Sunday, October 19, 2014

A Jack Russell has a large liver tumour

A 12-year-old Jack Russell came with a much swollen abdomen.

She was not spayed and so I thought she could have closed pyometra. This is a common problem of unspayed old female dogs. Yet the dog was active and could even walk 30 minutes to the Surgery. She had a very good appetite and drank a lot of water. She peed a lot. So, closed pyometra was ruled out.


Could there be an abdominal tumour since a vet had removed a breast tumour (MG 5 left side) some 8 months ago? Or metastasis of this breast tumour?

Could there be an ovarian tumour?

Next was ascites. On percussion of the abdomen, there was no tympany of gas or fluid thrill when I tap the right side of the abdomen and let my fingers of the other hand feel the other side.

I gave fruesemide to bring down any abdominal fluid and took an X-ray 12 hours later. There was the classical splenic neoplasia as diagnosed by Dr Daniel. This image was similar to the image in the Vet Surgery book which showed the lateral abdomen with the tail of the spleen being a globular shape.

According to an experienced older vet, an ovarian cyst would be higher up in the anterior abdomen.

So, the X-ray diagnosis is a splenic tumour. Could it have metastasized to the atrium causing an atrial tumour?











Exploratory surgery showed that the abdominal mass was a liver tumour, not a splenic tumour. Blood test showed liver hepatitis. The dog had a mammary tumour by another vet 8 months ago. No histopathology was done. It is likely that this liver tumour was a metastatic tumour from the breast. Prevention of this liver tumour might or might not be possible if the dog had been spayed at a young age. Spayed dogs seldom develop breast tumours. Primary malignant liver tumours (hepatocellular carcinoma) are rare in dogs and they are usually due to the spread from other organs with tumours. In this case, histopathology is in progress as at Oct 24, 2014.  













OCT 20, 2014. Exploratory laparotomy. Low dose of domitor + ketamine IV and isoflurane gas.

SURGERY
The large globular tumour was at one end of the lobe. The lobe was taken out. A scalpel blade cut one side of the lobe like "fracturing" the liver.  That meant that the liver was incised on one side while the assistant could hold up the liver for ligation of the parenchyma blood vessels.

Bleeding inside the parenchyma area where the one side was cut was profused. The suture needle is put inside the parenchyma and ligation was carried out..

3/0 absorbable "gullotine" ligatures were placed inside the parenchyma to ligate the blood vessels and bile ducts. Electro-coagulation was done. "Gullotine" ligatures were put on the other side of the lobe 2 cm below the tumour to control bleeding.

The liver tumour was then excised, using electro-excision needle to cut and coagulate the stump. Surprisingly, there was no bleeding after this electro-excision.

HISTOPATHOLOGY. Malignant tumour composed of anastomosing traeculae, nests and pseudoacinar structures. The tumour cells are plyonal with mildly enlarged round nuclei, vesicular chromatin and small round nucleoli. Areas of tumour necrosis are seen. The uninvolved liver shows evidence of steatosis.
Diagnosis: Malignant tumour, favour heptocellular carcinoma  

Liver neoplasia with multiple abscesses.
One 70% size of a tennis-ball-tumour in one lobe. Abscesses have spread all over the liver.
Another ping pong ball tumour in a smaller lobe.  Histopathology in progress - whether it is simply abscesses or abscessed tumours.

24 hours post-op, the dog was eating and very active. I advised in-patient for 10 days as the other dog at home would play with this dog, causing suture breakdown.

The owner asked about prognosis.

Poor prognosis.
1. Locally advanced stage of liver neoplasia with abscesses. This is to be confirmed on histopathology of samples sent..

BLOOD TEST.
No leucocytosis. No "neutrophilia",  but neutrophils % was 92%. (60-70% normal).
Liver enzymes SGOT and SGPT were raised.

TREATMENT IN DOGS.
In people, a combination of chemotherapy or radiation therapy to down-stage the cancer to a more early stage so that surgical resection can be done to provide a long-term survival or cure.

CONCLUSION
8 months ago, another vet had excised a breast tumour but did not send it for histology. This tumour was large and could have spread to the liver.  No lung X-rays were done to lower medical costs. If the dog had been spayed young, it is possible that she would not have breast tumours which could have spread to the liver, now at 12 years of age.

SEVEN DAYS POST OP.
The dog is presently eating and drinking and is active as at Oct 28, 2014. But she panted a lot when taken out for a short walk. Will go home on Day 14 when stitches are removed. As to life span, it is unlikely to be more than 6 months.    

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NOTES

In people, liver cancer (HCC or hepatocellular carcinoma) is the 6th most,  important cancer in the world and the 3rd most important cause of cancer mortality. 80% of all HCC patients are found in the Asia Pacific region because of the high incidence of viral hepatitis. In Singapore, it is the 4th most important cancer and the second cause of cancer death after lung cancer.


Reference; Down-staging of liver cancer to allow curative surgery: An emerging paradigm. Prof Pierce Chow, Pg. 2, Salubris Issue No. 30, Jul - Sep 2014

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