Sentinel node biopsy in head and neck squamous cell cancer: 5-year follow-up of a European multicenter trial

BACKGROUND

Sentinel node biopsy (SNB) may represent an alternative to elective neck dissection for the staging of patients with early head and neck squamous cell carcinoma (HNSCC). To date, the technique has been successfully described in a number of small single-institution studies. This report describes the long-term follow-up of a large European multicenter trial evaluating the accuracy of the technique.

METHODS

A total of 227 SNB procedures were carried out across 6 centers, of which 134 were performed in clinically T1/2 N0 patients. All patients underwent SNB with preoperative lymphoscintigraphy, intraoperative blue dye, and handheld gamma probe. Sentinel nodes were evaluated with hematoxylin and eosin (H&E) staining, step-serial sectioning (SSS), and immunohistochemistry (IHC). There were 79 patients who underwent SNB as the sole staging tool, while 55 patients underwent SNB-assisted elective neck dissection.

RESULTS

Sentinel nodes were successfully identified in 125 of 134 patients (93%), with a lower success rate observed for floor-of-mouth tumors (FoM; 88% vs. 96%, P = 0.138). Also, 42 patients were upstaged (34%); of these, 10 patients harbored only micrometastatic disease. At a minimum follow-up of 5 years, the overall sensitivity of SNB was 91%. The sensitivity and negative predictive values (NPV) were lower for patients with FoM tumors compared with other sites (80% vs. 97% and 88% vs. 98%, respectively, P = 0.034).

CONCLUSIONS

Sentinel node biopsy is a reliable and reproducible means of staging the clinically N0 neck for patients with cT1/T2 HNSCC. It can be used as the sole staging tool for the majority of these patients, but cannot currently be recommended for patients with tumors in the floor of the mouth.

Detection of relevant colonic neoplasms with PET/CT: promising accuracy with minimal CT dose and a standardised PET cut-off

Objective:

To determine the performance of FDG-PET/CT in the detection of relevant colorectal neoplasms (adenomas ≥10 mm, with high-grade dysplasia, cancer) in relation to CT dose and contrast administration and to find a PET cut-off.

Methods:

84 patients, who underwent PET/CT and colonoscopy (n = 79)/sigmoidoscopy (n = 5) for \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${\left( {{\hbox{79}} \times {\hbox{6}} + {\hbox{5}} \times {\hbox{2}}} \right)} = {\hbox{484}}$$\end{document} colonic segments, were included in a retrospective study. The accuracy of low-dose PET/CT in detecting mass-positive segments was evaluated by ROC analysis by two blinded independent reviewers relative to contrast-enhanced PET/CT. On a per-lesion basis characteristic PET values were tested as cut-offs.

Results:

Low-dose PET/CT and contrast-enhanced PET/CT provide similar accuracies (area under the curve for the average ROC ratings 0.925 vs. 0.929, respectively). PET demonstrated all carcinomas (n = 23) and 83% (30/36) of relevant adenomas. In all carcinomas and adenomas with high-grade dysplasia (n = 10) the SUV_max was ≥5. This cut-off resulted in a better per-segment sensitivity and negative predictive value (NPV) than the average PET/CT reviews (sensitivity: 89% vs. 82%; NPV: 99% vs. 98%). All other tested cut-offs were inferior to the SUV_max.

Conclusion:

FDG-PET/CT provides promising accuracy for colorectal mass detection. Low dose and lack of iodine contrast in the CT component do not impact the accuracy. The PET cut-off SUV_max ≥ 5 improves the accuracy.

Initial experience with 18F-fluoroethylcholine PET/CT in staging and monitoring therapy response of advanced renal cell carcinoma

OBJECTIVE

The use of 18F-fluoroethylcholine (FEC) PET/ CT in staging and monitoring therapy response of advanced renal cell carcinoma (RCC) was prospectively analysed.

METHODS

Preliminary results of two patients with metastatic RCC who underwent tumour nephrectomy as well as FEC PET/CT before and 10 weeks after two cycles of tyrosine kinase inhibitor therapy are presented.

RESULTS

All in all, 18 tumour lesions were detected by baseline PET/CT, of which 10 (56%) were positive in FEC PET and 17 (94%) visible on contrast-enhanced computed tomography (ceCT). Mainly, small lung metastases resulted in the lower detection rate of FEC PET compared with ceCT. In follow-up PET/CT of the first case, progressive disease (PD) occurred with increase in tumour diameters of all metastases but non-uniform metabolic response. In the second case, partial response (PR) was achieved with concordant results of PET and CT. These results were confirmed by further CT in the course of disease.

CONCLUSIONS

In this small sample more than half of the RCC metastases were evident in baseline FEC PET. Monitoring therapy, FEC PET showed heterogeneous results in the first case with PD and was consistent with ceCT in the second one displaying PR.

Comparison of positron emission tomography with [(18)F]FDG and [(68)Ga]DOTATOC in recurrent differentiated thyroid cancer: preliminary data

AIM

The aim of this study was to retrospectively analyse the value of positron emission tomography (PET) with a radiolabelled somatostatin analogue, [(68)Ga]DOTATOC, in recurrent radioiodine positive and negative differentiated thyroid cancer (DTC) compared to [(18)F]FDG PET.

METHODS

Seventeen patients with known or suspected recurrent DTC were enrolled in this study. All patients underwent PET with [(68)Ga]DOTATOC and [(18)F]FDG under TSH suppressive therapy and whole-body scintigraphy (WBS) after administration of [(131)I] following TSH stimulation. The total number of tumour lesions was defined as the sum of the lesions detected by at least one of these three imaging techniques. Pathologic findings were confirmed histopathologically or by follow-up and conventional radiological imaging.

RESULTS

Both PET tracers consistently detected metastases in 12 patients. In two cases, only [(131)I] WBS and computed tomography revealed metastatic disease; in the remaining three patients with an increased thyroglobulin no correlate could be found. From a total of 104 tumour lesions, [(18)F]FDG PET showed only slightly higher detection rate than [(68)Ga]DOTATOC PET in radioiodine positive patients (28/31 versus 25/31), whereas significant differences were seen in the group with negative [(131)I] WBS (70/73 versus 26/73, P<0.01). Three out of 104 lesions were only visible using [(68)Ga]DOTATOC PET.

CONCLUSIONS

[(68)Ga]DOTATOC and [(18)F]FDG PET showed comparable diagnostic performance in recurrent, radioiodine positive DTC. Due to much higher lesion detection rates, [(18)F]FDG PET should be preferred to [(68)Ga]DOTATOC PET in the work-up of radioiodine negative DTC relapse. These preliminary results have to be confirmed by more extensive data in further studies.

[PET and diagnostic technology evaluation in a global clinical process. DGN's point of view]

The German Society of Nuclear Medicine (DGN) criticizes the methodological approach of the IQWiG for evaluation of PET and the conclusions, which represent the opposite point of view compared to the most other European countries and health companies in the USA: 1.) Real integration of experienced physicians into the interpretation of data and the evaluation of effectiveness should be used for best possible reporting instead of only formal hearing. 2.) Data of the National Oncologic PET Registry (NOPR) from the USA have shown, that PET has changed the therapeutic management in 38% of patients. 3.) The decision of the IQWiG to accept outcome data only for their benefit analyses, is controversial. Medical knowledge is generated by different methods, and an actual analysis of the scientific guidelines has shown that only 15 % out of all guidelines are based on the level of evidence demanded by the IQWiG. Health economics has created different assessment methods for the evaluation of a diagnostic procedure. The strategy chosen by the IQWiG overestimated the perspective of the population and undervalue the benefit for an individual patient. 4.) PET evaluates the effectiveness of a therapeutic procedure, but does not create an effective therapy. When the predictive value of PET is already implemented in a specific study design and the result of PET define a specific management, the trial evaluate the whole algorithm and PET is part of this algorithm only. When PET is implemented as test during chemotherapy or by the end of chemotherapy, the predictive value of PET will depend decisively on the effectiveness of the therapy: The better the therapy, the smaller the differences in survival detected by PET. 5.) The significance of an optimal staging by the integration of PET will increase. Rationale is the actual development of "titration" of chemotherapy intensity and radiation dose towards the lowest possible, just about effective dosage. 6.) The medical therapy of malignancies will be improved continuously. It is the claim of the health insurances to implement innovative therapeutic approaches in controlled clinical trials with tools of quality control. The monitoring committee is responsible for the safety of the patients. PET is part of the health care. Internationally accepted rules for clinical trials stipulate that any interim analyses of those trials are confidential as long as recruitment is active. The delay until evidence is documented by the published final analysis is methodologically accepted and not a characteristic of PET. 7.) Procedures in nuclear medicine without the use of PET-tracers with short half-life will increase the radiation exposure of the patients; the use of non-PET-tracers with longer half-life is in contravention of the German regulation of radiation protection.

[Guideline for radioimmunotherapy of CD20+ follicular B-cell non-Hodgkin's lymphoma]

This guideline is a prerequisite for the quality management in the treatment of non-Hodgkon-lymphomas in patients with relapsed or refractory follicular lymphoma after rituximab therapy and as consolidation therapy after first remission following CHOP like treatment using radioimmunotherapy. It is based on an interdisciplinary consensus and contains background information and definitions as well as specified indications and detailed contraindications of treatment. Essential topics are the requirements for institutions performing the therapy. For instance, presence of an expert for medical physics, intense cooperation with all colleagues committed to treatment of lymphomas, and a certificate of instruction in radiochemical labelling and quality control are required. Furthermore, it is specified which patient data have to be available prior to performance of therapy and how treatment has to be carried out technically. Here, quality control and documentation of labelling are of great importance. After treatment, clinical quality control is mandatory (work-up of therapy data and follow-up of patients). Essential elements of follow-up are specified in detail. The complete treatment inclusive after-care has to be realised in close cooperation with those colleagues (hemato-oncologists) who propose, in general, radioimmunotherapy under consideration of the development of the disease.

Real-time elastography and contrast-enhanced ultrasound for the assessment of thyroid nodules

OBJECTIVE

Work-up of thyroid nodules remains challenging. Recent technologies enable determination of tissue elasticity and perfusion using ultrasound devices. The aim of the present study was to evaluate real-time elastography (RTE) and contrast-enhanced ultrasound with Sonovue (CEUS) for the differentiation of benign and malignant thyroid nodules.

MATERIALS AND METHODS

Inclusion criteria were: nodules ≥1 cm, non-functioning or hypo-functioning on radionuclide scanning, and cytological/histological assessment. All patients received conventional ultrasound, RTE and CEUS. RTE was classified as: Elasticity-Score (ES)1 = soft, ES2 = predominantly soft, ES3 = predominantly hard, ES4 = hard nodule. CEUS-video clips were digitally recorded and analyzed using time-intensity-curves within selected regions-of-interest.

RESULTS

Fifty-three nodules in 50 patients were available for analysis. Forty-six nodules were benign on cytology/histology, 6 nodules were papillary carcinoma and one nodule was a follicular carcinoma. Nodule margin irregularity was the ultrasound pattern most predictive of malignancy with sensitivity 57% (95% confidence interval: 18-90%) and specificity 85% (71-94% p<0.05). When using ES3&4 for the diagnosis of malignant nodules sensitivity and specificity were 86% (42-99.7%) and 87% (75-95%), respectively (p = 0.0003). The only malignant nodule missed with RTE was a follicular carcinoma. Sensitivity for the diagnosis of papillary carcinoma therefore was 100%. No specific CEUS pattern could be identified to differentiate between benign and malignant nodules.

CONCLUSIONS

RTE seems to be a useful tool in the work-up of thyroid nodules to exclude papillary thyroid cancer. However, follicular carcinoma remains a challenging problem. CEUS did not improve the characterization of thyroid nodules in this preliminary study.

18F-FDG PET for detecting metastases and synchronous primary malignancies in patients with oral and oropharyngeal cancer

AIM

Assessment of the efficiency of 18F-FDG-PET (PET) for the detection of distant metastases and synchronous primary malignancies in patients with oral and oropharyngeal squamous cell cancer (OOSCC).

PATIENTS, METHODS

Retrospective evaluation of PET studies of 422 patients with histologically confirmed OOSCC. 99 patients (23.5%) demonstrated a suspect distant finding of whom 84 could be interdisciplinary evaluated and consecutively confirmed or refuted by other diagnostic modalities or biopsy.

RESULTS

In 74 of 80 evaluable cases, PET showed the primary tumour (92.5%). 26/84 suspect distant lesions (31%) showed by means of PET were confirmed to be malignancies (mean SUV 3.96; range 1.4-9.37). Main sites were the lung, the upper aerodigestive tract, and the gastrointestinal system. In the other 58 cases (69%), where the suspect lesions were confirmed as benign, mean SUV was 2.65 (range 0.7-6.5) (difference statistically significant). The SUV above which every suspect finding was proven to be of malignant condition was 6.5 (specificity 100%, sensitivity 38%, accuracy 81%).

CONCLUSION

PET may have an important role in initial staging and the detection of distant metastases and synchronous primary malignancies. Setting a SUV threshold for determining malignancies can support interpretation. In borderline cases, however, interdisciplinary evaluation by means of other diagnostic modalities remains crucial.

Vitamin D receptor polymorphisms in differentiated thyroid carcinoma

BACKGROUND

Vitamin D receptor (VDR) expression has been shown to be upregulated in several tumors and is supposed to represent an important endogenous response to tumor progression. To investigate the role of the VDR gene and its influence on 25(OH)D(3) and 1,25(OH)(2)D(3) plasma levels in thyroid carcinoma, we analyzed four VDR polymorphisms in patients and healthy controls (HC).

METHODS

Patients with thyroid carcinoma (n = 172) (n = 132 for papillary and n = 40 for follicular) and HC (n = 321) were genotyped for the ApaI (rs7975232), TaqI (rs731236), BsmI (rs1544410), and FokI (rs10735810) polymorphisms within the VDR gene and correlated with 25(OH)D(3) and 1,25(OH)(2)D(3) plasma levels.

RESULTS

The genotypes AA of the ApaI (rs7975232) and FF of the FokI (rs10735810) polymorphisms were significantly less frequent (12.5% vs. 35.2% and 25% vs. 42.1%, respectively, both corrected p [p(c)] = 0.04) in patients with follicular thyroid cancer (FTC) than in HC. Additionally, the haplotypes, Ta (57.5% vs. 41.4%; p(c) = 0.0207), af (24.6% vs. 14.3%; p(c) = 0.0116), Tab (51.1% vs. 36.8%; p(c) = 0.0495), and Tabf (18.7% vs. 13.6%; p(c) = 0.0240) were more frequent, whereas the haplotypes AF (17.1% vs. 37.2%; p(c) = 0.0008), BF (11.4% vs. 31.9%; p(c) = 0.012), tF (7.9% vs. 25.5%; p(c) = 0.0016), and tABF (7.6% vs. 23%; p(c) = 0.0115) were less frequent in the FTC patients compared to HC. Neither genotype nor haplotype frequencies differed between patients with papillary thyroid cancer (PTC) and HC. Further, individuals with PTC and FTC had a significantly lower level of circulating 1,25(OH)(2)D(3) compared to controls. In contrast, no differences of the 25(OH)D(3) concentration between patients and HC were observed. VDR polymorphisms were not associated with 25(OH)D(3) and 1,25(OH)(2)D(3) plasma levels.

CONCLUSIONS

Lower circulating levels of 1,25(OH)(2)D(3) are observed in patients with differentiated thyroid carcinoma. Further, while the alleles AA and FF of the ApaI (rs7975232) and FokI (rs10735810) VDR polymorphisms and the haplotype tABF confer to protection from follicular carcinoma, the haplotype Tabf appeared to be associated with an increased FTC risk. Since this is the first report associating VDR polymorphisms with thyroid carcinoma, these findings need to be confirmed in studies with larger numbers of patients.

Calculation and validation of a plasma calcitonin limit for early detection of medullary thyroid carcinoma in nodular thyroid disease

BACKGROUND

The early diagnosis of medullary thyroid carcinoma (MTC) is crucial for effective therapy. Elevated plasma calcitonin concentrations (pCT-Cs) are generally a specific and sensitive indicator for C-cell hyperplasia or MTC. The presence of thyroid nodules raises the possibility of MTC. Hence, in endemic goiter regions, there is a need for information regarding the pCT-C values that are indicative of C-cell hyperplasia or MTC. The aim of this study, therefore, was to determine an upper pCT-C to distinguish patients with and without MTC in a collective with nodular thyroid disease, and to give an estimation of the prevalence of MTC in an endemic goiter area.

METHODS

Basal pCT-C was measured in 21,928 patients with thyroid nodules living in central Germany, an area with endemic goiter due to previous iodine deficiency. In 218 subjects with pCT-Cs exceeding 10 ng/L, stimulated pCT-C was additionally determined, as suggested by the German consensus recommendation. A nominal normal range for basal pCT-C was calculated with data from 21,900 subjects without known MTC. The predicted upper limit was then validated using the known diagnoses of 376 patients with pCT-Cs exceeding 10 ng/L, 28 of whom presented with MTC.

RESULTS

For basal pCT-C, calculation of the three-sigma borders after logarithmic transformation revealed upper limits of the nominal normal range of 14.6 ng/L in females and 32.8 ng/L in males, respectively. However, three male patients with small MTCs had basal pCT-Cs between 15 and 33 ng/L. None of the patients with MTC had a basal pCT-C below 15 ng/L or an increase in pCT-C after pentagastrin stimulation that was less than 80 ng/L. In the basal pCT-C range between 15 and 50 ng/L (n = 192; eight with MTC), the positive predictive value for the detection of MTC was 4% in our group. Applying an upper limit for basal pCT-C of 15 ng/L in both sexes, 329 of the total of 21,928 patients exceeded this range. Among these, the final outcome is known in 231 subjects, including all 28 MTCs.

CONCLUSIONS

An upper limit of 15 ng/L instead of 10 ng/L for basal pCT-C is able to detect all MTC and reduce false-positive cases. The prevalence of MTC in nodular thyroid disease in our group was approximately 1.8 per thousand.

Thyroid sonomorphology, thyroid peroxidase antibodies and thyroid function: new epidemiological data in unselected German employees

AIM

Employees of Sanofi-Aventis Deutschland GmbH underwent thyroid screening in 2006 to assess new data about the prevalence of irregular sonomorphological pattern, elevated thyroid peroxidase antibodies (TPO AB) and thyroid function in an unselected adult German population.

PARTICIPANTS, METHODS

The examination included 700 unselected employees. Blood samples were analyzed for serum TSH and TPO AB, and ultrasound of the thyroid was performed.

RESULTS

In 40.7% of the participants (n = 285) an irregular sonomorphological pattern was detected: goiter in 13.7%, nodules in 35.6%, nodular goiter in 8.6% and a hypoechogenic pattern of the thyroid gland in 20.4%. Serum TSH was increased in 3.9% and decreased in 0.6%. Elevated TPO AB values were observed in 13%. Only 1.4% (n = 10) showed elevated TPO AB combined with a TSH increase. Sonomorphological abnormalities were associated with increased TPO AB in 7.1%. Elevated TPO AB was observed significantly more often in combination with sonomorphological pathology (54.9%) than without (45.1%) (p = 0.003).

CONCLUSIONS

Sonomorphological disorders are still very common in Germany and our results are comparable with previous screening examinations. Elevated TPO AB correlated significantly with the sonomorphological pattern of nodules and goiter. This may reflect an improved iodine supply or a hypertrophic stage of autoimmune thyroiditis in some cases.

Multiparameter scoring system for the prognosis of differentiated thyroid cancer

The AIM of the study was to develop a scoring system consisting of multiple parameters that are significant for prognosis of thyroid cancer. The score was designed to permit a risk stratification with all available information at any time of presentation.

PATIENTS, METHODS

A score using 25 parameters was used for 171 patients with differentiated thyroid cancer, who were included in follow up over a mean of 9 (+/- 5) years. The significance of each parameter as well as of a summation outcome score was determined. The result of this scoring system was compared to other scores reported in the literature applied to the same patients' group. Thirty-two out of the 171 patients presented with recurrence during follow up.

RESULTS

The summation score was highly significant for prognosis of differentiated thyroid cancer. Out of 25 parameters, 18 showed a significant association with outcome also as individual parameters. In comparison to the scores commonly used, this new system showed the highest significance (p < 0.0001, chi square 90, df 1) to estimate recurrence free survival. At a cutoff of -5.95 the sensitivity and specificity for the distinction between high and low risk patients were 87.5 and 77.0%, respectively.

CONCLUSION

With our multiparameter scoring system a reliable prognosis with respect to recurrence free survival is possible in patients suffering from differentiated thyroid cancer. A summation score of all parameters gives the best results. Scoring is also possible, if several important parameters are missing.

Therapy of hepatocellular carcinoma with 131I-lipiodol: patient dosimetry

AIM

Dosimetry in (131)I-lipiodol therapy for hepatocellular carcinoma (HCC) in the hitherto largest existing patient cohort.

PATIENTS, METHODS

38 courses of intra-arterial (131)I-lipiodol therapy with a total activity up to 6.7 GBq were performed in 18 patients with HCC. Liver and tumour volume were measured by computed tomography (CT) and (131)I-activity by scintigraphy on day 3, 6, 14, 28 and 42 after injection. Lipiodol deposition in tumour nodules as shown by CT rendered definite attachment to scintigraphic data possible. The radiation dose in tumour nodules, liver and lungs was calculated according to the MIRD concept and the tumour dose related to pre-therapeutic tumour volume, response and survival.

RESULTS

Mean tumour dose was 23.6 +/- 3.6 Gy (14.2 +/- 2.1 mGy/MBq) with maximal 162 Gy (90.1 mGy/MBq) after one and 274 Gy after three courses. The dose to nontumourous liver was 1.9 +/- 0.2 Gy (1.2 +/- 0.1 mGy/MBq) and the mean dose ratio of tumour / nontumourous liver 11.1 +/- 1.7 (max. 82). The pulmonary dose was 25.9 +/- 1.8 mGy (16.3 +/- 1.2 microGy/MBq) and therefore much lower. There was a reciprocal relation between tumour dose and pretherapeutic tumour volume. Tumour dose had no effect on response or survival.

CONCLUSION

High radiation doses are particularly in small tumour nodes achievable but not necessarily related to tumour response. The dose of non-tumourous liver and lungs is much lower.

[Procedure guidelines for radioiodine therapy of differentiated thyroid cancer (version 3)]

The procedure guideline for radioiodine therapy (RIT) of differentiated thyroid cancer (version 3) is the counterpart to the procedure guideline for (131)I whole-body scintigraphy (version 3) and specify the interdisciplinary guideline for thyroid cancer of the Deutsche Krebsgesellschaft concerning the nuclear medicine part. Recommendation for ablative (131)I therapy is given for all differentiated thyroid carcinoma (DTC) >1 cm. Regarding DTC < or =1 cm (131)I ablation may be helpful in an individual constellation. Preparation for (131)I ablation requires low iodine diet for two weeks and TSH-stimulation by withdrawal of thyroid hormone medication or by use of recombinant human TSH (rhTSH). The advantages of rhTSH (no symptoms of hypothyroidism, lower blood activity) and the advantages of endogenous TSH-stimulation (necessary for (131)I-therapy in patients with metastases, higher sensitivity of (131)I whole-body scan) are discussed. In most centers standard activities are used for (131)I ablation. If pretherapeutic dosimetry is planned, the diagnostic administration of (131)I should not exceed 1-10 MBq, alternative tracers are (123)I or (124)I. The recommendations for contraception and family planning are harmonized with the recommendation of ATA and ETA. Regarding the best possible protection of salivary glands the evidence is insufficient to recommend a specific setting. To minimize the risk of dental caries due to xerostomia patients should use preventive strategies for dental hygiene.

[Guideline for radioiodine therapy for benign thyroid diseases (version 4)]

Version 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.

[Procedure guideline for iodine-131 whole-body scintigraphy for differentiated thyroid cancer (version 3)]

Version 3 of the procedure guideline for (131)I whole-body scintigraphy (WBS) is the counterpart to the procedure guideline for radioiodine therapy (version 3) and specify the interdisciplinary guideline for thyroid cancer of the Deutsche Krebsgesellschaft concerning the nuclear medicine part. (131)I WBS 3-6 months after (131)I ablation remains a standard procedure in an endemic area for thyroid nodules and the high frequency of subtotal surgical procedures. Follow-up without (131)I WBS is only justified if the following preconditions are fulfilled: low-risk group pT1-2, pN0 M0 with histopathologically confirmed pN0, (131)I uptake <2%, (131)I WBS during ablation without any suspicious lesion, stimulated thyroglobulin (Tg)-level 3-6 months after ablation <2 ng/mL, and absence of anti-thyroglobulin-antibodies with normal recovery-testing. If patients from the low-risk group show normal (131)I WBS 3-6 months after ablation and stimulated Tg is of <2 ng/mL, there will be no need for additional routine (131)I WBS. If patients from the high-risk group show normal (131)I WBS and stimulated Tg-level of <2 ng/mL 3-6 months after ablation, the follow-up care should include repeated stimulated Tg-measurements. If the Tg-level remains below 2 ng/mL, an additional (131)I WBS will be not necessary. The recommended intervals for stimulated Tg-testing are adapted to the prior intervals for (131)I WBS-testing in the high-risk group. Increased anti-thyroglobulin-antibodies or incomplete recovery-testing make an individual strategy of follow-up care necessary, which include (131)I WBS.

[Nuclear medicine techniques in the diagnosis of orthopaedic diseases]

Nuclear medicine techniques show metabolic processes, allowing the diagnoses of many bone and joint disorders. For most orthopaedic indications three-phase bone scintigraphy is used, showing inflammatory bone and joint diseases, traumatic and post-operative disorders as well as necrotic or malignant changes. In addition to bone scintigraphy, there are radiopharmaceuticals to depict inflammatory processes. Finally, positron emission tomography is a modern imaging technique used mainly for tumor diagnostics, but also for detection of inflammation.