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Zusammenfassung Einleitung Die Radiosynoviorthese (RSO) ist eine seit Jahrzehnten eingeführte nuklearmedizinische Lokalbehandlung entzündlicher Gelenkerkrankungen, die überwiegend ambulant in nichtuniversitären Einrichtungen durchgeführt wird. Trotz umfangreicher Erfahrungen in einzelnen Institutionen gibt es kaum fassbare oder vergleichbare Daten über die Durchführung und/oder Erfolge dieser Therapie. Fragestellung Ziel der Untersuchung war es, möglichst belastbare Daten zur RSO in Deutschland zu erhalten. Materialien und Methoden Es wurde ein webbasierter Fragebogen eingesetzt. In ihm wurden demografische Daten, Ausbildung/Erlernen der RSO, prätherapeutischer Diagnostik, klinischer Verfahren und Follow-up abgefragt. Die Umfrage stand 28 Tage lang zur Verfügung und wurde am 30. November 2020 geschlossen. Ergebnisse Insgesamt 78 Fachärzte für Nuklearmedizin beantworteten den Fragebogen, was einer Rücklaufquote von 23 % entspricht. Neben den hier erstmals dokumentierten Unterschieden und Übereinstimmungen bei prätherapeutischer Diagnostik, Durchführung und Nachsorge der RSO zeigt sich, dass weniger als 70 Fachärzte in Deutschland mehr als 75 % aller RSO-Behandlungen durchführen, und dass diese meist älter als 50 Jahre sind. Hieraus ergibt sich die Notwendigkeit einer verstärkten Nachwuchsförderung, um dieses hilfreiche Therapieverfahren auch in Zukunft den Patienten anbieten zu können. Schlussfolgerungen Zum Erreichen dieser Ziele ist ein Zusammenschluss von RSO-Experten sinnvoll, durch die unter anderem ein Ausbildungs-Curriculum RSO erarbeitet wird sowie Fortbildungen und Hospitationsmöglichkeiten organisiert werden. Darüber hinaus wären auch ambulant-stationäre Kooperationsmodelle im Rahmen der Facharztausbildung denkbar.

BACKGROUND Patients with stage IIC malignant melanoma are recommended to undergo cross-sectional imaging for initial staging. PET/CT is superior to other methods regarding its diagnostic accuracy of the tumor spread in stage III. So far there is no meaningful data on the nationwide availability, usage and cost recovery of this imaging technique. PATIENTS AND METHODS Questionnaires on the healthcare situation in 2018 were sent to all German dermatology clinics and PET/CT centers in March and April 2019. RESULTS 61.2 % of the dermatology clinics (71/115) and 48.2 % of the PET/CT centers (77/160) took part in the survey. A total of 22,645 patients with malignant melanoma were seen in these clinics in 2018. 16.8 % of the patients with stage IIC melanoma received a PET/CT for primary staging. The costs of this examination were covered for all statutory and privately insured patients in 40 % and 68 % of dermatology clinics (20/50 and 34/50), respectively. 68.0 % (34/50) of all dermatology clinics reported relevant changes of treatment according to PET/CT findings. Long examination periods by the health insurance companies and the time required to submit the application were the most common reasons for dermatology clinics to reject a request for PET/CT. Relevant incidental findings were reported in 90.2 % (47/51) of all PET/CT centers. CONCLUSIONS There are clear differences in the nationwide availability and cost coverage of PET/CT in primary staging for stage IIC melanoma. For these reasons, a two-tiered healthcare system may be assumed.

SummaryAim: Radiosynoviorthesis using intraarticular injection of beta-emitting radiocolloids is increasingly performed throughout Europe in patients with inflammatory joint disease. It is a cost-effective and safe treatment, local complications are very rare with only eight cases mentioned in the literature so far. No recommendations for therapy of tissue necrosis, infection or thromboembolism after radiosynoviorthesis are available. Methods: Using a standardized questionary, 260 nuclear medicine physicians and 20 medical liability insurances were asked for the kind and frequency of complications after radiosynoviorthesis between 1998 and 2003. The survey was terminated after nine months with a response of only 25.7%. Results: A total of 53 severe complications were documented (28 necroses, 12 thromboses, 13 joint infections). Eight other complications were seen but difficult to correlate directly with radiosynoviorthesis. Tissue necroses from yttrium-90 were successfully treated by surgical excision and closure of the defect. Rhenium-186-induced ulcers healed by hyperbaric oxygen therapy in two cases. Lesions from erbium-169 showed restoration by conservative treatment. Thromboembolic events happened after radiosynoviorthesis in joints of the lower limb only, mostly treated by conventional anticoagulation. Intraarticular infections showed restoration after intraarticular antibiotics in the majority of cases. Conclusion: Severe complications after radiosynoviorthesis seem to be rare. However, because of the low return rate, a reliable frequency cannot be calculated. Nevertheless, important advices regarding treatment concepts can be taken from our data.

The aim of the study was to assess the diagnostic value of the sentinel node method in patients suffering from squamous cell carcinoma of the upper aerodigestive tract. In 50 patients with oral, pharyngeal or laryngeal carcinomas staged N0 up to 50 MBq technetium-99m colloid were injected peritumorally. Sentinel nodes were localised using a gamma-probe in the setting of an elective neck dissection. Pathological findings of sentinel nodes and corresponding neck specimens were compared. In 46 patients sentinel nodes were detected. Of these 34 patients were free of metastatic disease in the sentinel nodes and in the neck specimens. In 12 patients clinically occult metastases were found in the sentinel nodes. Three metastases were detected only after additional sectioning of the sentinel nodes. In four patients, a sentinel lymph node could not be localised. Our results support the sentinel node concept in head and neck cancer and a definition of the sentinel nodes as the three nodes with the highest activity. Careful clinical staging of the neck and thorough pathological evaluation of the sentinel nodes are necessary to avoid false-negative results.

Background: Homocysteine metabolism may be impaired in chronic liver disease, possibly contributing to fibrogenesis and disease complications. Objective: The goal was to investigate the prevalence and determinants of basal and postprandial hyperhomocysteinemia in patients with chronic liver disease and after orthotopic liver transplantation (OLT). Design: This was a cross-sectional study of 323 patients with chronic liver disease (93 with hepatitis, 8 with fatty liver, 168 with cirrhosis, and 54 after OLT) and 25 healthy control subjects. Portohepatovenous gradients of total homocysteine (tHcy) and methionine and postload methionine and tHcy kinetics before and after 10 d of supplementation with folate plus vitamin B-6 were investigated in subgroups. Results: Basal hyperhomocysteinemia was observed in all patient groups (34% of patients with hepatitis, 50% with fatty liver, 54% with cirrhosis, and 52% after OLT). It was more frequently seen in patients with elevated plasma creatinine concentrations and at advanced stages of liver disease. Mean plasma folate was normal in patients with liver disease, but vitamin B-12 was elevated in cirrhosis and vitamin B-6 was low after OLT. There were significant negative associations between tHcy and folic acid or vitamin B-12 concentrations in control subjects and in patients with hepatitis and after OLT. No systematic association between portohepatovenous differences in tHcy and methionine concentrations was found. Cirrhosis was accompanied by impaired methionine clearance. After vitamin supplementation, the area under the tHcy curve improved in cirrhosis at nearly unchanged basal tHcy concentrations. Conclusions: Basal hyperhomocysteinemia is seen in � 50% of patients with cirrhosis and after OLT. Basal tHcy concentrations do not change significantly after supplementation with folate and vitamin B-6, but postprandial Hcy metabolism improves. Am J Clin Nutr 2003;77:1269‐77.

The pathophysiology of the reversible neurological manifestation in eclamptic women remains unclear. We report on 2 women with eclampsia who were repetitively examined by (1) transcranial Doppler (TCD), (2) magnetic resonance imaging (MRI) including T1- and T2-weighted images, fluid attenuated inversion recovery sequence, dynamic susceptibility-weighted perfusion imaging and magnetic resonance angiography (MRA), and (3) 18fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET). In both cases repetitive TCD revealed no signs of vasospasm; the same was true for MRA. MRI perfusion imaging showed completely homogenous cerebral blood flow in both cases. In the initial phase T2-weighted images revealed hyperintensities in both patients (predominantly bilateral frontal and parietal in 1 and in the temporo-occipital subcortex and the basal ganglia in the other). FDG-PET showed inhomogeneous glucose metabolism (GM) in both patients. Primary increased glucose utilization in the hyperintense T2-weighted areas as well as an attenuated GM parieto-occipital were observed in the 1st case; a high GM was found bilaterally in the basal ganglia and an attenuated one in the occipital cortex in the 2nd. In both cases MRI, and FDG-PET normalized within 3 weeks. These case reports document an altered cerebral GM in the presence of homogenous perfusion in eclamptic women. The high GM may be explained by a decoupling of cerebral perfusion and GM, possibly indicating an increased neuronal activity. The attenuation of the GM is most probably due to a deafferentation of cortical neurons.

Adverse effects of high vitamin B6 intake include peripheral neuropathy. Recent studies focussing on the reduction of plasma homocysteine as a risk factor for vascular disease showed that vitamin B6 reduces plasma folate levels. The significance of this finding is unclear. We therefore analyzed plasma folate and basal homocysteine levels as well as the response to an oral methionine loading test in 8 healthy individuals before and after a controlled supplementation with oral doses of 25 mg pyridoxine for 10 days. Plasma pyridoxal phosphate increased from 40.6 ± 13.6 to 426.8 ± 200.3 nmol/l (p < 0.001), whereas plasma folate decreased from 6.3 ± 1.6 to 4.6 ±1.5 ng/ml (p < 0.01), respectively. Plasma vitamin B12 and basal homocysteine levels remained unchanged (234.0 ± 27.8 vs. 217.1 ± 50.4 pg/ml and 10.9 ± 4.8 vs. 10.1 ± 3.6 µmol/l). There was no significant effect of vitamin B6 supplementation on the area under methionine and homocysteine concentration versus time curve. Significant correlations were found between pre- and post-supplement levels of folate as well as PLP levels (r = 0.73, p < 0.05; r = 0.75, p < 0.05). These data suggest that a dose of 25 mg vitamin B6 supplemented for 10 days reduces plasma folate but did not affect basal and postprandial homocysteine levels suggesting (1) a normal cellular availability of folate or (2) a compensation of impaired homocysteine remethylation by increased transsulfuration.

Summary Aim of this study was to prove the clinical value of nuclear medicine procedures to detect the sentinel lymph node (SLN) for SLN biopsy. Methods: In 132 patients with breast cancer we performed lymph scintigraphy of the breast as well as both pre- and intraoperative gamma probe measurements correlating the results with the findings of histopathology. Results: SLN were detectable in 62 of 110 patients according to a sensitivity of 56% when scanning was performed only at 1-2 h p.i. while the sensitivity increased to 86% (19 of 22 pts.) if sequential images were acquired up to 2 h p.i. One or more SLN were identified by a handheld gamma probe transcutaneously prior to surgery in 96% (113 of 118 pts.) of the patients who showed up with no clinically suspected lymph node metastases. Intraoperatively, in additionally 2 patients the SLN could be found resulting in a sensitivity of 97% (115 of 118 pts.). In only 3 patients with clinically no tumor spread to axillary lymph nodes no SLN could be identified by the probe. Skip lesions, i.e. lymph node metastases in patients with tumorfree SLN, occured in 2 cases: due to SLN biopsy in these patients lymph node staging was false negative compared to conventional staging by means of axillary lymph node dissection. Conclusion: The results demonstrate a high preoperative detection rate of SLN in patients with breast cancer using lymph scintigraphy and gamma probe measurements. Thus, nuclear medicine is capable of providing the basic requirements for SLN biopsy in the daily routine.

Summary Aim of this study was to assess the radiation exposure for the personnel in the operating room and in the pathology laboratories caused by radioguided SLN localization in breast cancer. Methods: In 15 patients dose rates were measured at various distances from the breast and tumor specimens during operation and pathological work-up at 3-5 h after peritumoral injection of 30 MBq Tc-99m-nanocolloid. Results: The dose rates were 84.1 ± 46.4 μGy/h at 2.5 cm, 3.57 ± 2.14 μGy/h at 30 cm, 0.87 ± 0.51 μGy/h at 100 cm, and 0.40 ± 0.20 μGy/h at 150 cm in the operating room and 44.4 ± 27.8 μGy/h at 2.5 cm, and 1.66 ± 1.34 μGy/h at 30 cm in the pathology laboratories. From these data the radiation exposure was calculated for 250 operations per year assuming a mean exposure time of 30 min for the surgical team members and of 10 min for the pathology staff. Under these conditions the finger dose is 10.5 mGy for the surgeon, and 5.55 mGy for the pathologist. The wholebody doses are 0.45 mSv, 0.11 mSv, 0.05 mSv, and 0.21 mSv for the surgeon, the operating room nurse, the anesthetist, and the pathologist, respectively. Conclusion: Since the radiation risk to staff members is low, a classification of the personnel in the operating room and in the pathology laboratories as occupational radiation exposed workers is not necessary.

During the normal operation of a land based gas turbine attack will occur of the gas washed surfaces of the rotating and stationary blades in the turbine hot section. This attack and its intensity can be variable depending on the blades position in the turbine hot section. This attack will progressively degrade these gas washed surfaces even if these surfaces have been previously coated with a protective layer. During the service period of the turbine, it will be necessary to refurbish the blades from the hotter section of the turbine. One of the refurbishment steps will be to provide the blades with a suitable replacement coating to afford protection until the next service period. Conventional refurbishment techniques used to clean the blade surface rely on abrasive cleaning and/or chemical pickling. These processes may be capable of removing superficial oxidation and any residual coating but are not able to consistently remove the substrate material that has suffered from corrosive attack. It is important that this attacked substrate layer is removed completely otherwise any residual corrosion products, particularly the presence of deeply penetrated sulphides in grain boundaries, could significantly reduce the life of any subsequent coating. The technique described in this Paper essentially activates the surface layer of the substrate that is corroded, thus rendering it more easily removed by chemical and physical means. It is possible by this method to remove up to 400 microns of the substrate material and provided that all the corrosion products are contained within this zone, it is demonstrated how this produces a clean unattacked surface that is necessary for any subsequent welding, brazing or recoating operation.

OBJECTIVE It is the aim of this study to compare the performance of 99mTc-d,l-hexamethylpropyleneamine oxime (HMPAO) SPECT with that of [18F]fluorodeoxyglucose (FDG) PET in detecting striatal dysfunction as it occurs in Huntington disease (HD). MATERIALS AND METHODS For the determination of regional cerebral glucose consumption, the PET camera PC-4096 was used; the cerebral uptake of HMPAO was measured using the three-head SPECT camera TRIAD. Eight patients with manifest HD, seven subjects at risk for HD, and nine normal individuals were included in the study. In both modalities data evaluation was performed using caudate-to-whole-slice (C/S) ratios. The patients' data were compared to 95% confidence intervals determined in the nine controls. RESULTS The PET and SPECT C/S values correlated significantly (n = 24; r = 0.87; p < 0.0001). The C/S values were significantly reduced in PET in all eight and in SPECT in seven of the eight HD patients studied. Five of the seven at-risk subjects had normal C/S values in PET and SPECT, one showed reduced C/S values in both diagnostic methods, and the remaining at-risk individual showed a reduced C/S value in PET only. Thus, concordant results between PET and SPECT were obtained in seven of eight patients and six of seven at-risk subjects studied, corresponding to an 87% accuracy of SPECT in the detection of striatal dysfunction as compared to the "gold standard" PET. CONCLUSION With use of a multidetector camera, HMPAO-SPECT comes near the performance of FDG-PET in the diagnosis of striatal dysfunction as it occurs in HD.

Tumor-induced osteomalacia is a rare syndrome characterized by urinary phosphate loss with hypophosphatemic osteomalacia. The proposed pathogenetic mechanism is paraneoplastic secretion of phosphaturic factors (so-called phosphatonins). We describe a 34-year-old male patient who presented with severe pain of the spine and ribs for at least 2 years. Bone scintigraphy using 99mTechnetium hydroxymethylene diphosphonate (99mTc HDP) showed multiple lesions suggesting metastatic disease. Bone biopsy however revealed osteomalacia. The patient had subnormal plasma phosphate levels (0.42 mmol/L; normal range, 0.87–1.45) and markedly increased phosphate clearance (82.8 mL/min; normal range, 5.4–16.2). The patient was treated with phosphate supplementation (up to 5 g daily) along with calcium (1000 mg daily) and calcitriol (1.5 μg daily). Although this therapy did not correct hypophosphatemia, it resulted in complete relief of pain within several months. 111In pentetreotide scintigraphy showed a tiny lesion of 1-cm diameter, which could be localized to the left femoral neck in close vicinity to the greater trochanter by MRI and image fusion analysis. This lesion had not been visualized by Tc-99m HDP bone scintigraphy. Intraoperatively, use of a hand-held gamma probe after administration of 111Indium pentetreotide (111In pentetreotide) clearly identified the tumor, which was completely removed and was shown to be a hemangiopericytoma. After removal of the tumor, phosphate metabolism normalized within 1 week without requirement of phosphate supplementation. Hypophosphatemic osteomalacia, although rare, raises an important differential diagnosis. An underlying tumor may be detected only by 111In pentetreotide scintigraphy. Preoperative labeling with 111In pentetreotide is a useful tool in detecting these tumors during surgery. This 34 year old man with osteomalacia had a small causative hemangiopericytoma detected in the 111indium pentetreotide scintography.

BACKGROUND A low metabolic rate may be inherited and predispose to obesity, whereas a higher metabolic rate in obesity may be acquired by obesity-associated cardiometabolic risk. OBJECTIVE We aimed to explain the interindividual variation in resting energy expenditure (REE) by assessing 1) the association between REE and body composition, thyroid hormones, and obesity-related cardiometabolic risk factors, and 2) the familial (genetic and environmental) contribution to REE. DESIGN REE and metabolic risk factors (ie, blood pressure and plasma insulin, glucose, and C-reactive protein concentrations) were assessed in 149 two- or three-generation families, including at least one overweight or obese member. Heritability of REE, respiratory quotient (RQ), thyroid hormones [thyrotropin (TSH), free triiodothyronine (FT3) and free thyroxine (FT4)], and body composition (fat-free mass and fat mass) were estimated by using variance components-based quantitative genetic models. RESULTS REE adjusted for body composition, sex, and age (REEadj) significantly correlated with systolic and diastolic blood pressure, plasma insulin and glucose concentrations, and the homeostasis model assessment (HOMA) (r = 0.14-0.31, P < 0.05). Thyroid hormones had a modest influence on REE variance only. Heritability was 0.30 +/- 0.07 for REEadj and 0.29 +/- 0.08 for REE after additional adjustment for thyroid hormones and metabolic risk. Furthermore, heritability was estimated to be 0.22 +/- 0.08 for RQ, 0.37 +/- 0.08 for TSH, 0.68 +/- 0.06 for FT4, and 0.69 +/- 0.05 for FT3 (all significantly larger than zero). CONCLUSIONS Obesity-related cardiometabolic risk factors contribute to interindividual variation in REE, with hypertension and insulin resistance being associated with a higher REE. REE was moderately heritable, independent of body composition, sex, age, thyroid function, and cardiometabolic risk.

Previous studies compared carotid endarterectomy (CEA) and carotid artery stent placement (CAS) for treatment of symptomatic carotid artery stenosis. Whereas most previous studies showed both treatment modalities to be associated with a comparable risk of periprocedural cerebrovascular complications, these previous studies have shown significantly more microemboli and significantly more lesions in diffusion-weighted MR imaging after CAS compared to CEA. The clinical relevance of these differences remains unknown. We therefore compared the neuropsychological consequences of CAS and CEA and additionally measured the S100beta protein, a marker of cerebral damage.A total of 48 patients with symptomatic carotid artery stenosis greater than 70 % (according to ECST criteria) were enrolled and 45 patients participated in the follow-up. The patients were randomly assigned for CEA (24 patients) or CAS (21 patients). S100beta protein values were evaluated 2 hours before the procedure, as well as one and two hours thereafter. Patients were assessed before treatment, and again 6 and 30 days after treatment using a comprehensive neuropsychological test battery.Patients of the CAS and the CEA groups did not significantly differ in terms of age, gender, education, degree of carotid artery stenosis, cerebrovascular symptoms and vascular risk factors. Following previously used criteria, a cognitive change in patients was assumed to have occurred when there was a decline of more than one standard deviation in two or more tests assessing various cognitive domains. Six days and 30 days after the treatment both groups showed a comparable number of patients with cognitive changes compared to baseline. There were no significant differences in S100beta protein values.These results provide some reassurance that CAS is not associated with greater cognitive deterioration than CEA is.

This prospective multicenter study was performed to assess the reliability of sentinel lymph node (SLN) biopsy in breast cancer and to analyze factors potentially influencing success rates.In 21 departments, SLN biopsy and consecutive axillary lymph node dissection were performed in 814 breast cancer patients. The 80 surgeons involved were free in the choice of lymphography technique. The detection rate and the sensitivity, as well as the impact of lymphography technique, patient selection, technical procedure and learning curves, were evaluated.The blue dye technique was used in 137 patients, radiocolloid in 169 patients, and combined blue dye/radiocolloid in 508 patients. The identification rate for the sentinel node was 83.9% for the entire group and showed a significant dependence on the lymphography technique (blue dye, 71.6%; radiocolloid, 78.8%; combined blue dye and radiocolloid, 89.6%). The overall sensitivity in detecting lymph node metastases was 91.3%. Immunostaining for cytoceratine revealed micrometastases in 19 (5.1%) of 374 patients in whom H/E staining was negative. The combined subdermal/peritumoral injection of the colloid showed a significantly higher identification rate than subdermal or peritumoral injection alone (96.8%, 84.6%, 78.6%; p0.001). There was also a significant higher detection rate in cases of SLN biopsy performed prior to lumpectomy, compared to SLN biopsy following lumpectomy (94.7% versus 82.8%; p0.001). Furthermore, there was a close correlation between the number of performed examinations and the detection rate.SLN mapping predicts the axillary lymph node status accurately. Learning curves and several technical features influence the detection rate significantly. However, the false negative rate was independent of experience and injection technique.

Radiation synovectomy was developed for local treatment of rheumatoid arthritis. In this study, the long-term efficacy of radiation synovectomy was retrospectively evaluated in patients with osteoarthritis (activated arthrosis) of the digital joints using an algofunctional score.Fifty-three digital joints in 29 patients (mean age 64.8 years) were treated by intra-articular injection of 169Er citrate. All joints were painful despite pharmacotherapy and showed an elevated blood pool pattern in a pretherapeutic three-phase bone scan, indicative for local synovitis. The patients were asked to classify their complaints with respect to different daily manual activities on a ten-step pain scale from 1 (total disability) to 10 (lack of any impairment) prior to and after treatment, with a mean follow-up of 41 months. Local signs of osteoarthritis such as joint swelling or pain were additionally evaluated and were scored from progression of complaints to excellent improvement based on patient self-evaluation.All patients reported a pronounced improvement in their manual activities. The mean total score of 4.73+/-0.58 for all activities prior to treatment increased significantly to 6.79+/-0.47 after radiation synovectomy (p0.05). The best results were obtained in the thumb base joints, whereas distal interphalangeal joints were frequently resistant to therapy.Radiation synovectomy is highly effective in digital joint osteoarthritis with concomitant local synovitis.

The aim of this study is to investigate the myeloprotective effects of different amifostine regimens in rabbits undergoing high-dose treatment with 186Rhenium-(tin)1,1-hydroxyethylidene diphosphonate (186Re-HEDP) and to analyze the impact of amifostine on the bone uptake of the radiopharmaceutical. All animals were treated with 1000 MBq 186Re-HEDP. Group ReA received 500 mg amifostine prior to radionuclide therapy, group ReA3 received 3 x 200 mg amifostine 24 hours and 30 minutes prior to and 24 hours after radionuclide therapy. Group ReC served as control receiving no amifostine. Scintigrams were acquired to quantify the skeletal uptake of 186Re-HEDP, and platelet and leucocyte counts were measured. The mean decrease in platelets was 36% +/- 2%, 37% +/- 3%, and 61% +/- 5% for ReA, ReA3, and ReC, respectively. The decrease in ReC was significantly higher than in amifostine-treated animals with no difference between ReA and ReA3. For the leucocytes the mean decrease was 75% +/- 12%, 82% +/- 5%, and 73% +/- 4%, with no significant differences between the respective groups. Bone uptake of 186Re-HEDP was significantly reduced by 50% in ReA and ReA3 compared to ReC. Thus, the 3-day amifostine regimen had no advantage over the single dose regimen, with both regimens reducing bone uptake and yielding a platelet-protective but no leucoprotective effect.

Accurate knowledge of lymphatic drainage facilitates planning of surgery for patients with squamous cell carcinoma of the head and neck. The aim of this study was to evaluate the feasibility of a new injection technique for lymph node detection in patients with squamous cell carcinoma of the hypopharynx and larynx, in whom simple peritumoural injection is hampered by the tumour localisation. Computed tomography (CT)-guided lymphoscintigraphy was performed in a total of 13 patients with squamous cell carcinoma of the hypopharynx and larynx who could not be injected by simple visual inspection. In a first step, contrast medium-enhanced axial 5-mm-thick CT slices of the neck were obtained. After tumour localisation on these CT images, 1–2 ml contrast medium and, in the event of appropriate distribution, subsequently 50 MBq technetium-99m colloid were injected at one to three peritumoural sites under CT guidance. Peritumoural tracer distribution was controlled by thin-slice CT. Subsequently, planar scintigrams from anterior, right and left lateral views were obtained. In all patients, peritumoural colloid application was feasible, as shown on control CT scans. Post injection, neither severe nor minor complications were noted. The patients complained of only low pain sensations with an average score of 1.8 on a pain scale from 0 to 10. Lymphatic drainage was identified in nine of the 13 patients, with a total of 14 detected lymph nodes. In six patients, ipsilateral sentinel lymph nodes were visualised; bilateral sentinel lymph nodes were identified in one patient and contralateral lymphatic drainage was observed in two patients. CT-guided lymphoscintigraphy is a feasible and minimally invasive diagnostic tool for sentinel lymph node detection in patients with squamous cell carcinoma of the hypopharynx and the larynx. In contrast to endoscopic colloid injection under general anaesthesia, this technique seems to be a well-tolerated method for lymphatic mapping prior to surgical procedures.

Background: Homocysteine (Hcy), is an atherogenic and thrombogenic risk factor which has also been proposed to be involved in hepatic fibrinogenesis. Hcy metabolism, depends on the cofactors folate, vit. B12, and the vit. B6 vitamer pyridoxalphosphate (PLP). Metabolism of these vitamins is frequently disturbed in cirrhotics, but little is known about plasma Hcy levels in these patients. Methods: Plasma levels of Hcy, methionine, serine, cysteine, PLP, vit. B12 and folate, and standard clinical/biochemical parameters of liver disease were measured in 43 postabsorptive patients with biopsy proven cirrhosis of different origin. Results: 74% of the patients had elevated plasma Hcy levels defined as >13.4 µmol/l (mean+2SD of healthy age matched controls). Increased plasma Hcy concentrations were seen in alcoholic as well as in non-alcoholic cirrhosis. Excluding patients with impaired renal function (n=7), Hcy concentrations remained elevated in 69% of the patients. We found a high prevalence of pathological plasma vitamin concentrations of 33% for increased vit. B12 levels and 5% and 80% for decreased folate and vit. B6 levels, respectively. Mean plasma vitamin B12 concentrations increased, folate remained unchanged and PLP concentrations decreased with deteriorating liver function. Hcy concentrations were correlated with levels of creatinine (r=0.44, P