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Prostate-specific membrane antigen (PSMA) PET/CT shows better diagnostic performance for detection of lymph node and bone metastases as compared to conventional imaging. Studies of PSMA PET/CT in primary staging comprise highly selected patient cohorts. This study evaluates 18F-DCFPyL PET/CT as first-line imaging modality for primary staging of high-risk prostate cancer. From February 2018 until April 2019, all patients with high-risk prostate cancer received 18F-DCFPyL PET/CT for staging of prostate cancer. Baseline characteristics, findings at 18F-DCFPyL PET/CT, number and type of required additional diagnostic procedures, findings at additional diagnostic procedures, and effects of therapy on PSA levels for all patients treated with curative intent were collected and evaluated. One hundred-sixty patients were included in the study of which 90 (56%) had evidence of metastasized disease (N1, M1a, M1b and, M1c in 49%, 28%, 31%, and 3% respectively). Additional diagnostic imaging was needed in 2/160 patients (1%) because of equivocal findings on 18F-DCFPyL PET/CT. Eighty-one patients had evidence of PSMA-positive lymph node metastases, of whom 39 (48%) had no enlarged lymph nodes on CT; 18F-DCFPyL PET detected additional metastatic lymph nodes in 41/42 patients that had evidence of lymph node metastases on CT. 18F-DCFPyL PET altered patients’ management in 17% of patients. 18F-DCFPyL PET/CT can be used as first-line imaging modality for therapy selection in patients with primary high-risk prostate cancer, without need for further diagnostic imaging procedures in the majority of patients.

Purpose Radiosynoviorthesis (RSO) using the intraarticular application of beta-particle emitting radiocolloids has for decades been used for the local treatment of inflammatory joint diseases. The injected radiopharmaceuticals are phagocytized by the superficial macrophages of the synovial membrane, resulting in sclerosis and fibrosis of the formerly inflamed tissue, finally leading to reduced joint effusion and alleviation of joint pain. Methods The European Association of Nuclear Medicine (EANM) has written and approved these guidelines in tight collaboration with an international team of clinical experts, including rheumatologists. Besides clinical and procedural aspects, different national legislative issues, dosimetric considerations, possible complications, and side effects are addressed. Conclusion These guidelines will assist nuclear medicine physicians in performing radiosynoviorthesis. Since there are differences regarding the radiopharmaceuticals approved for RSO and the official indications between several European countries, this guideline can only give a framework that must be adopted individually.

Funding Acknowledgements Type of funding sources: None. Background Coronary artery calcium (CAC) is a well-known predictor of major adverse cardiac events and is scored manually from dedicated, ECG-triggered CT scans. In the present study, we investigated the accuracy of risk categorisation based on visual and automatic AI calcium scoring from low dose CT (LDCT) scans and dedicated Calcium Score CT (CSCT) scans. Purpose To assess the agreement of risk prediction based on visual and automatic AI CAC scoring from CSCT scans and LDCT scans as compared to a gold standard, manual CSCT scoring. Methods We retrospectively enrolled 222 patients. Each patient received a 13N-ammonia PET with LDCT and CSCT scan. The time interval between LDCT and CSCT was less than 6 months. Each LDCT and CSCT scan was scored visually, manually, and automatically with AI. For visual scoring we used a previously described 6–points scale (0; 1-10; 11-100; 101-400; 401-100; >1000 Agatston score). For manual scoring we used a generally available software package (Syngo.via,Siemens). The automatic AI scoring was performed with commercially available software based on a deep learning algorithm (included in Syngo.via,Siemens). Each manually and automatically measured Agatston score was converted into the 6-points scale. We performed a per patient analysis; the risk group categorization was based on the total Agatston score. Spearman correlation coefficient was used to analyse the association between manual and automatic AI scoring methods. Agreement between visual, manual, and automatic AI scoring methods was determined using weighted kappa test with 95% confidence intervals (95%CI). Results The correlation between manual scoring from LDCT and CSCT scans was 0.96 (p < 0.001).The agreement between manual scoring from two scans, however, was low with weighted kappa equal 0.57 (95% CI 0.51 – 0.63). 91,9% of calcium scores measured by AI software on CSCT were in the same risk group as manual CSCT scores.The agreement between AI scoring and manual scoring using CSCT was excellent, the weighted kappa was equal 0.95 (95% CI 0.92 - 0.97).Based on visual scoring on LDCT scans, 74,3% of the scores were in the same category as manual scoring on CSCT scans. The agreement between the visual scoring on LDCT scans and a gold standard was strong, weighted kappa equal was 0.82 (95% CI 0.77 – 0.86). The agreement between manual and automatic scoring on LDCT using manual CSCT as the gold standard was low (0.57, 95 % CI 0.51 – 0.63; 0.49, 95 % CI 0.43 – 0.56, respectively). Based on visual LDCT scoring, 7 patients were incorrectly classified as calcium score 0, which underestimated the overall patients’ risk.The AI method scoring CSCT scans, classified 2 patients incorrectly as non-calcium risk group. Conclusions CAC can be automatically assessed from CSCT scans with commercially available AI software.Of manual, automatic, and visual CAC scoring on LDCT scans the visual scoring showed the highest agreement with the gold standard manual CSCT CAC scoring.

Background and aim Deep Learning has revolutionised image analysis and its implementation in cardiology is rapidly advancing. DL offers the possibility to abstract highly-complex patterns from any image in order to optimise classification and prediction tasks. At the same time, positron emission tomography (PET) represents the reference technique for quantitative evaluation of myocardial perfusion and is a powerful tool for the diagnosis of myocardial ischemia and infarction. Although pathological perfusion patterns in PET are easily recognised by expert clinicians, it is unclear whether PET images harbour complex patterns inherent to traditional cardiovascular risk traits (factors) recognisable in an individual-patient basis. Hence, we aimed to deploy Deep Learning in order to predict cardiovascular risk traits from individual quantitative PET myocardial perfusion images. Methods Data form 1180 patients evaluated through quantitative N13-ammonia PET-imaging for suspected myocardial ischemia was analysed. We implemented transfer learning with fine-tuning of individual concatenated instances of an ImageNet pre-trained convolutional neural network (ResNet-50). From each PET scan, the 3 standard quantitative polar maps (rest/stress/perfusion reserve) were used as network input. A 5-fold cross validation policy was applied to training and validation for hyperparameters optimisation. Deep Learning modelling was deployed to independently predict: sex, smoking, arterial hypertension, dyslipidemia and type 2 diabetes mellitus as cardiovascular risk traits. Final model performance was evaluated through AUC and accuracy (with associated standard deviations [SD]) on a hold-out test set of 104 scans. Deep Learning-based heat maps were generated to identify regions of interest in PET imaging related to each of the predicted risk trait Results Deep Learning was able to strongly predict sex (0.87±0.04, 78%±4) and diabetes mellitus (0.75±0.13,71%±8), while its performance was only discrete for smoking (0.63±0.11, 85%±2), hypertension (0.61±0.06,58%±3) and dyslipidemia (0.59±0.05,57%±3), albeit all statistically significant (p Conclusion Deep Learning is able to significantly predict cardiovascular risk traits from individual quantitative PET myocardial perfusion images. This suggests the existence of complex high-dimensional and localised features within cardiac imaging that relate to cardiovascular risk factors at the individual level, which definitely warrants further research. Funding Acknowledgement Type of funding source: None

The objective of this study was to describe the prevalence of incidental extra-cardiac findings (IECFs) on myocardial perfusion PET/CTs and the prevalence of potentially clinically relevant and clinically irrelevant IECFs, as well as detection rate of previously unknown malignancies. From September 2013 until February 2016, a total of 1397 consecutive patients referred for the evaluation of possible ischemia by 13NH3 PET/CT were prospectively included in a database. IECFs were categorized into three groups: potentially clinically relevant IECFs, IECFs that could potentially cause chest pain, and clinically irrelevant IECFs. Additionally, the prevalence of previously unknown malignancies was determined. In 717 (51%) of these patients, 775 IECFs were reported and 115 IECFs were categorized as potentially clinically relevant in 109 (8%) patients. A total of 145 IECFs that could potentially cause chest pain were detected in 139 (10%) patients and 515 clinically irrelevant IECFs were detected in 469 (34%) of the patients. An unknown primary malignancy was histologically proven in 19 patients (1.4%). IECFs are detected on myocardial perfusion PET/CT in approximately half of the patients. In the present study, IECFs were potentially clinically relevant in 8% of the patients and in 1.4% an unknown malignancy was found, most of which were lung cancers.

Purpose: Prostate-specific membrane antigen (PSMA) PET/CT is increasingly used in patients with biochemically recurrent prostate cancer (BCR), mostly using gallium-68 (168Ga)-labelled radiotracers. Alternatively, fluorine-18 (18F)-labelled PSMA tracers are available, such as 18F-DCFPyL, which offer enhanced image quality and therefore potentially increased detection of small metastases. In this study we evaluate the lesion detection efficacy of 18F-DCFPyL PET/CT in patients with BCR and determine the detection efficacy as a function of their PSA value. Methods: A total of 248 consecutive patients were evaluated and underwent scanning with 18F-DCFPyL PET/CT for BCR between November 2016 and 2018 in two hospitals in the Netherlands. Patients were examined after radical prostatectomy (52%), external-beam radiation therapy (42%) or brachytherapy (6%). Imaging was performed 120 min after injection of a median dose of 311 MBq 18F-DCFPyL. Results: In 214 out of 248 PET/CT scans (86.3%), at least one lesion suggestive of cancer recurrence was detected (‘positive scan’). Scan positivity increased with higher PSA values: 17/29 scans (59%) with PSA values 18F-DCFPyL PET/CT offers early detection of lesions in patients with BCR, even at PSA levels 68Ga-PSMA and 18F-PSMA-1007, with potentially increased detection efficacy compared to 68Ga-PSMA for patients with PSA

Purpose Prostate-specific membrane antigen (PSMA) PET/CT is increasingly used in patients with biochemically recurrent prostate cancer (BCR), mostly using gallium-68 (168Ga)-labelled radiotracers. Alternatively, fluorine-18 (18F)-labelled PSMA tracers are available, such as 18F-DCFPyL, which offer enhanced image quality and therefore potentially increased detection of small metastases. In this study we evaluate the lesion detection efficacy of 18F-DCFPyL PET/CT in patients with BCR and determine the detection efficacy as a function of their PSA value. Methods A total of 248 consecutive patients were evaluated and underwent scanning with 18F-DCFPyL PET/CT for BCR between November 2016 and 2018 in two hospitals in the Netherlands. Patients were examined after radical prostatectomy (52%), external-beam radiation therapy (42%) or brachytherapy (6%). Imaging was performed 120 min after injection of a median dose of 311 MBq 18F-DCFPyL. Results In 214 out of 248 PET/CT scans (86.3%), at least one lesion suggestive of cancer recurrence was detected (‘positive scan’). Scan positivity increased with higher PSA values: 17/29 scans (59%) with PSA values

Background Limited studies report on the additional prognostic value of coronary computed tomography angiography (CCTA) and the coronary artery calcium score (CACS). Methods For a median of 637 days, 1551 outpatients with chest pain, without known coronary artery disease (CAD) and low or intermediate pre-test probability of CAD, were followed for major adverse cardiac events (MACE), defined as death, myocardial infarction or late revascularisation. Cox proportional hazard regression was used to evaluate the independent prognostic value of CCTA and CACS. Results MACE occurred in 23 patients (1.5%): death (3, 0.2%), myocardial infarction (4, 0.3%) and late revascularisation (16, 1.3%). Multivariate analysis showed an independent prognostic value of CCTA (p < 0.001), CACS of 100-400 (p = 0.035) and CACS of > 400 (p = 0.021). CCTA showed obstructive CAD in 3.1% of patients with CACS = 0. No events occurred in patients with CACS = 0 without obstructive CAD at CCTA, whereas 2/23 patients (9%) with CACS = 0 with obstructive CAD had a MACE. Conclusions Our study shows that both CCTA and higher CACS categories have independent prognostic value in chest pain patients with low to intermediate pre-test probability of obstructive CAD, in which CCTA is appropriate. Furthermore a non-negligible amount of patients with CACS = 0 have obstructive CAD at CCTA. CCTA can be used in these patients to identify those at risk for MACE.

The objective of this study was to describe the prevalence of incidental extra-cardiac findings (IECFs) on myocardial perfusion PET/CTs and the prevalence of potentially clinically relevant and clinically irrelevant IECFs, as well as detection rate of previously unknown malignancies.From September 2013 until February 2016, a total of 1397 consecutive patients referred for the evaluation of possible ischemia byIECFs are detected on myocardial perfusion PET/CT in approximately half of the patients. In the present study, IECFs were potentially clinically relevant in 8% of the patients and in 1.4% an unknown malignancy was found, most of which were lung cancers.

BACKGROUND AND AIM: Primary percutaneous coronary intervention (PCI) is the preferred treatment option for acute myocardial infarction (MI). Off-site PCI reduces time-to-treatment, which could potentially lead to enhanced clinical outcomes. Therefore, we investigated whether off-site PCI improves 5-year clinical outcomes compared with on-site PCI and whether this is related to in-hospital (99m)Tc-sestamibi single photon emission computed tomography (MIBI SPECT) parameters. METHODS: We describe the 5-year follow-up for a combined endpoint of death or re-infarction in 128 patients with acute MI who were randomly assigned to undergo primary PCI at the off-site centre (n = 68) or to transferral to an on-site centre (n = 60). Three days after PCI, MIBI SPECT was performed to estimate infarct size. A multivariate Cox regression model was created to study the relation between MIBI SPECT parameters and long-term clinical outcomes. RESULTS: After a mean follow-up of 5.8 ± 1.1 years, 25 events occurred. Off-site PCI significantly reduced door-to-balloon time compared with on-site PCI (94 ± 54 versus 125 ± 59 min, p = 0.003). However, infarct size (17 ± 15 versus 14 ± 12%, p = 0.34) and 5-year death or infarct rate (21% versus 18%, p = 0.75) were comparable between treatment centres. With multivariate analysis, only Killip class ≥2 and Q wave MI, but not scintigraphic data, predicted long-term clinical outcomes. CONCLUSION: Off-site PCI reduced door-to-balloon time with a comparable 5-year death or infarct rate. Parameters from resting MIBI SPECT on day 3 after MI did not predict long-term clinical outcomes.

Does leakage impair the therapeutic effect of radiosynoviorthesis (RSO)? Are there differences in leakage between (169)Erbium and (186)Rhenium? At baseline and at 6 and 12 months after RSO, six clinical parameters were scored. Changes in clinical variables over time were summed to a change composite index (CCI), ranging from 0 (no effect) to 12 (maximal effect). CCIor= 6 was considered successful treatment. Differences in leakage between responders and non-responders, and between (169)Erbium and (186)Rhenium were examined. Regression analyses were performed to explore whether baseline variables predicted leakage. Both at 6 and 12 months response rates were 25 of 36 (69%). Five of 11 (45%) non-responders showed leakage versus 20 of 25 (80%) responders (P=0.06). Mean leakage to lymph nodes was 0.4+/-0.7% versus 2.4+/-0.8% (P=0.04). Median leakage to liver/spleen was 0% versus 0.3% (P=0.4). Only age at the time of injection correlated significantly with leakage to lymph nodes. The (169)Erbium group showed leakage in 1 of 7 (14%) versus 24 of 30 (80%) for the (186)Rhenium group (P=0.002). Mean leakage to lymph nodes was 0.11+/-0.3% versus 2.1+/-2.8% (P=0.001). Median leakage to liver/spleen was 0% versus 0.5% (P=0.006). Leakage to non-target organs does not impair the clinical effect of RSO. Only age predicted leakage to lymph nodes significantly. Other baseline characteristics did not predict leakage. (169)Erbium shows significantly lower leakage to non-target organs than (186)Rhenium in RSO.

The aim of this study was to evaluate the count rates of sentinel lymph nodes (SLNs) in patients with breast cancer in the operating theatre, using (99m)Tc-Nanocoll with different ratios of technetium-99m to technetium-99. After written informed consent had been obtained, we tested different ratios of (99m)Tc/(99)Tc-Nanocoll in a double-blinded randomised study performed in 161 patients. Twenty-five MBq/ microg (99m)Tc-colloid albumin was prepared in vacuum. In 87 patients (group A) a 2-h elution was used and in 74 patients (group B) a 24-h elution was used. Patients were subcategorised into subgroups 1 and 3, in which an SLN procedure for breast carcinoma was performed simultaneously with lumpectomy, and subgroups 2 and 4, in which an SLN procedure was performed 2-3 weeks after prior excision biopsy. All patients were injected along the lateral border of the areola (two injections: 50 MBq/0.3 ml intradermally and 50 MBq/2 ml intraparenchymally). Ex vivo measurement of count rates was performed with a gamma probe. Comparing groups A and B in respect of registered counts per second (cps) of excised SLNs, a significant difference was found ( P0.004). When comparisons were made between subgroups 1 and 2 (2-h elution) and between subgroups 3 and 4 (24-h elution) in respect of registered cps of excised SLNs, no significant difference was found (subgroup 1 vs 2, P=0.825; subgroup 3 vs 4, P=0.915). Use of a 2-h elution in vacuum yielded a significantly higher count rate of maximum specific activity of (99m)Tc-colloid albumin in SLNs than was achieved using a 24-h elution in vacuum. SLN procedures performed 2-3 weeks after prior excision biopsy proved reliable as compared to SLN procedures performed simultaneously with lumpectomy.

OBJECTIVE It is thought that immunosuppressive treatment of Graves' ophthalmopathy should be restricted to patients with active eye disease, but assessing disease activity is difficult. Octreotide scintigraphy has been claimed to differentiate active from inactive disease. Here we study the intraobserver variability and diagnostic accuracy of the quantitative measurement of orbital octreotide uptake. PATIENTS AND DESIGN Twenty-two consecutive patients with moderately severe ophthalmopathy were treated with retrobulbar radiotherapy. Pretreatment octreotide scintigraphic data were related to the response at six months after radiotherapy, using Receiving-Operator-Characteristic curves. MEASUREMENTS Octreotide uptake was measured at 4 and 24 h after i.v. injection of approximately 3 mCi (= 111 MBq; range 75–150 MBq) 111Indium-DTPA-Octreotide with a neuro-SPECT camera. Counts were measured in fixed regions-of-interest in 4 transversal slices of the orbit, the temporal and the occipital area. Measurements were done twice and intraobserver variability was analysed by coefficients of variations (CV). Uptake is expressed as orbital/background ratio. The nature of the temporal uptake was studied by matching an octreoscan with a technetium scan and MRI. RESULTS Intra-observer variability of measuring octreotide uptake was acceptable, and the coefficient of variation slightly better using the orbital/occipital ratio (11%), than the orbital/temporal ratio (16%). From matching studies it appears that the temporal uptake takes place, in part, in the parotid gland. The orbital/occipital ratio was used to predict the outcome of radiotherapy. Mean (± SD) uptake on the 4 h scan was higher in responders (2.2 ± 0.66) than in nonresponders (1.7 ± 0.39; P = 0.04). From the Receiving-Operator-Characteristic curve we determined a cut-off value of 1.85, which yielded a positive predictive value of 92% and a negative predictive value of 70%.The 24 h scan could not predict a response. CONCLUSION Quantitative measurement of orbital octreotide uptake is possible. Using the orbital/occipital ratio on the 4 h scan, the octreoscan seems useful in predicting response to subsequent radiotherapy. The 24 h scan seems not to be useful in predicting therapeutic outcome.

Objectives: To assess the impact of the intra-articular distribution of 90 yttrium-citrate ( 90 Y) on the clinical effect of radiosynoviorthesis (RSO) of the knee and on 90 Y leakage from this joint. Methods: Patients with arthritis of the knee received 185 MBq 90 Y combined with a glucocorticoid, followed by clinical bed rest. Intra-articular 90 Y distribution, measured with a dual-head gamma camera immediately or after 24 hours, was scored as mainly diffuse or mainly focal. Leakage to regional lymph nodes, the liver and spleen was assessed with a dual-head gamma camera after 24 hours. Clinical effect was scored after 6 months by a composite change index (CCI), range 0–12; responders were defined as having a CCI ⩾6. Results: Seventy-eight knees of 69 patients, mostly suffering from undifferentiated arthritis (42%) or RA (28%), were treated. 90 Y distribution was mainly diffuse in 54% and mainly focal in 46% with clinical response rates of 40% versus 56%, respectively, p = 0.3. CCI was not correlated with distribution. 90 Y leakage was found only to the liver and the spleen (mean leakage 0.4% and 1.1%, respectively). Leakage was significantly less in case of diffuse intra-articular 90 Y distribution, whereas leakage to the liver was correlated with distribution (r = 0.68, p 90 Y leakage was not correlated with CCI. Conclusions: Intra-articular 90 Y distribution does not influence the clinical effect of RSO of the knee. Although 90 Y leakage from the joint is less if 90 Y distributes diffusely in the joint cavity, leakage does not seem to hamper the clinical effect.

Background: Pulmonary embolism (PE) is a major complication of deep venous thrombosis (DVT) of the lower extremities. The incidence is approximately 50%. The incidence of DVT of the upper extremity (DVTUE) is increasing mainly due to the increasing use of central venous catheters. The percentage of PE secondary to DVTUE is still being investigated. Methods: The occurrence of PE in DVTUE was retrospectively analyzed in 78 patients with proven DVTUE. Furthermore, the literature was reviewed. Results: Of the identified patients with DVTUE 16 showed a primary DVTUE and 62 a secondary DVTUE. Secondary DVTUE was catheter-related in 41 (60%), which is 53% of all DVTUE. In this study the percentage of PE as a complication of DVTUE was 6 (95% CI: 0.2–30) in primary DVTUE, 13 (95% CI: 6–24) in secondary DVTUE and 17 (95% CI: 7–32) in catheter-related DVTUE. The relative risk for PE of catheter-related DVTUE versus other causes was 3.4 (95% CI: 0.4–53.5). The overall percentage was 12 (95% CI: 5–21). The literature review showed a percentage of 7 (95% CI: 4–9) in the retrospective studies and 17 (95% CI: 12–23) in the prospective studies. Conclusions: Indwelling catheters are the most common cause of DVTUE. PE is not an uncommon complication of DVTUE, and is more common in catheter-related DVTUE. The difference between the incidence of PE in DVTUE and DVT of the lower extremity may be explained by a number of factors, such as differences in fibrinolytic activity, mechanical forces and venous flow patterns.

Yersinia, Campylobacter, and Salmonella are pathological microorganisms which incidentally may specifically infect the ileocecal area (infectious ileocecitis). In such cases pain in the right lower quadrant is the predominant symptom, and diarrhea is absent or only mild. This symptomatology can lead to an unnecessary laparotomy for suspected appendicitis. At surgery a normal appendix is removed, while there is edematous thickening of ileum and cecum, and enlarged mesenteric lymph nodes. These ileocecal abnormalities give rise to a fairly characteristic US image, enabling the radiologist to rapidly differentiate infectious ileocecitis from appendicitis, thus preventing an unnecessary laparotomy. Infectious ileocecitis caused by Yersinia, Campylobacter, and Salmonella is a common mimicker of appendicitis, and its incidence at this moment is grossly underestimated. Ultrasound is presently the only means to prevent an unnecessary operation for this condition which is principally self-limiting and innocuous.

Objective To determine the long-term prognostic value of stress imaging and clinical risk scoring for cardiovascular mortality in chest pain patients after ruling out acute coronary syndrome (ACS). Methods A standard rule-out protocol was performed in emergency room patients with a normal or non-diagnostic admission electrocardiogram (ECG) within 6 h of chest 4 pain onset. ACS patients were identified by troponin T, recurrent angina and serial ECG. Dobutamine stress echocardiography (DSE) was performed after ACS was ruled out. Myocardial perfusion scintigraphy (MPS) was performed within 6 months in an outpatient setting according to the physician's discretion. Results 524 patients were included. GRACE and TIMI risk scores were 75 (57-96) and 1 (0-2) in the rule-out ACS group, and 89 (74-107) and 2 (1-3) in the ACS group, respectively (median, interquartile range). Follow-up (median 9.4 (8.9-10.0) years) was complete in 96%. 350 of 379 rule-out ACS patients had an interpretable DSE and 52 patients underwent an MPS. 21 of the rule-out ACS patients (6%) died of a cardiovascular cause compared with 24 (17%) ACS patients (p

We studied the effects of a custom-made lead collar on dose rates and hospitalization days of patients treated with high doses (>400 MBq) ofradioiodine ( 131 I). Between October 2005 and March 2006, the dose rates of 28 consecutive patients were studied. Dose rates of patients with and without the collar (5.5 mm lead) were measured daily until the rate dropped below the discharge dose rate of 20 μSv h -1 at 1 m. Age, sex, 131 I dose, uptake, thyroid disorder, and days of isolated hospitalization were recorded. The difference in mean dose rate with or without the collar was analyzed by t test or Mann-Whitney test, as appropriate. Twenty-eight patients (7 male, 21 female; mean age, 57 y; range, 29-82 y) were analyzed. Nine patients suffered from Graves'disease, 9 from toxic nodular goiter, and 10 from non-toxic nodular goiter. Patients were treated with a mean dose of 1,647 MBq 131 I (range, 511-3,276 MBq). The mean anterior dose rates were 28 ± 12 μSv h -1 at 1 m and 11 ± 6 μSv h -1 at 1 m without and with the lead collar, respectively (p < 0.001). The mean reduction in dose rate for patients wearing the collar was 61 ± 13%. The mean hospital stay was 2.6 ± 1.3 days without the collar vs. 1.2 ± 0.6 days with the collar (p < 0.001). A custom-made lead collar significantly reduced dose rates and could reduce compulsory hospitalization, especially in toxic- and non-toxic nodular goiter. Health Phys.

To perform a systemic review and meta-analysis on the effectiveness of radiosynoviorthesis (RSO).A search of medical databases was conducted. Criteria for inclusion: articles in English, minimum follow-up of 6 months, specification of joint disease, reported outcome of at least 5 RSOs. The studies were scored for quality by the Oxford Centre of Evidenced-based Medicine Levels of Evidence, from 1 to 4.Twenty-one (21) studies were included (3 quality 1b, 5 2b and 13 4), analysing 169Erbium/186Rhenium-RSO used predominantly in small joints and 49 (1 quality 1b, 10 2b and 38 4) on 90Yttrium-RSO used predominantly in knee joints. The reported success rates of 169Erbium/186Rhenium-RSO ranged from 69-100% at 6 months, and from 54-100% ator =12 months; for 90Yttrium they were 24-100% and 29-94%, res-pectively. Studies comparing the effect of RSO with that of glucocorticoid (GC) or saline injection alone were pooled. At 6 months, the pooled odds ratio favouring RSO of the knee with Yttrium over control is 4 (confidence interval (CI) 95% 1.2-14), p=0.02, but at 12 months the ratio was 1.7 (CI95% 0.69-4), p=0.26. For RSO of small joints with Erbium/Rhenium compared to controls, the pooled odds ratio at 6 months is 2 (CI95% 0.66-6), p=0.22 and at 12 months 2 (CI95% 1.09-3.5), p=0.03.Reported success rates of RSO are high, but differences in effect with GC injection are less evident, although there is marked heterogeneity in study design of the (small number of) comparative studies.

SPECT with Tc-99m HM-PAO as a radiopharmaceutical was performed in 17 patients meeting research criteria for Alzheimer's disease (AD), in 10 patients with a clinical diagnosis of multi-infarct-dementia (MID) and in 12 healthy volunteers. Regional tracer uptake was measured in frontal, parietal, and temporoparietal regions. A statistically significant decrease of tracer uptake in the temporoparietal region was found in AD-patients compared with controls. AD-patients showed less activity in this region than MID-patients, but this difference did not reach statistical significance. In both AD- and MID-patients decrease of tracer uptake was not correlated with dementia severity. We conclude that SPECT brain imaging is not yet ready for routine use in the distinction between AD and MID.

This study evaluated labelling efficiency and radiochemical purity of (99m)Tc colloid albumin to identify an optimal labelling protocol for sentinel node detection. Results indicate that a 72 h eluate is not recommended for high specific labelling of (99m)Tc colloid albumin. Ex vivo, significantly higher count rates were reached using a 2h eluate in vacuum or nitrogen. Labelling 26 MBq/microg (99m)Tc colloid albumin with a 2 h eluate under nitrogen is recommended because of the ease of labelling.

To compare the clinical efficacy of radiosynoviorthesis (RSO) with intra-articular radionuclide plus glucocorticoid (GC) injection (group A) with that of placebo plus GC injection (group B) for the treatment of persistent synovitis in joints of the upper extremity.At baseline and at 6 and 12 months after intra-articular injection, six clinical parameters were scored. Changes in clinical values over time were summed to provide a change composite index (CCI), ranging from 0 (no effect) to 12 (maximal effect). A CCIor =6 was considered to indicate successful treatment. Differences in response rate and CCI between groups A and B were examined. Regression analyses were performed to explore whether baseline variables could predict therapeutic effect.Sixty-eight joints in 44 patients were treated. Six months after intra-articular injection, response rates (CCIor =6) were 69% (25/36) in group A and 29% (9/31) in group B (p=0.001). The mean CCIs +/- standard deviation at 6 months were 6.7+/-3.2 for group A and 3.3+/-3.8 for group B (p=0.001). At 12 months the response rates were 69% (25/36) in group A and 32% (8/25) in group B (p=0.004). The mean CCIs at 12 months were 6.8+/-3.3 for group A and 4.2+/-4.7 for group B (p= 0.046). None of the baseline variables predicted the therapeutic effect.RSO (radionuclide plus GC) of upper extremity joints with immobilisation for 72 h shows a significantly better response rate than placebo plus GC in patients with persistent synovitis after at least one failed outpatient intra-articular GC injection.

Objective The sensitivity and specificity of 99m Tc-sestamibi scintimammography in patients with non-palpable breast lesions diagnosed by screening mammography and the value of 99m Tc-sestamibi to detect axillary lymph node metastases was determined. Methods Between September 2000 and December 2003, 103 females with non-palpable breast lesions were included for further evaluation. X-ray mammography was repeated and 99mTc-sestamibi scintimammography performed within one-week. Anterior, and left and right lateral images were obtained. The scintimammography was analysed by 2 experienced observers who were blinded to the clinical, pathological, and radiological results. The sensitivity and specificity of scintimammography to diagnose non-palpable lesion(s), including the axillary regions, was compared with histopathology, clinical, and radiological follow up. Results Two patients (one non-small lung cancer and one non-Hodgkin's disease) were excluded. Both showed 99m Tc-sestamibi avid lesions in the breast and axillary region. In the remaining 101 patients, 37 true positive (TP), 4 false positive (FP), 52 true negative (TN), and 8 false negative (FN) breast carcinomas were found. The specificity was 92.8%, sensitivity 82.2%, positive predictive value (PPV) 90.2%, and negative predictive value (NPV) 86.6%. 99m Tc-sestamibi scintimammography showed axillary lesions in 5/15 (33%) patients with axillary lymph node metastasis. Conclusion In patients with non-palpable lesions diagnosed by screening- X-ray-mammography, 99m Tc-sestamibi scintimammography provided high specificity and PPV. Furthermore, 99m Tc-sestamibi scintimammography detected 33% of patients with axillary lymph node metastases. Therefore, 99m Tc-sestamibi scintimammography could be of incremental value in the surgical work-up of these patients.

It is thought that immunosuppressive treatment of Graves' ophthalmopathy should be restricted to patients with active eye disease, but assessing disease activity is difficult. Octreotide scintigraphy has been claimed to differentiate active from inactive disease. Here we study the intraobserver variability and diagnostic accuracy of the quantitative measurement of orbital octreotide uptake.Twenty-two consecutive patients with moderately severe ophthalmopathy were treated with retrobulbar radiotherapy. Pretreatment octreotide scintigraphic data were related to the response at six months after radiotherapy, using Receiving-Operator-Characteristic curves.Octreotide uptake was measured at 4 and 24 h after i.v. injection of approximately 3 mCi (= 111 MBq; range 75-150 MBq) 111Indium-DTPA-Octreotide with a neuro-SPECT camera. Counts were measured in fixed regions-of-interest in 4 transversal slices of the orbit, the temporal and the occipital area. Measurements were done twice and intraobserver variability was analysed by coefficients of variations (CV). Uptake is expressed as orbital/background ratio. The nature of the temporal uptake was studied by matching an octreoscan with a technetium scan and MRI.Intra-observer variability of measuring octreotide uptake was acceptable, and the coefficient of variation slightly better using the orbital/occipital ratio (11%), than the orbital/temporal ratio (16%). From matching studies it appears that the temporal uptake takes place, in part, in the parotid gland. The orbital/occipital ratio was used to predict the outcome of radiotherapy. Mean (+/- SD) uptake on the 4 h scan was higher in responders (2.2 +/- 0.66) than in nonresponders (1.7 +/- 0.39; P = 0.04). From the Receiving-Operator-Characteristic curve we determined a cut-off value of 1.85, which yielded a positive predictive value of 92% and a negative predictive value of 70%. The 24 h scan could not predict a response.Quantitative measurement of orbital octreotide uptake is possible. Using the orbital/occipital ratio on the 4 h scan, the octreoscan seems useful in predicting response to subsequent radiotherapy. The 24 h scan seems not to be useful in predicting therapeutic outcome.

In 2003, a 63-year-old female patient was presented to the gynaecological clinic. Her main complaint was of severe hirsutism, for which she had undergone several intense pulsed light hair removal therapy sessions since 1999. In 2002, she had consulted an ENT specialist because of a deepening of the voice, which was particularly annoying to her because she sang in a choir. She had undergone an abdominal hysterectomy and left oophorectomy in 1983 because of a benign non-hormone secreting cyst. Physical examination revealed clitoromegaly and severe hirsutism, albeit partly masked by the light therapy. The right ovary was not enlarged on pelvic examination nor visible on transvaginal ultrasound examination. Laboratory tests showed an elevated plasma testosterone of 14 nmol/l (normal value 0.3–3 nmol/l) and normal levels of thyroxine, thyroid stimulating hormone, cortisol, adreno-cortico-trophic hormone, prolactin, human chorionic gonadotrophin, progesterone, oestradiol and dihydroepiandrostendione sulphate. The luteinising and follicle stimulating hormone levels were in the postmenopausal range. A differential diagnosis of an androgen-producing tumour in the ovary or the adrenal cortex was made. A computerised tomography scan could not confirm an adrenal adenoma, ovarian tumour or any other tumour so it was decided to first remove the right ovary laparoscopically. To our disappointment, an atrophic ovary with only a small, simple cyst was found. Histology was normal and the plasma testosterone-level remained elevated. In our continued search for of a testosterone-producing tumour, a PET scan and a 131I-norcholesterol scan under dexamethasone suppression were subsequently performed. The PET scan showed a normal tracer uptake. 131I-norcholesterol scan revealed a lesion in the right lower abdomen (Fig. 1). The integrated SPECT (low dose) CT scan localised the tumour anatomically: in the retroperitoneal region near the caecum and the ovarian vessels (Fig. 2). Revision of the first CT scan, with this knowledge in mind, demonstrated the initially overlooked small tumour. The patient was scheduled for surgery with the aid of a gamma probe. During operation, a black tumour of 2–2.5 cm, localised next to the caecum, was detected and extirpated. The use of the gamma probe was not very helpful because of physiological tracer uptake in the bowel. Histology showed a benign adrenal-type adenoma and post-operatively the plasma testosterone levels immediately returned to normal values. Although the hirsutism decreased, the clitoromegaly persisted, as expected.

Background: Elevated admission plasma glucose (APG) in acute coronary syndrome (ACS) patients is associated with increased mortality. Clinical trials of glucose regulation provided inconsistent results with respect to cardiovascular outcomes. Target glucose levels might have been suboptimal. Aim: To study the effectiveness and safety of intensive glucose management in ACS patients with hyperglycemia, aiming at a strict blood glucose normalization. Methods: BIOMArCS-2 Glucose is a single-centre, prospective, open-label, randomized, clinical trial that enrolled 294 ACS patients with an APG 7.8-16 mmol/l. Patients were randomized to an intensive glucose management strategy, aiming at a plasma glucose 4.7-6.1 mmol/l by using intravenous insulin, or conventional expectative glucose management. Endpoints were high sensitivity Troponin T 72 hours after admission (hsTropT72) (primary), the area under the curve (AUC) of CKMB release, and myocardial perfusion scintigraphy (MPS) parameters at 6 weeks follow-up. Results: In the intensive arm hsTropT72 was 1197 ng/L (541-2296) vs. 1354 ng/L (530-3057) in the conventional arm, p-value 0.41. Median AUC-CKMB was 2372 U/L (1242 – 5004) vs. 3171 U/L (1620 – 5337), p-value 0.18. The median extent of myocardial injury measured by MPS was comparable (2% vs. 4%, p value 0.07). Severe hypoglycemia (

Background Patients with an elevated erythrocyte sedimentation rate (ESR) and non-specific symptoms often pose a diagnostic dilemma. PET/CT visualises infection, inflammation and malignancy, all of which may cause elevated ESR. Objectives To determine the contribution of 18F-fluorodeoxglucose positron emission tomography (PET/CT) in the diagnostic work-up of referred patients with an elevated ESR, in whom initial routine evaluation did not reveal a diagnosis, in order to detect large vessel vasculitis, among other diseases. Methods In a combined retrospective (A) and prospective (B) study PET/CT was performed in elderly patients (> 50 years of age) who presented with a significantly elevated ESR (≥ 50 mm/h) and non-specific complaints. In addition, a protocolised work-up (including chest X-ray, abdominal ultrasound and protein electrophoresis) was used in study B. In both studies, the final diagnosis was based on histology, clinical follow-up, response to therapy and/or additional imaging. Results In study A, 30 patients were included. PET/CT results suggested malignancy (8 patients), inflammatory disease (8 patients, including 5 with large-vessel vasculitis) and infection (3 patients). In 2 patients, non-specific abnormalities were found. Of the 21 patients with abnormal PET/CT results, final diagnoses were in accordance with PET/CT results in 12 patients (including 5 with large-vessel vasculitis). In 9 patients, abnormalities detected by PET/CT did not contribute to the final diagnosis. Two diagnoses (tendinitis and acute myeloid leukaemia) were established in 9 patients with a normal scan. In study B, 58 patients were included. PET/CT results suggested inflammatory disease (25 patients), particularly large-vessel vasculitis (14 cases), infection (5 patients) and malignancy (3 patients). 7 scans demonstrated non-specific abnormalities. Of the 40 patients with abnormal PET/CT results, final diagnoses were in accordance with PET/CT results in 22 patients (including 14 with large-vessel vasculitis). In 18 patients PET/CT abnormalities did not contribute to a final diagnosis. One final diagnosis (PMR) was established in 20 patients with a normal scan. Conclusions PET/CT may be of potential value in the diagnostic work-up of patients with non-specific complaints and an elevated ESR. In particular, large-vessel vasculitis appears to be a common finding. A normal PET/CT scan in these patients suggests that it is safe to follow a wait-and-see policy. Disclosure of Interest None Declared

Evaluation of clinical management in patients suspected of pulmonary embolism as compared with the Dutch consensus for diagnosing pulmonary embolism.Retrospective.Medical Centre Alkmaar.Retrospective analysis of clinical management in patients subjected to ventilation-perfusion scintigraphy on suspicion of pulmonary embolism.In 55 (24%) of the 225 patients included a high-probability scan was found, in 68 (30%) a non-high-probability scan and in 102 (45%) a normal scan. The clinical management in all patients with a normal or high-probability scan was according to the consensus. In the 68 patients with a non-high-probability scan the consensus was completely followed in 16%, partially in 18% and not at all in 66%.Clinical management of patients with a non-high-probability scan in the vast majority of cases was not according to the consensus. The consensus was followed in all patients with a normal or high-probability scan.