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ZusammenfassungMehr als 90 % aller differenzierten Schilddrüsenkarzinome lassen sich mit einem multimodalen Therapiekonzept kurativ behandeln, sodass die Prognose hinsichtlich Rezidivfreiheit und Langzeitüberleben ausgezeichnet ist. Das Behandlungskonzept für Patienten mit radiojodrefraktären (und meist FDG-PET/CT-positiven) Rezidiven und/oder Metastasen ist im interdisziplinären Tumorboard festzulegen. Der fehlende szintigraphische Nachweis einer Radiojodaufnahme in einzelne oder alle lokoregionäre Tumormanifestationen oder Fernmetastasen begründet noch nicht die Initiierung einer systemischen Behandlung bei metastasierten Schilddrüsenkarzinomen. Erst der Nachweis eines klinischen Progresses (Größenzunahme der Metastasen, Befall weiterer Kompartments oder Organe) von radiojodrefraktären Tumormanifestationen und die Symptomatik des Patienten bilden eine Grundlage für die Einleitung einer Therapie mit Tyrosinkinaseinhibitoren (TKI). Weitere zu berücksichtigende Faktoren sind die Lokalisation der Metastasen, der Tumormetabolismus in der FDG-PET/CT, das biologisches Patientenalter, Komorbiditäten und die Einsatzmöglichkeit lokal wirksamer Therapieverfahren. Bei klinisch relevanter Progredienz des radiojodrefraktären Schilddrüsenkarzinoms sollte eine Erstlinientherapie mit TKI angeboten werden. Insbesondere Lenvatinib und Cabozantinib weisen eine hohe Wirksamkeit in Bezug auf die Tumorkontrolle bei häufigem, obgleich gut steuerbarem Toxizitätsprofil auf. Die frühzeitige molekulargenetische Tumorprofilierung kann den Einsatz selektiver Inhibitoren von BRAF, MEK, RET oder TRK in dieser Patientengruppe begründen.

Lung cancer is the second most common cancer and the leading cause of cancer-related death worldwide. Molecular imaging using [18F]fluorodeoxyglucose Positron Emission Tomography and/or Computed Tomography ([18F]FDG-PET/CT) plays an essential role in the diagnosis, evaluation of response to treatment, and prediction of outcomes. The images are evaluated using qualitative and conventional quantitative indices. However, there is far more information embedded in the images, which can be extracted by sophisticated algorithms. Recently, the concept of uncovering and analyzing the invisible data extracted from medical images, called radiomics, is gaining more attention. Currently, [18F]FDG-PET/CT radiomics is growingly evaluated in lung cancer to discover if it enhances the diagnostic performance or implication of [18F]FDG-PET/CT in the management of lung cancer. In this review, we provide a short overview of the technical aspects, as they are discussed in different articles of this special issue. We mainly focus on the diagnostic performance of the [18F]FDG-PET/CT‐based radiomics and the role of artificial intelligence in non-small cell lung cancer, impacting the early detection, staging, prediction of tumor subtypes, biomarkers, and patient's outcomes.

Purpose Osteopenia is common in postmenopausal women and effective interventions increasing or stabilizing bone mineral density (BMD) to prevent fractures are urgently needed. Methods Sixty-five postmenopausal women diagnosed with osteopenia (T-score between -1.0 and -2.5) were randomly assigned to either a vibration training group (VT), a resistance training group (RT), or a control group (CG). BMD T-score values (primary endpoint) were assessed at baseline (T0) and after 12 months (T12), secondary endpoints (muscle strength, postural control, and health-related quality of life) at baseline (T0), after 6 months (T6), after 12 months (T12), and as follow-up after 15 months (T15). Results After the intervention period, neither the VT nor the RT showed any significant changes in BMD T-score values compared to the CG. Isokinetic strength improved significantly within all training groups, with the exception of the flexors of VT at an angular velocity of 240°/s. Health-related quality of life as well as postural control improved significantly for the RT only. Conclusions We conclude that participants of all three groups were able to maintain their BMD. The improvements in quality of life and postural control after resistance training are nevertheless meaningful for postmenopausal osteopenic women and support the importance of regular loadings of the musculoskeletal system. This study was retrospectively registered in January 2022 at the DRKS (S00027816) as clinical trial.

Nuklearmediziner*innen sollten mit Normvarianten in der Bildgebung und häufigen Pitfalls, die zu Fehlinterpretationen und damit zu potenziellen Änderungen des Managements bei Patienten mit Hodgkin und Non-Hodgkin-Lymphomen führen könnten, vertraut sein. In diesem Artikel geben wir einen Überblick über häufig auftretende Pitfalls in der [18F]FDG PET/CT bei Lymphomen sowie über seltene Ursachen für Fehlbefunde und deren Interpretation.

Purpose The main objective of this prospective study was to assess the value of gallium-68 prostate-specific membrane antigen ([68 Ga]Ga-PSMA-11) positron emission tomography/computed tomography (PET/CT) in primary N and M staging of intermediate- and high-risk prostate cancer (PCa) patients before planned curative-intent radical prostatectomy (RPE) and extended pelvic lymph node dissection (ePLND). The second objective was to compare the [68 Ga]Ga-PSMA-11 PET/CT findings with standard of care pelvic multi-parametric magnetic resonance imaging (mpMRI) in the detection of locoregional lymph node metastases and intraprostatic prostate cancer. Procedures A total of 81 patients (mean age: 64.5 years, baseline mean trigger PSA (tPSA) 15.4 ng/ml, ± 15.9) with biopsy proven PCa (24 intermediate- and 57 high risk) scheduled for RPE and ePLND were enrolled in this prospective study. In 52 patients [68 Ga]Ga-PSMA-11 PET/CT, pelvic mpMRI, and RPE with ePLND have been performed. Clinical risk stratification and related biomarkers as well as Gleason score (GS) were recorded. The location of the index lesion (IL) was documented systematically for each modality using a standardized segmentation of the prostate in six segments. Distant bone and lymph node metastasis detected by [68 Ga]Ga-PSMA-11 PET/CT were documented. [68 Ga]Ga-PSMA-11 PET/CT findings were correlated with results of mpMRI and histopathology. A consensus of imaging, clinical and/or follow-up findings were used for determining the distant metastases, which were not verified by histopathology. Results In the patient cohort who underwent RPE, [68 Ga]Ga-PSMA-11 PET/CT and mpMRI detected the IL in 86.5% and 98.1% of the patients, respectively. The median of the maximum standardized uptake value (SUVmax) in the intraprostatic IL was 12 (range, 4.7–67.8). Intraprostatic IL of the high-risk patients showed significantly higher SUVmax than those in patients with intermediate risk for distant metastases (n = 48; median: 17.84 vs. 8.77; p = 0.02). In total 729 LN were removed by ePLND in 48 patients. The histopathology verified 26 pelvic lymph node metastases (pLNM) in 20.8% (10/48) of the patients, which have been correctly identified in 60% of the patients on [68 Ga]Ga-PSMA-11 PET/CT, and in 50% on mpMRI. All but one pLNM had a maximum diameter below 10 mm. Bone metastases (BM) and distant LNM (dLNM) were found in 17.3% of the patients on [68 Ga]Ga-PSMA-11 PET/CT imaging. 39.0% of the [68 Ga]Ga-PSMA-11 PET-positive BM showed no suspicious morphological correlation on CT. Conclusion [68 Ga]Ga-PSMA-11 PET/CT shows high diagnostic performance for N and M staging of patients with intermediate- and high-risk prostate cancer and seems to be superior to pelvic mpMRI in the detection of locoregional lymph node metastases. A significant correlation was found between SUVmax of the intraprostatic index lesion and risk stratification based on tPSA level and GS. The results of this study emphasize again on the role of metabolic molecular imaging using specific tracers in selected patients, leading to tailored therapy approach.

The aim of the study was to evaluate the clinical impact of pre-ablation rhTSH-stimulated fluorine-18 fluorodeoxyglucose (F-18 FDG) PET/CT in addition to post-therapeutic whole body radioiodine scanning in patients with intermediate to high risk differentiated thyroid carcinoma (DTC). This was a retrospective single center study including 73 patients with thyroid cancer (44 females, mean age 43.2±16.2 years, 62% papillary, 31% follicular, 7% poorly differentiated). All patients underwent ablative radioiodine treatment (mean activity: 3661±673 MBq I-131) using rhTSH after thyroidectomy and lymph node (LN) dissection (01/2013–10/2016) and TSH-stimulated F-18 FDG PET/CT (4 MBq/kg body weight, low dose CT). Post-treatment I-131 whole body scan (I-131 WBS) was obtained 9 days afterwards in planar technique and in case of equivocal or abnormal findings using SPECT/CT. Thirty-one patients (42%) showed F-18 FDG avid lesions, 14 patients showed more FDG than iodine positive lesions and 5 patients more iodine positive lesions in I-131 WBS, respectively. Fifty-three patients showed identical F-18 FDG PET/CT and I-131 WBS. The initial treatment plan was changed from follow-up to therapy (surgery, systemic therapy using tyrosine-kinase inhibition) in 11 patients (15%) on the basis of F-18 FDG PET/CT imaging. Six of these 11 patients had papillary thyroid cancer. Three patients with histologically proven LN metastases had stimulated thyroglobulin-levels

Objective Controversy exists about the impact of bone mineral density (BMD) and fracture risk in newly diagnosed patients with breast cancer (BC). It is presumed that there are differences in BMD between women with BC and healthy controls. BMD is therefore considered as a potential marker to predict BC risk. This study was conducted to investigate the association of BMD, trabecular bone score (TBS) and fracture risk in younger postmenopausal women with hormone responsive BC. Methods Overall, 343 women were examined. Women with BC were matched to a control group of the general population. Forty-nine women and fifty-nine controls were included in the final analysis. All subjects underwent dual energy x-ray absorptiometry (DXA) of the lumbar spine, femoral neck, and the total hip to evaluate bone mineral density. The 10-year fracture risk for a major osteoporotic fracture was assessed using the FRAX-score and the TBS-adjusted FRAX-Score, respectively. Results Lumbar and femoral neck BMD were similar in BC patients and controls. No difference was found for TBS of the spine (1.38 ± 0.1 vs.1.36 ± 0.09) in the BC and the control group, respectively (p = 0.19). The 10- year probability for a major osteoporotic fracture (MoF) or femoral neck (FN) fracture was 6.1 (± 2.6%) and 0.9 (± 1.2%) in the BC group vs. 6.7 (± 3.5%) (p = 0.33) and 0.9 (± 1.1%) (p = 0.73) in the control group. Conclusion Postmenopausal women younger than 60 years with breast cancer do not show any differences in baseline BMD, TBS, or TBS adjusted FRAX in comparison to controls.

Background: We aimed to compare the established metabolic response criteria PERCIST and EORTC for their applicability and predictive value in terms of clinical response assessment early after the initiation of lenvatinib therapy in patients with metastatic radioiodine-refractory (RAI) thyroid cancer (TC). Methods: In 25 patients treated with lenvatinib, baseline and 4-month follow-up F-18 FDG PET/CT images were analyzed using PERCIST 1.0, modified PERCIST (using SUVpeak or SUVmax) and EORTC criteria. Two groups were defined: disease control (DC) and progressive disease (PD), which were correlated with PFS and OS. Results: PERCIST, mPERCIST, PERCISTmax and EORTC could be applied in 80%, 80%, 88% and 100% of the patients based on the requirements of lesion assessment criteria, respectively. With PERCIST, mPERCIST, PERCISTmax and EORTC, the patients classified as DC and PD ranged from 65 to 68% and from 32 to 35%, respectively. Patients with DC exhibited a longer median PFS than patients with PD for EORTC (p < 0.014) and for PERCIST and mPERCIST (p = 0.037), respectively. Conclusion: EORTC and the different PERCIST criteria performed equally regarding the identification of patients with PD requiring treatment changes. However, the applicability of PERCIST 1.0 using SULpeak seems restricted due to the significant proportion of small tumor lesions.

The accurate detection of hyperfunctioning parathyroid tissue (HFPT) is pivotal in the preoperative assessment of primary hyperparathyroidism (PHPT). PET/CT using [18F]fluorocholine ([18F]FCH) showed superior diagnostic performance compared to conventional functional imaging modalities. We aimed to evaluate the diagnostic performance of [18F]FCH PET/CT as a first-line functional imaging approach in patients with clinically diagnosed PHPT. The imaging and clinical data of 321 PHPT patients, including 271 overt PHPT and 50 mild PHPT, who underwent [18F]FCH PET/CT as first-line imaging were analysed in this retrospective study. Histopathology was the reference standard. In case of no available histopathology evaluation (conservative management), imaging and clinical follow-ups were considered reference standards. In the overt group (n = 271), [18F]FCH PET/CT showed sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 0.99, 0.91, 1.00, 0.80, and 0.99, respectively. Regarding the correlation of the index lesions and initial laboratory data, all [18F]FCH PET/CT parameters (SUVs, SULs, and mSAD) were significantly correlated with the serum iPTH level. Additionally, SUVmax, SULpeak, and mSAD were significantly associated with the serum calcium level. In the mild group (n = 50), [18F]FCH PET/CT showed a sensitivity, specificity, PPV, NPV, and accuracy of 0.93, 0.75, 0.95, 0.67, and 0.90. In conclusion, [18F]FCH PET/CT revealed high diagnostic performance in the detection of HFPTs and the potential to be considered as a first-line imaging modality in the assessment of PHPT, including both overt and mild types. However, its cost–benefit concerning the clinical impact of early PHPT detection should be investigated in future studies.

Simple Summary Accurate primary staging for determining the extent of prostate cancer is crucial for planning treatment in high-risk patients for distant metastases. Recurrence is still common after curative intent therapy, in spite of developments in the clinical nomograms for appropriate pre-treatment screening of patients for selective therapeutic approaches. This is partly due to suboptimal diagnostic performance of standard conventional imaging modalities such as computed tomography and bone scintigraphy. Molecular imaging by means of PET/CT and PET/MRI imaging using novel specific radiotracers might provide more precise staging of disease, allowing for better personalized treatments. This article reviews current developments and future trends for functional hybrid PET-targeted imaging in primary staging of prostate cancer. Abstract Accurate primary staging is the cornerstone in all malignancies. Different morphological imaging modalities are employed in the evaluation of prostate cancer (PCa). Regardless of all developments in imaging, invasive histopathologic evaluation is still the standard method for the detection and staging of the primary PCa. Magnetic resonance imaging (MRI) and computed tomography (CT) play crucial roles; however, functional imaging provides additional valuable information, and it is gaining ever-growing acceptance in the management of PCa. Targeted imaging with different radiotracers has remarkably evolved in the past two decades. [111In]In-capromab pendetide scintigraphy was a new approach in the management of PCa. Afterwards, positron emission tomography (PET) tracers such as [11C/18F]choline and [11C]acetate were developed. Nevertheless, none found a role in the primary staging. By introduction of the highly sensitive small molecule prostate-specific membrane antigen (PSMA) PET/CT, as well as recent developments in MRI and hybrid PET/MRI systems, non-invasive staging of PCa is being contemplated. Several studies investigated the role of these sophisticated modalities in the primary staging of PCa, showing promising results. Here, we recapitulate the role of targeted functional imaging. We briefly mention the most popular radiotracers, their diagnostic accuracy in the primary staging of PCa, and impact on patient management.

The 2-fluorodeoxyglucose positron emission tomography/computed tomography (2-[In this retrospective study, 51 metastatic melanoma patients, who had received immunotherapy, were included. Patients with baseline and two follow-up 2-[The 3- and 5-year OS rates were 49% and 43.1%, respectively. On baseline 2-[Metabolic parameters derived from 2-[

PSMA-based nuclear medicine imaging impacts increasingly the clinical decision process in prostate cancer patients. A well-known PSMA pitfall is uptake into autonomic ganglia. The intensity of uptake, the shape, and the exact location of the correlating structure in CT are supposed to aid discriminating between ganglia and lymph node metastases. In this patient, we found intense uptake in a nodular shaped para-aortal soft tissue lesion suspicious of a lymph node metastases at staging as well as restaging. After secondary resection, the lesion was histologically proven an autonomic ganglion with intense PSMA expression.

Background Chemoradiotherapy (CRT) is the standard treatment for patients with inoperable stage III non‐small cell lung cancer (NSCLC) stage III. With a median OS beyond 30 months, adequate pulmonary function (PF) is essential to ensure acceptable quality of life after treatment. Forced expiratory volume in 1 second (FEV1) and diffusing capacity of the lung for carbon monoxide (DLCO) are the most widely used parameters to assess lung function. The aim of the current study was to evaluate dose‐volume effects of accelerated high‐dose radiation on PF. Methods A total of 72 patients were eligible for the current analysis. After induction chemotherapy, all patients received dose‐differentiated accelerated radiotherapy with intensity‐modulated radiotherapy (IMRT‐DART). PF tests were performed six weeks, three and six months after the end of radiotherapy. Results The median total dose to the tumor was 73.8 Gy (1.8 Gy bid) with a size dependent range between 61.2 and 90 Gy. In the whole cohort, 321 pulmonary function tests were performed. At six months, the median FEV1 relative to baseline was 0.95 (range: 0.56–1.36), and the relative median DLCO decreased to 0.98 (range: 0.64–1.50). The correlation between V20total lung and FEV1 decline was statistically significant (P = 0.023). A total of 13 of 34 (38%) COPD patients had a 4%–21% FEV1 decrease. Conclusion Patients with a V20total lung

Introduction we examined the consequences of applying the new EWGSOP2 algorithm for sarcopenia screening instead of the former EWGSOP algorithm (EWGSOP1) in geriatric inpatients. Methods the dataset of our formerly published Sarcopenia in Geriatric Elderly (SAGE) study includes 144 geriatric inpatients (86 women, 58 men, mean age 80.7±5.6 years) with measurements of gait speed, handgrip strength and appendicular muscle mass by dual x-ray absorptiometry (DXA). We analysed the agreement between EWGSOP and EWGSOP2 algorithms in identifying patients as sarcopenic/non-sarcopenic. Differences in the distribution sarcopenic vs. non-sarcopenic were assessed by Chi²-test. Results sarcopenia prevalence according to EWGSOP1 (41 (27.7%)) was significantly higher than with EWGSOP2 (26(18.1%), p Discussion there is a substantial mismatch in sarcopenia case finding according to EWGSOP1 and EWGSOP2. The overall prevalence and the number of men diagnosed with sarcopenia are significantly lower in EWGSOP2. While the absolute number of women identified as sarcopenic remains relatively constant, the overlap of individual cases between the two definitions is low.

Background Approximately 15% of lung cancer patients are diagnosed in early stages. Microscopic proof of disease cannot always be obtained because of comorbidity or reluctance to undergo invasive diagnostic procedures. In the current study, survival data of patients with and without pathology are compared. Methods One hundred and sixty three patients with NSCLC I-IIb (T3 N0) treated between 2002 and 2016 were eligible: 123 (75%) had pathological confirmation of disease, whereas 40 (25%) did not. In accordance with international guidelines, both groups received radiotherapy. Comorbidity was assessed with the Charlson Comorbidity Index (CCI). Results The median follow-up was 28.6 months (range: 0.3-162): 66 (40%) patients are still alive, while 97 (59%) patients died: 48 (29%) cancer-related deaths and 49 (30%) from causes other than cancer. Median overall survival (OS) in patients without pathological confirmation was 58.6 months (range: 0.5-162), which did not differ from those with microscopic proof of disease (39.4 months, range: 0.3-147.5; logrank P = 0.481). Median cancer-specific survival (CSS) also did not differ at 113.4 months (range: 0.5-162) in the non-confirmation group (logrank P = 0.763) versus 51.5 months (range: 3.7-129.5) in patients with pathology. In Cox regression, a CCI of ≥ 3 was associated with poor OS (hazard ratio 2.0; range 1.2-3.4; P = 0.010) and CSS (hazard ratio 2.0; 1.0-4.0; P = 0.043). Conclusion OS and CSS in early lung cancer patients depend on comorbidity rather than on pathological confirmation of disease.

Background Quantification of skeletal muscle mass is mandatory for diagnosing sarcopenia, a highly prevalent geriatric syndrome. While dual energy X-ray absorptiometry (DXA) is the reference method in a clinical context, bioimpedance analysis (BIA) is more readily applicable on a broad scale. Recently BIA equations for the prediction of appendicular skeletal muscle mass in higher age groups have been published, but data on their performance in geriatric inpatients are lacking. Methods In 144 geriatric inpatients (86 women and 58 men, mean age 80.7 ± 5.6 years) appendicular skeletal muscle mass was predicted by 4 different BIA equations and measured by DXA. Results were compared by linear regression analysis and Bland Altmann plots. The agreement with DXA in classifying subjects to have normal or reduced muscle mass was calculated for the BIA based approaches. Results The 4 BIA equations showed only minor differences in regression analysis, but major differences in mean error (range −0.98 kg to + 0.19 kg in women and −2.47 kg to −0.58 kg in men). Considering regression parameters and mean error, the equation of Scafoglieri et al. performed best, resulting in an agreement with DXA of more than 83%. Sensitivity to detect subjects with reduced muscle mass was Conclusion The BIA equation of Scafoglieri et al. performs best in geriatric inpatients, with more than 83% of subjects classified correctly as having normal or reduced muscle mass compared to DXA. Low sensitivity to detect subjects with reduced muscle mass in geriatric inpatients remains a limitation of BIA.

Background High-performance time-of-flight (TOF) positron emission tomography (PET) systems have the capability for rapid data acquisition while preserving diagnostic image quality. However, determining a reliable and clinically applicable cut-off of the acquisition time plays an important role in routine practice. This study aimed to assess the diagnostic equivalence of short acquisition time of 57 with routine 75 seconds per bed position (s/BP) of [18F]-fluoro-deoxy-glucose (FDG) PET. Phantom studies applying EARL criteria suggested the feasibility of shortened acquisition time in routine clinical imaging by 3D TOF PET/CT scanners. Ninety-six patients with melanoma, lung or head and neck cancer underwent a standard whole-body, skull base-to-thigh or vertex-to-thigh [18F]-FDG PET/CT examination using the 3D TOF Ingenuity TF PET/CT system (Philips, Cleveland, OH). The [18F]-FDG activity applied was equal to 4MBq per kg body weight. Retrospectively, PET list-mode data were used to calculate a second PET study per patient with a reduced acquisition time of 57 s instead of routine 75 s/BP. PET/CT data were reconstructed using a 3D OSEM TOF algorithm. Blinded patient data were analysed by two nuclear medicine physicians. The number of [18F]-FDG-avid lesions per body region (head&neck, thorax, abdomen, bone, extremity) and image quality (grade 1–5) were evaluated. Semiquantitative analyses were performed by standardized uptake value (SUV) measurements using 3D volume of interests (VOI). The visual and semiquantitative diagnostic equivalence of 214 [18F]-FDG-avid lesions were analysed in the routine standard (75 s/BP) as well as the calculated PET/CT studies with short acquisition time. Statistical analyses were performed by equivalence testing and Bland–Altman plots. Results Lesion detection rate per patient’s body region agreed in > 98% comparing 57 s/BP and 75 s/BP datasets. Overall image quality was determined as equal or superior to 75 s in 80% and 69%, respectively. In the semiquantitative lesion-based analyses, a significant equivalence was found between the 75 s/BP and 57 s/BP PET/CT images both for SUVmax (p = 0.004) and SUVmean (p = 0.003). Conclusion The results of this study demonstrate significant clinical and semiquantitative equivalence between short acquisition time of 57 s/BP and standard 75 s/BP 3D TOF [18F]-FDG PET/CT scanning, which may improve the patient’s workflow in routine practice.

Background This study assesses the value of image fusion using 18F-fluoro-L-DOPA (18F-DOPA) positron emission tomography (PET) and magnetic resonance imaging (MRI) for examining patients with neuroendocrine tumors (NETs) and a suspicion of metastasis of the liver. Methods Eleven patients (five women and six men aged between 20 and 81, with a mean age of 54.6 years) were included in the study. All patients underwent whole-body 18F-DOPA PET examinations and contrast-enhanced MRI with diffusion-weighted sequences (DWS). Image fusion was performed using a semiautomatic voxel-based algorithm. Images obtained using PET and MRI were assessed separately. Side-by-side evaluations of fused PET/MRI images were also performed. Results In total, 55 liver lesions (52 liver metastases and 3 benign lesions) were detected in the 11 patients. Sensitivity detection for liver lesions was higher when using PET/CT than when using contrast-enhanced MRI without DWSs and lower than using MRI with DWSs. The sensitivity of PET/MRI image fusion in the detection of liver metastasis was significantly higher than that of MRI with DWSs (P Conclusion Images of the liver obtained using PET and MRI in patients with NETs exhibited characteristic features. These findings suggest that an appropriate combination of available imaging modalities can optimize patient evaluations.

Background. Lenvatinib has proven efficacy in progressive, radioiodine- (RAI-) refractory thyroid cancer (TC). Dose reductions are commonly performed due to decreased tolerability and adverse effects. This retrospective multicenter study analyzed overall survival (OS) and progression-free survival (PFS) and tolerability in the Austrian patient population treated with lenvatinib. Methods. Clinical data of 43 patients (25 males and 18 females) with a median age of 70 years (range: 39–91 years) and RAI-refractory TC with metastases to the lymph nodes (74%), lungs (86%), bone (35%), liver (16%), and brain (12%) were analyzed. The mean duration of treatment with lenvatinib was 26.6 ± 15.4 months with dosage reductions required in 39 patients (91%). Results. PFS after 24 months was 71% (95% CI: 56–87), and overall survival (OS) was 74% (95% CI: 60–88), respectively. OS was significantly shorter ( p = 0.048 ) in patients with a daily maintenance dosage ≤ 10 mg (63%) (95% CI: 39–86) as compared to patients on ≥ 14 mg lenvatinib (82%) (95% CI: 66–98) daily. Dose reduction was noted in 39 patients (91%). Grade ≥3 toxicities (hypertension, diarrhea, weight loss, and palmar-plantar erythrodysesthesia syndrome) were most common leading to discontinuation of lenvatinib in 7 patients (16%). Conclusion. Lenvatinib showed sustained clinical efficacy in patients with metastatic RAI-refractory TC even with reduced maintenance dosages over years. The effects were comparable to the registration trial, although patients had a higher median age and, more commonly, dose reductions.

Die Nebenschilddrusenszintigrafie nimmt neben der Sonografie einen wichtigen Stellenwert in der praoperativen Lokalisationsdiagnostik von Nebenschilddrusenadenomen ein. Der nuklearmedizinische diagnostische Standard ist bislang die Technetium-99m-Sestamibi-Szintigrafie. Der Einsatz der Positronenemissionstomographie/Computertomographie (PET/CT) mit Markern des Phospholipidmembranmetabolismus (F-18 Cholin) verspricht auf Basis erster Studien hohere Genauigkeit fur die Aufarbeitung des primaren Hyperparathyreoidismus als die konventionelle MIBI-2-Phasen-Szintigrafie in planarer, SPECT oder SPECT/CT Technik. Diese Ubersicht fasst die Ergebnisse jener Studien zusammen, die mit F‑18 Cholin PET/CT durchgefuhrt wurden. Es wurde eine selektive Literaturrecherche in PubMed mit den Stichworten „primary hyperparathyroidism and choline“, „primary hyperparathyroidism and PET“, „parathyroid adenoma and choline“ und „parathyroid adenoma and PET“ durchgefuhrt. Es wurden 6 Studien, die den Einsatz der F‑18 Cholin PET/CT beim Hyperparathyreoidismus evaluierten, identifiziert. Diese schlossen 5 bis 151 Patienten ein. Die Studien belegen, dass die Cholin PET/CT hohe Nachweisraten (80 bis 96 %) fur solitare Nebenschilddrusenadenome aufweist. Vorteile des Verfahrens sind die hohe Sensitivitat auch bei Rezidiveingriffen oder gleichzeitig bestehenden Knotenstrumen, sowie eine exakte anatomische Zuordnung auch von atypisch gelegenen Adenomen. Die Cholin PET/CT ermoglicht bei der Mehrzahl der Patienten mit pHPT eine exakte Lokalisation solitarer Nebenschilddrusenadenome und fuhrt zu einer Verbesserung der praoperativen Lokalisationsdiagnostik. Daraus folgt ein moglichst minimal-invasives chirurgisches Vorgehen mit verringerter Komplikationsrate bei gleichbleibender Erfolgsrate. Die Bewertung der Erfassung der Genauigkeit bei Mehrdrusenerkrankungen bedarf weiterer Studien.

Purpose In this prospective study we compared the accuracy of 18F-fluorocholine PET/CT with that of 99mTc-MIBI or99mTc-tetrofosmin SPECT/CT in the preoperative detection of parathyroid adenoma in patients with primary hyperparathyroidism. We also assessed the value of semiquantitative parameters in differentiating between parathyroid hyperplasia and adenoma. Methods Both 18F-fluorocholine PET/CT and 99mTc-MIBI/tetrofosmin SPECT/CT were performed in 100 consecutive patients with biochemical evidence of primary hyperparathyroidism. At least one abnormal focus on either 18F-fluorocholine or 99mTc-MIBI/tetrofosmin corresponding to a parathyroid gland or ectopic parathyroid tissue was considered as a positive finding. In 76 patients with positive findings on at least one imaging modality, surgical exploration was performed within 6 months, and the results were related to histopathological findings and clinical and laboratory findings at 3–6 months as the standard of truth. In 24 patients, no surgery was performed: in 18 patients with positive imaging findings surgery was refused or considered risky, and in 6 patients imaging was negative. Therefore, data from 82 patients (76 undergoing surgery, 6 without surgery) in whom the standard of truth criteria were met, were used in the final analysis. Results All patients showed biochemical evidence of primary hyperparathyroidism with a mean serum calcium level of 2.78 ± 0.34 mmol/l and parathormone (PTH) level of 196.5 ± 236.4 pg/ml. The study results in 76 patients with verified histopathology and 3 patients with negative imaging findings were analysed. Three of six patients with negative imaging showed normalized serum PTH and calcium levels on laboratory follow-up at 3 and 6 months, and the results were considered true negative. In a patient-based analysis, the detection rate with 18F-fluorocholine PET/CT was 93% (76/82), but was only 61% (50/82) with 99mTc-MIBI/tetrofosmin SPECT/CT. In a lesion-based analysis, the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of 18F-fluorocholine PET/CT in the detection of parathyroid adenoma were 93.7%, 96.0%, 90.2%, 97.4% and 95.3%, respectively, and of 99mTc-MIBI/tetrofosmin SPECT/CT were 60.8%, 98.5%, 94.1%, 86.3% and 87.7%, respectively. Although 18F-fluorocholine PET-positive adenomatous lesions showed higher SUVmax values than the hyperplastic glands (6.80 ± 3.78 vs. 4.53 ± 0.40) in the semiquantitative analysis, the difference was not significant (p = 0.236). The mean size (measured as the length of the greatest dimension) and weight of adenomas were 15.9 ± 7.6 mm (median 15 mm, range 1–40 mm) and 1.71 ± 1.86 g (median 1 g, range: 0.25–9 g), respectively. Among the analysed parameters including serum calcium and PTH and the size and weight of parathyroid adenomas, size was significantly different between patients with negative 99mTc-MIBI/tetrofosmin SPECT/CT and those with positive 99mTc-MIBI/tetrofosmin SPECT/CT (mean size 13.4 ± 7.6 mm vs. 16.9 ± 7.4 mm, respectively; p = 0.042). Conclusion In this prospective study, 18F-fluorocholine PET/CT showed promise as a functional imaging modality, being clearly superior to 99mTc-MIBI/tetrofosmin SPECT/CT, especially in the detection and localization of small parathyroid adenomas in patients with primary hyperparathyroidism. SUVmax was higher in parathyroid adenomas than in hyperplasia. However, further evaluation of this modality is needed.

In this prospective study, we evaluated the optimal time-point for 68Ga-PSMA-11 PET/CT acquisition in the assessment of prostate cancer. We also examined, for the first time the feasibility of tracer production using a PSMA-11 sterile cold-kit in the clinical workflow of PET/CT centres. Fifty prostate cancer patients (25 staging, 25 biochemical recurrence) were enrolled in this study. All patients received an intravenous dose of 2.0 MBq/kg body weight 68Ga-PSMA-11 prepared using a sterile cold kit (ANMI SA, Liege, Belgium), followed by an early (20 min after injection) semi-whole-body PET/CT scan and a standard-delay (100 min after injection) abdominopelvic PET/CT scan. The detection rates with 68Ga-PSMA-11 were compared between the two acquisitions. The pattern of physiological background activity and tumour to background ratio were also analysed. The total preparation time was reduced to 5 min using the PSMA-11 sterile cold kit, which improved the final radionuclide activity by about 30% per single 68Ge/68Ga generator elution. Overall, 158 pathological lesions were analysed in 45 patients (90%) suggestive of malignancy on both (early and standard-delay) 68Ga-PSMA PET/CT images. There was a significant (p

Summary Objective The aim of our investigation was to evaluate the clinicopathological characteristics and mutation patterns in newly diagnosed cases of thyroid cancer in the federal state of Salzburg, Austria, in the year 2013. Methods The medical records of all patients newly diagnosed with thyroid cancer in 2013 in the federal state of Salzburg were retrospectively reviewed. The clinicopathological characteristics and mutations of thyroid cancers were analyzed. Results 63 patients (mean age: 51.0 years, range: 21–81 years; female 75%, male 25%) were identified. 53 patients had papillary (12 follicular variant), 4 patients follicular (1 oxyphilic variant), 3 patients medullary, and 3 patients anaplastic thyroid cancer. T1 tumors were found in 34 patients (pT1a, 20 patients; pT1b, 14 patients), T2 tumors in 10 patients, T3 tumors in 16 patients, and T4 tumors in 3 patients. Lymph node involvement was seen in 15 patients and metastatic disease in 1 patient. Mutations of BRAF (B-type Raf kinase) were detected in 23 and mutation of NRAS (Neuroblastoma RAS Viral Oncogene Homolog) in 2 papillary thyroid cancers. No concomitant mutations of BRAF and NRAS were found. Conclusion Females accounted for 75% of the patients with newly diagnosed thyroid cancer and the incidence peaked at a younger age than in males. Papillary thyroid cancer was the most frequent tumor type, accounting for 84% of the cases. A high frequency of T1 tumors and cancers with no lymph node involvement was found. Males had a higher proportion of large tumors and more aggressive forms of thyroid cancer than females. Mutations (mostly of BRAF) were found in 47% of the cases. Neither mutations of KRAS (Kirsten rat sarcoma viral oncogene homologue) nor concomitant mutations of BRAF and NRAS were found.

Bone metastasis is a disastrous manifestation of most malignancies, especially in breast, prostate and lung cancers. Since asymptomatic bone metastases are not uncommon, early detection, precise assessment, and localization of them are very important. Various imaging modalities have been employed in the setting of diagnosis of bone metastasis, from plain radiography and bone scintigraphy to SPECT, SPECT/CT, PET/CT, MRI. However, each modality showed its own limitation providing accurate diagnostic performance. In this regard, various tumor-targeted radiotracers have been introduced for molecular imaging of bone metastases using modern hybrid modalities. In this article we review the strength of different cancer-specific radiopharmaceuticals in the detection of bone metastases. As shown in the literature, among various tumor-targeted tracers, Ga-68 DOTA-conjugated-peptides, Ga-68 PSMA, F-18 DOPA, F-18 galacto-RGD integrin, F-18 FDG, C-11/F-18 acetate, C-11/F-18 choline, In-111 octreotide, I-123/131 MIBG, Tc-99m MIBI, and Tl-201 have acceptable capabilities in detecting bone metastases depending on the cancer type. However, different study designs and gold standards among reviewed articles should be taken into consideration.

Objective: 18FDG-PET is considered the most sensitive test to detect hibernating myocardium. We compare the predictive value of 18FDG-PET for long-term survival of patients with ischemic cardiomyopathy and diabetes versus those without diabetes that were referred for 18FDG-PET to assess hibernating myocardium. Patients and methods: 80 patients (24 diabetics) with angiographically documented ischemic cardiomyopathy who underwent myocardial perfusion scintigraphy with 99mTc-tetrofosmin and myocardial viability evaluation by 18FDG PET/CT (after hyperinsulinemic-euglycemic clamp protocol with acipimox) were investigated. Median follow-up after viability testing was 62.4±33.2 months. Results: All patients had impaired left ventricular ejection fraction (mean 32.9±9.3%). Diabetic patients had fewer percent of scar tissue (16.0±12.0) as compared to nondiabetic patients (25.7±18.7) (p

99mTc-MDP whole-body bone scintigraphy is a highly sensitive imaging method that has been used for decades to evaluate prostate cancer bone metastasis based on its availability and low cost; however, because of accumulation of this radiotracer in degenerative, traumatic, and inflammatory lesions, it suffers from noncomparable specificity. The modality is also used to monitor response to therapy and to predict patients' prognosis. As planar imaging may not give enough information for lesion detection or anatomical localization, it can be supplemented with SPECT to increase image contrast particularly in the evaluation of small and complex skeleton. In addition, hybrid SPECT/CT can be used to assess both functional and morphologic changes leading to more accurate detection of the metastatic bone lesions in a single-section test. 18F-NaF-PET/CT offers excellent advantages in investigating bone metastases. It provides greater spatial resolution and better image quality, resulting in better sensitivity and specificity. Furthermore, 18F-NaF-PET/CT is able to evaluate response to therapy more accurately and to detect occult bone metastases in lower prostate-specific antigen levels when comparing with conventional 99mTc-labeled whole-body bone scan. Owing to smaller administered dose and shorter half-life of 18F-NaF, the total actual radiation absorbed dose is almost comparable with 99mTc-labeled conventional bone scintigraphy. Hence, we believe that conventional bone scintigraphy would be replaced by 18F-NaF-PET/CT in the assessment of metastatic bone disease where PET/CT scanners are available.

18F-fluorocholine is a specific promising agent for imaging tumor cell proliferation, particularly in prostate cancer, using PET/CT. It is a beneficial tool in the early detection of marrow-based metastases because it excludes distant metastases and evaluates the response to hormone therapy. In addition, 18F-fluorocholine has the potential to differentiate between degenerative and malignant osseous abnormalities because degenerative changes are not choline-avid; however, the agent may accumulate in recent traumatic bony lesions. On the other hand, 18F-NaF PET/CT can indicate increased bone turnover and is generally used in the assessment of primary and secondary osseous malignancies, the evaluation of response to treatment, and the clarification of abnormalities on other imaging modalities or clinical data. 18F-NaF PET/CT is a highly sensitive method in the evaluation of bone metastases from prostate cancer, but it has problematic specificity, mainly because of tracer accumulation in degenerative and inflammatory bone diseases. In summary, 18F-NaF PET/CT is a highly sensitive method, but 18F-fluorocholine PET/CT can detect early bone marrow metastases and provide greater specificity in the detection of bone metastases in patients with prostate cancer. However, the difference seems not to be significant.

ZusammenfassungFür die Therapie eines Patienten mit Radioiod- refraktärem, differenziertem Schilddrüsenkarzinom sind zurzeit keine klaren Standards definiert. Mit dem kürzlich in dieser Indikation zugelassenen Multitarget-Kinase - inhibitor Sorafenib ist die therapeutische Landschaft erweitert worden.Ein interdisziplinäres Experten-Panel bestehend aus endokrinen Chirurgen, internistischen Onkologen und Nuklearmedizinern hat Empfehlungen für die Definition und das Vorgehen bei Radioiod-refraktären Karzinomen erarbeitet.

Ultrasound and sestamibi scintigraphy are the recommended standard procedures for initial diagnosis in primary hyperparathyroidism (pHPT). Recently, F‑18 choline positron emission tomography computed tomography (choline PET/CT) has been shown promising results for the diagnostic work up of primary hyperparathyroidism (pHPT) suggesting superiority over conventional scintigraphy using Tc99m sestamibi based protocols using planar dual-phase imaging, SPECT or SPECT/CT.This review presents the results of F‑18 choline PET/CT on the basis of a literature search using the keywords "primary hyperparathyroidism and choline", "primary hyperparathyroidism and PET", "parathyroid adenoma and choline" und "parathyroid adenoma and PET".6 studies were identified dealing with the diagnostic impact of choline PET/CT. The studies included 5 to 151 patients. Localization of single gland adenomas can be achieved with choline PET/CT in 80 up to 96% of cases. A high sensitivity and accuracy of choline PET/CT imaging is documented even in cases of repeated surgery for recurrent pHPT, in coexistant nodular goiter or in the detection of adenoma in atypical localization.Using choline PET/CT parathyroid adenoma and probably parathyroid hyperplasia can be exactly localized in most patients with pHPT. Thus, a minimal-invasive surgical procedure is feasible with decreased risk of complications but high success rate in terms of biochemical cure. The diagnostic accuracy in multiglandular disease remains to be established.

In this prospective study, we evaluated the optimal time-point forFifty prostate cancer patients (25 staging, 25 biochemical recurrence) were enrolled in this study. All patients received an intravenous dose of 2.0 MBq/kg body weightThe total preparation time was reduced to 5 min using the PSMA-11 sterile cold kit, which improved the final radionuclide activity by about 30% per singleThe PSMA-11 sterile cold kit seems to be feasible for use in routine clinical practice, and it has a shorter radionuclide preparation time and is less operator-dependent than the synthesizer-based production method. In addition, early

Background IQ SPECT consists of a new pinhole-like collimator, cardio-centric acquisition, and advanced 3D iterative SPECT reconstruction. The aim of this paper was to compare diagnostic accuracy and functional parameters obtained with IQ SPECT versus conventional SPECT in patients undergoing myocardial perfusion scintigraphy with adenosine stress and at rest. Methods Eight patients with known or suspected coronary artery disease underwent [99mTc] tetrofosmin gated SPECT. Acquisition was performed on a Symbia T6 equipped with IQ SPECT and on a conventional gamma camera system. Gated SPECT data were used to calculate functional parameters. Scores analysis was performed on a 17-segment model. Coronary angiography and clinical follow-up were considered as diagnostic reference standard. Results Mean acquisition time was 4 minutes with IQ SPECT and 21 minutes with conventional SPECT. Agreement degree on the diagnostic accuracy between both systems was 0.97 for stress studies, 0.91 for rest studies and 0.96 for both studies. Perfusion abnormalities scores obtained by using IQ SPECT and conventional SPECT were not significant different: SSS, 9.7±8.8 and 10.1±6.4; SRS, 7.1±6.1 and 7.5±7.3; SDS, 4.0±6.1 and 3.9±4.3, respectively. However, a significant difference was found in functional parameters derived from IQ SPECT and conventional SPECT both after stress and at rest. Mean LVEF was 8% lower using IQ SPECT. Differences in LVEF were found in patients with normal LVEF and patients with reduced LVEF. Conclusions Functional parameters using accelerated cardiac acquisition with IQ SPECT are significantly different to those obtained with conventional SPECT, while agreement for clinical interpretation of myocardial perfusion scintigraphy with both techniques is high.

Thyroid hormones have a widespread effect on human metabolism. Their biochemical peculiarity is the need of iodine for their synthesis. Any lack of thyroid hormones is called hypothyroidism, the diagnosis of which can easily be established by testing a patient’s serum. However, many different forms of hypothyroidism can be distinguished. Some of them occur already at birth, are usually caused by genetic defects like those encountered in Pendred syndrome and are called congenital forms of hypothyroidism. Others are acquired during lifetime and are usually caused by either iodine deficiency or several different types of thyroiditis. Also, some very distinct drugs can cause hypothyroidism. Another differentiation is to distinguish primary forms and central forms of hypothyroidism. The term primary refers to a lack of thyroid hormones due to an impaired production of hormones at the thyroid gland itself, whereas in central forms hypothalamic or pituitary disturbances lead to an absence of thyroid stimulation.

We evaluated (18)F-fluoride PET/CT for the diagnosis of screw loosening after intervertebral fusion stabilization and compared the results with those from functional radiography.A group of 59 patients with pain in the region of previous intervertebral fusion stabilization and suspicion of implant instability due to screw loosening were investigated with (18)F-fluoride PET/CT and functional radiography, 30.1 ± 3.4 and 29.3 ± 3.2 months, respectively, after surgery. The criterion for loosening was increased focal uptake surrounding the screw entry point and shaft. SUVmax and SUVmean were measured in a region of interest (ROI) drawn around each screw (334 screws analysed). The final diagnosis was established by surgical exploration in 27 patients and clinical follow-up after intervertebral fusion stabilization in 32 patients.Of the 59 patients, 20 were proven positive for implant failure due to screw loosening and 39 were confirmed negative. The sensitivity, specificity and accuracy of (18)F-fluoride PET/CT were 75%, 97.4% and 89.8% in the patient-based analysis, and 45.6%, 100% and 80% in the screw-based analysis, respectively. The positive and negative predictive values were 93.8% and 100 % in the patient-based analysis, and 88.4 and 76% in the screw-based analysis, respectively. CT signs in PET/CT allowed screw breakage to be detected in three patients. SUVmax, SUVmean and SUVmax/SUVmean ratios in screw ROIs and respective values in reference regions were all found to be significantly different between screws positive for loosening (58 screws) and screws negative for loosening (276 screws). The ratio between SUVmax in screw ROIs and the values in reference regions was the most significant parameter for distinguishing screws positive and screws negative for loosening.(18)F-Fluoride PET/CT imaging is useful for the diagnosis of screw loosening in patients with persistent symptoms after intervertebral fusion stabilization.

Mutual clinical and molecular interactions between iron and glucose metabolism have been reported. We aimed to investigate a potential effect of glucose on iron homeostasis. We found that serum iron concentrations gradually decreased over 180 min after the administration of 75 g of glucose from 109.8 ± 45.4 mg/L to 94.4 ± 40.4 mg/L (P

Accurate staging of lung cancer is essential for effective patient management and selection of appropriate therapeutic strategy. The aim of this paper was to compare the value of bone scintigraphy and FDG PET-CT for detecting bone metastases in lung cancer patients and the impact of these modalities in disease staging.One hundred sixty-four lung cancer patients who had undergone both FDG PET-CT and bone scintigraphy within 14 days were included into this study. The analysis of FDG PET-CT and bone scintigraphy was carried out patient- and lesion-based.One hundred twenty-one patients were negative and 43 patients positive for bone metastases. FDG PET-CT found bone metastases in 42/43 patients and bone scintigraphy in 38/43 patients. Sensitivity, specificity and accuracy of FDG PET-CT and bone scintigraphy for detecting bone metastases were 97.7%, 100% and 99.4%, and 87.8%, 97.5% and 94.2%, respectively. FDG PET-CT identified 430 bone metastases and bone scintigraphy 246 bone metastases. Skull was the only region where bone scintigraphy identified more lesions than FDG PET-CT. Based on both scintigraphic modalities disagreement concerning disease stage was found in 3 patients.FDG PET-CT yielded a higher sensitivity, specificity and accuracy than bone scintigraphy for identifying bone metastases in lung cancer patients. FDG PET-CT thus can be recommended for initial staging of lung cancer patients without applying bone scintigraphy for the detection of bone metastases.