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The future of imaging in veterinary oncology:

Learning from human medicine

Article in The Veterinary Journal June 2013

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 The Veterinary Journal 197 (2013) 541552

Contents lists available at SciVerse ScienceDirect

The Veterinary Journal

journal homepage: www.elsevier.com/locate/tvjl

Review

The future of imaging in veterinary oncology: Learning from human

medicine
John S. Mattoon a,, Jeffrey N. Bryan b
a
Department of Veterinary Clinical Sciences, Washington State University, Pullman, WA 99164, USA
b
Department of Veterinary Medicine and Surgery, University of Missouri, Columbia, MO 65211, USA

a r t i c l e i n f o a b s t r a c t

Article history: Imaging technology is critical for adequate diagnosis and staging in human and veterinary oncology. Sen-
Accepted 6 May 2013 sitive detection of lesions is necessary to determine appropriate local or systemic therapy and to monitor
therapeutic results. New technology in digital radiography, ultrasound, and computed tomography (CT)
scanning are now widely available in veterinary medicine. Advanced imaging with high-detail CT scans,
Keywords: magnetic resonance imaging (MRI), and positron-emission tomography (PET) are now available in aca-
Cancer demic centers and some private specialty practices. This review describes the current and future appli-
Diagnostic imaging
cations of these new imaging systems and modalities in veterinary oncology and how advanced
Molecular imaging
Dog
imaging contributes to diagnosis, staging, and monitoring of cancers. The potential of molecular imaging
Cat for accurate, minimally invasive diagnosis and monitoring is discussed.
2013 Elsevier Ltd. All rights reserved.

Introduction radiographs are the mainstay for pulmonary metastasis monitor-

Diagnostic imaging is central to oncology practice to identify
primary and metastatic lesions while staging patients, and then
subsequently to monitor those lesions. While imaging cannot re-
place histology, several modalities facilitate diagnostic sampling
and in the future scans may also be able to identify tissue type.
The quality of image generation and contrast agents has evolved
dramatically in the last few years. All imaging modalities used in
human medicine are becoming available in veterinary medicine,
including positron emission tomography (PET) and PET combined
with computed tomography (CT) imaging. Images can be anatomic,
functional, and molecular in nature. Each imaging modality has its
strengths and weaknesses for the diagnosis and staging of cancer.
The purpose of this review is to describe the current state-of-
the-art in veterinary oncology imaging using examples to illustrate
the application for several specic disease processes.
Imaging modalities
Radiography
Radiography is routinely used to obtain baseline information of
the thorax and musculoskeletal system. Radiography complements
ultrasound by providing information about the relative size and
position of organs and skeletal metastasis. Like in humans, thoracic
Corresponding author. Tel.: +1 509 335 0713.
E-mail address: mattoon@vetmed.wsu.edu (J.S. Mattoon).
ing, especially in light of recent concerns about cumulative diag-
nostic radiation dose from CT (Brenner, 2010). The increased
sensitivity of digital radiography reveals pulmonary nodules smal-
ler than possible with lm-screen systems (Fig. 1).
Ultrasound
Ultrasound has become the foundation of abdominal imaging in
veterinary medicine. It can better dene organ-specic location of
radiographically identied lesions or discover lesions not apparent
radiographically. However, the identication of an intraparenchy-
mal lesion is generally poorly specic and must be investigated
cytologically or histologically for a denitive diagnosis. A notable
exception is that alterations of the normal ultrasonographic
appearance of gastrointestinal wall thickness, layering, and lymph
node characteristics may differentiate lymphoma from inamma-
tion (Zwingenberger et al., 2010).
Ultrasound facilitates guidance for ne needle aspirates and tis-
sue core biopsies. Doppler ultrasound provides information about
blood ow and vascular invasion. Doppler imaging has increased
the safety of sampling, but does not reliably distinguish the benign
from the malignant. Nonetheless, ultrasound has become a sensi-
tive tool in the staging of cancer (Flory et al., 2007). Contrast ultra-
sound techniques borrowed from human medicine are also useful
in differentiating benign from malignant hepatic lesions. Contrast
can also increase conspicuity of lesions which may be poorly seen,
if at all, on conventional ultrasound scans.

1090-0233/$ - see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.tvjl.2013.05.022
542 J.S. Mattoon, J.N. Bryan / The Veterinary Journal 197 (2013) 541552
Fig. 1. Hemangiosarcoma pulmonary metastasis in a 13-year-old German shepherd
dog. (A) Right lateral digital thoracic radiograph showing the resolution limits of
pulmonary nodule detection. (B) Multiple, 45 mm soft tissue nodules are
identied in the magnied image (inset, arrowheads). Digital radiography enables
optimized adjustment of image contrast and magnication, essential for detection
of small or subtle pathology. (Image courtesy of Washington State University).
A small number of veterinary studies have evaluated contrast
ultrasound for characterization of splenic, hepatic, and renal le-
sions. As in human medicine, contrast ultrasound may differentiate
malignant from benign lesions (Rossi et al., 2008; Webster and
Holloway, 2008; Ivancic et al., 2009; Kanemoto et al., 2009; Haers
et al., 2010). Contrast has also been used to assess lymph node
pathology and to increase conspicuity of small sentinel nodes for
biopsy (Salwei et al., 2005; Lurie et al., 2006; Gelb et al., 2010).
While human medicine often relies heavily on CT, ultrasound is
the mainstay of abdominal imaging in veterinary medicine. This is
mostly due to smaller patient size, lack of need for general anes-
thesia, lack of ionizing radiation exposure, and the lower cost of
ultrasound equipment relative to CT. In addition, most abdominal
ultrasound examinations of humans are technologist-acquired re-
gional or focal examinations. In veterinary medicine most abdom-
inal scans can be considered an abdominal exploratory requiring a
veterinarian to directly perform or monitor the entire scan.
Perhaps the biggest inadequacy of abdominal ultrasound is the
limited cross-sectional eld-of-view when compared to CT or mag-
netic resonance imaging (MRI). This can manifest as unrecognized
or misidentied lesions. The inability to visualize the entire lesion
within the eld-of-view makes it impossible to accurately measure
large lesions. Ultrasound yields poorly reproducible measurements
in the urinary bladder, making therapy monitoring of bladder
masses difcult (Hume et al., 2010).
The newest ultrasound machines have extended eld-of-view
capability, allowing the sonographer to create a panoramic image
of the entire lesion (Fig. 2). This is a very useful feature, but cannot
provide accurate measurements and is a static image (vs. real-
time). Although ultrasound is used in practice to assess the extent
of cancer and its margins for surgical resection and radiation ther-
apy, it is of limited value in this application; CT and MRI provide
better information. Despite these inherent limitations, ultrasound
is used appropriately to screen for disease, assess for multi-organ
involvement in known disease, acquire guided samples, and re-
evaluate disease during or following therapy.
Computed tomography
CT is a cross-sectional imaging modality that can be recon-
structed in essentially unlimited multiplanar and three-dimen-
sional orientations following single data acquisition. CT data can
be acquired rapidly using sedation or even gentle restrain, in place
of general anesthesia for most studies (Oliveira et al., 2011). Large
eld-of-view permits a global perspective for accurate assessment
of large and complex lesions for surgical and radiation therapy
planning (Fig. 3). Detailed reconstructions are particularly useful
for identifying margins and vasculature in surgical planning for
complex bony tumors. Algorithms control image acquisition fol-
lowing contrast injection to generate arterial and venous phase
studies, enhancing visualization of tumor vascular supply and
invasion (Nitzl et al., 2009).
CT is the most sensitive modality for detection and assessment
of pulmonary lesions in human and veterinary medicine (Fig. 4)
(Nemanic et al., 2006; Choi et al., 2010; Somboonporn et al.,
2010). However, CT has not replaced thoracic radiography due to
cost and more limited availability. While CT is also preferred for
evaluation of human abdominal disease, its use in veterinary med-
icine is far more limited. Newer CT technology available to veteri-
narians will expand collective expertise in image evaluation
(Fig. 5).
Recent press attention has raised public awareness of health
risks associated with the possible high radiation dose received
from CT scans. It is worth noting that current algorithms do include
optimizing protocols that minimize patient dose in the scanning
process (Mayo, 2008; Brix et al., 2009; Sodickson et al., 2009; Bren-
ner, 2010). A similar health risk has not yet been identied in com-
panion animals, but is likely to exist as this technology is
increasingly available.
Magnetic resonance imaging
MRI is the standard technique for neuroimaging in human and
veterinary medicine with application to essentially all body sys-
tems. Large eld-of-view cross-sectional images can be obtained
in any chosen plane. Use of a variety of imaging sequences enables
the selective enhancement and ne-detail resolution of soft tissues
based on the molecular composition of tissues. The soft-tissue de-
tail is far superior to CT (Fig. 6). MRI requires much longer data
acquisition time compared to CT and therefore general anesthesia
for animals. Many radiation planning systems cannot use MRI data
as they rely on the X-ray density data present in CT scans to calcu-
late absorbed dose.
Because of the superb detail, MRI is most useful for the identi-
cation of tumors and tumor margins within soft tissue before sur-
gery or radiation therapy. MRI is also a very sensitive monitoring
tool following therapy that carries some risk of identifying other
abnormalities with unknown relationship to the primary disease
process (Koppelmans et al., 2011). Compared to other imaging
modalities, lesions identied on MRI appear to be more extensive
(Kafka et al., 2004). This may reect true disease extent or may
overestimate lesion size.
 J.S. Mattoon, J.N. Bryan / The Veterinary Journal 197 (2013) 541552 543

Fig. 2. Older neutered male dog with carcinoma of the trigone (arrow) of the urinary bladder and prostate gland. Extended eld-of-view sagittal ultrasound image of urinary
bladder cancer (UB) and prostate cancer (P), with regional lymph node (ln) metastasis. The large eld view provides a panoramic perspective of large lesions or lesions
involving more than one organ, partially overcoming one of ultrasounds major limitations of small eld view. While precise measurements are not possible, size estimates
can be made using the depth (vertical) and length (horizontal) cm markers located along the right and bottom margins, respectively. We have found extended eld view
imaging to be valuable in subjective assessment pre- and post-cancer therapy. This image was obtained with a Biosound Esaote MyLab 70 ultrasound machine using a 4
13 MHz linear array transducer, operating in VPan mode. Cranial is to the left, caudal to the right. (Image courtesy of Washington State University).

Nuclear medicine
Nuclear medicine generates images through tissue physiology
rather than anatomic abnormalities. Nuclear medicine uses in-
jected radioactive substances to create a functional diagnostic im-
age. Radioactive substances are termed radionuclides, or
radiopharmaceuticals when combined with specic compounds.
Radiopharmaceuticals can be selected which preferentially target
certain organs. A detector called a gamma camera records gamma
rays emitted from the patient. Lesions are identied by altered
radiopharmaceutical metabolism. Because nuclear medicine
images provide poor anatomic detail, they can be combined with
CT or MRI to yield both functional and anatomic information. There
are three fundamental forms of diagnostic nuclear medicine: (1)
two-dimensional planar scintigraphy; (2) three-dimensional sin-
gle-photon emission computed tomography (SPECT), and (3) PET.
in a radiation isolation facility until their radioactive emissions are
below a prescribed level.
Single photon emission computed tomography (SPECT)
SPECT uses collimated scintillation crystals moving around the
patient to generate a three-dimensional (3D) rendering of the
structure of interest. The principal advantage of SPECT is a more
accurate image of the distribution of the agent within the eld.
Identifying the target of interest within a tumor or organ could se-
lect candidates for targeted treatment and guide therapy decisions
in the future. SPECT imaging has been used to evaluate tumor
metabolism in dogs with cancer (Ogilvie, 2000; Whittemore
et al., 2004).
Positron emission tomography imaging (PET)

PET imaging has become routine in human cancer detection,

Nuclear scintigraphy
The planar (2D) gamma camera consists of a collimator lter in
front of a scintillation crystal backed by photomultiplier tubes that
localize radioactive events of the proper energy in space in front of
the camera. Static studies identify the imaging agent within the
body at a single point in time or as a composite image gathered
over a dened period of time. Dynamic studies observe the accu-
mulation of radioactivity in real-time. Dynamic studies can be used
to calculate uptake and kinetics of the radioactive agent to dene
distribution, excretion, or ow dynamics properties.
Most current veterinary studies rely on the radionuclide tech-
netium (99mTc). This metastable compound decays by releasing a
uniform-energy gamma ray of 140 keV that is readily detected.
Its chemical properties allow 99mTc to be incorporated into differ-
ent targeting compounds for delivery to the tissue of interest. Re-
cently, 67Ga-citrate has been used to image primary and
metastatic oral melanoma lesions in a dog (Liuti et al., 2009). Scin-
tigraphy studies generally require that the patient be hospitalized
staging and monitoring. Limited by the cost of both equipment
and imaging agents, this modality has been used largely experi-
mentally in veterinary oncology (Lawrence et al., 2009, 2010; Lee
et al., 2010a). PET detects the energy of a positron (essentially a
positively charged electron) annihilating with an electron, result-
ing in two, diametrically opposed 511 keV photon emissions. The
simultaneous creation of these photons localizes the origin within
the patient using high energy detectors surrounding the patient in
a ring. PET produces excellent image resolution, limited only by the
distance of travel of the positron in tissue prior to annihilation and
the resolution of the scanner itself.
The rst Federal Drug Administration (FDA)-approved PET
agent for imaging of cancer, 18F-FDG, relies on excessive glucose
utilization by cancer to localize in tumors. 2-Deoxyglucose is a sub-
strate for glucose transporters (GLUT) and hexokinase, which phos-
phorylates glucose, trapping it irreversibly within the cell.
However, once phosphorylated, the lack of a 2-hydroxyl group pre-
vents conversion to fructose by phosphoglucose isomerase, pre-
venting its metabolism. Unfortunately, the uptake of 18F-FDG is
544 J.S. Mattoon, J.N. Bryan / The Veterinary Journal 197 (2013) 541552

Fig. 3. A 9-year-old, spayed female mixed breed dog was presented for evaluation of a subcutaneous mast cell tumor over the left dorsal thorax. The mass appeared mobile
relative to underlying tissue on examination. Thoracic radiographs were normal for a dog of this age (A, left lateral; B, dorsoventral). (C and D) CT scan revealed a markedly
enlarged contrast enhancing left axillary lymph node (black arrow) (C) and intrathoracic invasion of the mast cell tumor (white arrow) (D). The original treatment plan of
surgery was abandoned in favor of medical therapy in light of a more extensive and metastatic tumor than identied on clinical examination and thoracic radiography. The CT
images are displayed in a soft tissue window and level setting. A, aorta; T, trachea; E, esophagus; GB, gallbladder. (Images courtesy of Washington State University).

not unique to cancer cells as metabolically active tissue, including
inammation, can concentrate the molecule, yielding a false-posi-
tive scan (Ballegeer et al., 2006). In human oncology, 18F-FDG
imaging is indicated for staging a variety of tumors including
breast cancer, hepatocellular carcinoma, lung tumors, head and
neck carcinoma, brain tumors, and many sarcomas (Alberini
et al., 2011). Some human tumors, such as prostate cancer, cannot
be imaged well with 18F-FDG (Sharkey et al., 2007).
The utility of 18F-FDG in veterinary patients has been only min-
imally explored to date (Lawrence et al., 2010; Hansen et al., 2011;
LeBlanc et al., 2012). Imaging results with 18F-FDG in dogs are very
similar to those in humans. The most commonly used PET
 J.S. Mattoon, J.N. Bryan / The Veterinary Journal 197 (2013) 541552
Fig. 4. A 10-year-old Labrador retriever mix dog presented with an oral melanoma.
Computed tomography (CT) was used to asses the extent of the oral tumor and to
evaluate the lungs for metastasis. This thin-slice (3 mm) CT image of the thorax at
the level of the heart (H) and tracheal bifurcation () shows two pulmonary nodules
(arrows), one in the dorsal left lung (4 mm) and one in the right dorsal lung (2 mm).
Numerous additional nodules were identied on review of the complete examina-
tion. None of the pulmonary lesions were visible on digital thoracic radiographs.
This axial CT image is displayed in a lung window and level, a setting that optimizes
the appearance of pulmonary parenchyma. (Images courtesy of Washington State
University).
radionuclide is uorine-18 with a half-life <2 h. Thus, a producer
must be located within a few hours to support the use of a PET
scanner. The radionuclide 64Cu has a half-life of 12.7 h, so could
be shipped from a greater distance, but its use has not yet become
routine in clinical imaging.
PET CT
PET imaging is combined with CT imaging (PET/CT) in humans
to marry functional information with exact anatomical localiza-
tion.(Lawrence et al., 2010) There are only a few veterinary facili-
ties capable of PET/CT studies with few reports in the literature
(Fig. 7) (Hansen et al., 2011; LeBlanc et al., 2009; Lee et al.,
2010a,b,c; Souza et al., 2011). PET/MRI is also available in a small
number of locations and has been used in veterinary medicine
(Kang et al., 2009, 2010; Wehrl et al., 2011).
Molecular imaging
Molecular imaging is the creation of a diagnostic image by tar-
geting a molecule or a tissue property for imaging using the tech-
nologies described above. Most commonly, the images derived are
nuclear medicine images, but contrast agents for MRI can also tar-
get tumor-associated molecules or processes (Makowski et al.,
2009). The target could be a metabolic pathway unique to the tis-
sue of origin of the cancer, such as iodine trapping in thyroid can-
cer, or a specic antigen that is overexpressed in the type of cancer,
such as prostate specic membrane antigen (PSMA) in prostate
cancer. Molecular imaging is evolving towards specic diagnostic
assays that might identify the exact type of cancer in vivo, giving
545
early evidence of therapeutic efcacy for real-time decision mak-
ing tailored to individual patients responses.
Targeted monoclonal antibody imaging
Monoclonal antibodies (mAbs) have been evaluated for use in
imaging and treating cancer because of their exquisite specicity
of molecule recognition. However, these molecules are large, hav-
ing circulating half-lives of several days, resulting in increased
background radioactivity on scans due to slow washout from the
blood pool, decreasing image quality. In addition, many of these
proteins are xeno-antigens to people and dogs, limiting the num-
ber of times the agents can be administered.
Targeting PSMA, capromab pendetide (Prostascint) is approved
for imaging prostate cancer in humans. Recent literature suggests
that this antigen is expressed in half of canine prostate cancers
(Lai et al., 2008). Carcinoembryonic antigen (CEA) has been tar-
geted using mAbs and portions of mAbs for staging purposes for
colon cancer (Obradovic et al., 2006). CEA has been identied in ca-
nine cholangiocarcinomas and mixed hepatocellular carcinomas,
among others (Martin de las Mulas et al., 1995).
Targeted peptide imaging
Although of lower binding afnity than mAbs, peptides can be
designed to target specic receptors on the surface of cells and
have more favorable circulation kinetics. The result is reasonable
targeting efciency with more rapid loss of background blood pool
activity to result in a better image. Somatostatin analogues have
been used to image endocrine tumors in dogs and both endocrine
tumors and lymphoma in people, and may be used for therapy
(Kwekkeboom et al., 2005).
In dogs, radiolabeled somatostatin analogues have been shown
to accumulate in both gastrinomas and insulinomas (Altschul et al.,
1997; Lester et al., 1999; Garden et al., 2005). In human beings,
non-Hodgkins lymphoma expresses somatostatin receptors
approximately 80% of the time (Lugtenburg et al., 2001; Raderer
et al., 2001; Cholewinski et al., 2004; Ferone et al., 2005). Similarly,
in dogs an 111In-labeled somatostatin analogue delivering an anti-
Bcl2 antisense molecule accumulated in lymphoma tissue at a ratio
signicantly higher than background (Statham-Ringen et al., 2012).
Pretargeted imaging
Pretargeting can improve the kinetics of a mAb imaging agent
by tagging a tumor with mAb, clearing the mAb from the circula-
tion, then labeling the bound mAb with radiolabeled biotin in-
jected into the patient (Lewis et al., 2004). Such a technique was
employed to image metastatic prostate cancer in a canine clinical
patient (Fig. 8). The experiment successfully identied all known
disease, and revealed a metastatic location previously unsuspected
(Lewis et al., 2006).
Selected disease entities
Hemangiosarcoma
Hemangiosarcoma is a highly metastatic form of cancer that
arises from a malignant endothelial cell precursor of myeloid der-
ivation (Lamerato-Kozicki et al., 2006). It arises most commonly in
the spleen, skin/subcutis, right atrium, and liver, but may occur in
almost any tissue in dogs. The disease may spread from any pri-
mary site to the lung, liver, right atrium, omentum, mesentery, kid-
ney, skeleton, adrenal glands, and cerebrum (Snyder et al., 2008).
546 J.S. Mattoon, J.N. Bryan / The Veterinary Journal 197 (2013) 541552

Fig. 5. Dog with extensive soft-tissue sarcoma of the left ventral neck. (A) Axial post-contrast computed tomography (CT) image at the level of the occipital bone and ears
shows extensive and complex tumor (T). (B) Sagittal reconstruction post-contrast CT image to the left of midline through the tumor (T). The head is to the left (HR). B, brain; C,
cervical spine. (C) Dorsal plane reconstruction post-contrast CT image through the tumor (T). The head is pointed upward (HR). ET, endotracheal tube. (D) Three-dimensional
reconstruction of the head and neck showing the extensive nature of the tumor (T) and complex blood supply. The head is pointed toward the top of the image, the patients
left is to the right (LH). C, common carotid arteries; M, mandible; ET, endotracheal tube. (Images courtesy of Washington State University).

Hemangiosarcoma is similar to the relatively rare disease, angi-
osarcoma, in people. The imaging appearance of angiosarcoma in
human beings is very similar to that of hemangiosarcoma in dogs.
In humans, ultrasound examination reveals angiosarcoma as a
complex mass with heterogeneous echotexture containing cystic
regions (Abbott et al., 2004). On CT angiosarcoma will appear ill-
dened with heterogeneous contrast uptake and areas of necrosis.
MRI examination tends to be enhanced by hemorrhage within and
around the angiosarcoma in the spleen (Abbott et al., 2004). Heter-
ogeneity on T1 and T2 weighted images suggest bleeding from the
mass into splenic parenchyma (Abbott et al., 2004). Gadolinium
contrast enhancement causes heterogeneic enhancement of the le-
sions and can be used to distinguish them from benign lesions (Ab-
bott et al., 2004). Radiographic images of the thorax are used to
stage angiosarcoma patients for pulmonary metastasis.
Dogs and cats with hemangiosarcoma should be staged with
three view thoracic radiographs, abdominal ultrasound, and echo-
cardiogram. Thoracic radiographs should be assessed extremely
carefully for subtle signs of metastatic disease (Fig. 1). CT of the
thorax is even more sensitive than radiography for metastatic
events (Fig. 4) (Nemanic et al., 2006). Contrast CT has also been re-
ported to facilitate the differentiation of malignant from benign
splenic lesions (Fife et al., 2004). However, in our practice, CT dif-
ferentiation has not been reliable. Doppler ultrasound examination
of splenic masses can identify vascular tumors.
Recently, contrast harmonic ultrasonography has been sug-
gested as useful for differentiating metastatic HSA from benign le-
sions in liver parenchyma (Ivancic et al., 2009). The enhanced
imaging was not, however, benecial in distinguishing hemangio-
sarcoma and splenic hematoma. In another study, contrast har-
monic ultrasonography was highly predictive of malignancy for
lesions that were moderately or markedly hypoechoic (Ohlerth
et al., 2008). Even so, there are no pathognomonic signs of heman-
giosarcoma on ultrasound examination. Ultrasound examination of
the heart base should be performed to identify lesions in that loca-
tion. Use of an echocardiogram to detect right atrial masses has
been associated with a 92% positive predictive value and a 64%
negative predictive value (Fruchter et al., 1992).
Thyroid carcinoma
Nuclear imaging of the thyroid gland and thyroid tumors relies
on the unique metabolic property of iodine trapping and organi-
cation of thyroid tissue. The most common imaging agent is
 J.S. Mattoon, J.N. Bryan / The Veterinary Journal 197 (2013) 541552 547

Fig. 6. Cat with an injection site brosarcoma (arrows) of the shoulder. (A) Axial T1 post-contrast magnetic resonance imaging (MRI). (B) Sagittal T1 post-contrast MRI. (C)
Post-contrast axial computed tomography (CT). (D) Post-contrast sagittal CT. This comparison illustrates the exquisite resolution of the tumor and surrounding soft tissues by
MRI. (E) Three-dimensional CT reconstruction shows excellent anatomic detail of the complex vascular nature of the tumor (arrows). CT images (C and D) are displayed in a
soft tissue window and level setting maximizes the relatively small differences in soft tissue contrast. This setting renders the lung almost entirely black. R, right; L, left. White
arrowhead indicates trachea. l, cranial lung; m, cranial mediastinum; c, cranial vena cava; H, heart. (Images courtesy of Washington State University).
548 J.S. Mattoon, J.N. Bryan / The Veterinary Journal 197 (2013) 541552

Fig. 7. Positron emission tomography (PET; A and B) and PET/computed tomography (PET/CT; CE) images of a 9-year-old spayed female Labrador retriever with thyroid
carcinoma and a small pulmonary nodule. The images were acquired following the administration of 18FDG. (A) Ventral PET image. The thyroid mass (T) is easily identied
with lobulated uptake of FDG-18. A small focus of uptake is seen in the right caudal thorax overlying the cranial margin of the liver (black arrow). (B) Lateral PET image. The
thyroid mass (T) is seen as an area of inhomogeneous increase in FDG-18 uptake. (C) Ventral PET/CT image shows the tumor (T). The ventral PET image (A) has been fused
with a CT scan. (D) Lateral PET/CT image shows the thyroid tumor (T). The lateral PET image (B) has been fused with a CT scan. (E) Axial PET/CT image showing the right caudal
pulmonary nodule (white arrow), presumed to be metastatic disease. (Images courtesy of Colorado State University).

pertechnetate (99mTcO4-). This radionuclide is trapped by the thy- Bone tumors

roid gland and is excreted by organs that secrete high chloride con-
taining uids, including the salivary and gastric glands (Nap et al.,
1994). Dogs with bulky disease not amenable to surgery and met-
astatic thyroid carcinoma can be expected to respond to radioio-
dine therapy if a pertechnetate scan is positive (Turrel et al.,
2006). Even dogs with advance pulmonary metastasis from thyroid
carcinoma can live a year or more following this therapy (Fig. 9).
Recently, CT and MRI have been shown to most reliably identify
margins of thyroid tumors in dogs, facilitating pre-operative plan-
ning (Taeymans et al., 2013).
The hydroxyappatite matrix of bone is a readily accessible tar-
get for imaging and potential therapy. This matrix of bone will
avidly bind phosphorous-containing molecules. By attaching
99m
Tc as an imaging nuclide the localization of the phosphorus-
containing chelator can be identied by planar scintigraphy. Bone
scintigraphy is useful in patients with osteosarcoma to identify
early osseous metastatic lesions or metachronous primary lesions
of bone, which have been reported to occur in approximately 8%
of cases (Fig. 10) (Jankowski et al., 2003).
 J.S. Mattoon, J.N. Bryan / The Veterinary Journal 197 (2013) 541552
Fig. 8. Pretarget planar images of a dog with prostate cancer. In the 4.5 h image (a) the kidneys (white arrows) and a small shadow (dark arrow) of the bladder are visible. In
the 49 h image, the dark accumulation of activity (dark arrow) is not the bladder, but a metastatic lymph node that was not identied on earlier ultrasound imaging. (Image
courtesy of Drs. Michael R. Lewis and Jeffrey N. Bryan).
Fig. 9. A 14-year-old spayed female Dalmatian was presented for a bulky thyroid
carcinoma causing respiratory distress with multiple pulmonary metastases.
Pertechnetate scintigraphy conrmed that all metastatic lesions concentrated the
radionuclide. The dog was treated with radioiodine and survived more than a year
after therapy. Presented are the dogs left lateral thoracic radiograph (A) and
matching lateral thoracic pertechnetate scan (B). (Image courtesy of the University
of Missouri).
Scintigraphy has also been used to assess tumor margin prior to
resection for limb-spare surgery. While plain radiographs tend to
549
Fig. 10. In a study of 399 dogs presenting with osteosarcoma, 7.8% had a second
skeletal lesion consistent with an osteosarcoma metastasis detected on 99mTc-HDP
nuclear scintigraphy (Jankowski et al., 2003). Presented is a representative bone
scintigraphic scan with two apparent rib lesions (arrows) that were conrmed as
osteosarcoma metastases. The dog head is to the right, dorsal is at the top of the
image. (Image courtesy of Washington State University).
underestimate the microscopic extent of tumor, scintigraphy
overestimates it, allowing a safe, tumor-free margin to be resected
(Leibman et al., 2001). MRI has been shown to best estimate the
extent of osteosarcoma lesions in comparison to CT, radiography,
and scintigraphy (Wallack et al., 2002).
In addition to imaging, nuclear medicine employs radiopharma-
ceuticals like Samarium-153-EDTMP (153Sm or Quadramet) as a
combination imaging and therapy nuclide, In addition to a gamma
ray that can be imaged, 153Sm emits three b-particles with a range
of up to 3 mm in tissue which can palliate pain signs and delay tu-
mor growth (Barnard et al., 2007; Vancil et al., 2012). Technetium
scintigraphic intensity of osteosarcoma has been shown to be
prognostic for outcome in dogs treated with 153Sm-EDTMP (Forrest
et al., 1992).
Adrenal incidentalomas: A by-product of advances in medical imaging
The proliferation of high quality diagnostic imaging in human
and veterinary medicine has resulted in the discovery of an
550 J.S. Mattoon, J.N. Bryan / The Veterinary Journal 197 (2013) 541552
increasing number of abnormalities of unknown signicance. The
increased frequency of abdominal ultrasound imaging and in-
creased quality of ultrasound machines, has led to the incidental
discovery of adrenal nodules or masses in dogs with increased fre-
quency (Myers, 1997). This has been observed in parallel in hu-
mans receiving abdominal CT and MRI imaging, giving rise to the
term adrenal incidentaloma (Terzolo et al., 2009).
The discovery of an adrenal mass during the routine staging
workup of a cancer patient requires careful consideration. The fre-
quency of adrenal tumors in the dog population has been
estimated to be between 1.2% and 1.5% in a study examining data
from veterinary teaching hospitals (Myers, 1997). The frequency
seen in the general population has been estimated to be between
one-half and one-fth of that seen in the referral population
(Myers, 1997). The frequency of feline adrenal masses has been re-
ported to be even lower at approximately 2% (Myers, 1997).
In veterinary patients, adrenal masses are most commonly ade-
nomas or carcinomas, with pheochromocytomas, cysts, and myel-
olipomas next most frequent (Myers, 1997). Metastatic disease
occurs at a higher rate than primary adrenal masses in oncology
patients (Myers, 1997; Labelle and De Cock, 2005). In dogs, the
most common tumors to metastasize to adrenal glands are
pulmonary carcinoma, mammary carcinoma, and prostatic carci-
noma (Labelle and De Cock, 2005). In cats, the most common tu-
mors to metastasize to adrenal glands were lymphoma,
transitional cell carcinoma, and melanoma (Labelle and De Cock,
2005). The frequency of discovery of these tumors in humans has
led to the development of clinical algorithms to manage patients
who have incidentalomas based primarily on functional testing
and imaging characteristics.
While functional testing is not clinically available in veterinary
patients to the extent that it is in human patients, imaging charac-
teristics including size and texture can be used to increase index of
suspicion for more aggressive lesions. Current ultrasound technol-
ogy allows accurate measurement of adrenal nodules and masses,
and adrenal glands larger than normal may represent ndings of
clinical signicance (Barthez et al., 1995). With MRI imaging, ade-
nomas are isointense while pheochromocytomas, adrenal carcino-
mas and metastatic tumors are hyperintense to liver on T2
weighted images (Young, 2007). In human patients, MRI is rela-
tively sensitive and specic for benign lesions. Ultimately histology
may be necessary for denitive diagnosis.
Conclusions
Exploiting technological advances from human medicine, pets
with cancer can be more rapidly, accurately, and minimally inva-
sively diagnosed, staged, and monitored. Enhancements to current
radiographic and ultrasound equipment improve the ability to
identify and dene tumors in private practice. The increased avail-
ability of cross-sectional imaging of CT and MRI improves the diag-
nostic offering at referral centers, making tumor margin
identication more sensitive and accurate. New targeted PET,
SPECT, and nuclear medicine agents will facilitate less invasive,
more comprehensive tumor identication and localization in the
future. As these technologies become more widely available, veter-
inarians will need to be familiar with their function and
applications.
Conict of interest statement
Neither of the authors of this paper has a nancial or personal
relationship with other people or organizations that could inappro-
priately inuence or bias the content of the paper.
Acknowledgements
The authors gratefully acknowledge Dr. Michael Lewis for con-
tributing the pretarget images and Dr. Susan Kraft for the PET/CT
images.
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