C10010096 / invoice 10000

 ULTRASOUND +  LIVER FNA ? DIFFUSE HEPATIC CARCINOMA \ PTS History:Referred from CCV for hepatopathy with cystic change noted on previous ultrasound.  Health declining – see referring history for full details.  Referred for assessment and consideration of exploratory laparotomy with biopsies ± liver lobectomy.  Was 8kg a few months ago, now only 4.5 Owner Communication:Have reviewed CCV abdominal ultrasound and my main concern is that we are not seeing any normal liver parenchyma.  Advised it can be difficult reviewing images rather than being there and hands on the probe.  We do not yet have a diagnosis either.  I feel the best option is admission ultrasound and guided FNA.  We are very lucky to have MR here who can analyse samples on the spot, and if more samples are needed we can collect them immediately rather than facing the 24–48 hr turnaround delays often encountered by GPs.  I feel there is ~90% chance we can obtain a diagnosis with FNA rather than invasive biopsy.  Unfortunately neoplasia is high on the list.  If this is the case, then for surgery to be considered there would need to be at least some normal liver present.  Abdominal ultrasound will be used to check for this, as well as metastatic disease.  Also discussed vomiting/inappetance and the potential role of an oesophageal tube.  O-tube not useful in vomiting patients, however if inappetant and we can solve the cause of vomiting (e.g. liver lobectomy etc) then an O-tube would be appropriate.  Owners understand and happy to proceed. Sedation: - Unable to place IV ? brief gas down to enable. - IVC, Alfaxalone IV to twilight for imaging and FNAs. Ultrasonography:  FULL ABDO  (VS) - FREE FLUID – 2/4 (small volume). - LIVER – Hepatomegaly with multifocal polycystic change.  One large cyst with many smaller cysts.  Intervening parenchyma heterogeneous and vaguely nodular.  Right lobes have relatively more normal appearance than left but appear swollen with mildly hyperechoic, flattened echotexture. - GALLBLADDER – WNL. - SPLEEN – NAD. - GASTROINTESTINAL TRACT – NAD. - PANCREAS – NAD. - LYMPH NODES – Enlarged but reactive in appearance. - URINARY TRACT – NAD. - ADRENALS – Not imaged. Cytology: LIVER (VS for MR) - L diseased lobe – carcinoma ++ - R “normal” lobe – pockets of carcinoma also present Owner Communication:VS spoke to owners and advised of findings.  Unfortunately this is an aggressive carcinoma and there are no disease-free portions of liver.  Surgery will not be curative and we are in the end stages of disease.  Owners understand and elect PTS. Outcome:5ml lethabarb with O's, went peacefully. Plan:To P2R for cremation. O emailed with return options and will let us know next week what they would like.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ CYTOLOGY – MICROSCOPIC FINDINGS MRLI- High cellularity; well-preserved samples- Cords and clusters of polygonal epithelial cells in a clear background with low RBCs- Cells with distinct borders, moderate lightly basophilic cytoplasm- Round nuclei with reticular chromatin and occasional small nucleolus- Moderate to marked anisocytosis and anisokaryosis; rare mitoses- Low neutrophils present- Occasional eosinophilic fibrillar material (collagen)- Scattered vacuolated hepatocytesInterpretation: Findings consistent with carcinoma, most suggestive of biliary ductal carcinoma.    Vital Signs    Weight: 4.5;       MMColour: Yellow;       BodyScore: 2;       CRT: 1-2;