Exam 3 - Approach To Liver Masses Flashcards
what are the 6 lobes of the liver in the dog/cat?
- left lateral lobe
- left medial lobe
- right medial lobe
- right lateral lobe
- quadrate lobe
- caudate lobe - caudate process of caudate lobe & papillary process of the caudate lobe
label numbers 1-7
- right medial lobe
- right lateral lobe
- caudate process of the caudate lobe
- papillary process of the caudate lobe
- left lateral lobe
- left medial lobe
- quadrate lobe
what is included in the left division of the liver?
left lateral lobe, left medial lobe, & papillary process of the caudate lobe
what is included in the right division of the liver?
right lateral lobe & caudate process of the caudate lobe
what is included in the central division of the liver?
quadrate lobe & right medial lobe
in dogs, ________ liver lesions are more common than _____ tumors (2.5X)
metastatic
primary
in cats, _________ __________ tumors are more common than ________ tumors
primary hepatobiliary
metastatic
what is the signalment of animals affected with liver masses?
usually older animals - no breed or sex predilection
when may an animal with a liver mass have more severe clinical signs?
hemoperitoneum
caval occlusion
biliary obstruction
what are the non-specific signs associated with animals with a liver mass?
inappetence, weight loss, etc
what is the common history seen in dogs & cats with a liver mass upon presentation?
symptomatic in 50% of cats & 75% of dogs - particularly when malignant
T/F: in 75% of cases, there is a palpable mass upon physical exam of an animal with a liver mass
true
what else, other than a palpable mass, may you see on physical exam on a patient with a liver mass?
pale mucus membranes, jaundice, & fluid wave/abdominal distension
what clin path abnormalities may be seen on a patient with a liver mass?
non-specific changes reflecting hepatobiliary damage/stasis
elevated AlkP/ALT very common - especially with primary tumors
with metastatic disease - elevated AST/Tbili may be more common
paraneoplastic hypoglycemia possible with hepatic adenomas
what is the gold standard in humans for diagnosing a liver mass?
MRI
what is the preferred imaging used for diagnosing a liver mass in dogs/cats?
ultrasound is most common with CT used for surgical planning
CT is better at localized mass origin & provides more information on the relationship of the mass with the caudal vena cava
why are rads minimally useful in diagnosing a liver mass in dogs/cats?
need to look at the entire abdomen & get information on where the mass is arising from
before doing an ultrasound guided liver FNA, what should you do?
check for bleeding disorders!!! CBC & coagulation panel
what are some risk factors for hemorrhage for patients with a liver mass done prior to an FNA?
thrombocytopenia
prolonged PT in dogs
prolonged APTT in cats
what are some contraindications for doing an ultrasound guided liver FNA on a patient with a liver mass?
ascites
hepatic cysts
vascular tumor
lesions close to large bile ducts or vessels
if you have a patient with a defined liver tumor, do you do a liver biopsy? why?
no!! risk of hemorrhage is too high
what are the 3 types of primary liver tumors?
- massive - single large mass within 1 lobe of the liver
- nodular - multifocal & in more than 1 lobe of the liver
- diffuse - global effacement or nodules in all liver lobes
T/F: benign, hyperplastic nodules are very common in older dogs, 70% in dogs > 6 years of age & 100% in dogs > 14 years
true
T/F: typically surgery is only indicated for tumors with massive morphologic distribution
true
what is the number one malignant liver tumor in dogs? what is the second?
- hepatocellular carcinoma
- bile duct carcinoma
in dogs, are benign or malignant liver tumors more common?
malignant
in cats, are benign or malignant liver tumors more common?
benign
what is the number one benign liver tumor in cats? what is the second?
- bile duct adenoma
- hepatocellular adenoma
what is the prognosis of a dog with a malignant bleeding liver mass?
poor, <100 days
what is the prognosis of a dog with a benign bleeding liver mass?
~900 days
what are the likely tumor types present if a dog presents with hemoabdomen due to a ruptured liver mass?
63.5% of hepatocellular carcinoma or other benign mass
36.5% hemangiosarcoma or other malignant mass
__________ ___________ represents up to 77% of all non-hematopoietic tumors in the dog with up to 30% being benign _________ __________
hepatocellular carcinoma
hepatocellular adenoma
of the occurrence of hepatocellular carcinomas in dogs, what is the most common morphological type?
- massive - 60%
nodular is 30% & diffuse is 10%
of the morphological types, which ones have the highest potential for metastasis? what sites is metastasis seen?
nodular or diffuse - 93%!!!!
regional lymph nodes & peritoneum
T/F: metastatic potential of hepatocellular carcinomas varies based on distribution type (morphological types)
true
what is the most effective treatment for massive hepatocellular carcinoma? what is the median survival time? what is the prognosis?
surgery - >1500 days & without surgery, <300 days
prognosis is good even with incomplete resection
what tumor type makes up 50% of biliary tumors in cats?
bile duct adenoma aka biliary cystadenoma
when do cats develop clinical signs from biliary cystadenomas?
only when the tumor starts to press on organs
what is the preferred treatment of biliary cystadenomas? what is the prognosis?
surgical removal - good prognosis
what is the most common malignant tumor in cats which is also the second most common in dogs?
bile duct carcinoma aka cholangiocarcinoma
what is the morphological presentation of cholangiocarcinomas?
can be any of the 3 - massive, diffuse, & nodular
what is the metastatic rate of bile duct carcinomas in dogs & cats? what is the prognosis?
dogs - 88%
cats - 67-80%
carcinomatosis
generally poor prognosis
what is a carcinoid? what is its morphology?
neuroendocrine tumor - always diffuse or nodular
what is the prognosis of carcinoids?
poor - metastasis >90%, die in weeks
T/F: carcinoids are rarely a primary tumor
true - more common to develop primary in gi tract or pancreas with metastasis to the liver
this histopathology shows what type of tumor?
carcinoid - neuroendocrine
what is the prognosis for sarcomas in the liver?
prognosis is poor unless it is massive (amenable to surgery) with no metastatic disease
what are the morphological types of sarcomas seen in the liver?
nodular - 64%
massive - 36%
what is the metastatic rate of sarcomas of the liver?
85-100%
although rare, what are the most commonly reported primary hepatic sarcomas in dogs & cats?
dogs - leiomyosarcomas
cats - hemangiosarcomas
is surgery indicated for metastatic liver disease?
nope - only for biopsy & staging
the liver is a common site for metastasis in dogs from what primary tumor types?
splenic tumors, pancreatic tumors, & gi tract tumors
lymphoma, malignant histiocytosis, & systemic mastocytosis also possible
why is chemo not used commonly for treating primary liver tumors? what are some other treatment options apart from surgery?
limited utility
microwave ablation, radiation therapy
how much of the liver can you remove with out complication? how much would cause death?
~70% - can be acutely removed without complications
removal of 84% will cause death
what things may slow liver regeneration?
comorbidities such as biliary obstruction & diabetes
after acute surgical removal of part of the liver, when does regeneration begin? when does it finish?
begins almost immediately
near complete by 1 week
when may you use the guillotine technique for an open liver biopsy? how is it performed?
better for diffuse disease or lesions at the margins of the liver
isolate a corner/margin of the liver & place a circumferential suture around the region with a surgeon’s knot using 3-0 PDS
use metzenbaums to remove the sample a few mm from the suture
when may you use the punch biopsy for an open liver biopsy? how is it performed?
better for centrally located/focal lesions
use a 4-6mm punch & absorbable gelatin sponge - insert instrument & rotate
use metzenbaums to amputate the deep margin of the sample & carefully remove
pack site with gel foam
what are some pre-op considerations before doing a liver lobectomy?
must blood type the patient & have blood available
need coagulation panel
what are the complication rates associated with liver lobectomies?
26% overall complication rate & 40% for right divisional tumors - massive hemorrhage is very real, so you need close post-op monitoring
what is the peri-operative mortality associated with liver lobectomies?
5-11%
when doing a liver lobectomy, what equipment might you have on hand?
surgical stapler
ligasure
vascular clamps
hemoclips
poole suction tip
what is the hilar lobectomy technique? when is it used?
ligation of the vasculature & bile ducts at the hilus of the liver lobe/division in question - many liver tumors when doing a lobectomy
T/F: when doing a liver lobectomy, you ideally need a margin of normal liver between the resection site & the mass
true
what is the most common liver tumor in the dog? what is the prognosis?
massive hepatocellular carcinoma - good prognosis with surgery
what is the most common liver tumor in the cat? what is the prognosis?
biliary cystadenomas - good prognosis with surgery
what is the best imaging modality for planning liver tumors? does it determine if it can be resected or not?
CT is best for planning
DOES NOT DETERMINE IF IT CAN BE RESECTED
should you refer a liver lobectomy surgery to a referral center?
A&M wants you to
should you refer a liver lobectomy surgery to a referral center?
A&M wants you to
label numbers 1-7
- right lateral lobe
- caudate process of caudate lobe
- right lateral lobe
- right medial lobe
- quadrate lobe
- left lateral lobe
- papillary process of caudate lobe
