Case Study

Hepatocellular carcinoma in a 10 year old MN Maltese mix dog

A 10-year-old MN Maltese mix dog with a history of chronic elevated liver enzyme activity was presented for polyuria/polydipsia and inappropriate urination at home. Abnormalities on physical examination were a palpably enlarged liver, stenotic left ear canal, left submandibular lymphadenomegaly, and a 2-pound weight loss. Urinalysis showed normal pH and specific gravity, 3+ proteinuria, 3+ glycosuria, and trace hematuria. On blood chemistry elevated ALP and elevated ALT activity, hypercholesterolemia, and hyperglycemia. The patient was treated with antibiotics pending abdominal ultrasound.

A 10-year-old MN Maltese mix dog with a history of chronic elevated liver enzyme activity was presented for polyuria/polydipsia and inappropriate urination at home. Abnormalities on physical examination were a palpably enlarged liver, stenotic left ear canal, left submandibular lymphadenomegaly, and a 2-pound weight loss. Urinalysis showed normal pH and specific gravity, 3+ proteinuria, 3+ glycosuria, and trace hematuria. On blood chemistry elevated ALP and elevated ALT activity, hypercholesterolemia, and hyperglycemia. The patient was treated with antibiotics pending abdominal ultrasound.

DX

Hepatocellular carcinoma, marked midzonal hepatocellular vacuolization, areas of nodular hyperplasia

Sonographic Differential Diagnosis

Complex left liver mass with separate deep left cystic liver nodule. Mass appears resectable. Suspect hepatocellular carcinoma or other neoplasia with associated hemorrhage, inflammation, or biliary leakage.

Image Interpretation

A complex and echogenic left medial liver mass was present deviating the stomach caudally. A minor amount of free fluid was noted suggestive for hemorrhage, inflammation, or biliary leakage. The mass is localized to the left liver and appears resectable. Intrahepatic vascular congestion is noted. A separate 4 cm echogenic and anechoic cystic nodule is also noted in the deep left liver, The GB is elongated and mildly dilated to the right of the screen in this short axis view.

Outcome

The patient was started on insulin therapy, enalapril (for the hypertension), antibiotics, and liver protectants. Recheck urinalysis showed normal pH and specific gravity, and 3+ glycosuria. Urine culture was negative. Once the diabetes had been stabilized a CT scan was done to determine if hepatic mass was resectable. The patient underwent exploratory surgery with resection and biopsy of hepatic mass. Fructosamine level a month later showed good glycemic control. Low-dose dexamethasone suppression showed cortisol values at 0, 4, and 8 hours of 7.1, 3.0, and 5.2, respectively; consistent with PDH. Trilostane was added to treatment plan. A random blood glucose was 129 mg/dl and the owner reported that the patient was doing well at home. ACTH stimulation test showed high post-ACTH cortisol level and the trilostane dose was increased. Recheck ACTH stimulation test several weeks later still showed elevation, but improved post-ACTH cortisol level. Patient continued to do well on current trilostane dose and the diabetes was well regulated on insulin.

Clinical Differential Diagnosis

Multi-organ pathology: diabetes mellitus, Cushing’s disease, liver disease, neoplasia

Sampling

Full-thickness surgical biopsy of the liver mass showed hepatocellular carcinoma, marked mid-zonal hepatocellular vacuolization, with areas of nodular hyperplasia, and marked mid-zonal hepatocellular vacuolation.