Case Study

Lymphoma and hepatocellular carcinoma diagnosed on FNA and biopsy in an 11 year old FS Golden Retriever mix

An 11-year-old FS Golden Retriever mix, with a history of elevated liver enzymes, was presented due to a possible seizure. This seizure was described by the owner as a collapsing episode with the patient taking several minutes to return to standing. On physical examination, tachypnea, a grade II-III/VI heart murmur, and bilateral nuclear sclerosis were present. Elevated ALT and ALP were noted on the liver blood profile.

DX

Early lymphoma and hepatocellular carcinoma

Sonographic Differential Diagnosis

The 8 cm liver mass in the deep left liver appears low grade, and is most consistent with hepatoma or possible early hepatocellular carcinoma. It appears resectable with full left lobectomy.
The enlarged appearance of the spleen 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 and to rule out underlying early infiltrative disease. 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.

Image Interpretation

The liver presented an 8 cm mass in the deep left lobe without significant loss of structural detail. The spleen was uniformly enlarged without evidence of masses. The capsule was mildly swollen and slightly irregular parenchyma was noted.

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 a coagulation profile revealed subnormal clotting, 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 transferred to a 24-hour emergency facility for monitoring and possible blood transfusion. At the emergency clinic, 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 an oncologist. At last communication the owners were still considering surgical intervention.

Clinical Differential Diagnosis

Seizure – intracranial/extracranial disease, syncope (cardiac/metabolic/ respiratory). Increased liver values – neoplasia, toxic, infectious (bacterial/fungal). Metabolic illness (hyperadrenocorticism, diabetes).

Sampling

US-guided Tru-cut biopsies (14 gauge) of the liver mass revealed a well differentiated, trabecular-type hepatocellular carcinoma. US-guided FNAs from the spleen were suggestive of early lymphoma.