Difference between revisions of "Hepatic Neoplasia"

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==Description==
+
{{Unfinished}}
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Primary hepatic tumours are rare, accounting for less than 1.5% of all canine tumours and 1.0-2.9% of all feline tumours. However, the liver is a common site for the establishment of metastatic tumours due to its rich blood supply from the hepatic portal vein and hepatic artery.  In dogs, hepatic neoplasia are 2.5 times more likely to be metastases than primary neoplasia whereas primary hepatobillary tumours are more frequent than metastatic tumours in cats.
 
  
−
Malignant tumours are more common in dogs but benign neoplasia are more common in cats.  Primary tumours found in the liver include:
+
* Primary hepatic tumours are rare (less than 1.5% of all canine tumours and 1.0-2.9% of all feline tumours) * However, the liver is a common site of metastatic tumours due to the rich blood supply (hapatic portal vein and hepatic artery)
−
* [[Carcinoma#Hepatocytic|Hepatocellular carcinoma]] or [[Adenoma#Hepatocytic|adenoma]] (hepatoma)
+
* In dogs, metastasis to the liver is 2.5 times more likely than primary neoplasia
−
* [[Carcinoma#Cholangiocellular|Cholangiocellular carcinoma]] or [[Adenoma #Cholangiocellular|cystadenoma]]
+
* In cats, primary hepatobillary tumours are more frequent than metastatic tumours
−
* Gall bladder carcinoma or adenoma
+
* Malignant tumours are more common in dogs
−
* [[Haemangiosarcoma|Haemangiosarcoma]]
+
* Benign tumours are more common in cats
−
* Mast cell tumour
+
* Malignant primary tumours include:
−
* Hepatic carcinoids (neuroendocrine)
+
** [[Liver Proliferative - Pathology #Hepatocytic|Hepatocellular carcinoma]] - the most common primary liver tumour in dogs and the second most common in cats
−
* Lymphoma
+
** [[Liver Proliferative - Pathology #Cholangiocellular|Cholangiocellular carcinoma]]
 +
** Gall bladder carcinoma
 +
** [[Liver Proliferative - Pathology #Haemangiosarcoma|Haemangiosarcoma]]
 +
** Mast cell tumour
 +
** Hepatic carcinoids (neuroendocrine)
 +
* Benign tumours include:
 +
** [[Liver Proliferative - Pathology #Hepatocytic|Hepatocellular adenoma]] (hepatoma)
 +
** [[Liver Proliferative - Pathology #Cholangiocellular|Cholangiocellular adenoma]]
 +
** Gall bladder adenoma
 +
Note: Distinction must be made between all hepatic tumours and benign nodular hyperplasia frequently observed in the older canine. The most significant primary tumours in the dog are hepatomas, hepatocellular and cholangiocellular carcinomas and hepatic carcinoids. Hepatocellular carcinomas and cholangiocarcinomas are the most significant in cats.
 +
 
 +
 
 +
==Diagnosis==
 +
Symptomatic in approximately 75% of dogs and 50% of cats, particularly if malignant.
 +
===Clinical signs===
 +
* Usually non-specific:
 +
** Weight loss
 +
** Inappetance
 +
** Lethargy
 +
** Polyuria-Polydipsia
 +
** Vomiting
 +
** Ascites
 +
* Neurological Signs - seizures, ataxia and weakness occur less frequently. They may be due to metastasis to the central nervous system, hepatic encephalopathy or hypglycaemia which can occur as a paraneoplastic syndrome
 +
* Icterus - Particularly in dogs with extrahepatic cholangiocarcinomas and diffuse carcinoids
  
−
Care must be taken to distinguish between all hepatic tumours and [[Liver - Nodular Hyperplasia|'''benign nodular hyperplasia''']] which is frequently observed in older dogs. The most significant primary tumours in the dog are hepatomas, [[Carcinoma #Hepatocytic|hepatocellular]] and [[Carcinoma#Cholangiocellular|cholangiocellular]] carcinomas and hepatic carcinoids. [[Carcinoma#Hepatocytic|Hepatocellular carcinomas]] and  [[Carcinoma#Cholangiocellular|cholangiocellular carcinomas]] are the most significant tumours to occur in cats.
+
===Physical Examination===
 +
* Cranial abdominal mass - palpable in up to 75% of cats and dogs
  
−
==Signalment==
+
===Haematology and Biochemistry===
−
===Hepatocellular Tumours===
+
* Usually non-specific. The following are frequently observed in dogs:
−
Hepatocellular tumours include [[Carcinoma#Hepatocytic|hepatocellular '''carcinomas''']] (HCC) and [[Adenoma#Hepatocytic|'''hepatomas''']]. HCC occurs more frequently in dogs but hepatomas are more common in cats. These are the most common primary liver tumour in dogs and the second most common in cats.  
+
** Mild non-regenerative anaemia - cause idiopathic, however, anaemia of chronic disease, inflammation, red blood cell sequestration and iron deficiency may play roles
 +
** Leukocytosis - resulting from the associated inflammation and necrosis with large liver masses
 +
** Thrombocytosis - potential causes include production of thrombopoietin as a parneoplastic syndrome, iron deficiency, inflammatory cytokines and anaemia
 +
* Elevated hepatic enzymes - likely due to hepatocellular damage or biliary stasis though the level of enzyme increase is not proportional to severity of liver damage
 +
* Raised serum bilirubin - particularly in cats iwth hepatocellular carcinoma
 +
* Hypoalbuminaemia
 +
* Hyperglobulinaemia
 +
* Hypoglycaemia - can occur as a paraneoplastic syndrome where there is increased utilisation of glucose or increased produciton of hormones with insulin-like activity.
 +
* Elevated pre- and postprandial bile acids
  
−
Male dogs over 10 years old are most frequently affected by HCC and the Miniature schnauzer breed may be predisposed to the disease.  The metastatic rate of hepatocellular tumours depends on the nature of the mass, with massive tumours spreading at a rate of 0-37% and nodular or diffuse tumours metastasising in 93-100% of cases.  The most common sites of metastasis are the regional lymph nodes (the hepatic and diaphragmatic nodes), the peritoneum and lungs.  [[Adenoma#Hepatocytic|Hepatomas]]) are usually incidental findings but they may cause hypoglycaemia as a paraneoplastic syndrome.
+
* The following have been observed in cats:
 +
** Azotaemia
 +
** Elevated hepatic enzymes
 +
** Elevated bilirubin
  
−
===Cholangiocellular Tumours ===
+
===Plain Abdominal Radiography===
−
Cholangiocellular tumours include bile duct '''carcinomas''' and '''adenomas'''.  Bile duct carcinomas are the most common malignant hepatobillary tumours in cats and the second most frequent in dogs, with female animals possibly being predisposed. Intra-hepatic carcinomas are more frequent in dogs but in cats, it is unclear whether extra-hepatic masses occur more frequently or whether intra- and extra-hepatic masses occur with equal frequency.
+
Hepatomegaly, rounding of the margins of the liver and a cranial abdominal mass may be observed with displacement of the stomach caudally and laterally with massive hepatic neoplasms. Occasionally mineralisation of the biliary tree is observed in dogs with cholangiocellular carcinoma. Three thoracic views should also be taken to assess lung metastasis although this is uncommon at the time of diagnosis.
  
−
Bile duct carcinomas are aggressive and they often metastasise to distant sites. In dogs, these metastases are most common in the regional lymph nodes and lungs but diffuse intra-peritoneal metastasis and carcinomatosis are more common in cats. Bile duct adenomas (also known as biliary or hepatobiliary cystadenomas) are common in cats, particularly in males.  These tumours are generally insignificant unless they of sufficient size to compress surrounding soft tissue structures and cause [[Biliary Tract Obstruction|biliary tract obstruction]].
+
===Ultrasonography===
 +
Always recommended to evaluate the condition of surrounding structures. It also allows classification of the mass as massive, nodular or diffuse. Doppler techniques can also be utilised to assess the vascular structure of tumours. Guided fine-needle aspirates or core biopsies can also be taken at this time (a coagulation profile is hightly advised prior to liver biopsy due to risk of haemorrhage). If the lesion is solitary and massive surgical resection without preoperative biopsy is usually undertaken as diagnosis and treatemnt are accomplished in the single procedure.
  
−
===Carcinoids===
+
===Advanced Imaging===
−
Carcinoids are neuroendocrine tumours that usually occur in younger animals than do the other primary hepatobiliary tumours.  Primary tumours are aggressive and often affect more than one liver lobe with frequent metastasis to the regional lymph nodes, lungs and peritoneum.  
+
CT and MRI are more sensitive in detecting small lesions and confirming the relationship of the mass with surrounding tissues and vasculature.  
  
−
===Sarcomas===
+
===Abdominocentesis===
−
The most common sarcomas encountered are [[Haemangiosarcoma|'''haemangiosarcomas''']] (HSA), '''leiomyosarcomas''' and '''fibrosarcomas'''.  HSA is the most common hepatic sarcoma in cats whereas leiomyosarcomas are more common in dogs. These tumours are aggressive and metastasis to the spleen and lungs is frequently observed.
+
Cytological examination of the sediment may reveal neoplastic cells. Effusions are usually modified transudates and haemorrhage may indicate tumour rupture.
  
−
==Diagnosis==
 
−
Tumours are symptomatic in approximately 75% of dogs and 50% of cats and this is more likely to be the case with malignant neoplasia.
 
−
===Clinical signs===
 
−
Signs are usually non-specific or they may indicate a disease of the liver:
 
−
*'''Weight loss''', inappetance and lethargy.
 
−
*'''Polyuria''' and '''polydipsia'''.
 
−
*'''[[Vomiting]]'''
 
−
*'''[[Modified Transudate|Ascites]]''' due to the development of portal hypertension.
 
−
*'''Neurological signs''', including seizures, ataxia and weakness are not as common as the signs described above. They may be due to metastasis to the central nervous system, [[Hepatic Encephalopathy|hepatic encephalopathy]] or hypoglycaemia which can occur as a paraneoplastic syndrome.
 
−
*'''[[Icterus]]''' occurs particularly in dogs with extrahepatic cholangiocellular carcinomas and diffuse carcinoids.
 
−
*A '''cranial abdominal mass''' will be palpable in up to 75% of cats and dogs
 
  
−
===Laboratory Tests===
+
==Signalment and Description==
−
The results of blood samples are usually unremarkable but the following findings may be documented in affected animals:
+
===Hepatocellular Tumours (Hepatocellular carcinomas (HCC) and Hepatomas)===
−
*Mild '''non-regenerative anaemia''' of unknown cause. The anaemia may be caused by anaemia of chronic disease, inflammation, red blood cell sequestration and iron deficiency may play roles
+
* HCC occurs more frequently in dogs and hepatomas more commonly in cats. Male dogs over 10 years old are the most frequently affected. Miniature schnauzers may have a breed predisposition.
−
*'''Leucocytosis''' resulting from the associated inflammation and necrosis that can occur with large liver masses.
+
* Regional lymph nodes (hepatic and diaphragmatic nodes), peritoneum and lungs are the most frequent sites of metastasis in dogs with nodular and diffuse HCC.
−
*'''Thrombocytosis''', of which potential causes include production of thrombopoietin as a paraneoplastic syndrome, iron deficiency, production of inflammatory cytokines and presence of concurrent anaemia.
+
* Metastatic rate for dogs with massive HCC: 0-37%
−
*Elevation in the blood levels of '''hepatic enzymes''' probably occurs due to hepatocellular damage or biliary stasis.  The extent of the elevation is not proportional to severity of liver damage.
+
* Metastatic rate for dogs with nodular and diffuse HCC: 93-100%
−
*'''[[Hypoalbuminaemia]]''' due to reduced hepatic synthesis of albumin.
+
* Hepatomas are usually incidental findings and non-significant
−
*'''Hyperglobulinaemia''' due to a chronic inflammatory process.
 
−
*'''Hypoglycaemia''' can occur as a paraneoplastic syndrome where there is increased utilisation of glucose or increased production of hormones with insulin-like activity (such as the somatomedins or insulin-like growth factors).
 
−
*Elevated pre- and post-prandial '''[[Bile acids|bile acids]]'''
 
−
*[[Bilirubin|'''Hyperbilirubinaemia]]''' which may be sufficiently severe to cause [[Icterus|icterus]].
 
  
−
===Diagnostic Imaging===
+
===Cholangiocellular Tumours (Bile duct  carcinomas and adenomas)===
−
====Radiography====
+
* Bile duct carcinomas are the most common malignant hepatobillary tumours in cats and the second most frequent in dogs, particularly females
−
'''Plain radiographs of the abdomen''' may show hepatomegaly and rounding of the margins of the liver. With massive hepatic neoplasia, a cranial abdominal mass may be visible with displacement of the stomach caudally and laterally. Mineralisation of the biliary tree is occasionally observed in dogs with cholangiocellular carcinoma. Ideally, all three thoracic views should also be taken to assess for the presence of pulmonary metastases, although this finding is uncommon at the time of diagnosis.
+
* Intrahepatic carcinomas are more frequent in dogs. In cats there have been reports of both equal levels of occurrence of intra-and extrahepatic tumours and of a a extrahepatic dominance.
 +
* Bile duct carcinomas are aggressive with metastasis to particularly the regional lymph nodes and lungs frequently being observed in dogs and diffuse intraperitoneal metastasis and carcinomatosis being common in cats.
 +
* Bile duct adenomas (also known as biliary or hepatobiliary cystadenomas) are common in cats, particularly males.
 +
* Bile duct adenomas are non-significant unless they of sufficient size to compress surrounding soft tissue structures
  
−
====Ultrasonography====
+
===Carcinoids (Neuroendocrine Tumours)===
−
An abdominal ultrasound scan is advised to evaluate the condition of structures surrounding the liver. It also allows classification of the mass as massive, nodular or diffuse. Doppler techniques can be utilised to assess the vascular structure of tumours and guided fine-needle aspirates or core biopsies can be taken at this time, although it is desirable to await the results of a coagulation profile before undertaking this procedure.  It is traditionally stated that hepatic lymphoma produces a hyperechoic texture on an ultrasound scan.  
+
* Usually occur in younger animals compared with other primary hepatobiliary tumours.
 +
* Primary tumours are aggressive and often affect more than one liver lobe and metastasise to most frequently the regional lymph nodes, the lungs and peritoneum.  
  
−
====Advanced Imaging====
+
===Sarcomas (Haemangiosarcoma (HSA), Leiomyosarcoma, Fibrosarcoma)===
−
CT and MRI are more sensitive in detecting small lesions and confirming the relationship of the mass with surrounding tissues and vasculature. They may also be used to detect early metastases.
+
* HSA is the most common hepatic sarcoma in cats
 +
* Leiomyosarcoma is the most common hepatic sarcoma in dogs
 +
* These tumours are aggressive and metastasis to the spleen and lungs is frequently observed.
  
−
===Other Tests===
 
−
Cytological examination of ascitic fluid may reveal the presence of neoplastic cells. Effusions are usually [[Modified Transudate|modified transudates]] but [[Haemorrhagic Effusion|haemorrhage]] may indicate that the tumour has ruptured.
 
  
 
==Treatment==
 
==Treatment==
 
===Surgery===
 
===Surgery===
−
Surgical excision is advised for hepatic adenomas, bile duct adenomas and massive [[Carcinoma#Hepatocytic|hepatocellular carcinomas]]. Nodulectomy or lobectomy can be used for focal tumours involving only one or a small number of lobes. Diffuse tumours and widespread nodular disease carry a poorer prognosis and they have frequently metastasised by the time they are diagnosed.
+
Surgical excision is adivsed for hepatic adenomas, bile duct adenomas and massive hepatocellular carcinomas. Nodulectomy or lobectomy can be used for focal tumours of one or more lobes. Diffuse tumours and widespread nodular disease carry a worse prognosis.
  
−
===Chemotherapy===
+
===Chemotherpay===
−
This treatment modality is not recommended for primary hepatic neoplasia. Some metastatic sarcomas, such as [[Haemangiosarcoma|haemangiosarcomas]], may show some response.
+
Not currently recommended for primary hepatic neoplasia. Some metastatic sarcomas for example haemangiosarcomas may show some response.
  
 
===Radiotherapy===
 
===Radiotherapy===
−
This procedure is not undertaken as it involves irradiating the entire abdomen and some surrounding organs may show poor tolerance.
+
Not reported. Surrounding abdomina organs may show poor tolerance.
 +
 
  
 
==Prognosis==
 
==Prognosis==
−
The median survival time for massive [[Carcinoma#Hepatocytic|hepatocellular carcinomas]] following surgery is approximately 1 year. Otherwise the prognosis is poor for other types of malignant and metastatic tumours. If successfully excised the prognosis for benign tumours is good.
+
The mean survival time for massive hepatocellular cacinomas following surgery is approximately 1 year. Otherwise the prognosis is poor for other malignant and metastatic tumours. If successfully excised the prognosis for benign tumours is good.
  
−
{{Learning
 
−
|Vetstream = [https://www.vetstream.com/canis/Content/Disease/dis01101.asp Liver: neoplasia in canines]<br>[https://www.vetstream.com/felis/Content/Disease/dis01101.asp Primary hepatic neoplasia in felines]
 
−
}}
 
  
 
==References==
 
==References==
−
* Morris J, Dobson J (2001) Gastrointestinal Tract, in Small Animal Oncology, Blackwell Science, pp 137-140
 
  
−
* Liptak J. M, Withrow S.J, (2007), Cancer of the Gastrointestinal Tract, in Withrow and MacEwen's Small Animal Clinical Oncology, fourth edition, Eds Withrow S.J, Vail D.M, Missouri, Saunders Elsevier, pp 483-489
 
  
−
 
+
Carcinogens and toxins for example nitrosamines can induce hepatic tumours in an experimental environment.
−
{{Unfinished}}
 
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[[Category:Liver_-_Proliferative_Pathology]]
 
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[[Category:Neoplasia]]
 
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[[Category:To_Do_-_Alimentary]][[Category:To Do - Major]]
 
−
[[Category:Liver Diseases - Dog]][[Category:Liver Diseases - Cat]]
 

Revision as of 11:24, 12 August 2009


 This article is still under construction.


  • Primary hepatic tumours are rare (less than 1.5% of all canine tumours and 1.0-2.9% of all feline tumours) * However, the liver is a common site of metastatic tumours due to the rich blood supply (hapatic portal vein and hepatic artery)
  • In dogs, metastasis to the liver is 2.5 times more likely than primary neoplasia
  • In cats, primary hepatobillary tumours are more frequent than metastatic tumours
  • Malignant tumours are more common in dogs
  • Benign tumours are more common in cats
  • Malignant primary tumours include:
  • Benign tumours include:

Note: Distinction must be made between all hepatic tumours and benign nodular hyperplasia frequently observed in the older canine. The most significant primary tumours in the dog are hepatomas, hepatocellular and cholangiocellular carcinomas and hepatic carcinoids. Hepatocellular carcinomas and cholangiocarcinomas are the most significant in cats.


Diagnosis

Symptomatic in approximately 75% of dogs and 50% of cats, particularly if malignant.

Clinical signs

  • Usually non-specific:
    • Weight loss
    • Inappetance
    • Lethargy
    • Polyuria-Polydipsia
    • Vomiting
    • Ascites
  • Neurological Signs - seizures, ataxia and weakness occur less frequently. They may be due to metastasis to the central nervous system, hepatic encephalopathy or hypglycaemia which can occur as a paraneoplastic syndrome
  • Icterus - Particularly in dogs with extrahepatic cholangiocarcinomas and diffuse carcinoids

Physical Examination

  • Cranial abdominal mass - palpable in up to 75% of cats and dogs

Haematology and Biochemistry

  • Usually non-specific. The following are frequently observed in dogs:
    • Mild non-regenerative anaemia - cause idiopathic, however, anaemia of chronic disease, inflammation, red blood cell sequestration and iron deficiency may play roles
    • Leukocytosis - resulting from the associated inflammation and necrosis with large liver masses
    • Thrombocytosis - potential causes include production of thrombopoietin as a parneoplastic syndrome, iron deficiency, inflammatory cytokines and anaemia
  • Elevated hepatic enzymes - likely due to hepatocellular damage or biliary stasis though the level of enzyme increase is not proportional to severity of liver damage
  • Raised serum bilirubin - particularly in cats iwth hepatocellular carcinoma
  • Hypoalbuminaemia
  • Hyperglobulinaemia
  • Hypoglycaemia - can occur as a paraneoplastic syndrome where there is increased utilisation of glucose or increased produciton of hormones with insulin-like activity.
  • Elevated pre- and postprandial bile acids
  • The following have been observed in cats:
    • Azotaemia
    • Elevated hepatic enzymes
    • Elevated bilirubin

Plain Abdominal Radiography

Hepatomegaly, rounding of the margins of the liver and a cranial abdominal mass may be observed with displacement of the stomach caudally and laterally with massive hepatic neoplasms. Occasionally mineralisation of the biliary tree is observed in dogs with cholangiocellular carcinoma. Three thoracic views should also be taken to assess lung metastasis although this is uncommon at the time of diagnosis.

Ultrasonography

Always recommended to evaluate the condition of surrounding structures. It also allows classification of the mass as massive, nodular or diffuse. Doppler techniques can also be utilised to assess the vascular structure of tumours. Guided fine-needle aspirates or core biopsies can also be taken at this time (a coagulation profile is hightly advised prior to liver biopsy due to risk of haemorrhage). If the lesion is solitary and massive surgical resection without preoperative biopsy is usually undertaken as diagnosis and treatemnt are accomplished in the single procedure.

Advanced Imaging

CT and MRI are more sensitive in detecting small lesions and confirming the relationship of the mass with surrounding tissues and vasculature.

Abdominocentesis

Cytological examination of the sediment may reveal neoplastic cells. Effusions are usually modified transudates and haemorrhage may indicate tumour rupture.


Signalment and Description

Hepatocellular Tumours (Hepatocellular carcinomas (HCC) and Hepatomas)

  • HCC occurs more frequently in dogs and hepatomas more commonly in cats. Male dogs over 10 years old are the most frequently affected. Miniature schnauzers may have a breed predisposition.
  • Regional lymph nodes (hepatic and diaphragmatic nodes), peritoneum and lungs are the most frequent sites of metastasis in dogs with nodular and diffuse HCC.
  • Metastatic rate for dogs with massive HCC: 0-37%
  • Metastatic rate for dogs with nodular and diffuse HCC: 93-100%
  • Hepatomas are usually incidental findings and non-significant

Cholangiocellular Tumours (Bile duct carcinomas and adenomas)

  • Bile duct carcinomas are the most common malignant hepatobillary tumours in cats and the second most frequent in dogs, particularly females
  • Intrahepatic carcinomas are more frequent in dogs. In cats there have been reports of both equal levels of occurrence of intra-and extrahepatic tumours and of a a extrahepatic dominance.
  • Bile duct carcinomas are aggressive with metastasis to particularly the regional lymph nodes and lungs frequently being observed in dogs and diffuse intraperitoneal metastasis and carcinomatosis being common in cats.
  • Bile duct adenomas (also known as biliary or hepatobiliary cystadenomas) are common in cats, particularly males.
  • Bile duct adenomas are non-significant unless they of sufficient size to compress surrounding soft tissue structures

Carcinoids (Neuroendocrine Tumours)

  • Usually occur in younger animals compared with other primary hepatobiliary tumours.
  • Primary tumours are aggressive and often affect more than one liver lobe and metastasise to most frequently the regional lymph nodes, the lungs and peritoneum.

Sarcomas (Haemangiosarcoma (HSA), Leiomyosarcoma, Fibrosarcoma)

  • HSA is the most common hepatic sarcoma in cats
  • Leiomyosarcoma is the most common hepatic sarcoma in dogs
  • These tumours are aggressive and metastasis to the spleen and lungs is frequently observed.


Treatment

Surgery

Surgical excision is adivsed for hepatic adenomas, bile duct adenomas and massive hepatocellular carcinomas. Nodulectomy or lobectomy can be used for focal tumours of one or more lobes. Diffuse tumours and widespread nodular disease carry a worse prognosis.

Chemotherpay

Not currently recommended for primary hepatic neoplasia. Some metastatic sarcomas for example haemangiosarcomas may show some response.

Radiotherapy

Not reported. Surrounding abdomina organs may show poor tolerance.


Prognosis

The mean survival time for massive hepatocellular cacinomas following surgery is approximately 1 year. Otherwise the prognosis is poor for other malignant and metastatic tumours. If successfully excised the prognosis for benign tumours is good.


References

Carcinogens and toxins for example nitrosamines can induce hepatic tumours in an experimental environment.

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