Monday, April 15, 2013

Thyroid Scintigraphy for Diagnosis and Staging of Cats to be Treated with Radioiodine


Thyroid scintigraphy provides valuable information regarding both thyroid anatomy and physiology and can play an integral role in the diagnosis, staging, and management of thyroid disease in cats (1-5). The procedure is extremely safe, does not require the use of anesthesia, and is cost-effective, especially when considering the costs of an incorrect diagnosis or inappropriate treatment.

What radiosotopes are used for thyroid imaging?
The basis for this procedure is the unique physiology of the thyroid gland that results in the selective uptake of iodide by thyroid tissue (4-7). Although various isotopes of iodine are available for use in thyroid scintigraphy, their concurrent beta emission and associated local tissue damage (e.g., 131-I) or greater expense (e.g., 123-I), have limited their use in veterinary medicine.

The pertechnetate ion has a similar size, molecular shape, and charge compared to iodide, which results in its uptake by thyroid tissue. The radionuclide technetium-99m pertechnetate (99m-TcO4) is a pure gamma emitter with a low photon energy (140 KeV) that makes it ideal for diagnostic imaging (4-7). Because of these properties, as well as the fact that technetium is relatively inexpensive, it has become the radionuclide of choice for routine thyroid imaging in veterinary medicine.

How a thyroid scan is performed in cats
To perform thyroid imaging in cats, a small dose (3-4 millicuries of  technetium is administered subcutaneously. Between 20 to 60 minutes later, the cats are laid on their abdomen (ventral view) or side (lateral view) while the gamma camera acquires the thyroid image. The scanning process itself usually takes less than a minute and generally does not require sedation (4-6).

Fig 1: Thyroid scintigraphy
in a normal cat
In normal cats, the thyroid gland appears on thyroid scans as two well-defined, focal (ovoid) areas of radionuclide accumulation in the cranial to middle cervical region. The two thyroid lobes are symmetric in size and shape and are located side by side (Figure 1). On the scan, we expect the thyroid and salivary glands to be equally bright (a 1:1 brightness ratio).  In addition to visual inspection, we can calculate the percent thyroidal uptake of the radioactive tracer or the thyroid:salivary ratio. Both of these calculations are strongly correlated with circulating thyroid hormone concentrations and provide an extremely sensitive means of diagnosing hyperthyroidism (4-9).

5 reasons why a thyroid scan is performed
There are five reasons why thyroid scintigraphy should be considered in any cat with suspected hyperthyroidism, especially before radioiodine treatment.

Reason 1— First, thyroid scintigraphy helps confirm the diagnosis of hyperthyroidism, which is very useful in cats in which a thyroid nodule cannot be palpated (4-9). Because thyroid scintigraphy directly visualizes functional thyroid tissue and the “uptake” of the radioisotope can be estimated by determining the thyroid:salivary ratio, thyroid imaging can diagnose hyperthyroidism before laboratory tests are consistently abnormal (Figure 2). Thyroid scintigraphy is considered the gold standard for diagnosing mild hyperthyroidism in cats.

Fig 2: Thyroid imaging in 2 cats with mild hyperthyroidism. The cat on the left has a unilateral thyroid adenoma, whereas the cat on the right has bilateral adenomas. In both cats, notice that the uptake of the radionuclide by the thyroid adenoma(s) is higher than the uptake by the cats' salivary tissue.

Reason 2—Thyroid scintigraphy can also exclude the diagnosis of hyperthyroidism in euthyroid cats that have false-positive elevations in their serum T4 or free T4 values. Studies of cats with nonthyroidal illness (e.g., diabetes, renal, gastrointestinal, or liver disease) have shown that between 6% and 12% of these cats have falsely high serum free T4 values, despite the fact that they are not hyperthyroid (10,11).

In addition, routine screening of an apparently healthy senior cat occasionally reveals laboratory abnormalities that include slightly high total or free T4 concentrations, consistent with mild hyperthyroidism (12). As with sick cats with falsely high free T4 values, however, no thyroid nodule can be palpated in many of these cats and thyroid imaging may fail to confirm hyperthyroidism. Therefore, not every cat with a high total T4 or free T4 value is truly hyperthyroid, and treatment for hyperthyroidism would be contraindicated.

Fig 3: Ectopic thyroid adenoma
in the chest cavity of a hyperthyroid cat
Reason 3—In addition to visualization of functional cervical thyroid nodules, thyroid scintigraphy is an excellent method for evaluating the size of ectopic thyroid tissue, which can be located anywhere from the base of the tongue to the heart (Figure 3).

In addition, thyroid images can locate large tumors that gravity has pulled into the thoracic cavity, which cannot be palpated on physical examination (4-9).

Reason 4— By providing a visual image of hyperfunctional thyroid tissue, thyroid scintigraphy allows for the determination of thyroid tumor mass or volume, which is useful in calculating each cat’s radioiodine dose (6,12,13). The goal of 131-I therapy is to restore euthyroidism with a single dose of radiation without producing hypothyroidism.

Recent research confirms that iatrogenic hypothyroidism contributes to the development of azotemia and shortened survival times in cats overtreated with radioiodine (14). To minimize the incidence of iatrogenic hypothyroidism, it is important to administer the lowest effective dose to each individual cat, rather than giving a fixed dose of radioiodine to all cats (12). Again, thyroid scintigraphy provides an excellent method for evaluating the size of the hyperfunctional thyroid tissue, which aids in determining the proper dose to treat the individual hyperthyroid cat.

Reason 5—Thyroid scintigraphy also provides valuable information in the diagnosis and evaluation of hyperthyroid cats with thyroid carcinoma (Figure 4). Our recent studies suggest that, although thyroid carcinoma is rare in cats with recently diagnosed hyperthyroidism, the prevalence of carcinoma progressively increases in cats treated long term with antithyroid medications. Of cats treated for longer than 4 years with medical treatment, over 20% had scintigraphic evidence of thyroid carcinoma (15).

Fig 4: Thyroid images of 6 hyperthyroid cats with thyroid carcinoma. Notice the large tumor volumes, with extension of disease beyond the limits of the thyroid capsule into the chest cavity in all cases.
The diagnosis of thyroid carcinoma can be challenging (even with histopathology) but without pre-treatment scanning these cases would go undetected. Because of the large tumor volume associated with thyroid carcinoma, as well as the potential for local invasion and metastasis, most of these cats are treated with high doses of radioiodine (e.g., 30 mCi) in order to completely ablate all thyroid tissue (12), thereby curing the cat’s thyroid cancer (Figure 5).
Fig 5: Thyroid images of a hyperthyroid cat with thyroid carcinoma before and after high-dose radioiodine treatment.
Notice the complete ablation of all thyroid cancer tissue 2 months after treatment (right).
Is a thyroid scan mandatory in all cats treated with radioiodine?
No, a thyroid scan is not absolutely mandatory — most treatment facilities in the USA do not do thyroid imaging prior to treatment.

Despite the valuable information obtained by performing thyroid scintigraphy, it is not required prior to radioiodine therapy, just as thoracic radiographs are not required prior to amputating a limb in a patient with a primary bone tumor or a preanesthetic laboratory screening is not required prior to dental prophylaxis or other elective procedures requiring anesthesia. Nevertheless, use of thyroid scintigraphy is considered good medicine because the findings can and do result in modification of the therapeutic dose, aid in the diagnosis of hyperthyroidism, and provide prognostic information.

References:
  1. Mooney CT, Peterson ME: Feline hyperthyroidism, In: Mooney C.T., Peterson M.E. (eds), Manual of Canine and Feline Endocrinology (Fourth Ed), Quedgeley, Gloucester, British Small Animal Veterinary Association, 2012; 199-203.
  2. Baral R, Peterson ME: Thyroid gland disorders, In: Little, S. (ed), The Cat: Clinical Medicine and Management. Philadelphia, Elsevier Saunders, 2012;571-592.
  3. Peterson ME: Hyperthyroidism in cats In: Rand JS, Behrend E, Gunn-Moore D, et al., eds. Clinical Endocrinology of Companion Animals. Ames, Iowa Wiley-Blackwell, 2013;295-310.
  4. Peterson ME, Becker DV. Radionuclide thyroid imaging in 135 cats with hyperthyroidism. Veterinary Radiology 1984;25:23-27. 
  5. Daniel GB, Brawnier WR. Thyroid scintigraphy In: Daniel GB,Berry CR, eds. Textbook of Veterinary Nuclear Medicine. 2nd ed. Harrisburg, PA: American College of Veterinary Radiology, 2006;181-199.
  6. Broome MR. Thyroid scintigraphy in hyperthyroidism. Clinical Techniques in Small Animal Practice 2006;21,10-16. 
  7. Feeney DA, Anderson KL. Nuclear imaging and radiation therapy in canine and feline thyroid disease. Vet Clin North Am Small Anim Pract 2007;37:799-821, viii. 
  8. Harvey AM, Hibbert A, Barrett EL, et al. Scintigraphic findings in 120 hyperthyroid cats. J Feline Med Surg 2009;11:96-106. 
  9. Peterson ME, Broome MR. Thyroid scintigraphic findings in 917 cats with hyperthyroidism. Journal of Veterinary Internal Medicine 2012;26:754.
  10. Mooney CT, Little CJ, Macrae AW. Effect of illness not associated with the thyroid gland on serum total and free thyroxine concentrations in cats. J Am Vet Med Assoc 1996;208:2004-2008. 
  11. Peterson ME, Melian C, Nichols R. Measurement of serum concentrations of free thyroxine, total thyroxine, and total triiodothyronine in cats with hyperthyroidism and cats with nonthyroidal disease. J Am Vet Med Assoc 2001;218:529-536
  12. Peterson ME, Broome MR. Radioiodine for feline hyperthyroidism In: Bonagura JD,Twedt DC, eds. Kirk's Current Veterinary Therapy, Volume XV. Philadelphia: Saunders Elsevier, 2013;in press.
  13. Volckaert V, Vandermeulen E, Saunders JH, et al. Scintigraphic thyroid volume calculation in hyperthyroid cats. J Feline Med Surg 2012;14:889-894. 
  14. Williams TL, Elliott J, Syme HM. Association of iatrogenic hypothyroidism with azotemia and reduced survival time in cats treated for hyperthyroidism. J Vet Intern Med 2010;24:1086-1092. 
  15. Peterson ME, Broome MR:  Hyperthyroid cats on long-term medical treatment show a progressive increase in the prevalence of large thyroid tumors, intrathoracic thyroid masses, and suspected thyroid carcinoma. J Vet Intern Med 26:1523,2012.

8 comments:

Jo said...

Awesome photo, Dr. Peterson!

Lori Blitz said...

My 14 yo cat was losing weight, thyroid levels only slightly elevated. Started medication, levels now normal on meds.and he is slowly gaining weight. Scintigraphy showed no tumor. Are we still too early to show tumor? Will it likely show later? We are anxious to do the l 132. Your opinion is much appreciated!

Dr. Mark E. Peterson said...

If cats have natural hyperthyroidism, they must have a thyroid lesion, which is typically nodular goiter (one or more adenomas of the thyroid).

Was the scan completely normal? Ie, two normal thyroid lobes with normal pertechnatate uptake? If so, I'd worry about dietary hyperthyroidism, either from too much iodine or thyroid hormone in the food.

Alternately, the diagnosis may just not be correct. Something isn't right here...

Lori Blitz said...

Thank you for the reply! I doubt food is the source as we have 3 senior cats eating the same food, Halo wet and dry food, and only one with symptoms. He had all the usual symptoms of hyperthyroidism prior to medication. Methimazole is keeping levels in check. He is happy and active for his age and otherwise healthy. Do you think another scan is a few months is reasonable?

Dr. Mark E. Peterson said...

Yes... in 3 to 6 months.

Lori Blitz said...

Thank you! We are going to try a low iodine diet (not Hill's) and recheck levels. We will see what happens. By the way, in all my research on the internet of this subject, you're the author of about 90% of the articles and studies. Thank you for taking your valuable time to chat with me!

Dr. Mark E. Peterson said...

You are most welcome. Have a good weekend!

Fabio Baia Medico Veterinario said...

Wonder !
There is no clinic / hospital well in Brazil ...