Liver Cancer

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Article Written by Dr. Daniel A. Degner, Board-certified Veterinary Surgeon (DACVS)

Key Points

Single large liver tumors frequently are the kind that have a low tendancy to spread to other parts of the body and are amenable to surgery

Liver tumors can cause nonspecific signs such as vomiting, weight loss, decreased appetite, lethargy and pale gums

Patients having surgery frequently have a good prognosis, providing that the tumor is self-contained and the surgeon can completely remove the tumor

Recent research on liver tumor resection is helping surgeons more precisely remove these masses


Types of liver tumors

  • Metastatic liver tumors are those that spread from a primary tumor else where in the body
    • example is a dog that has a tumor of the spleen which has spread to the liver
    • metastatic liver tumors generally are usually multiple
    • if your dog has multiple liver masses they could just be benign nodular change (hyperplastic regenerative nodules) which has a good prognosis and does not require surgical removal
  • Primary liver tumors originate from the liver tissue
    • the most common primary liver tumor is the hepatocellular carcinoma
    • these tumors usually do not spread, but invade into the liver tissue

Clinical signs of liver tumors

  • Vomiting
  • Loss of appetite
  • Weight loss
  • In the early stages, there may be no clinical signs, but your veterinarian may find the tumor on a routine ultrasound or x-ray of the abdomen

Testing done for patients in preparation for surgery

  • Complete Blood cell count
  • Chemistry profile
  • Coagulation profile
  • Urinalysis
  • Chest radiographs - left side, right side and front-back views
  • Abdominal ultrasound
  • CT scan of the abdomen
  • Fine needle biopsy of the liver mass is occasionally recommended    
 

Metastatic liver tumors

  • A diagnosis of cancer can only be definitively be made with a liver biopsy and histopathology
  • If there is no evidence of a primary tumor in the body and multiple nodules are found in the liver, a minimally invasive liver biopsy can be done by placing a laparoscope (camera) into the abdomen to obtain a sample of liver; animals that have this done can usually go home the same day after the procedure; this test will confirm a diagnosis of cancer

Primary liver tumors

  • Surgery is recommended for these cases if there is no evidence of metastatic disease
  • If needed, more than half of the liver can be safely removed and the liver will regenerate
  • Usually the tumor is removed through an incision made on the midline of the abdomen
  • In some cases the breast bone must be divided (median sternotomy) so that the tumor can be accessed
  • Even tumors that seem to invade deep into the liver can be safely removed using a technique that we developed called the hilar liver dissection technique (see reference below). With this technique, liver tumors can be removed with much less bleeding and with a better chance that all of the tumor has been completely removed. The procedure does not require fancy equipment such as the "Cavitron Surgical Aspirator", just a sound knowledge of the vascular anatomy of the liver. The video (right) demonstrates the resection of a tumor located on the left side of the liver.
 

Aftercare following liver tumor removal

  • IN HOSPITAL
    • Pain medication is given to your pet either by injection or via an epidural catheter, or through the intravenous as a constant rate infusion
    • Antibiotics are usually just given at the time of surgery and not given in the postop period
    • Intravenous fluids are given to keep your pet hydrated
  • AT HOME
    • Limit exercise to short leash walks for 3 weeks if a midline abdominal incision was performed; limit exercise for 6 weeks if a median sternotomy was performed
    • Administer oral pain medications as needed
    • Monitor respirations to make sure that these are not labored
    • Monitor gums and tongue to make sure that these are pink
    • Encourage eating
    • Monitor the incision for signs of infection
    • Do not allow licking or scratching of the incision
      • Put a tee shirt on your pet to help prevent this
  • Chemotherapy may be recommended by an oncologist, pending the tumor type; hepatocellular carcinomas usually are not too responsive to chemotherapy and surgery is usually the only treatment needed

Potential complications

  • Anesthetic death - uncommon
  • Seroma formation at the incision - fluid accumulation which will resolve within about 3 to 4 weeks
  • Infection - uncommon
  • Internal hemorrhage - uncommon
  • Spread of tumor - dependant on type and stage of tumor

References

  1. Covey J, Degner DA, Jackson AH, Hofeling A, Walshaw R. Hilar liver resection in dogs. Accepted for publication. Vet Surgery 2008
  2. Liptak, JM:  Hepatobiliary tumors, in Withrow SJ, Vail DM (eds): Small Animal Clinical Oncology (ed 4). St. Louis, WB Saunders, 2007, pp 483-485
  3. Bachellier P, Ayav A, Pai M, et al:  Laparoscopic liver resection assisted with radiofrequency. Am J Surg 193:427-430, 2007
  4. Tobias KM: Surgical stapling devices in veterinary medicine: A review. Vet Surg 36:341-349, 2007
  5. Gayet B, Cavaliere D, Vibert E, et al:  Totally laparoscopic right hepatectomy. Am J Surg 194:685-689, 2007
  6. Saiura A, Yamamoto J, Koga R, et al:  Usefulness of LigaSure for liver resection: Analysis by randomized clinical trial. Am J Surg 192:41-45, 2006
  7. Liptak JM, Dernell WS, and Withrow SJ. Liver tumors in cats and dogs. Comp Cont Ed Vet 26:50-57, 2004
  8. Martin RA, Lanz OI, Tobias KM: Liver and Biliary System, in Slatter DH (ed): Textbook of Small Animal Surgery (ed 3).  Philadelphia, PA, Saunders 2003, pp 716-717
  9. Morgan, P: A novel technique for parenchymal division during hepatectomy. Am J Surg 181:236-237, 2001
  10. Nuzzo G, Giulante F, Giovannini I, et al:  Liver resection with or without pedicle clamping. Am J Surg 181:238-246, 2001
  11. Takayama T, Makuuchi M, Kubota K, et al:  Randomized comparison of ultrasonic vs. clamp transection of the liver. Arch Surg 136:922-928, 2001
  12. Jarnagin WR, Gonen M, Fong Y, et al:  Improvement in perioperative outcome after hepatic resection: analysis of 1, 803 consecutive cases over the past decade.  Ann Surg 230:309-321, 1999
  13. Fan ST, Lai EC, Lo CM, et al:  Hepatectomy with an ultrasonic dissector for hepatocellular carcinoma.  Br J Surg  83:117-120, 1996
  14. Trout NJ, et al: Surgical Outcome of hepatobiliary cystadenomas in cats: five cases (1988-1993). JAVMA 206: 505, 1995
  15. Gozzetti G, Mazziotti A, Grazi GL, et al:  Liver resection without blood transfusions.  Br J Surg 82:1105-1110, 1995
  16. Lewis DD, Bellenger CR, Lewis DT, et al: Hepatic lobectomy in the dog—a comparison of stapling and ligation techniques. Vet Surg 10:221-225, 1990
  17. Bjorling DE, et al: Partial hepatectomy in dogs.  Compend Contin Educ Pract Vet 3:257, 1985
  18. Francavilla A, et al: Liver regeneration in dogs: Morphologic and chemical changes. J Surg Res 25:409, 1978.
  19. Sleight DR, Thomford NR: Gross anatomy of the blood supply and biliary drainage of the canine liver. Anat Rec 166: 153-160, 1970

Frequently Asked Questions After Surgery

When should my dog have the first bowel movement after surgery?

  • Many dogs will not have a bowel movement for the first 4 to 5 days after surgery
  • Reasons that a dog will not have regular bowel movements after surgery include:
    • The dog has been fasted prior to surgery
    • Dogs do not eat well during the hospital stay
    • They frequently do not eat well when they go home
    • They are fed highly digestible food that produces little stool
    • Pain medication that contain narcotics (such as morphine, fentanyl patches, and tramadol) can be constipating
  • If a pet does not have a bowel movement on the 5th day of being home, a stool softener such as metamucil can be fed
    • Dose of metamucil is 1 tsp per 25 Kg mixed in with each meal (canned dog food); feed immediately after mixing, as the metamucil will gel the food and may make it less palatable

My pet had surgery and will not eat.  What can be done?

  • Dogs
    • Most pets will not eat their regular dog food after surgery, especially if it is kibble.
    • Offer a cooked diet having a 1:1 ratio of a protein source and carbohydrate source.  The protein source can be any meat (example: chicken breast, turkey breast, lean hamburger) that is low in fat and should be cooked (drain off all fat after the meat has been cooked).   The carbohydrate can be pasta, potato or white rice.
    • Try canned dog food; to enhance the flavor sprinkle a very small amount of garlic powder or chicken or beef broth (Chicken-in-a- MugTM or Beef-in-a-MugTM products)
    • Try Gerber strained meats for babies such as the chicken, beef, turkey, or veal
    • Try Hill's A/D diet available at most veterinary hospitals
    • Hand feeding: place a small amount of food in the mouth so that your dog gets the flavor
    • Warm the food slightly in a microwave, as the food will be more aromatic; stir the food before feeding and test the temperature on the bottom side of your wrist; it should only be luke warm.
    • Remember that most pets will not eat the first day or two after they get home from surgery
  • Cats
    • Offer smelly foods that contain fish such as tuna or smelly cat foods
    • Try Gerber strained meats for babies such as the chicken, beef, turkey or veal
    • Hand feeding:  with your finger place a small amount of food on the roof of your cat's mouth; use a syringe to get soft food into the mouth
    • Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature; it should be only luke-warm
    • Some cats will only eat dry food, try kibble if your cat normally has been fed that food
    • Petting and stroking your cat frequently will help to stimulate appetite
    • Remember that most pets will not eat the first day or two after they get home from surgery
    • Appetite stimulants such as cyproheptadine may be helpful
    • If your cat refuses to eat anything for 7 days a stomach tube or nasogastric tube should be placed to provide nutrition so that a serious liver problem (hepatic lipidosis) does not develop

My pet is vomiting.  What can be done?

  • The first thing for you to discern is whether your pet is vomiting or regurgitating.  Both will result in fluid or food being brought up.  Vomiting always will have heaving or retching of the abdomen prior to expulsion of the vomitus.  Regurgitation is not associated with heaving and the pet usually just opens the mouth and fluid or food will be expelled.  Usually the regurgited material will be clear or brown colored fluid. 
  • Next is to identify the cause of the vomiting or regurgitation.
  • Causes and treatment of vomiting after surgery
    • When some pets return home after a stay in the hospital they may drink excessive amounts of water at one time and then vomit; if this appears to be the case, the water should be limited to frequent smaller amounts.
    • Medications such as antibiotics, narcotics or nonsteroidal anti-inflammatory medication commonly cause vomiting after surgery.  In order to see which medication is causing the problem, the administration of each drug should be separated 2 hours apart.  Usually the pet will vomit or appear nauseated (drooling and sick look) within 1 hour of administration of the medication that they are sensitive to.  The antibiotic in some cases may be changed to a different one, or may be discontinued. 
    • Stomach upset from anesthesia is a potential cause of vomiting and will pass within a couple of days. 
    • An uncommon cause of vomiting after surgery is internal organ failure.  Blood testing will confirm this problem. For this reason vomiting should not be ignored if it persists for more than 24 hours.
    • If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it may indicate that infection of the abdominal cavity, called peritonitis, is present.  Do not ignore this sign.
    • Symptomatic treatment of vomiting involves withholding food for 12 to 24 hours, then introducing small amounts of bland food such as rice and lean cooked hamburger, if your pet does not vomit after that then gradually wean him/her back onto the regular diet after 3 days.  In order to decrease the acidity of the stomach, Pepcid AC 0.5 mg/kg can be given by mouth twice daily for 5 days.  Metoclopramide and Cerenia are good anti-vomiting medications for dogs and cats.  You should always consult a veterinary healthcare professional before administering medication.
  • Causes and treatment of regurgitation after surgery
    • The most common cause of regurgitation is reflux of acid from the stomach into the esophagus while your pet is under anesthesia.  Acidic fluid from the stomach can cause a chemical burn of the esophagus and result in a bad case of heart burn, called esophagitis.  This results in poor motility of the esophagus, therefore water and food will accumulate in this structure.  In most cases, esphagitis is self-eliminating and will resolve within two or three days. 
    • If the esophagitis is severe the esophagus may develop one or more strictures.  A stricture is a narrowing or stenosis of the esophagus and does not allow passage of food down the esophagus, in regurgitation that lasts longer than one week.  This problem should be brought to the attention of your pet's doctor within the first two weeks so that it can be treated by ballooning the stricture (minimally invasive procedure, as it is done with the aide of an endoscope).  If an esophageal stricture is chronic surgery is needed.
    • Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland food, and administering a coating agent (sucralfate) and an acid blocker (omeprazole or other).  Consult a veterinary health care professional if the regurgitation continues for more than a couple of days.

How do I know that my dog is in pain following surgery?

  • Signs of pain include
    • crying
    • biting if you get near the surgical site
    • grimacing (lips are pulled back and the the dog looks anxious)
    • tragic facial expression
    • panting
    • restlessness and unable to sleep; pacing
    • if abdominal surgery was done the pet will not lie down on the incision, or will continually sit up in spite of appearing very tired
    • the worst pain will be for the first 2 to 3 days after surgery

What can I do to control my dog's pain?

  • Narcotic medications that control pain: tramadol, butorphanol, Duragesic (fentanyl patch)
  • Anti-inflammatories used to control pain: Deramaxx, Rimadyl, Previcox, or Etogesic
  • If an orthopedic surgery has been done cold packing the surgical site may be helpful
    • A cold pack may be a pack of frozen peas, crushed ice in a Ziploc bag, or a cold gel pack; place a thin barrier between the skin and the cold pack.  An alternative to a cold pack is to freeze water in a styrofoam cup; after frozen cut the bottom of the styrofoam cup out. Cool the surgical site around the incision by rubbing the exposed ice directly on the skin in a circular pattern.  Cooling the surgical site helps to numb the area.

How do I know that my cat is in pain following surgery?

  • Pain is more difficult to assess in cats versus dogs, as signs can be more subtle and they usually do not vocalize when in pain
  • Signs of pain in a cat include the following:
    • biting if you get near the surgical site
    • growling or deep cry
    • not wanting to eat
    • hiding and not wanting to be near owner (remember that this could also be caused by the cat just being upset about leaving home and coming back)

What can be done for pain at home for my cat?

  • Pain medication such as buprenorphine or a Duragesic (fentanyl) patch
  • Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver
  • Anti-inflammatories can be used, but the dose is much less than dogs

Is it okay for my pet to lick the incision?

  • If a dog licks the incision, the healing process may be delayed.
  • Licking can remove stitches and cause the incision to open
  • Licking can become a severe habit that is difficult to break
  • Licking can cause infection as the mouth has many bacteria
  • Dogs will frequently lick the incision when the owner is not watching such as at night time; if the skin looks red or excoriated the most common cause is from licking.
  • To stop your pet from licking the following can be tried:
    • Elizabethan collar can be placed on the neck; this will not help stop your pet from scratching at the region
    • Cervical collar (bite not collar) is a less awkward device and can be effective at stopping a pet from licking the surgical site
    • A tee shirt can be used to cover an incision on the chest or front part of the abdomen; gather the waist of the shirt up over the dog's back and wrap an elastic band around this part of the shirt.
    • A bandage or sock can be used to cover an incision on a limb; fasten the top of the sock to the dog's limb with tape.
    • Bitter apple can be applied around the incision; many dogs will continue to lick  after application of this topical
    • Bitter Apple and Liquid HeetTM (obtain this from a drugstore...it is used for sore muscles) mixed in a 2:1 ratio can be applied around the skin incision
    • Antipsychotic medication in some cases is needed

Board-certification by the American College of Veterinary Surgeons

What does it mean?

  • Four years of advanced training in surgery beyond the Doctor of Veterinary Medicine Degree

  • Experience in the development of new surgical treatments

  • Rigorous examination by the American College of Veterinary Surgeons to ensure competency in advanced surgical techniques

  • Assurance that a veterinarian is a surgical specialist

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