis was present. Abnormalities on liver profile were elevated ALT and ALP activity.

DX

Hepatocellular carcinoma. FNAs from the spleen were suggestive of early lymphoma.

Sonographic Differential Diagnosis

Hypersplenism, possible early infiltrative disease. Likely reactive hypersplenism. Low grade 8 cm liver mass in the deep left liver. This appears resectable.

Image Interpretation

The liver presented an 8 cm mass in the deep left lobe without significant loss of structural detail. This is most consistent with hepatoma or possible early hepatocellular carcinoma. 14-guage ultrasound-guided biopsies were performed 2 days after the original ultrasound. This appears resectable with full left lobectomy. The spleen was uniformly enlarged with relatively uniform parenchyma without evidence of masses. The capsule was mildly swollen. This is most consistent with hypersplenism and reactive hyperplasia deriving from splenic white or red pulp. However, early infiltrative disease, such as lymphoma or mast cell neoplasia can, at times, present in this manner. US-guided FNA would be best in order to ensure only reactive hyperplasia is present. If clinical signs fit with potential neoplasia or mast cell disease, then Benadryl injection (1 mg/pound IM) 15 minutes prior to FNA would be recommended. Slight irregular parenchyma was noted. Fine-needle aspirates would be warranted to rule out underlying early infiltrative disease.

Outcome

As blood pressure measurements were high, Enalapril was started. Fast panel PCR canine tick borne panel profile results were negative. Although platelet count was low and the coagulation profile was subnormal but stable, biopsies of the liver and splenic FNA’s were performed via ultrasound. Several hours later the patient was weak, bradycardic, and the mucous membranes were pale pink in color. CBC showed anemia, which rapidly deteriorated. The patient was recommended for transfer to a 24-hour emergency facility for monitoring and possible blood transfusion where the patient was treated with Hetastarch and Ampicillin. At one point the patient’s PCV had dropped down to 16, but no blood transfusion was given. Blood pressure measurements were within normal range. The patient eventually stabilized and was discharged to the care of her owners with no medications. Removal of the liver mass in conjunction with a splenectomy was recommended by the oncologist. At last communication the owners were still considering surgical intervention.

Comments

The patient was lost to follow up.

Clinical Differential Diagnosis

Seizure – intracranial/extracranial disease, syncope (cardiac/metabolic/ respiratory.) Liver – neoplasia, toxic, infectious (bacterial/fungal.) Metabolic (Cushing’s, Diabetes.)

Sampling

US-guided Tru-cut biopsies of the liver mass revealed a well differentiated, trabecular type hepatocellular carcinoma. US-guided FNA`s from the spleen were suggestive of early lymphoma.