2011 Radiology Exam - Ultrasound Case 2

History: 14 year old Persian cat with elevated AST and ALP (3 times greater than normal), anorexia, and recent drooling.

Sonographic Observations:

• The left side of the liver contains a mass that is about 2cm, does not bulge liver contour, and is hyperechoic with many, tiny, multioculated anechoic fluid cavities that cause far enhancement artifact.
• Also, the liver is diffusely mildly hyperechoic compared to falciform fat and contains a few small (about .5 cm) hypoechoic nodules.
• The left limb of the pancreas is focally enlarged with a poorly margined region of abnormal hypoechogenicity and is surrounded by focal abnormal hyperechoic mesentery.

Synthesis:

• This patient’s clinical problems are likely attributed to pancreatic disease, either acute pancreatitis or primary neoplasm of the pancreas such as carcinoma.
• The 2 cm left liver liver mass is likely a biliary cystadenoma and not necessarily an important problem. Biliary cystadenocarcinoma could have similar appearance but is less common. Liver abscess/infected cystic lesion is also possible but uncommon.
• Mildly hyperechoic liver is a nonspecific finding that might represent diffuse hepatopathy.
• The few small liver nodules are also nonspecific findings that are often incidental such as nodular hyperplasia, but could be a more important lesion, for instance if the pancreas contains adenocarcinoma then hepatic metastasis is possible.

Management:

• Various management strategies are reasonable.
• Medical management for pancreatitis with reassessment of routine blood work and recheck sonography of the pancreas might be recommended.
• Alternatively, fine needle cytology of pancreas, hyperechoic liver, small hepatic nodules, and/or cytic hepatic mass might be recommended.
• Additional recommendations might include three view thoracic radiographs to evaluate for metastatic pulmonary or thoracic neoplasm, evaluation of feline specific lipase, and monitoring growth of the cystic hepatic mass by serial recheck sonography.