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ZusammenfassungEine 69-jährige Patientin und ein 70-jähriger Patient wurden mit rezidivierenden, schweren Hypoglykämien und klinischer Whipple-Trias aufgenommen. Bei der Patientin ließen erhöhte Spiegel an Insulin und C‑Peptid, ein pathologischer insulinogener Index und ein Fastentest an ein Insulinom denken, welches im 68Ga-DOTATOC-PET-CT im Pankreasschwanz detektiert wurde. Es bestand eine Koinzidenz mit einem neuroendokrinen Merkel-Zell-Karzinom. Bei dem Patienten zeigten sich hingegen supprimierte Spiegel an Insulin und C‑Peptid und es konnte eine tumorassoziierte, paraneoplastische Hypoglykämie infolge IGF-2-Sekretion gesichert werden, mit Nachweis eines erhöhten Glukoseverbrauchs in der Skelettmuskulatur (18F‑FDG-PET-CT).

Mycobacterium genavense infection, a rare nontuberculous mycobacteria infection, occurs in heavily immunocompromised patients (i.e., those with advanced HIV disease, genetic disorders, or acquired immunologic disorders and those undergoing immunosuppressive therapy). We report a case of disseminated M. genavense infection preceding Hodgkin lymphoma in a patient without obvious risk factors for this infection.

The purpose of this study was to assess the diagnostic accuracy of computed tomography pulmonary angiogram (CTPA) including dual energy and reconstruction of iodine maps for diagnosing CTEPH. This method for detecting embolisms and perfusion failures was compared with V/Q-SPECT. An additional purpose was to compare the applied radiation dose of both techniques. 71 patients (49 women) with suspected CTEPH were included in this prospective study. The patients received a V/Q-SPECT and a dual-energy CTPA. Iodine maps were reconstructed from the data set. CTPA and the iodine maps were read by an experienced radiologist unaware of the clinical information as well as the results of the V/Q-SPECT. Results were compared to the V/Q-SPECT. DLP and the applied amount of radionuclides (MAA, Technegas) were obtained for comparison of radiation dose. For the diagnosis of CTEPH, the sensitivity of DECT was 1.000, specificity 0.966, PPV 0.867 and NPV 1.000, respectively. There was not a considerable difference in the x-ray exposure between the DECT examination and the V/Q-SPECT (1.892 mSv vs. 1.911 mSv; p = 0.6115). Both examination modalities were highly consistent regarding the classification of pathological segments (1177/1278 segments, 92,09 %, κ = 0,5938). This study presents the DECT, in combination with reconstructed iodine maps, as a potential alternative to the current imaging technique of first choice, V/Q-SPECT. For creating future prospective diagnostic algorithms, the implementation of DECT screening with iodine maps should be considered.· DECT correctly identified all CTEPH patients.. · There is substantial agreement between DECT and V/Q-SPECT in the classification of pathological segments.. · There is no significant difference in radiation exposure during DECT examination and V/Q-SPECT examination.. · Reduced radiation dose does not negatively impact image quality..· Schüßler A, Richter M, Tello K et al. Evaluation der diagnostischen Genauigkeit und der Strahlendosis der Dual-Energy-Computertomografie (DECT) bei chronisch thromboembolischer pulmonaler Hypertonie (CTEPH). Fortschr Röntgenstr 2021; 193: 1318 - 1326.ZIEL: Ziel der Studie war es herauszufinden, wie exakt die diagnostische Genauigkeit der computertomografischen Pulmonalisangiografie (CTPA) unter Hinzunahme von Dual-Energy und Rekonstruktionen von Jodkarten bei der Diagnosestellung einer CTEPH ist. Zudem wurde die Übereinstimmung der CTPA mit der Ventilations-/Perfusionsszintigrafie (V/Q-SPECT) bei der Detektion von Embolien und Perfusionsausfällen untersucht. Ein weiteres Ziel war es, die applizierte Strahlenexposition beider Techniken miteinander zu vergleichen. 71 Patienten (49 Frauen) mit dem Verdacht auf eine CTEPH wurden in diese prospektive Studie eingeschlossen. Die Patienten erhielten eine V/Q-SPECT und eine Dual-Energy-CTPA und hieraus rekonstruierte Jodkarten. Die Analyse der CTPA und der Jodkarten erfolgte durch einen erfahrenen Radiologen, verblindet zu den klinischen Angaben und in Unkenntnis des V/Q-SPECT-Befundes. Die Ergebnisse wurden mit dem Befund der V/Q-SPECT verglichen. DLP und die applizierten Radionuklidmengen (MAA, Technegas) wurden zur Ermittlung der Strahlenexposition erfasst. Die DECT erzielte eine Sensitivität von 1,000, eine Spezifität von 0,966, einen PPV von 0,867 und einen NPV von 1,000. Zwischen den beiden Untersuchungsmodalitäten gab es, in Bezug auf die Strahlenexposition, nahezu keinen Unterschied (1,911 mSv vs. 1,892 mSv). Die Untersuchungsmodalitäten zeigten im Hinblick auf Perfusionsdefizite eine hohe Übereinstimmung (1177/1278 Segmente, 92,09 %; κ = 0,5938). Die DECT präsentierte sich, in Kombination mit den Jodkarten, als potenzielle Alternative zum gegenwärtigen bildgebenden Verfahren der ersten Wahl, der V/Q-SPECT. Bei der Erstellung zukünftiger diagnostischer CTEPH-Untersuchungsalgorithmen sollte die Implementierung der DECT erwogen werden. · Die DECT stufte alle CTEPH-Patienten als richtig positiv ein.. · Hohe Übereinstimmung zwischen DECT und V/Q-SPECT bei der Einteilung pathologischer Segmente.. · Strahlenexposition DECT-Untersuchung und V/Q SPECT kein signifikanter Unterschied.. · Trotz eingesparter Strahlendosis keine Einbußen der Bildqualität..· Schüßler A, Richter M, Tello K et al. Evaluation of Diagnostic Accuracy and X-Ray Exposure of Dual-Energy Computed Tomography (DECT) in the Course of Chronic Thromboembolic Pulmonary Hypertension (CTEPH). Fortschr Röntgenstr 2021; 193: 1318 – 1326.

BACKGROUND: In the EuroNet Pediatric Hodgkin Lymphoma (EuroNet-PHL) trials, decision on Waldeyer's ring (WR) involvement is usually based on clinical assessment, that is, physical examination and/or nasopharyngoscopy. However, clinical assessment only evaluates mucosal surface and is prone to interobserver variability. Modern cross-sectional imaging technology may provide valuable information beyond mucosal surface, which may lead to a more accurate WR staging. PATIENTS, MATERIALS, AND METHODS: The EuroNet-PHL-C1 trial recruited 2102 patients, of which 1752 underwent central review including reference reading of their cross-sectional imaging data. In 14 of 1752 patients, WR was considered involved according to clinical assessment. In these 14 patients, the WR was re-assessed by applying an imaging-based algorithm considering information from 18 F-fluorodeoxyglucose positron emission tomography, contrast-enhanced computed tomography, and/or magnetic resonance imaging. For verification purposes, the imaging-based algorithm was applied to 100 consecutive patients whose WR was inconspicuous on clinical assessment. RESULTS: The imaging-based algorithm confirmed WR involvement only in four of the 14 patients. Of the remaining 10 patients, four had retropharyngeal lymph node involvement and six an inconspicuous WR. Applying the imaging-based algorithm to 100 consecutive patients with physiological appearance of their WR on clinical assessment, absence of WR involvement could be confirmed in 99. However, suspicion of WR involvement was raised in one patient. CONCLUSIONS: The imaging-based algorithm was feasible and easily applicable at initial staging of young patients with Hodgkin lymphoma. It increased the accuracy of WR staging, which may contribute to a more individualized treatment in the future. ispartof: PEDIATRIC BLOOD & CANCER vol:68 issue:4 ispartof: location:United States status: published

Objectives 18 F-FDG PET/CT is widely used in clinical oncology. Human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) represents an emerging disease that differs from HPV-negative OPSCC in clinical behavior and tumour biology. In these tumours, HPV-oncogenes might lead to distinct alterations in metabolic pathways. Therefore, we compared metabolic parameters using 18 F-FDG PET/CT in HPV-positive and HPV-negative OPSCC in relation to histopathological findings. Materials Eighty-six patients with OPSCC received pre-therapeutic 18 F-FDG PET/CT. Standardised uptake volume (SUV), total lesion glycolysis (TLG) and metabolic tumour volume (MTV) were analysed for the primary tumour. SUVmax was determined for neck lymph nodes. HPV-status was determined; overall survival rates (OS) were estimated. Results 32/86 patients (37.2%) had HPV-related OPSCC. Overall, PET-parameters in primary tumours of both groups did not differ significantly. Comparing early with locally advanced primary tumours, there was a significant increase in 18 F-FDG uptake in HPV-negative patients (p 18 F-FDG uptake between primary and respective positive nodes in HPV-related primary OPSCC (p = 0.001). SUV-max and –mean values did not correlate with OS in HPV-related OPSCC. Conclusion The intraindividual homogeneity of 18 F-FDG uptake in HPV-related OPSCC could reflect the more homogenously, HPV-triggered carcinogenesis compared to the mutation-driven carcinogenesis in the HPV-negative OPSCC with heterogenic 18 F-FDG uptake.

A substantial part of the oncologic surgical procedure in non-small cell lung cancer (NSCLC) is systematic lymph node dissection (sLND). However, controversies still exist regarding the quality of minimally invasive (video-assisted thoracoscopic surgery, VATS) sLND in oncologic resections. The rate of stage migration from clinical to pathological N-status has been discussed as one parameter for the quality of sLND. Between March 2011 and May 2014, seventy-seven patients (62 male, 15 female) were scheduled for anatomical lung resection and sLND by VATS for clinical stage I (UICC 7th edition) NSCLC. Preoperative staging was performed by [18F]-fluorodesoxyglucose positron emission tomography with computed tomography (FDG-PET/CT). Patient data were retrospectively analyzed with regard to divergence in clinical and pathological N-factor. FDG-PET/CTs of patients with lymph node (LN) upstaging after VATS resections were blindly re-evaluated by an experienced radiologist. In FDG-PET/CT, preoperative tumor stage was cT1N0M0 in 41 (53.2 %) and cT2aN0M0 in 28 (36.4 %) patients. In six (7.8 %) patients the primary tumor was not suspicious for malignancy, and in two (2.6 %) patients the tumor was not evaluable due to prior wedge resection before FDG-PET/CT. Thirty-one (40.3 %) left-sided and 46 (59.7 %) right-sided pulmonary resections with sLND were performed; 19.57 ± 0.99 LNs were dissected. In 13 (16.9 %) patients a nodal stage migration from preoperative clinical to postoperative pathological N-stage was observed [cN0 to pN1 in 9 (11.7 %) and cN0 to pN2 in 4 (5.2 %) cases]. In correlation to the clinical T-factor, the rate of N-factor upstaging for cT1 was 12.2 % and for cT2a was 28.6 %, respectively. In 50 % of the patients with postoperative nodal staging shift, no changes were observed on re-evaluation of the preoperative FDG-PET/CT. In this series of clinical stage I NSCLC patients, the rate of nodal stage migration after sLND by VATS is higher than previously reported. Prospective randomized controlled trials are needed to prove the oncologic quality of a sLND by VATS versus standard open approach.

Eighty-six patients with OPSCC received pre-therapeutic32/86 patients (37.2%) had HPV-related OPSCC. Overall, PET-parameters in primary tumours of both groups did not differ significantly. Comparing early with locally advanced primary tumours, there was a significant increase inThe intraindividual homogeneity of 18F-FDG uptake in HPV-related OPSCC could reflect the more homogenously, HPV-triggered carcinogenesis compared to the mutation-driven carcinogenesis in the HPV-negative OPSCC with heterogenic

Objective To evaluate the effect of dose rate on the therapeutic success of radioiodine therapy (RIT) by retrospective analysis of two groups of patients with different dose rates during RIT. Methods The average dose rateuntil deposition of 50% of the total radiation dose achieved (the DL 5 0 value) was calculated. Ninety patients with autonomy of the thyroid receiving radiation doses between 300 and 400 Gy were separated in groups with high DL 5 0 values (the DL50 H group) and low DL 5 0 values (the DL50L group). Before and 4 months after RIT free triiodothyronine (FT3), free thyroxine (FT4), basal thyroid stimulating hormone (TSHB), stimulated TSH (TSHS), thyroidal technetium uptake (TcTU), and the existence of focal abnormalities in thyroid scintigraphy were evaluated. Results The DL50 H and DL50L groups showed no differences before RIT in the parameters assessed as well as in total achieved dose and autonomous thyroid volume. After therapy a significant difference was found in TSHB with higher values in DL50 H (1.89 ′ 1.49 vs. 1.31 ′ 1.48mU l - 1 , P

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This prospective, observational study of a cohort of thyroid cancer patients in Germany focusses on the "real-world" practice in the management of thyroid cancer patients. This report includes data from 2376 patients with primary differentiated thyroid carcinoma first diagnosed in the year 1996. The study reveals considerable differences in actual practice concerning surgery and radioiodine treatment. The results indicate that consensus is lacking with respect to the multimodality treatment approach for differentiated thyroid carcinoma. Our analysis represents the most current and comprehensive national assessment of presenting patient characteristics, diagnostic tests, treatment and complications for thyroid cancer.

Summary Aim: Because of a similar tracer accumulation, we assumed to get the same information about synovitis in arthritic joint disease with HIG scintigraphy and bloodpool scintigraphy using HDP. Therefore, we compared retrospectively 23 patients. Methods: In HIG scintigraphy, synovitis was diagnosed according to increasing activity from early to late image. In bloodpool scintigraphy according to an increased activity in comparison to the surrounding tissues. Results: In 694 joints comparison of both scintigraphic modalities was possible, resulting in a 2 × 2 kappa coefficient of 0.93 or 0.97 by using late-phase bone scintigraphy as an anatomical marker. For intra- and interobserver agreement, 2 × 2 kappa coefficients of 0.93 and 0.88 in HIG scintigraphy, respectively 0.96 and 0.90 in blood-pool scintigraphy were calculated. Conclusion: This study shows an excellent agreement in the visualization of synovitis by HIG and bloodpool scintigraphy. Because of its higher objectivity and lower cost, investigation of synovitis should be performed by bloodpool scintigraphy.

Dynamic renal scintigraphy (DRS) during controlled diuresis is the method of choice to diagnose the functional relevance of urinary tract obstruction in children with sonographically demonstrated hydronephrosis. However, there are no commonly accepted scintigraphic criteria for surgical intervention. On the basis of our findings, we propose four stages of washout (WO) of tracer following diuresis: in stage I, WO50%, neither further diagnosis nor intervention is necessary; in stage II, 50%/=WO/=12%, repetition of DRS is advised within 3-4 months; and in stage III, 12%WO/=5%, DRS should be repeated within 1-2 months. Only in stage IV, WO5%, should surgery be done immediately. This procedure reduces surgical interventions by 50% without increasing the risk of residual renal damage.

Fragestellung: Die dynamische Radionuklidnephrographie (99mTc-MAG3) stellt die wichtigste Untersuchungsmethode zur Klarung einer oberen Harnwegobstruktion dar. Untersucht wurde, ob die Methode, unter standardisierten Bedingungen (i.v.-Hydratisierung, Furosemidgabe und Sedierung) angewandt, eine strenge Operationsindikation erlaubt und sich als Verlaufsbeobachtung eignet. Dabei wurde insbesondere gepruft, ob bei minimalem Abfall der Traceraktivitat (10–25%) und guter Nierenfunktion ein konservatives Vorgehen moglich ist. Methode: Bei 55 Kindern mit ausgepragter Hydronephrose (>12 mm Dilatation des Nierenbeckens und der Kelche in der Sonographie) wurde eine Radionuklidnephrographie veranlast. Die Untersuchung erfolgte nach i.v. 4stundiger Hydratisierung mit 30–40 ml/kg KG. Ergebnisse: Bei 24 Kindern war ein Abflus von mehr als 50% und bei 13 von mehr als 25% der Aktivitat nachweisbar. Bei 3 Patienten war nur eine geringe Ausscheidung (10–25%) zu dokumentieren, die sich bei einer Kontrollradionuklidnephrographie nach 8 Wochen bei allen Patienten eindrucksvoll besserte. Von 15 Kindern mit fehlendem Tracerabfall wurden 6 Monate nach erfolgreicher Korrektur der Ureterabgangsstenose bei 13 Kindern mehr als 50% der Traceraktivitat ausgeschieden, bei den beiden anderen mehr als 30%. Schlusfolgerungen: Die standardisierte Radionuklidnephrographie ermoglicht eine wichtige funktionelle Aussage uber die urodynamische Relevanz der Harntransportstorung. Ein geringer Auswascheffekt (10–25%) erlaubt bei Sauglingen mit normaler Nierenfunktion primar ein konservatives Vorgehen, und ein Tracerabfall

DIE VERESTERUNG und die Esterhydrolyse sind seit langem bekannte Standardschulversuche, die die langsame Einstellung eines Gleichgewichtszustands von beiden Seiten anschaulich zeigen, insbesondere wenn sie computerunterstutzt ausgefuhrt werden. Vielfach wird die Geschwindigkeit der Gleichgewichtseinstellung auch kinetisch ausgewertet. Hier soll beschrieben werden, das sich am Estergleichgewicht. R-COO-R′ + H2O R-COOH + R′-OH nicht nur zeigen last Gleichgewichte stellen sich von beiden Seiten ein, sondern das daran fast alle schulrelevanten Aussagen uber chemische Gleichgewichte und Katalyse erarbeitbar sind:— Die Gleichgewichtskonstante ist sowohl experimentell bestimmbar als auch aus thermodynamischen Daten berechenbar. Kaum genutzt wird im Unterricht, das auch exemplarische Betrachtungen der Katalyse am Estergleichgewicht moglich sind: — Die Geschwindigkeit der Reaktion mit und ohne Katalysator kann verglichen werden. — Der Reaktionsweg kann am gegebenen Energieprofil diskutiert werden. Es soll aber auch auf die Grenzen, jenseits derer keine Umsetzungen der Stoffe mehr feststellbar sind oder Aussagen und vereinfachende Annahmen nicht mehr zutreffen, hingewiesen werden.— Die Verringerung der Aktivierungsenergie durch einen Katalysator ist experimentell bestimmbar. Nur die protonenkatalysierte Veresterung und Esterhydrolyse fuhren bei einem pH-Wert < 5 zu dem oben genannten mesbaren Gleichgewicht mit einem K-Wert nahe 1. Die alkalische Verseifung R-COO-R′ + OH R-COO + R′-OH fuhrt zu anderen Produkten, hat ein K > 1 und ist als Konkurrenzreaktion unerwunscht. Sie soll hier nicht untersucht werden; es mus aber berucksichtigt werden, das sie oberhalb pH 5 uberwiegt [1].

The aim of this study was the scintigraphic visualization of points of segmental irritation resulting from reversible articular dysfunction. Because of increased cellular metabolism as a result of muscular hypertonus, scintigraphic visualization of these points should be possible with 99mTc-MIBI. This radiopharmaceutical is localized in cells, depending on the metabolism.

Immunoscintigraphy with the use of the antigranulocyte antibody BW 250/183 is a reliable method for detecting infection, especially in septic loosening of hip prostheses, for which purpose quantitative interpretation of the time-activity course is employed. Therefore, we retrospectively studied whether similar results could be achieved in knee prostheses. We verified 28 scintigraphic examinations in 26 patients by histology. Scintigraphy was performed during an early (4–6 h post injection) and a late phase (23–25 h post injection). Infection was diagnosed when activity around the knee prosthesis increased by more than 10% compared with bone marrow. We found a sensitivity and a negative predictive value of 100%, a specificity of 80%, a positive predictive value of 81% and an accuracy of 89%. Specificity and accuracy are lower than in the evaluation of hip prostheses; however, in comparison to other scintigraphic modalities, scintigraphy with the antigranulocyte antibody BW 250/183 is superior in excluding infection and has better specificity and accuracy. Therefore, as in the case of hip prostheses, the described methodology appears to be the scintigraphic modality of choice for knee prostheses.

A 29-year-old woman was examined because of malnutrition and recurrent diarrhea. Her serum glutamate oxaloacetate transaminase and serum gamma glutanyl transferase (SGGT) levels were found to be elevated. The patient denied alcohol abuse, blood transfusion, and foreign travel, and she had never used oral contraceptives. Findings of ultrasonography of the liver were normal. A computed tomographic examination suggested focal nodular hyperplasia (FNH), although adenoma could not be excluded. Hepatobiliary imaging was normal and did not manifest the three typical signs of FNH: hypervascularization, increased tumor uptake, and trapping in later images. Repeated scintigraphy using a modified SPECT technique clearly showed FNH.

Familial amyloidotic polyneuropathy (FAP) caused by amyloidogenic transthyretin (ATTR) mutations is the most common form of hereditary amyloidosis. We investigated the diagnostic value of the bone scanning agent technetium-99m 3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD) in this disease. Eight patients (four males, four females; age 54.4+/-8.3 years, range 43-67 years) with ATTR-FAP proven by immunohistochemistry and molecular analysis and a control group comprising ten oncological out-patients (five males, five females; age 53.4+/-8.5 years, range 34-66 years) without evidence of bony metastases were studied using 99mTc-DPD. Whole body tracer retention was 80.1%+/-10.3% (range 65.1%-94.8%) in FAP patients and 55.7%+/-8.1% (range 40.2%-66.7%) in controls at 3 h p.i. (P

Amyloidosis occurs when certain soluble proteins are transformed into amyloid fibrils in the extracellular space. Most common are the light-chain amyloidoses; less common is the AA-amyloidosis, which follows chronic inflammatory diseases, and the amyloidoses of transthyretin (TTR) origin. We report on a women of Italian-German origin with the mutation TTR (Ser23Asn). Whole body scintigraphy using TC99m-DPD showed end stage hereditary amyloidosis caused by ATTR with predominant tracer retention in the myocardium. Myocardial biopsies revealed the presence of amyloid by Congo red staining. Further immunohistochemical analysis showed ATTR amyloidosis. DNA sequencing revealed a point mutation of the transthyretin gene leading to a single amino acid substitution. The only effective treatment in patients with manifest cardiac ATTR amyloidosis is combined heart and liver transplantation. Our patient was placed on a list for this procedure, but unfortunately she died during the standby procedure due to urosepsis.

Nach Ausschluss einer Protheseninfektion ermoglicht die Skelettszintigraphie den Nachweis einer aseptischen Knieprothesenlockerung und kann so die Therapieplanung wesentlich beeinflussen. Allerdings fanden sich bislang in Studien kontroverse Ergebnisse bezuglich der Wertigkeit der Skelettszintigraphie. Dies ist moglicherweise auf die bisher verwendeten, rein klinischen Daten als Goldstandard zuruckzufuhren. Ziel dieser Studie war, den Nutzen der quantitativen Skelettszintigraphie unter Verwendung des intraoperativen Ergebnisses der Wechseloperation als Goldstandard zu untersuchen. Methodik: Retrospektiv war eine Auswertung der tibialen Prothesenkomponente bei 31 zementierten Knieprothesen moglich. Eine Infektion war intraoperativ mikrobiologisch oder histologisch ausgeschlossen. Zur Quantifizierung der Skelettszintigraphie wurde der Knochenstoffwechsel des medialen und lateralen Tibiakopfes mit dem Knochenstoffwechsel des kontralateralen Femurs mittels ROI-Technik verglichen. Ergebnisse: Fur die Diagnose einer Lockerung wurde fur den maximalen Quotienten der beiden Tibia-ROIs zum Femur ein Grenzwert von 5,0 und fur den Unterschied der Quotienten beider Tibia- ROIs von 18% gefunden. Unter Verwendung dieser Grenzwerte ergaben sich im untersuchten Kollektiv fur Sensitivitat, Spezifitat, negativen und positiven Vorhersagewert sowie die Genauigkeit Werte von 0,9, 1, 0,85, 1 und 0,94. Um eine Sensitivitat von 1,0 zu erreichen, wurde fur den maximalen Quotienten ein unterer Grenzwert von 3,3 gefunden. Schlussfolgerung: Die quantitative Skelettszintigraphie ermoglicht eine gute Trennung von fester und gelockerter Knieendoprothese, wenn die Grenzen der Aktivitatsquotienten mit den intraoperativen Ergebnissen als Goldstandard bestimmt werden.