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Maggie. VMB 967A NCSU CVM Lauren Richman 3 April, 2007. Signalment. 9 ½ year old SF West Highland White Terrier. History.

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Maggie

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Maggie

Maggie

VMB 967A

NCSU CVM

Lauren Richman

3 April, 2007


Signalment

Signalment

  • 9 ½ year old

  • SF

  • West Highland White Terrier


History

History

  • In 10/06 Maggie's behavior became very strange, she began to "graze on the lawn," was very listless, was heat seeking and not as athletic as before, unable to jump up on the couch from the floor. Her coat became thinner and her skin got "liver spots" on it. She also began to lick at her front paws, which became very irritated between the toes and on the dorsal aspect as well, then she moved on to all 4 paws, which eventually became quite lame. The owners brought her in for work-up to their regular vet, where they suspected hyperadrenocorticism. The performed an ACTH stim (pre 6.7, stim 22), a LDDS (pre 6.7, 4h 1.2, 8h 0.8), and Urine cortisol:creatinine (23 normal =<13). The rDVM noted the dermatitis on the feet, but did not want to initiate treatment for the feet or for the "Cushing’s" without confirmation by an abdominal ultrasound. The owners applied Neosporin and baby socks to her feet which improved them enough so that she is no longer lame. Maggie lives with one other dog and a cat, has a fenced backyard, and gets leash walks (although hasn't wanted to take walks recently). Her vaccination status is up to date (rabies due in 08, all others due in March 07) is also regularly on Frontline and Heartgard, and was heartworm tested in 3/06 and was negative.


Maggie

PE

  • Temp: 101.0 Pulse: 84 Resp: 20 MM: pk (slightly dry) CRT: < 2Wt: 8.8kg Attitude: BAR; Pain score: 0; BCS 5/9

  • EENT: mild lenticular sclerosis, minimal yellow ceruminous accumulation in ears, no smell. Moderate dental tartar and halitosis.

  • H/L: no murmurs or arrhythmias ausculted, lungs clear, pulses strong and synchronous

  • PLN: submandibular LNs wnl, prescapulars and popliteals prominent

  • GIGU: abdomen tense, but not painful on palpation, cranial abdomen difficult to palpate, bladder not palpable.

  • MS: no significant abnormalities noted

  • Int: thin haircoat, hyperpigmentation on dorsum, dermatitis and saliva discoloration on dorsal and volar aspects of all 4 feet and in-between toes.

  • Neuro: no significant abnormalities noted


Clinpath findings

ClinPath Findings

  • Diagnostic Tests: CBC: No significant abnormalities

  • Chem: Elevations in both ALT and ALP, low end of normal cholesterol and BUN.

  • UA (cysto): SG 1.047, pH 5, Trace protein and bumin, 1+ ketones, 3+ Bilirubin, trace blood. 0-5 WBCs and epithelial cells/hpf, 2-5 granular casts/lpf, moderate fat droplets.

  • Bile acids: within normal limits

  • LN aspirates: Right prescap: reactive/hyperplastic LN; Left popliteal: low cellularity specimen; suggestive of reactive/hyperplastic LN.


Abdominal ultrasound

Abdominal Ultrasound

Left adrenal


Abdominal ultrasound1

Abdominal Ultrasound

Right adrenal


Abdominal ultrasound2

Abdominal Ultrasound

Liver nodule 1


Abdominal ultrasound3

Abdominal Ultrasound

Liver nodule 2


Abdominal ultrasound4

Abdominal Ultrasound

Liver mass


Abdominal ultrasound5

Abdominal Ultrasound

Liver mass


Abdominal ultrasound6

Abdominal Ultrasound

Portal vein (and nodule)


Abdominal ultrasound7

Abdominal Ultrasound

Portal vein resistive index ~ 14 cm/s


Abdominal ultrasound8

Abdominal Ultrasound

Color Doppler of liver mass


Ultrasound report

Ultrasound Report

  • The liver is irregularly marginated and contains multiple hypoechoic nodules. There is a 6.0 mm hyperechoic nodule and a 25.5 mm by 32.4 mm hyperechoic mass on the left side. There is a 25.0 mm, heterogeneous pedunculated mass that appears to be adjacent to the gall bladder and possibly originating from the quadrate liver lobe. These nodules may all be regenerative such as with cirrhosis but a neoplastic infiltrate cannot be ruled out. The right side of the liver is decreased in size which is also consistent with cirrhosis. There is no evidence of hepatic lymphomegaly. There is no evidence of portal hypertension. The left adrenal gland measures 4.0 mm wide caudally; the right is 4.2 mm.


Other imaging reports

Other Imaging Reports

  • Thoracic Radiographs: Liver mass visible in ventral aspect of liver, no abnormalities except aging changes in lung fields. No other abnormalities noted.

  • Computed Tomography: Abdominal mass; possible lymphomegaly, gastric wall mass or body wall mass. Hepatic mass; primary differentials include neoplasia, regenerative hyperplasia and extramedullary hematopoesis. Irregular liver; possible severe nodular hyperplasia.


Thoracic radiographs

Thoracic Radiographs


Thoracic radiographs1

Thoracic Radiographs


Thoracic radiographs2

Thoracic Radiographs


Liver fna

Liver FNA

  • "Normal" liver looks cytologically unremarkable. Mass lesion near the gallbladder is suggestive of malignant neoplasia, may be consistent with histiocytic or poorly differentiated neoplasia.


Course of action

Course of Action

  • Maggie underwent abdominal exploratory surgery with excision of the mass


Biopsy results

Biopsy Results

  • Liver: Marked multifocal hepatocellular necrosis with bridging fibrosis, nodular regeneration, and biliary hyperplasia

  • Mass: Hemangiosarcoma

  • COMMENTS - The changes seen within the liver are consistent with chronic, end-stage liver disease. There is severe collapse of lobular architecture with abundant fibrosis and nodular regeneration. The inciting cause of the liver disease is unknown, and there is no active inflammation present. The mass within the adipose tissue near the liver is a hemangiosarcoma. This likely represents metastasis of a primary neoplasm elsewhere in the body. Thorough evaluation for the primary tumor is recommended. The most common primary sites in dogs are spleen, liver, right auricle, and skin/subcutis. Visceral hemangiosarcomas are highly aggressive tumors with a poor prognosis.


Assessment

Assessment

  • It is possible that the hemangiosarcoma could have been sending toxins or metastases to the liver which caused it to necrose and fibrose.

  • As her liver became more and more necrotic and fibrotic, her liver enzymes increased, and the cholesterol and BUN, which are indicators of hepatic function, decreased.

  • Bilirubin in the urine is a more sensitive indicator of hepatocellular or cholestatic damage than bilirubinemia, and occurs before an animal is bilirubinemic.

  • The fact that her bile acid levels were within normal limits indicates that she still has enough functional hepatic parenchyma, despite the gross and microscopic degenerative changes.


Assessment contd

Assessment Contd.

  • The reason she was referred to us was for workup of borderline hyperadrenocorticism.

  • One of the clinical manifestations of end stage hepatic disease is an abnormal release of neurotransmitters causing an increase of ACTH release and the sequelae of cushinoid symptoms such as the ones Maggie was showing; haircoat and pigmentation changes, behavioral changes, and body shape changes.

  • Hyperadrenocorticism can also be responsible for the elevated ALT and ALP, proteinuria, casts, and secondary urinary tract infection causing hematuria.


Outcome

Outcome

  • Maggie was sent home after a successful surgery with the recommendation of follow-up with the Oncology Service for chemotherapy.


Pros of ultrasound

Pros of Ultrasound

  • Aided in the identification of the abdominal mass and liver disease better than radiographs

  • Allowed examination of the other abdominal organs and lymph nodes for evaluation of the extent of the neoplasia

  • Helped to determine if the mass was a surgical lesion

  • Helped to establish hepatic function with color doppler/resistive index measurements


Cons of ultrasound

Cons of Ultrasound

  • Was not able to determine that the mass was of falciform and not hepatic origin (however, neither radiographs or CT showed that either)

  • Was not able to appreciate any other abdominal masses which may have been the primary tumor


Thank you

Thank You


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