Transcript Maggie Rogers

Maggie
VMB 967A
NCSU CVM
Lauren Richman
3 April, 2007
Signalment
• 9 ½ year old
• SF
• West Highland White Terrier
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.
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 inbetween toes.
• Neuro: no significant abnormalities noted
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
Left adrenal
Abdominal Ultrasound
Right adrenal
Abdominal Ultrasound
Liver nodule 1
Abdominal Ultrasound
Liver nodule 2
Abdominal Ultrasound
Liver mass
Abdominal Ultrasound
Liver mass
Abdominal Ultrasound
Portal vein (and nodule)
Abdominal Ultrasound
Portal vein resistive index ~ 14 cm/s
Abdominal Ultrasound
Color Doppler of liver mass
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
• 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 Radiographs
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
• Maggie underwent abdominal exploratory
surgery with excision of the mass
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
• 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.
• 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
• Maggie was sent home after a successful
surgery with the recommendation of
follow-up with the Oncology Service for
chemotherapy.
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
• 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