Veterinary Vertex
Veterinary Vertex is a weekly podcast that takes you behind the scenes of the clinical and research discoveries published in the Journal of the American Veterinary Medical Association (JAVMA) and the American Journal of Veterinary Research (AJVR). Tune in to learn about cutting-edge veterinary research and gain in-depth insights you won’t find anywhere else. Come away with knowledge you can put to use in your own practice – along with a healthy dose of inspiration to remind you what you love about veterinary medicine.
Veterinary Vertex
Primary Liver Tumors in Dogs: Additional Liver Masses Are Often Benign
Your heart sinks when a dog’s CT shows a primary liver tumor plus extra lesions. Ours used to as well—until we dug into data showing how often those additional masses are actually benign. In this conversation with surgical oncologists Drs. Samuel Burkhardt and Hunter Piegols, we rethink what “multiple hepatic lesions” really means, and how that shift can change everything from pre-op counseling to what you sample in the OR.
We walk through their study design—primary liver tumors paired with additional lesions verified by surgical exploration and histopathology—and why imaging alone couldn’t separate benign from malignant with confidence. You’ll hear practical guidance on interpreting CT findings without leaping to metastasis, framing owner conversations to avoid a falsely negative outlook, and planning targeted biopsies that refine staging and inform follow-up. We also tackle the language problem: nodule versus mass. Without common definitions, clinicians and researchers risk misreading severity and muddying the literature. The case for cross-disciplinary standards and working groups is compelling.
Looking ahead, we explore tools that could improve preoperative decisions: contrast-enhanced ultrasound, more rigorous imaging criteria adapted from human medicine, and the promise of liquid biopsy and biomarkers to flag “bad actor” hepatocellular carcinomas. We discuss sample-size limits in veterinary studies, the value of multi-institutional collaboration, and related puzzles like what a solitary pulmonary nodule really means for prognosis. Along the way, you’ll pick up succinct surgical maxims, practical tips for histopath submission, and a reminder that small resets outside the clinic help us think clearly when cases get complex.
If this conversation helps you reframe your next liver case, share it with a colleague, subscribe for more evidence-based episodes, and leave a review so others can find the show.
JAVMA article: https://doi.org/10.2460/javma.25.07.0514
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Welcome to Veterinary Vertex, the Avium Made Journals podcast, where we delve into behind-the-scenes look with manuscript authors. I'm editor-in-chief Lisa Fordier, joined by Associate Editor Sarah Wright. Today we're discussing how benign additional liver masses frequently occur with dogs with primary liver masses, with authors Samuel Burkhart and Hunter Peagles. Hey Sam and Hunters, thanks so much for taking time out of your busy schedules to be with us here today.
SPEAKER_00:Thank you for joining us, Samuel and Hunter.
SPEAKER_03:Thanks for having us. Yeah, thank you.
SPEAKER_00:Before we dive in, Samuel, could you share a little bit about your background and what brought you to investigating liver tumors in dogs?
SPEAKER_02:Absolutely. So uh initially in residency, I actually had a project on liver tumors evaluating basically the efficacy of kind of standard coagulation panels evaluating PT and APTT. And it seemed natural when I was doing a surgical oncology fellowship at the Ohio State University for a next kind of project for fellowship requirements to also further kind of evaluate the liver and um to continue on sort of a project that takes a kind of a different perspective, I guess, about uh another, I think, common um maybe misconception about the liver and diagnostics and our evaluation of such things. So that's kind of where we came up with this project idea uh along with Hunter and um wanted to again evaluate something further.
SPEAKER_00:Samuel, how did you design the study to differentiate benign additional liver masses from malignant ones?
SPEAKER_02:Yeah, so really, of course, to be able to even make such a kind of, I guess, standardization between the two, it really did require that any cases where you know we had a primary liver tumor and subsequently found, you know, through imaging, uh generally CT for our study, that there was going to be an additional mass, which we kind of accepted a mass kind of of any size to not uh you know exclude um too many cases. Um, it really required that we had also followed up with uh a surgical explorer to actually have a diagnosis, histopathologic diagnosis, um, to be able to kind of delineate between benign and malignant because there wasn't imaging characteristics that we could rely on to make such a delineation between the two. So that was a lot of our kind of inclusion criteria was dogs with a primary liver tumor, where we had uh done a liver lobectomy and then also you know followed up with a biopsy of the uh the mass that had also been identified on imaging, or at least had a mass that was also identified, I guess, at the time of surgery.
SPEAKER_01:Yeah, tough area to navigate. Uh Hunter, how might these findings influence diagnostic decision making, like that classic decision tree one if two then be uh such as imaging interpretation, or as Sam was just talking about, surgical planning?
SPEAKER_03:Yeah, I think from a clinician standpoint, taking a look at your imaging, you see multiple masses. That should be on your problem list, but where do you put your deferentials with that? So should that be viewed as potential metastatic disease or multiple malignant processes? I think our data would suggest that potentially um one malignant versus benign or both being benign is still a very real possibility. So being able to have that conversation with owners, I think is really important. And then from a surgical standpoint, I would still recommend getting at least biopsies and multiple masses when you're in there so you can make the most informed decision making.
SPEAKER_00:That makes sense. So, Hunter, what are the key take-home messages you hope veterinarians will remember?
SPEAKER_03:I would say probably one of the biggest takeaways is when you have dogs with multiple liver masses, additional benign masses is quite common. And we shouldn't overinterpret the presence of multiple masses as being an indication of metastatic disease. And again, this is really important when discussing with owners because we could paint a falsely negative picture potentially.
SPEAKER_01:Looking forward, Samuel, are there sp I know there's a lot of liquid biopsies and other things, but are there specific diagnostic tools or biomarkers that future studies might better distinguish from benign and malignant masses?
SPEAKER_02:Yeah, I think that's a great point to bring up because, you know, obviously we were talking a lot about having to go to surgery to get, you know, perhaps a lot of these answers, but hopefully changing people's perspectives uh about their kind of preoperative evaluation. So the more tools that we could have before, you know, going into surgery and spending a client's money and uh, you know, putting them under anesthesia, uh, I think the better that we can set them up. Um so you know, other preoperative things, I feel like in humans, um they're able to uh, you know, use imaging a lot more perhaps than we are and have been able to use things such as like cult contrast ultrasound to be able to delineate a little bit more between malignant and benign. I feel like they're also maybe a little bit more adept at using, you know, um contrast ultrasound, looking for specific imaging characteristics and things of that nature that have been able to, again, separate out or at least kind of guide people a little bit more between um, you know, benign and malignant. And, you know, specifically for this study too, uh, you know, I would say one of our limitations, which we unfortunately run into so often, just in veterinary medicine in general, is just you know, a small sample size. And so I think even, you know, further uh growing this study a bit more and making it possibly multi-institutional or having other um clinics and large clinics being able to evaluate kind of the same problem through the same lens would would also be uh beneficial to kind of you know further make this a bit more robust, um, even though we of course feel quite confident with what we found.
SPEAKER_00:So if anyone's listening and wants to collaborate, you know who to reach out to.
SPEAKER_03:Yeah, that's right. Always happy to collaborate. Yes.
SPEAKER_00:It's great. So, Hunter, are there any particular patient populations, tumor types, or stages of disease that deserve closer investigation next?
SPEAKER_03:Yeah, I think one somewhat untapped area is we typically say dogs with primary liver tumor, so hepassillar carcinoma have an excellent prognosis. Once in a while, though, we have uh what I would call bad actors where they do develop metastatic disease, which at this point I really can't tell you what that dog, which dog is going to develop metastatic disease until what time? Um, so like what um Lisa mentioned too about biomarkers, like could there be a way to help distinguish these cases either in a pre-operative or in the immediate postoperative period, so we can help set expectations for owners.
SPEAKER_00:And what's one thing, a tool or something else that would have helped you in this study?
SPEAKER_03:I think one of the challenges we ran into is there's not a great definition for nodule versus mass uh in liver tumors and dogs. So even just some standardization of our terminology, I think, could be helpful for cleaning things up.
SPEAKER_01:I didn't know that, Hunter. Uh what are some of the different definitions? I would have thought it it was based on size. I didn't know there was lack of homogeneity.
SPEAKER_03:Yeah, we reached out to our radiology team and some people will say two centimeters, some will say three centimeters. Then when we went through the records, we would find sometimes like a one and a half centimeter mass or a three centimeter nodule. So I think having more uh strict definitions might be really helpful in the future.
SPEAKER_01:Why would it matter? I think the size matter?
SPEAKER_03:Yeah, I guess of all like potentially, right? It does, I think, you know, too, just what size potentially correlate with like nodule or hyperplasia within the liver rather than being a true like neoplasia being, you know, either uh hypacillar carcinoma or adenoma. So I think teasing that apart more too would be helpful.
SPEAKER_02:Yeah. And I think it it does matter a little bit for, you know, the more we can standardize things in research, I think the better. Because I mean, it just inherently by itself, mass sounds scarier to me than nodule, even as you know, just a surgeon. And, you know, if you have one study like ours, it's like, oh, we define this as a nodule, and then another study uses that same measurement, but like this is a mass. I think that just again, you kind of end up with this bias as you're reading through it about one maybe being worse than the other when maybe we're actually comparing the same thing.
SPEAKER_01:So, okay, how do you go about standardizing it? How do how do you go about ensuring that surgeons and radiologists and everybody else have a consensus on mass versus nodule?
SPEAKER_03:Yeah, I think that's a great question. I think having potentially more cross-disciplinary discussion is helpful. I also think too, uh could there be working groups that help with this? Um with like VSSO, the Surgical Oncology Society. Uh, we've talked about it a little bit more for some of our histopathology, but I think there's a lot of opportunities for these working groups.
SPEAKER_01:Yeah, it even could be something done retrospectively.
SPEAKER_03:Yeah, very true.
SPEAKER_01:And I teed up my own next question. Uh, every time we do a study, we're like, well, this is frustrating if this were better, or it comes up with other questions. So, what did this study open up for future questions for you two to answer?
SPEAKER_02:It's interesting. So, of course, this focus was kind of like uh primary liver tumors and you know, uh specifically evaluating liver. Although, even, you know, when researching this, I found uh another study that was talking about, you know, splinic masses and splinic tumors and then you know finding nodules within the liver and how often do those correlate. And again, I think that potential misconception, well, as Hunter mentioned earlier, very fair to say have on your differential list how often do we have other masses and say other areas that then result in, say, um, you know, pulmonary, say metastatic disease or just seeing pulmonary nodules. But, you know, if we see one nodule or or something of that nature, how often does that potentially correlate? And is that something that should then end up in a, you know, a quote unquote, um, I don't want to say death sentence, but really sort of starting to conclude the worst for that case just, you know, preemptively, whereas said nodule could be, you know, something else entirely, or knowing that even just in some specific histopathologic diagnoses, um, even the presence of you know metastatic disease or pulmonary metastatic disease specifically, may not actually carry, you know, extremely guarded prognosis as dogs might still have a reasonable mean survival time, you know, depending upon your definition of reasonable. But thyroid comes to mind in those dogs sometimes even reaching like a year, even in the presence of pulmonary metastatic disease. So I think it'd be interesting to explore, you know, that kind of realm a little bit more. Now, trying to get the histopath, say, on, you know, a single pulmonary nodule and getting enough case volume for something like that might be more challenging, but it was a question that kind of came to my mind at least.
SPEAKER_03:Yeah, building on that too, I think pairing what we did with like surgical findings and uh histopathology with some of these more novel imaging techniques, as well as with outcome data. So being more formulate on that might allow for a more robust interpretation too.
SPEAKER_01:Yeah, it sounds great. We are very privileged to have this manuscript and several others on liver nodules, masses in dogs. It's it's clearly a uh very difficult circumstance and situation for the veterinarian and the team and the owner as well.
SPEAKER_03:Yeah, I think it's one of as a not so decent uh surgical trainee, one of the more intimidating areas, even for surgery residents, our surgical oncology fellow candidates. So uh definitely a lot of opportunities.
SPEAKER_00:Well, thank you both. We learned so much from your article and from talking with you today. Now we get to move on to the fun part of the podcast. And this is a little off script, but I have to ask you, Samuel, is that the Death Star behind you?
SPEAKER_02:Uh it is the Death Star behind me. I'm actually I I am in my like true office, but I am a little bit of a Lego nerd. So there's a lot of a lot of builds. Yeah, and the Death Star happens to frame right behind my desk.
SPEAKER_00:I love it. I've been looking at this whole time trying to figure it out. I'm like, I think it's the Death Star. That's very cool.
SPEAKER_02:Yeah.
SPEAKER_00:All right. Now we have a few more fun questions too, besides just what's in your background. So, Hunter, what's one belief or habit in veterinary medicine that you'd love to gently retire?
SPEAKER_03:Yeah, I would have to go with as a surgical oncologist, that histopathology is optional after a mass removal. Uh my general opinion is if it's worth removing, it's worth re worth submitting for histopathology.
SPEAKER_01:That's a really good one.
SPEAKER_02:Hunter could list uh little sayings, I'm sure, for like the next 30 minutes. He's no he's known for having his catchphrases that are all very good for practice. Big mass, big incision.
SPEAKER_03:So no. Yeah.
SPEAKER_01:One of ours in equine surgery was if it's not working, do something different.
SPEAKER_03:Exactly.
SPEAKER_01:Sam, for you, uh you know, there's a lot of talk about work-life balance and all these things. What's one small thing at work or outside of it that reliably makes your day better?
SPEAKER_02:Uh I guess I would have to lean on that. Yeah, going back to my background. So um Lego, they're building with Lego, um, I feel like uh it's been very beneficial to me. Kind of you know, did it throughout residency, did it in fellowship. I have more free time now in my first kind of uh two position outside of all the training. So uh building with Lego and and also I guess separately too, something I'm incorporating a lot more is, you know, whether after work or before work, um, just going for a walk. I always used to walk to work and I'm, you know, trying to kind of get back into the habit of it here now that I have a little bit of a driving commute, but I feel like going for a walk kind of separates, you know, a little bit of what I was doing with work and then trying to, you know, get back back home and gives you a little time to clear your head.
SPEAKER_01:Yeah, that's fantastic. Did you like Legos when you were a child?
SPEAKER_02:I sure did. I never I never stopped. So always been building.
SPEAKER_01:Yeah, my my stepbrother uh, and I use this as an icebreaker when I'm sitting at tables or conversations with people that I might not know very well, or if the conversation's taking a lull. My step or sorry, is my brother-in-law always said, What made you happy as a child will still make you happy as an adult. And true. Like just the smell of going into the barn full of horses is and just getting touching my horses, just having to can all the other things seem to fade away then.
SPEAKER_02:Yeah.
SPEAKER_00:Well, Samuel Hunter, thank you so much for joining us. We're so happy to have you here today to learn more about your article.
SPEAKER_02:Of course, so that's our pleasure. Yeah, thank you so much for having us.
SPEAKER_00:And for our listeners and viewers, you can read Samuel and Hunter's article in JAVMA. I'm Sarah Wright here at Lisa48. Be sure to tune in next week for another episode of Veterinary Vertex. And don't forget to leave us a rating and review on Equal Podcasts or wherever you listen.
