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Konventionelle Ansatze in der onkologischen Therapie wie Operation, Chemotherapie und/oder Strahlenbehandlung fuhren bei vielen Patienten nicht zu einer Verbesserung des Uberlebens, sind aber oft mit erheblichen Nebenwirkungen verbunden. Durch die aktuelle Forschung auf dem Gebiet der molekularen Medizin ist ein Therapieansatz hinzugekommen, den man als „zielgerichtete Therapie“ („targeted therapy“) bezeichnet. Recherche und Auswertung von Literatur. Auf der Grundlage des Verstandnisses der Pathogenese von Erkrankungen werden auf molekularer Ebene Medikamente entwickelt, die spezifisch auf die entscheidenden Zielmolekule der jeweiligen Erkrankung wirken. Im Rahmen der Indikationsstellung und Verlaufskontrolle unter zielgerichteten Therapien haben sowohl die mikroskopische (optische) Bildgebung operativer Praparate – eingeschlossen molekularpathologische Untersuchungsmethoden – als auch die makroskopische (molekulare) Bildgebung einen besonderen Stellenwert. Der kombinierte Einsatz dieser komplementaren Verfahren wird als „multiscale imaging“ bezeichnet. Es besteht die Aussicht auf individualisierte und nebenwirkungsarmere Therapien fur Patienten mit onkologischen Erkrankungen. Eine wichtige Rolle spielen dabei PET/CT-Gerate der neuen Generation, die Verfugbarkeit „neuer“ Radionuklide und die Anwendung von Proteomik und Genomik auf der Basis der Entschlusselung des humanen Genoms.

SummaryThe clinical significance of 18F-FDG-PET/CT in the follow-up of patients with differentiated thyroid carcinoma was evaluated and the results were compared with those of 18F-FDGPET, 131I-whole-body scintigraphy including SPECT/CT (WBS) and ultrasound. In addition, it was the aim to investigate the impact of 18F-FDG-PET/CT on the therapeutic management. Patients, methods: 327 patients (209 women, 118 men; mean age 53 ± 18 years) with differentiated thyroid cancer (242 papillary, 75 follicular, 6 mixed, 1 Hürthle cell and 3 poorly differentiated tumours) were analyzed retrospectively at four tertiary referral centres. 289 18F-FDG-PET/CT and 118 18F-FDG-PET studies were performed in these patients between 2007 and 2010. In addition, an overall clinical evaluation was performed, including cytology, histology, thyroglobulin level, ultrasound, WBS, and subsequent clinical course in order to compare the molecular imaging results. Finally, the change in therapeutic management due to findings of 18F-FDG-PET/CT was investigated. Results: The sensitivity of 18F-FDG-PET/CT was 92%, the specificity was 95%. Sensitivity and specificity of 18F-FDG-PET alone were 67% and 93%, respectively. WBS showed a sensitivity of 65% and a specificity of 94%. The corresponding values of ultrasound were 37% and 94%, respectively. The sensitivity of 18F-FDG-PET/CT in the group of patients with a negative WBS (n=194) amounted to 96%. When 18F-FDG-PET/CT and WBS were considered in combination, tumour tissue was missed in only 2 out of 133 patients; when 18F-FDG-PET and WBS were combined, tumour tissue was missed in 1 out of 24 patients. 18F-FDG-PET/CT resulted in management change in 43% (n=57/133) with a decision on surgical approach in 20% (n=27/133). Conclusions: 18F-FDG-PET/CT is superior to 18F-FDG-PET alone in patients with differentiated thyroid cancer and has a direct impact on the therapeutic management of patients with suspected local recurrence or metastases, particularly in those with negative WBS.

ZusammenfassungDiese Leitlinie ist die Kurzfassung der bei der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) publizierten Leitlinie zur Myokard-Perfusions-Szintigraphie. Sie soll eine praxisorientierte Hilfestellung zur Indikation, Durchführung und Auswertung der Myokard-Perfusions-Szintigraphie geben und den aktuellen Stand des Verfahrens darstellen.Nach der Einführung in die Grundlagen folgen konkrete und detaillierte Angaben zur Indikationsstellung, zur Untersuchungsvorbereitung, zu Belastungsverfahren, Radiopharmaka, Akquisitionsprotokollen und -techniken, Strahlenexposition, Datenrekonstruktion sowie zur visuellen und quantitativen Bildanalyse und -interpretation. Zusätzlich werden Fehlerquellen behandelt und Grundelemente des Befundberichtes aufgezeigt.

SummaryDifferentiated thyroid carcinomas (DTC) have an excellent prognosis, with 10-year overall survival rates over 90%. In addition, DTC patients benefit from their lifelong medical surveillance. The aim of the study was to compare the patients’ overall survival with that of a matched general population. Patients and methods: We have analyzed 1497 consecutive patients with DTC, who underwent radioiodine therapy in Münster, Germany, according to international standards. We classified our patients according to the current 7th edition of the UICC (Union Internationale Contre le Cancer) classification and we compared the overall survival of the patients with the expected survival based on age and sex of the general population as provided by the Federal Statistical Office, Germany. Results: There were no significant differences in overall survival rates between DTC patients of the cohort in stages I to IVa compared to the expected survival based on age and sex of the general population. However, patients in stage IVc showed a significantly worse overall survival rate using the log-rank test (p < 0.0001). Conclusion: Patients with DTC showed excellent overall survival rates in stages I, II, III and IVa. All patients, except for those in stage IVc (M1 ≥ 45 years), had overall survival rates similar to the general population.

In der Therapie gutartiger Schilddrusenerkrankungen werden neben der medikamentosen Therapie auch operative Verfahren und die Radioiodtherapie angewandt. Insbesondere die Entscheidung Operation vs. Radioiodtherapie ist individuell in Absprache mit dem Patienten unter Berucksichtigung aller Vor- und Nachteile der beiden Verfahren zu treffen. Die Therapie mit Radioiod ( 131 Iod) ist ein sicheres und nebenwirkungsarmes Therapieverfahren. Nach entsprechender Aufklarung und Vorbereitung des Patienten wird 131 Iod oral appliziert. Die verabreichte Aktivitat muss sich nach individuell ermittelten Werten von Zielvolumen, Uptake und Verweildauer (Halbwertszeit) des Tracers richten. Eine standardisierte Dosimetrie wird gefordert, konnte bisher aber noch nicht uberall umgesetzt werden. Posttherapeutische Messungen des Uptakes sind erforderlich zur Bestimmung der Halbwertszeit und letztlich der Dosis. Die Radioiodtherapie muss stationar durchgefuhrt werden. Die wesentlichen Indikationen fur eine Radioiodtherapie gutartiger Schilddrusenerkrankungen sind bei ausreichendem Radioiod-Uptake die Hyperthyreose bei Autonomien oder beim Morbus Basedow sowie die Strumaverkleinerung bei grosen Strumen oder Rezidivstrumen, sowie bei Kontraindikationen einer operativen Therapie. Beim Morbus Basedow ist die Radioiodtherapie bei Patienten mit hohem Rezidivrisiko sowie bei persistierender Hyperthyreose nach 6- bis 12-monatiger medikamentoser Therapie indiziert, insbesondere aber in der Rezidivsituation. Unter begleitender Steroidmedikation ist das Risiko einer sich entwickelnden endokrinen Orbitopathie unter der Radioiodtherapie zu vernachlassigen. Die Wirkung der Radioiodtherapie ist erst nach 2–3 Monaten zu erwarten. Eine standardisierte Nachsorge ist erforderlich und vorgeschrieben. Eine medikamentose Therapie muss dabei individuell an die Stoffwechsellage angepasst werden.

SummaryAim: Radioiodine remnant ablation (RRA) after (near-)total thyroidectomy (TE) is a key element in patients with differentiated thyroid cancer (DTC). The use of exogenous TSH stimulation (rhTSH) prior to RRA has shown promising results as compared to conventional thyroid hormone withdrawal (THW). As yet, the efficacy of RRA after brief THW and single rhTSH administration has not been assessed. Patients, methods: The study sample comprised 147 patients with DTC referred to our center between May 2008 and September 2010. All patients received TE with subsequent RRA. None of these 147 patients had evidence of distant metastasis. 93 patients had endogenous TSH stimulation 4–5 weeks after surgery (group I) and twenty-six received two rhTSH injections (group II). 28 patients were treated with a single rhTSH injection after a brief THW (group III). RRA-Efficacy was assessed three months after therapy by diagnostic whole-body scan and measurement of the tumour marker thyroglobulin (Tg) under TSH stimulation. Results: Three categories of success were defined for remnant ablation. Based on the definition of successful remnant ablation no visible uptake and a Tg ≤ 2.0 ng/ ml (category 1) was seen in 62/93 patients in group I, in 17/26 patients in group II (p = n.s.) and in 12/28 patients in group III (p < 0.05). Visible radioiodine uptake and a Tg ≤ 2.0 ng/ml (category 2) was seen in 16/28 patients of group III and thus significantly more frequent than in group I (28/93 patients) (p < 0.01). However, patients in group III (16/28 patients) and group II (8/26 patients) showed no significant difference in this category (p = n.s.). Visible radioiodine uptake and a Tg > 2.0 ng/ml (category 3) was found in 3/93 patients in group I and 1/26 patients in group II but in no patient in group III. Conclusion: The third strategy of remnant ablation using a single injection of rhTSH after a brief THW period resulted in a significant higher rate of patients with residual uptake in the thyroid bed and a Tg level below 2 ng/ml three months after remnant ablation in comparison to THW. However, the overall efficacy of the third protocol was not significantly different as compared to two rhTSH injections. Under the aspect of the supply shortage of rhTSH the combined endogenous and exogenous TSH stimulation may be an attractive alternative for remnant ablation in differentiated thyroid cancer.

The updated guidelines for the determination of irreversible loss of brain function include a substantial innovation, i. e., the use of CT angiography as a supplementary technical examination. Adherence to a standardized protocol is the prerequisite for the application of CT angiography. The guidelines for standardized execution of perfusion scintigraphy are unchanged and still valid. Requirements regarding the quality of examining physicians are specified. Key points: • The guidelines for determining irreversible loss of brain function were updated. • The approval of CT angiography as a supplementary examination method is a major innovation. • CT angiography is to be performed to determine the cessation of cerebral blood circulation according to a standard protocol. • The guidelines for the standardized implementation of perfusion scintigraphy continue to be valid. • Quality requirements regarding examining physicians were specified. Citation Format: • Lanfermann H, Schober O. Imaging of Irreversible Loss of Brain Function. Fortschr Rontgenstr 2016; 188: 23 – 26

In general, differentiated thyroid carcinomas have an excellent prognosis. In addition to the biological behavior of this tumor entity this is based on optimized diagnostic procedures as well as a standardized therapeutic management and after-care. The combination of surgery, radioiodine ablation and levothyroxine medication is an effective therapeutic algorithm recommended by national and international guidelines. Thereby, survival rates of 80-100% can be achieved. In this respect, a correct risk-stratification is of particular importance which relies primarily on the UICC/AJCC TNM-classification to determine the local tumor extent and lymph node or distant metastasis. In the literature, several distinct prognostic scores have been defined accounting for different risk factors. Patient age at diagnosis, tumor size, extrathyroidal growth, lymph node and distant metastases are the most commonly used parameters integrated into these scores. Prospective studies on the long-term prognosis of patients with differentiated thyroid carcinomas are rare because of the favourable prognosis requiring long-term follow-up times and large patients cohorts. In general, this can only be achieved by multicentre studies. Retrospective analyses of large patient populations, however, can help to identify reliable risk factors of patients with differentiated thyroid carcinomas.

Die verschiedenen Verfahren der nuklearmedizinischen Diagnostik bieten dem Herz-Thorax-Chirurgen essenzielle Informationen, die a priori keine andere diagnostische Disziplin zu bieten in der Lage ist; sie sind deshalb ein unabdingbarer Bestandteil gewissenhafter Therapieplanung und des Follow-up der meisten kardiochirurgischen Eingriffe an Herz und grosen Gefasen. Der vorliegende Artikel gibt einen Uberblick uber den Einsatz verschiedener Akquisitionstechniken, Radiopharmaka und Untersuchungsprotokolle in der nuklearmedizinischen kardiovaskularen Bildgebung und deren Stellenwert innerhalb der Diagnostik von Ischamien, Vitalitatseinschrankungen des Myokards, kardialen Tumoren, Entzundungen sowie der Indikationsstellung fur Bypassoperationen, Herztransplantationen (pra- und postoperatives Monitoring), den Einsatz von Schrittmachern/Defibrillatoren und Klappeneingriffen. Daruber hinaus wagen die Autoren einen Ausblick auf die kunftigen Entwicklungen: in naher Zukunft entstehen klinisch einsetzbare, vielversprechende fusionierte Bildgebungsverfahren, die die integrierte Bewertung von funktionellen und morphologischen Informationen deutlich voranbringen und so ein Mehr an Gesamtinformation als die Summe der Einzelinformationen der separaten Methoden liefern. Daneben wird die molekulare Bildgebung kunftig mittels neuer radiochemischer Tracer eine prospektive Beurteilung der Entstehung kardiovaskularer Probleme ermoglichen und insbesondere Fragen der Plaquediagnostik und des programmierten Zelltods klaren helfen.

Summary Aim: The working group Cardiovascular Nuclear Medicine of the German Society of Nuclear Medicine in cooperation with the working group Nuclear Cardiology of the German Cardiac Society herewith present the results of the 4th survey on myocardial perfusion scintigraphy (MPS) of the year 2008. Method: 310 questionnaires (191 private practices (PP), 93 hospitals (HO), 31 university hospitals (UH)) were evaluated. Results: MPS of 98 947 patients were reported. 15% of them were younger than 50 y, 57% between 50 and 70 y and 28% older than 70 y. 88% [2007: 83%] of all were studied with Tc-99m perfusion tracers. The patient radiation exposure of a stress and rest protocol considering German standard recommended doses was 8.5 mSv, of a stress-only protocol 1.9 mSv. 77% [2007: 76%] of the MPS were performed in PP, 15% [2007: 15%] in HO and 8% [2007: 9%] in UH. From 2005 to 2008 there was a mild increase in the MPS numbers by 1.2% (PP +7.1%, HO −5.5%, UH −31.4%). The type of stress was pharmacological in 30% [2007: 27%]; 68% adenosine (of these 22% with exercise), 29% dipyridamole (of these 64% with exercise), and

Die Autoren veroffentlichen eine Verfahrensanweisung zur szintigraphischen Lokalisation von Wachterlymphknoten beim malignen Melanom und anderen Hauttumoren, beim Mammakarzinom, bei Kopf-Hals-Tumoren, beim Prostatakarzinom und beim Peniskarzinom. Wesentliche Ziele der szintigraphischen Wachterlymphknotendiagnostik bestehen in der Minimierung des Operationsausmases und der postoperativen Morbiditat sowie der Optimierung der histopathologischen Aufarbeitung durch Fokussierung auf die relevanten Lymphknoten. Die Wachterlymphknotenszintigrahie trifft selber keine Aussage zu einem evtl. tumorosen Befall und ist nicht indiziert, wenn bereits eine lymphogene Metastasierung diagnostiziert ist. Es werden Vorgehensweisen zur Durchfuhrung zusammengestellt, die zum Ziel haben, den oder die Wachterlymphknoten zuverlassig und mit hoher Nachweisrate typischerweise in einem fruhen Stadium einer Tumorerkrankung zu detektieren. Die Strahlenexposition des Patienten ist so niedrig, dass Schwangerschaft keine Kontraindikation darstellt. Aufgrund der sehr geringen Strahlenexposition von

The endothelin (ET) axis plays a major role in cardiovascular diseases and a number of human cancers. This review summarizes the work that has been published in the past ten years using labeled endothelin receptor ligands for the visualization of endothelin receptor expression in vivo.

Die Einfuhrung und Zertifizierung eines Qualitatsmanagement-Systems an einer grosen nuklearmedizinischen Universitatsklinik hat das Potenzial, Arbeitsablaufe besser zu gestalten, Aufgaben in Management und Personalfuhrung systematischer zu gestalten und Mitarbeiter aktiv in Entscheidungsprozesse zu involvieren. Dies fuhrt zu einer Steigerung der Qualitat, zu einer effizienteren Nutzung der Ressourcen und durch Einbindung, Verantwortung und Schulung zu einer hoheren Zufriedenheit bei den Mitarbeitern. Die Zertifizierung dokumentiert nach ausen das gelebte Qualitatsmanagement-System und stellt in einem zunehmend kompetitiven Umfeld einen Wettbewerbsvorteil dar. The implementation of a certified quality management system in a large nuclear medicine department at a university hospital offers the potential to increase work-flow effectiveness, to approach management duties and human resource issues more systematically and to involve members of the staff in decision processes. This results in an increased quality of patient care and a more efficient utilisation of resources. Participation, responsibility and systematic training improve satisfaction with the job. The certificate documents a policy of quality and is a competitive advantage.

Nuclear cardiology has been well established in clinical diagnostic algorithms for many years now. This is an update (2009) of the first common position paper by the German Society of Nuclear Medicine and the German Cardiac Society published in 2001 and aims to provide an overview of state-of-the-art applications of nuclear cardiology in clinical diagnostic algorithms.

Technetium-99 m labelled lipophilic radiopharmaceuticals are well established in documenting the loss of cerebral perfusion in the context of brain death diagnosis. The procedures are non invasive, can easily be applied in intensive care patients and are highly standardized. No cases have been reported in whom a complete loss of cerebral perfusion has been diagnosed with 99 m Tc-ECD or 99 m Tc-HMPAO scintigraphy in whom the diagnosis of brain death has not been confirmed thereafter. Owing to the far reaching consequences of the diagnosis “brain death”, the procedures should only be employed by experienced nuclear medicine physicians.

SummaryNuclear cardiology is well established in clinical diagnostic algorithms for many years. This is an update 2008 of the first common position paper of the German Association of Nuclear Medicine and the German Association of Cardiology, Heart and Circulation Research published in 2001 aiming at an overview of state-of-the-art scintigraphic methods.

During a ten-year period (1975-85) 56 patients with medullary carcinoma of the thyroid were under treatment. A family screening programme discovered such a tumour in the offspring of a 47-year-old female patient and her 56-year-old sister. In four of seven offspring from three lines of this family ultrasonography revealed changes in the thyroid. Positive preoperative pentagastrin test with stimulation of calcitonin as tumour marker resulted in the histological diagnosis of thyroid carcinoma.

BACKGROUND AND OBJECTIVE: According to the Medical Association’s professional code of conduct a consultation of the responsible ethics committee has to be undertaken prior to biomedical research. Up to date there has been no systematic analysis of published results after an approval from the research ethics committee of the Medical Association Westfalen-Lippe. A measure for the importance are publications of concluded trials. This work presents a comprehensive collection and evaluation of clinical trials that were approved in 1996. METHODS: Clinical trials that were approved by the ethics committee in the year 1996 were analysed concerning their publication parameters, if results have been reported to the ethics committee, the design of the study and their funding. Publications were found by database mining in the Internet sources "Pubmed” and "ISI Web of Knowledge”. RESULTS: 70 % out of the 99 approved clinical trials were published as specified in the initial proposal, whereas in 2 % only aspects of the proposal were published. In 21 % of the cases only publications in closely related subjects could be identified. 7 % however remained unpublished. Of these studies 63 % were designed as mono centre study and 37 % as multi centre studies. The time from approval of the study until publication was 46 months (median value). Furthermore the analysis revealed, that 45 % of the studies were funded by industry. CONCLUSION: This work represents an unprecedented and detailed analysis of the clinical studies approved by a German ethics committee. In the course of this work a comprehensive catalogue with criteria to facilitate a collection and tracking mechanism was established. This should enable the ethics committee to comply with their new duties. A great amount of the clinical trials were presented in publications to the scientific community.

SummaryThe working group Cardiovascular Nuclear Medicine of the German Society of Nuclear Medicine (DGN), in cooperation with the working group Nuclear Cardiology of the German Cardiac Society (DGK), decided to conduct a national survey on myocardial perfusion scintigraphy (MPS). Method: A questionnaire to evaluate MPS for the year 2005 was sent. Results: 346 completed questionnaires had been returned (213 private practices, 99 hospitals and 33 university hospitals). MPS of 112 707 patients were reported with 110 747 stress and 95 878 rest studies. The majority (>75%) was performed with 99mTc-MIBI or tetrofosmin. 201Tl stress-redistribution was used in 22 637 patients (20%). The types of stress were exercise in 78%, vasodilation with adenosine or dipyridamol in 21% and dobutamine in 1%. 99.97% of all MPS were SPECT studies. Gated SPECT was performed in 36% of the stress and in 32% of the rest studies. An attenuation correction was used in 21%. 29 institutions (8%) performed gated SPECT (stress and rest) and attenuation correction. 47% of all MPS were requested by ambulatory care cardiologists, 17% by internists, 12% by primary care physicians, 21% by hospital departments and 2% by others. Conclusion: In Germany, MPS is predominantly performed with 99mTc-perfusion agents. The common type of stress is ergometry. Gated SPECT and attenuation correction do not yet represent standards of MPS practice in Germany, which indicates some potential of optimization.

Die Verfahrensanweisung zur Radioiodtherapie (RIT) und zur 131I-Ganzkorperszintigraphie beim differenzierten Schilddrusenkarzinom im Kindes- und Jugendalter reiht sich thematisch neben die entsprechenden Verfahrensanweisungen (Version 3), die fur erwachsene Patienten verfasst sind, und konkretisiert die interdisziplinare Leitlinie der Deutschen Krebsgesellschaft um die nuklearmedizinischen Aspekte. Besonderheiten im Kindes- und Jugendalter sind die hohere Aggressivitat des papillaren Schilddrusenkarzinoms, die Haufigkeit eines organuberschreitenden Tumorwachstums und einer disseminierten pulmonalen Metastasierung sowie die hohe lokale Rezidivrate. Die TNM-Klassifikation wird aufgrund der geringen Ausdehnung der normalen kindlichen Schilddruse der Risikostratifikation nicht gerecht. Grundsatzlich besteht auch bei Kindern die Empfehlung zur Radioiodtherapie, wobei die 131I-Aktivitat gewichtsabhangig appliziert wird. Bei kleinen papillaren Schilddrusenkarzinomen (≤1 cm) ist die Indikation zu einer ablativen Radioiodtherapie eher groszugig zu stellen. Nach Hormonentzug wird die TSH-Stimulation bereits nach zwei Wochen (Kinder) bzw. drei Wochen (Jugendliche) erreicht. Antiemetika werden groszugig verordnet. Die Indikation zur CT des Thorax und zur Lungenfunktionsuntersuchung ist bei Metastasenverdacht groszugig zu stellen. Auf die diagnostische 131I-Ganzkorperszintigraphie drei bis sechs Monate nach ablativer Radioiodtherapie sollte wegen der Haufigkeit einer lymphogenen Metastasierung nicht verzichtet werden. Nachsorgeintervalle sind eher kurzer zu wahlen, um eine unzureichende Compliance bei Kindern fruhzeitig zu erfassen und um die Hormondosis gewichtsbezogen anzupassen. Der hohere Normbereich von fT3 fur Kinder ist zu beachten. Es liegt keine ausreichende Evidenz vor, ob und wann eine nicht-suppressive Einstellung der Schilddrusenfunktion sinnvoll ist. Daher ist die TSHSuppression grundsatzlich anzustreben.

SummaryVersion 4 of the guideline for radioiodine therapy for benign thyroid diseases includes an interdisciplinary consensus on decision making for antithyroid drugs, surgical treatment and radioiodine therapy. The quantitative description of a specific goiter volume for radioiodine therapy or operation was cancelled. For patients with nodular goiter with or without autonomy, manifold circumstances are in favor of surgery (suspicion on malignancy, large cystic nodules, mediastinal goiter, severe compression of the trachea) or in favor of radioiodine therapy (treatment of autonomy, age of patient, co-morbidity, history of prior subtotal thyroidectomy, profession like teacher, speaker or singer). For patients with Graves' disease, radioiodine therapy or surgery are recommended in the constellation of high risk of relapse (first-line therapy), persistence of hyperthyroidism or relapse of hyperthyroidism. After counseling, the patient gives informed consent to the preferred therapy. The period after radioiodine therapy of benign disorders until conception of at least four months was adapted to the European recommendation.

Radioiodtherapie und 131I-Ganzkorperszintigraphie zwischen evidentia1 und evidence2 - Anmerkungen zur Aktualisierung der Verfahrensanweisungen und Leitlinien

Curative therapies for Ewing sarcoma have been developed within cooperative groups. Consecutive clinical trials have systematically assessed the impact and timing of local therapy and the activity of cytotoxic drugs and their combinations. They have led to an increase of long-term disease-free survival to around 70% in patients with localized disease. Translational research in ES remains an area in which interdisciplinary and international cooperation is essential for future progress. This article reviews current state-of-the art therapy, with a focus on trials performed in Europe, and summarizes novel strategies to further advance both the cure rates and quality of survival.

The subject of our work is the biological investigation of 99m Tc-MAG 3 and of the by-products occurring during the labeling reaction

Diagnosis of chronic inflammatory bowel disease (IBD) in children requires noninvasive, atraumatic diagnostic tools that depict localization and acuity of inflammation and yield only a low radiation dose. This retrospective analysis evaluates the diagnostic potential of FDG-PET. Twenty-six consecutive FDG-PET scans of 23 patients (age: 2-16, years, 14 M, 9 F) with suspected IBD were analyzed in this retrospective study. Results were compared to endoscopic, histologic, and abdominal ultrasound (US) finding. In these examinations, presence of inflammation was evaluated in each patient in 8 bowel segments (score 1-4). Standardized uptake values (SUVs) for FDG-PET were measured for all segments. Sensitivity, specificity, and accuracy were calculated using histology as the standard of reference on a segment-based analysis (pathologic if inflammation score > or = 3 or SUV(max)/SUV(liver)>1.2). With histology as the standard of reference, FDG-PET showed a sensitivity/specificity/accuracy of 98%/68%/8%/3 as compared to endoscopy (90%/75%/82%) and US (56%/92%/75%). For the small bowel, FDG-PET was even more reliable (100%/86%/90%). Because of its high sensitivity and accuracy,FDG-PET is an excellent, noninvasive diagnostic tool for IBD. Depicting inflammation in the whole bowel, while being not traumatic, it is attractive for use especially in children. FDG-PET is especially reliable for the small bowel and can inform application of topical therapy.

Beim differenzierten Schilddrusenkarzinom besteht bei nicht Organkapsel uberschreitendem Tumorwachstum und adaquater Operation keine Indikation zur postoperativen Bestrahlung. Bei Patienten mit Organkapsel uberschreitendem Wachstum wird nach vollstandiger Resektion der Nutzen einer zusatzlichen perkutanen Radiotherapie kontrovers diskutiert. Die MSDS-Studie (Multizenterstudie Differenziertes Schilddrusenkarzinom), die eine Randomisierung genau zu dieser Fragestellung durchfuhrte, musste aufgrund der mangelnden Rekrutierung vorzeitig beendet werden. Beim anaplastischen Schilddrusenkarzinom wird die vollstandige Resektion angestrebt. Die postoperative Bestrahlung ist dann obligat. Bei Therapieprotokollen mit zusatzlicher Adriamycingabe konnten erhohte lokale Kontroll- und Uberlebensraten beobachtet werden. Bei medullarem Schilddrusenkarzinom und inkompletter Tumorresektion geht eine additive Radiotherapie mit einer verbesserten lokalen Kontrolle einher. Bei nicht Radiojod speichernden Metastasen des Schilddrusenkarzinoms wird die Radiotherapie im Bereich des Knochens bei Schmerzen, Frakturgefahr oder Myelonkompression eingesetzt.

Summary Aim: The clinical value of positron emission tomography using fluorine-18 fluoro-deoxy-glucose (FDG-PET) in the staging of adult lymphoma has been shown in many studies. However, there are only few data regarding childhood lymphoma. The purpose of this retrospective study was to compare the staging of childhood lymphoma using FDG-PET and the established computed tomography (CT). Method: Whole-body FDG-PET was performed in 25 children with histologically proven Hodgkin ´s disease (n = 18) and non-Hodgkin´s lymphoma (n = 7) using a dedicated PET. The findings were compared with the CT results. Both examinations, FDG-PET and CT, were assessed by two experienced physicians. In each patient, 30 regions were analysed (22 nodal, 8 extranodal). Each region was assessed using a fivevalue scale (definitely/probably positive, equivocal, probably/definitely negative). Results: 662 regions (470 nodal, 192 extranodal) were compared. 91 regions (81 nodal, 10 extranodal; 14%) were concordant positive and 517 regions (347 nodal, 170 extranodal; 78%) were concordant negative. In 47 regions, 48 discordant findings (7%) were described: 27 findings (22 nodal, 5 extranodal) were positive using FDG-PET and negative using CT whereas 21 findings (17 nodal, 4 extranodal) were positive using CT and negative using PET. A total of 7 regions (1%) were judged equivocal in one imaging modality (1 FDG-PET, 6 CT). Using FDG-PET as compared to CT, resulted in a higher staging in 4 of 25 patients and in a lower staging in 2 of 25 patients. Conclusion: Staging of childhood lymphoma using FDGPET shows differences compared with CT resulting in a different staging in 6 of 25 patients. Prospective studies are required to evaluate the impact of these discrepancies on the clinical management of pediatric patients.

Summary Purpose: To evaluate single photon emission computed tomography (SPECT) using the amino acid l-3-[123I]-α-methyl tyrosine (IMT) and contrast enhanced magnetic resonance imaging (MRI) as diagnostic tools in primary paediatric brain tumours in respect of non-invasive tumour grading. Patients, materials, methods: 45 children with primary brain tumours were retrospectively evaluated. IMT uptake was quantified as tumour/nontumour- ratio, a 4-value-scale was used to measure gadolinium enhancement on contrast enhanced MRI. Statistical analyses were performed to evaluate IMT uptake and gadolinium enhancement in low (WHO I/II) and high (WHO III/ IV) grade tumours and to disclose a potential relationship of IMT uptake to disruption of blood brain barrier as measured in corresponding MRI scans. Results: IMT uptake above background level was observed in 35 of 45 patients. IMT uptake was slightly higher in high grade tumours but the difference failed to attain statistical significance. Grading of individual tumours was neither possible by IMT SPECT nor by gadolinium enhanced MRI. Conclusion: IMT is accumulated in most brain tumours in children. Tumour grading was not possible using IMT or contrast enhancement as determined by MRI. Neither morphological nor functional imaging can replace histology in paediatric brain tumours.

Summary:Motion in PET/CT leads to artifacts in the reconstructed PET images due to the different acquisition times of positron emission tomography and computed tomography. The effect of motion on cardiac PET/CT images is evaluated in this study and a novel approach for motion correction based on optical flow methods is outlined. The Lukas-Kanade optical flow algorithm is used to calculate the motion vector field on both simulated phantom data as well as measured human PET data. The motion of the myocardium is corrected by non-linear registration techniques and results are compared to uncorrected images.

Die hoch dosierte Radiojodtherapie wird gemas den Leitlinien der Deutschen Krebsgesellschaft bei allen differenzierten Schilddrusenkarzinomen zur Ablation des nach Thyroidektomie verbliebenen Schilddrusenrestgewebes durchgefuhrt. Einzige Ausnahme ist das auf die Schilddruse beschrankte unifokale papillare Mikrokarzinom ≤1 cm ohne Lymphknoten oder Fernmetastasen. Durch die Sterilisation (pra-)maligner Zellen im Schilddrusenrestgewebe oder in zervikalen Lymphknoten wird die lokoregionare Rezidivrate im Gegensatz zur ausschlieslichen chirurgischen Therapie wirksam auf unter 10% in 10 Jahren gesenkt. Eine effektive Therapie Jod speichernder Metastasen ist ebenfalls moglich. Durchfuhrung der Therapie und Nachsorge sollten aufgrund der Seltenheit des Krankheitsbilds spezialisierten Zentren vorbehalten bleiben.

Combining positron emission tomography (PET) and X-ray computed tomography (CT) with simultaneous acquisition may improve diagnostic accuracy in oncology. Moreover this combination holds considerable promise in radiotherapy. Metabolic information may be used in decision making in radiotherapy and in planning target volumes. Furthermore early evaluation of treatment efficacy becomes possible. New tracers for the assessment of tumour hypoxia or apoptosis in clinical routine are currently being developed. These tracers may yield high relevance in radiotherapy. Hybrid scanners facilitate patient handling and shorten the duration of acquisition. Furthermore fusion accuracy is optimal. Prospective studies have to be conducted to show that the new technology improves patient care in terms of efficiency and quality.

SummaryThe procedure guidelines for radioiodine therapy (RIT) of differentiated thyroid cancer (version 2) are the counterpart to the procedure guidelines for 131I whole-body scintigraphy (version 2) and specify the interdisciplinary guidelines for thyroid cancer of the Deutsche Krebs-gesellschaft and the Deutsche Gesellschaft für Chirurgie concerning the nuclear medicine part. Compared with version 1 facultative options for RIT can be chosen in special cases: ablative RIT for papillary microcarcinoma ≤1 cm, ablative RIT for mixed forms of anaplastic and differentiated thyroid cancer, and RIT in patients with a measurable or increasing thyroglobulin concentration but without detectable metastases by imaging. The description of the pretherapeutic dosimetry now includes the isotopes 123I and 124I as well as a broader range of the activity of 131I. Activities of 2-5 GBq 131I are recommended for the first ablative RIT. If high accumulative activities of 131I are expected, men who have not yet finished their family planning should be advised to the option of sperm cryoconservation. An interdisciplinary consensus is necessary whether the new TNM-classification (UICC, 6th edition, 2002) will lead to modified recommendations for surgical or nuclear medicine therapy, especially for the surgical completeness and for the ablative RIT of pT1 papillary cancer.

SummaryPapillary thyroid microcarcinomas £1 cm have an excellent prognosis both in terms of overall and relapse-free survival. Their high prevalence in autopsy series suggests that most papillary microcarcinomas do not progress to clinically relevant cancer. The extent of surgery is still controversial. Lobectomy or subtotal resection are standard procedures, but multifocal microcarcinomas or lymph node metastases might be overlooked. The pros and cons of completion thyroidectomy and ablative radioiodine therapy are based on limited evidence due to heterogenous inclusion criteria in published series. The retrospective data analyses included subgroups with infiltration of the thyroid capsule, lymph node metastases or multifocal microcarcinomas at the primary staging. The local relapse rate reached approximately 7% after different therapeutic regimes. Radioiodine ablation decreased the recurrence rate in some retrospective studies, but data are inconsistent. Successful radioiodine ablation is possible also after less radical surgery without complete thyroidectomy with postoperative 131I uptake of 10 to 20% or remnants of 3-8 ml. This concept was evaluated successfully in a monocentric series of patients with multifocal microcarcinomas. The therapeutic consideration should include the diameter of the carcinoma, neigh-bourhood to the thyroid capsule, histopathologic subgroups, age, familiar occurrence, patient’s informed consent and in future moleculargenetic tests, too. Therefore, limited surgical procedures for small papillary carcinomas as therapeutic standard, respectively thyroidectomy, lymph node dissection in the central compartment of the neck and ablative radioiodine therapy for individual cases are options for experienced surgeons and specialized tumour centers.

Hintergrund. Bei Patienten mit malignem Melanom der Haut erlaubt die Dissektion des Sentinel-Lymphknotens (SLND) eine zuverlassige Aussage uber das Vorliegen einer regionaren Lymphknotenmetastasierung.

Summary Aim: The Multicenter Study Differentiated Thyroid Carcinoma (MSDS) is an ongoing study in Germany, Austria, and Switzerland on the clinical benefit of adjuvant external beam radiotherapy (RTx) for locally invasive differentiated thyroid carcinoma (DTC) in TNM stages pT4 pN0/1/x M0/x (5th ed. 1997). Methods: MSDS was designed as a prospective randomized trial. Patients receive thyroidectomy, radioiodine therapy (RIT) to ablate the thyroid remnant, and TSH-suppressive L-thyroxine therapy with or without RTx after documented elimination of cervical iodine-131 uptake (http://msdsstudie.uni-muenster.de). Results: 311 patients were enrolled between January 2000 and March 2003. 279 patients met the trial’s inclusion criteria. 45 consented to randomization, of whom 17 were randomized into treatment arm A (RTx) and 18 into arm B (no RTx).Advised by the trial’s independent Data Monitoring and Safety Committee, the MSDS steering committee decided to terminate randomization in April 2003 and continue MSDS as a prospective cohort study. 23 of the 234 patients in the observation arm of the trial were prescribed RTx by their physicians. Thus, 14% of the trial cohort were randomized or assigned to receive RTx (intention-to-treat analysis). In contrast, at least 44% of all patients with pT4 papillary DTC in Germany in the nationwide PCES study underwent RTx in 1996 (p

Summary: Aim: As results of cardiac biopsies suggest, myocardial β1-adrenoceptor density is reduced in patients with chronic heart failure. However, changes in cardiac β2-adrenoceptors vary. With suitable radiopharmaceuticals single photon emission computed tomography (SPECT) and positron emission tomography (PET) offer the opportunity to assess β-adrenoceptors non-invasively. Among the novel racemic analogues of the established β1-selective adrenoceptor antagonist ICI 89.406 the iodinated 2-I-ICI-H showed high affinity and selectivity to β1-adrenoceptors in murine ventricular membranes. The aim of this study was its evaluation as a putative sub-type selective β1-adrenergic radioligand in cardiac imaging. Methods: Competition studies in vitro and in vivo were used to investigate the kinetics of 2-I-ICI-H binding to cardiac β-adrenoceptors in mice and rats. In addition, the radiosynthesis of 2-125I-ICI-H from the silylated precursor 2-SiMe3-ICI-H was established. The specific activity was 80 GBq/µmol, the radiochemical yield ranged from 70 to 80%. Results: The unlabelled compound 2-I-ICI-H showed high β1-selectivity and -affinity in the in vitro competition studies. In vivo biodistribution studies apparently showed low affinity to cardiac β-adrenoceptors. The radiolabelled counterpart 2-125I-ICI-H showed a high degree of non-specific binding in vitro and no specific binding to cardiac β1-adrenoceptors in vivo. Conclusion: Because of its high non-specific binding 2-125I-ICI-H is no suitable radiotracer for imaging in vivo.

SummaryThe version 2 of the guideline for diagnostic standards of thyroid disorders is an update of the guideline published in 1999 and describes standards of in vitro and in vivo procedures. The following statements are modified: In vitro procedures: When measurement of the TSH-receptor antibodies is indicated, the guideline recommends the use of a second generation assay (recombinant human TSH-receptor as antigen). The functional assay sensitivity for the measurement of thyroglobulin should reach a value ≤1 ng/ml. Moleculargenetic tests (RET proto-oncogen) are indicated in patients with a newly diagnosed medullary thyroid cancer and in the relatives of patients with hereditary medullary thyroid cancer. In vivo procedures: The sonographic examination should use a probe with a frequency of at least 7.5 MHz. Indications for the thyroid scintigraphy: nodule size ≥1 cm in diameter, autonomous goitre/nodule with clinical or subclinical hyperthyroidism, necessity of a differentiation between Graves’ disease and chronic lymphocytic thyroiditis, therapy control after a definitive treatment and – in individual cases – the follow-up of untreated autonomous nodules.

Summary Aim: Elevated iodine intake is a serious problem in the diagnostic and therapeutic application of 131iodine in patients with differentiated thyroid cancer. Therefore, iodine avoidance is necessary 3 months in advance. Additionally, endogenous stimulation requires withdrawal of thyroid hormone substitution for 4 weeks. Exogenous stimulation using recombinant human TSH (rhTSH) enables the continuous substitution of levothyroxine, which contains 65.4% of its molecular weight in iodine. Thus, a substantial source of iodine intake is maintained during exogenous stimulation. Although this amount of stable iodine is comparable to the iodine intake in regions of normal iodine supply, it may reduce the accumulation of radioiodine in thyroid carcinoma tissue. The aim of this study was to assess the iodine excretion depending on different ways of stimulation. Methods: Iodine excretion was measured in 146 patients in the long term follow up after differentiated thyroid carcinoma. Patients were separated into 2 groups, those on hormone withdrawal (G I) and rhTSH-stimulated patients on hormone substitution (G II). Results: Iodine excretion was significantly lower in hypothyroid patients (G I, median 50 μg/l, range: 25-600 μg/l) than in those under levothyroxine medication (G II, median 75 μg/l, 25-600 μg/l, p

Summary:Aim: 18F-FDG-PET (FDG-PET) is established in staging and follow-up of malignant melanoma. The legs are affected in 10-40% at time of diagnosis even if the primary is at the arms and torso. Imaging including the legs may detect distant manifestations but increases duration of the scan by ~30 min. We intended to disclose the diagnostic benefit of scanning the legs and to evaluate the therapeutic benefit resulting. Patients, Methods: In this retrospective analyse 213 consecutive PET studies of 153 patients with suspected or recent malignant melanoma were re-evaluated for metastastic spread by a blinded investigator. Histopathological follow-up was assessed for confirmation. Results: Suspicious findings at the legs were depicted in 53 patients on 76 occasions. 38/53 showed pathologic uptake in the torso as well. In 15/53 patients it was restricted to the legs. One of them had a hitherto unknown, clinically relevant finding that was not apparent in palpation and inspection. In 6 other patients with primary location at the legs a validation of the positive PET findings was not possible up to now. Conclusion: Metastases and local recurrence of malignant melanoma at the legs were found in 41% of women and 27% of men. However, a long scan does not yield relevant additional data. We found isolated new manifestations at the legs in only 1/153 patients. We recommend performing a long scan only in patients with previous melanoma manifestations restricted to the legs. In all other cases a short scan of the torso and proximal thighs is sufficient. This allows a higher number of PET-scans without loss of diagnostic power and a shorter examination time.