Hepatocellular Carcinoma

Baker College

Megan O’Kelly

May 22, 2017

Animal Signalment:

Tesla is an 11-and-a-half-year-old canine, spayed female,

Labrador Siberian husky mix.

History:

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Tesla was in a loving home until her elderly owners fell ill

and were no longer able to care for her. Her previous owners did not have any major concerns

about her health. She was spayed while in their care, and was current on her vaccines.

Presenting Complaint:

Tesla was obese upon intake at Mackenzie’s Animals Sanctuary (MAS), and had several masses

on her body. Dr. Gillhespy wanted to take fine needle aspirates of the 5 masses, perform LDDS

(Low Dose Dexamethasone Suppression) testing, and an NSAID panel. Dr. Gillhespy noted

hindlimb muscle wasting and bilateral stifle arthritis at this visit.

Diagnostic Workup:

LDDS testing results: normal, NSAID panel: ALP and ALT slightly elevated, FNAs show

epithelial cells, lipocytes, red blood cells, amorphous debris, and rare elliptical cells without

clear cytoplasmic borders, and 1 to 4 nucleoli. Tesla was scheduled to have a recheck of her

NSAID panel 2 weeks after this, and also have abdominal radiographs taken if her liver values

were still elevated. After 2 weeks, blood work showed mild ALP elevation so lateral and VD

abdomen radiographs were obtained. Radiographs showed hepatomegaly with markedly

rounded, irregular margins ventral and caudally. An ultrasound of the abdomen was scheduled

for two weeks later. The ultrasound appointment was a fasted abdominal ultrasound of the

cranial abdomen. The kidneys, stomach, and liver all are normal in appearance. The spleen was

normal in appearance but was located along the left body wall, Dr. Gillhespy noted this appears

displaced due to an abdominal mass. The gall bladder shows moderate amounts of formed

sludge, and there is an abdominal mass that measures 9cm x 5cm with irregular edges, it does not

appear to be attached to the liver, stomach, or spleen at this time. An abdominal exploratory

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surgery with biopsies was tentatively scheduled for the next week. Anaerobic and aerobic

culturette samples of the gall bladder were obtained to be sent to Idexx, the results from Idexx

were normal, no aerobic growth and no organisms were isolated anaerobically. Biopsies were

collected from the following locations and sent to Idexx for testing: two biopsies from a large

mass on the left middle liver lobe, three biopsies from a small mass on the left middle liver lobe,

two biopsies from the quadrate liver lobe, two biopsies from the left middle liver lobe, and one

biopsy from the spleen. Visually there is one very large mass and one medium sized mass on

Tesla’s liver, with several abnormal appearing areas.

Diagnosis and the Disease Condition:

Idexx sent back the following microscopic interpretations of the biospies: “spleen: lymphoid

hyperplasia, left middle and quadrate liver lobes: nodular hyperplasia with diffuse hepatocyte

vacuolation, large and small masses of left middle lobe: hepatocellular carcinoma, mitotic index:

1, margins: neoplastic cells extend to the margins of the submitted tissue, vascular invasion: not

observed.”. According to Idexx, “hepatocellular carcinoma is the most common primary liver

tumor in dogs, accounting for 50% of cases.” (Nobrega-Lee, 2017). There are several types of

hepatocellular carcinoma, massive, nodular, or diffuse. Tesla’s tumor was classified as

“massive”, which means it was comprised of a single large tumor, where as a “nodular” tumor is

one that is made up of several discrete tumors within one or several liver lobes and a “diffuse”

tumor involves the entire liver. The majority of the cases involving hepatocellular carcinoma

include are made up of the “massive” form and have a slower rate of metastasis compared to the

other forms. According to the Ryan Veterinary Hospital of the University of Pennsylvania,

“Animals with liver tumors can be asymptomatic, or alternatively, can exhibit nausea or

vomiting, weight loss, loss of appetite, diarrhea, abdominal distension, lethargy, or increased

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drinking and urination, among other signs. Occasionally, discoloration or yellowing of the skin

and eyes (jaundice), or neurological signs, such as seizures, disorientation, stumbling, and

weakness, can be seen.” Tesla was asymptomatic in the time period that she was diagnosed

("Liver Tumors in Dogs and Cats," n.d.).

Treatment Protocol:

Surgery is the best treatment for the type of tumor that was discovered in Tesla. In a study done

on 48 dogs diagnosed with hepatocellular carcinoma, 42 of these dogs had surgery, and the other

6 had incisional biopsies and were treated in a conservative manner (the study does not state

what was used to treat the dogs). According to the study, in the group of dogs that had surgery,

“the median survival time was not reached by the end of the study and was greater than 1,460

days” and the dogs who did not have surgery, “the median survival time was 270 days” (Harari,

2006). This study concludes stating “The authors concluded that massive hepatocellular

carcinoma in dogs should be treated with careful surgical resection to avoid intraoperative

hemorrhage and provide prolonged survival time.” (Harari, 2006). The tumor removal surgery

took place at a specialty hospital, as we have limited resources for emergency situations at the

sanctuary.

The following drugs were used at the sanctuary during the abdominal exploratory surgery:

Drug/Concentration/

Category/Amount given

Calculations Expected Effects Side Effects

Midazolam 5mg/mLBenzodiazepine

66lb/(2.2kg/lb) = 30kg30kg (0.1mg/kg) = 3mg3mg (mL/5mg) = 0.6mL

Pre-operative medication used as a sedative, also

Potential for respiratory depression is

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0.6mL IM has an anxiolytic effect and has muscle relaxant properties.

one of the biggest concerns.

Buprenorphine0.3mg/mLOpiate partial agonist 2mL IM

66lb/(2.2kg/lb) = 30kg30kg (0.02mg/kg) = 0.6mg0.6mg (mL/0.3mg) = 2mL

Analgesia, is also often used as part of a component in short term “immobilization” cocktails.

Rarely, respiratory depression.

Cerenia10mg/mLAntiemetic3mL IV

66lb/(2.2kg/lb) = 30kg30kg (1mg/kg) = 30mg30mg (mL/10mg) = 3mL

Prevention of acute vomiting.

Well tolerated.

Cefazolin100mg/mLCephalosporin6.6mL IV x 2

66lb/(2.2kg/lb) = 30kg30kg (22mg/kg) = 660mg600mg (mL/100mg) = 6.6mL

Used for surgical prophylaxis for a systemic infections, typically given during orthopedic and soft tissue procedures, and also sepsis

Well tolerated, anaphylaxis is rare and thrombophlebitis is possible when given IV.

Tesla was also put on Ursodiol, a bile acid, for management of gall bladder mucocele, also

known as “sludge” that is present in her gall bladder, this medication is very well tolerated. The

calculations for this drug are as follows: 66lb/2.2kg/lb = 30kg, 30kg (10mg/kg) = 300mg, 300mg

(capsule/300mg) = 1 capsule by mouth twice daily. This will be a lifelong medication for Tesla.

Prognosis and Outcome:

Tesla’s prognosis is good, and she is available for adoption at this time. A large portion of her

hepatocellular carcinoma was removed, and the vet is confident that she has a 3 to 4 years of

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quality life ahead of her. Her adoptive family will need to be willing to provide her with regular

vet care and be willingly to give her the daily medication of Ursodiol for her gall bladder.

Technician Role:

During Tesla’s initial diagnostics, I performed her blood work. Many of the diagnostic

procedures took place before my time at the sanctuary. During the abdominal exploratory

surgery, I injected Tesla with her pre-medications, placed her IV catheter, gave her the induction

medication, intubated her, and monitored her anesthesia (the DVM did the surgery site

preparation, as she felt more comfortable doing it for this procedure). While monitoring

anesthesia, I also took notes for Dr. Gillhespy on specific parts of her surgery. Part way through

the procedure, I scrubbed in and was able to feel parts of the tumor, and then I was able to assist

the doctor in running her sutures so they did not tangle while she was closing up. After the

procedure, Tesla was recovered in a kennel up at the medical building.

Discharge instructions:

Although Tesla did not go home to an owner, we do provide discharge instructions to the kennel

staff. Tesla’s discharge instructions are as follows:

Medications: Continue on TriCox and Ursodiol as previously prescribed, Give Rimadyl 125mg

by mouth once daily.

E-Collar: Tesla must keep an e-collar on for the next 10 to 14 days.

Incision: Monitor Tesla’s incision site daily for redness, swelling, discharge, or pain.

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Activity: Please restrict Tesla’s activity (no play yards, no running, jumping, no outside run

exposure, and no “E-time” (“e-time” is exercise time)) for the next 10 to 14 days. Individual

training and cuddling (“T-time”) allowed to begin tomorrow.

Diet: 1/3 water bucket tonight. Regular water tomorrow morning. Canned I/D post-op, starting

regular diet tomorrow morning.

Recheck: Suture removal in 10 to 14 days.

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References

Harari, J. (2006, March 1). Research Update: Is surgery best for massive hepatocellular

carcinoma in dogs? Retrieved from

http://veterinarymedicine.dvm360.com/research-update-surgery-best-massive-

hepatocellular-carcinoma-dogs

Liver Tumors in Dogs and Cats. (n.d.). Retrieved from

https://www.vet.upenn.edu/docs/default-source/ryan/oncology-handouts/liver-

tumors-in-veterinary-patients.pdf?sfvrsn=4

Nobrega-Lee, M. (2017, April 8). Idexx Reference Laboratories [PDF].

Plumb's Veterinary Drugs. (n.d.). Retrieved from

https://www.plumbsveterinarydrugs.com/#!/monograph/4yqiVGLueS/

Wanamaker, B. P., & Massey, K. L. (2015). Applied pharmacology for veterinary technicians.