[Joint DGN, OGNMB and SGNM S1 guideline for radiosynoviorthesis]. / Gemeinsame Handlungsempfehlung (S1-Leitlinie) von DGN, OGNMB und SGNM ­ Radiosynoviorthese ­ Stand: 9/2019 ­ AWMF-Registernummer: 031-023.

This recommendation is intended to provide a guideline for radiosynoviorthesis (RSO) in the effective local treatment of chronic inflammatory (non-infectious) joint diseases. It was developed in an interdisciplinary manner and describes the general objectives, definitions, clinical background information, indication and contraindications of this radionuclide therapy. The requirements to be met by a treatment center, the results of pretherapeutic examinations as well as recommendations on how the treatment should be carried out. Here, organizational and technical issues have been considered. Furthermore, information on the surveillance and follow-up of the treated patients can be found. In general, treatment and follow-up should be done in in close cooperation of the participating disciplines.

Post-radiosynovectomy imaging utilizing Erbium-169 citrate.

Currently, there is no imaging procedure for radionuclide therapy utilizing Erbium-169 (Er-169). We have recently published the first post-radiosynovectomy imaging of Er-169 citrate in a case report (Farahati et al., 2017). In this study, we performed in-vitro and in-vivo studies to evaluate the feasibility to assess the distribution of Er-169 citrate after radiosynovectomy in fourteen patients with seventeen affected joints treated for refractory chronic synovitis. Post-radiosynovectomy imaging revealed the feasibility of post-radiosynovectomy detection and distribution utilizing Er-169 citrate in all cases. However, additional in-vitro studies including in-vitro imaging, gamma spectrometry and analysis of half-life indicated that emitted gamma-rays of the Ytterbium-169 in the radiopharmaceutical together with bremsstrahlung induced by Er-169 are the imaging source of emitted counts. Post-radiosynovectomy imaging utilizing Er-169 citrate is feasible and should be implemented in the guidelines for theranostics for quality control, patient safety and therapy monitoring.

Changing trends of incidence and prognosis of thyroid carcinoma.

AIM: to evaluate the time trend of epidemiology of follicular cell derived thyroid cancer (TC) based on data from a well documented cancer registry. METHODS: Population based data on TC from Lower Franconia (LF), Germany, within 1981 and 2015 were analysed to estimate the regional epidemiology of TC. The incidence was assessed in 5-year-intervals for gender, histology, and tumor stage. RESULTS: Incidence of TC solely attributable to papillary TC (PTC) doubled mainly in T1- and T2-stages within the evaluation period from 4.5 to 8.7/100.000/y in females and 1.7 to 4.1/100.000/y in males. There was no significant change of follicular TC (FTC), whereas anaplastic TC (ATC) decreased in the same interval. The number of lymph-node metastases and T3-cases increased, while the frequency of T4-stage and distant metastases decreased. Increased incidences of T1- and T2-stages suggest an over-diagnosis. In contrast, increasing number of tumors at T3-stage and with lymph node involvement contradict the over-diagnosis as the only reason for rising incidence. Declining of T4-stages in spite of increasing of T3-stages and N1-cases indicates the value of timely detection and treatment of TC. In accordance, reduced incidence of advanced cancers with M1-stage and ATC cases promote our current management of TC. CONCLUSION: Timely diagnosis and adequate risk-adopted treatment of thyroid cancer reduce the frequency of high-risk cases with distant metastases and the possible protracted dedifferentiation of TC to anaplastic features. Our analyses support the management algorithm in thyroid cancer according to the recent guidelines of German Nuclear Medicine Society.

Diagnostic accuracy of [99mTc]Tc-Sestamibi in the assessment of thyroid nodules.

[99mTc]Tc-Sestamibi (MIBI) is an increasingly used tool for evaluation of thyroid nodules. However, there is a lack of evidence about the accuracy of this method in the European population. The aim of this study was to assess the utility of MIBI for the differentiation of thyroid nodules in a large cohort. 161 patients underwent MIBI, followed by a thyroidectomy. We used a dual phase MIBI protocol. Interpretation of the images included a scoring system from 0 (absent) to 3 (increased); this was to provide a scale for the uptake of the thyroid nodule in comparison to the paranodular tissue. Additionally, we evaluated the tracer uptake trend in late images compared to early images. We used the final histopathology as the reference standard. Scores 0-1 in early images, scores 0-2 in late images, and an absence of increasing uptake in the thyroid nodule in late images, showed the best predictive values to exclude malignancy, respectively (negative predictive value (NPV) 89%). Highest sensitivity (91%) for malignant nodules was evident in early images with a score 1-3. Highest specificity (91%) was obtained when the negative was defined as an absence of uptake-increase, in the late images. This study confirms that the most valuable feature of MIBI is the high NPV. Thus, with the appropriate interpretation method, high sensitivity and specificity, and moderate PPV can be obtained.

Post-radiosynovectomy imaging of Er-169 using scintigraphy and autoradiography.

Currently, there is no protocol for the detection of intra-articular distribution of Er-169 citrate after radiosynovectomy. We propose post-therapeutic imaging using scintigraphy and cobalt-57 pen-marker autoradiography. This technique evaluates the efficacy of the radiosynovectomy and patient safety and could be utilized for dosimetric protocol.

Diffuse skeletal metastasis and low thyroglobulin level in a pediatric patient with papillary thyroid carcinoma.

Thyroglobulin (Tg) is frequently measured in follow-up of patients with differentiated thyroid carcinoma. A low stimulated Tg level (<1 ng/ml) associated with normal neck ultrasonography is considered as the most reliable criteria for complete remission in low risk patients. We are reporting a case of pediatric thyroid cancer with diffuse skeletal metastasis associated with low serum Tg level bringing a point of caution in evaluation of patients with low Tg.

Ethnicity, Clothing Style, and Body Mass Index are Significant Predictors of Vitamin D Insufficiency in Germany.

OBJECTIVE: To analyze risk factors for vitamin D insufficiency in Germany with respect to ethnicity, sex, and clothing style. METHODS: We analyzed the routine diagnostic work-ups of 1,231 adult (45.9 ± 17.9 years old) German (n = 1,034) and Turk residents (n = 197) referred with nonspecific symptoms to the Thyroid Centers at St. Elisabeth-Hospital in Dorsten, Germany and Bottrop, Germany to assess for metabolic diseases. All subjects underwent a routine examination that consisted of a questionnaire, lab tests for 25-hydroxyvitamin-D (25OHD), and thyroid profile. Turk females with traditional clothing (headscarf and covered legs and arms) were considered to wear "covered clothing." Logistic-regression was performed to identify factors that could predict vitamin D deficiency (<20 ng/mL) and insufficiency (20-30 ng/mL). RESULTS: Vitamin D insufficiency was seen in 33% of Germans and 74.1% of Turks, and vitamin D deficiency was present in 11.3% and 44.2% of Germans and Turks, respectively (P<.001). The mean 25OHD value in Turk females with covered clothes was lower than that in Turk females with conventional clothing (16.3 ± 12.3 vs. 27.2 ± 15.8, P<.001). Vitamin D insufficiency was present in 86.0% of Turk females with covered clothing versus 62.8% with conventional clothing (odds ratio [OR] = 3.6, P = .002). Ethnicity, body mass index (BMI), and clothing style were significant predictors of vitamin D deficiency and insufficiency by logistic regression (P<.001). CONCLUSIONS: (1) Vitamin D insufficiency among Turk residents in Germany is higher compared to Germans. The highest prevalence was present in Turk females with covered clothing. (2) Monitoring vitamin D in Turk residents in Germany is warranted. (3) Vitamin D supplements and access to facilities with sunlight exposure for females with covered clothing and all individuals with poor diets or limited access to sun exposure may prevent future health burden due to vitamin D insufficiency.

Ultrasound-guided fine-needle aspiration biopsy of clinically suspicious thyroid nodules with an automatic aspirator: a novel technique.

BACKGROUND: Fine-needle aspiration biopsy (FNAB) is a simple technique for the investigation of suspicious thyroid nodules. However, low success rates are reported in the literature. The aim of this prospective study was to compare the clinical performance and impact of an automatic aspirator, referred to here as Aspirator 3, to those of the manual technique for the FNAB of clinically suspicious thyroid nodules. METHODS: One hundred nine consecutive patients with 121 clinically suspicious thyroid nodules underwent a biopsy twice of the same site with the clinically approved Aspirator 3 and with the manual technique. The number of follicular cell formations and the total number of follicular cells in the aspirate were counted using the ThinPrep® method. RESULTS: With the Aspirator 3, the total number and the mean number of extracted cell formations were significantly higher than the values achieved with the manual technique (total: 3222 vs. 1951, p=0.02; mean: 27 vs. 16). The total number of cells that were biopsied was also higher when the Aspirator 3 was utilized (47,480 vs. 23,080, p=0.005). Overall, the Aspirator 3 was superior in 65 biopsies, and the manual technique was superior in 39 biopsies. CONCLUSIONS: In terms of cell formations and the total number of cells aspirated, the Aspirator 3 was superior to the manual technique. Further, the Aspirator 3 was more convenient to use and had a greater precision in needle guidance.

Anti-thyroid peroxidase antibodies are associated with the absence of distant metastases in patients with newly diagnosed breast cancer.

BACKGROUND: The presence of thyroid peroxidase antibodies (TPOab) are reported to be associated with improved outcome among breast cancer patients. We evaluated the correlation between TPOab and diagnostic parameters among newly diagnosed breast cancer patients. METHODS: Three hundred and fourteen newly diagnosed patients with breast cancer, diagnosed and treated in Bethesda Essen between January 2002 and June 2006, were included in this study; 258 (82.2%) without TPOab (≤100 IU/mL) and 56 (17.8%) with TPOab (>100 IU/mL). Blood analysis was performed to measure serum levels of carcinoembryonic antigen (CEA), cancer antigen 15-3 (CA-15-3), free triiodothyronine (fT3), free thyroxine (fT4), thyroid-stimulating hormone (TSH) and TPOab by radioimmunoassay. Data regarding age, tumor size, grading, TNM classification, receptor status, lymph node, and distant metastases were collected and analyzed from patient reports. Statistics were performed using Pearson's χ2-test and logistic regression analysis. RESULTS: There were no incidences of distant metastasis among 56 patients with TPOab, whereas 17 (6.6%) of 258 cases without TPOab displayed distant metastases (p=0.04). Logistic regression showed an inverse association of TPOab with CA-15-3 and CEA levels (p<0.001, respectively). Both groups, with and without TPOab, revealed no significant differences with respect to age, tumor size, grading, TNM classification, fT3, fT4, and receptor status. TPOab positive patients had higher TSH levels (2.55±3.58), compared to TPOab negative cases (1.20±1.15) (p<0.001). CONCLUSIONS: TPOab occurrence is associated with significantly lower frequency of distant metastases in breast cancer. TPOab level inversely correlates with the conventional tumor markers CA-15-3 and CEA.

Gender-specific determinants of goiter.

Despite the strong implications of differences between females and males in the risk of goiter, gender-specific issues have not been extensively addressed in investigations of goiter prevalence. The objective of our analysis was to investigate the gender-specific determinants of goiter. Between April 2001 and April 2002. A total of 853 healthy employees from 4 institutions in the western part of Germany between 18 and 68 yr of age were examined by ultrasound of the neck to determine the thyroid volume. Information on sex, age, daily use of iodized salt, the history of goiter in the first-degree relatives, type and amount of smoking, oral contraceptives, and number of pregnancies were assessed by standardized questionnaires. Gender-specific predictors of goiter prevalence were assessed by multivariate logistic regression. The overall prevalence of goiter among study subjects was 204/853 (23.9%). Goiter was present in 80 out of 370 females (21.6%) vs 124/483 (25.7%) in males. In general, smoking (p < 0.0001), increasing age (p < 0.0001), and lack of daily intake of iodized salt (p = 0.004) were associated with goiter prevalence, but not sex (p = 0.39) and family history of goiter (p = 0.16). In 370 females, parity (p = 0.004) and lack of daily intake of iodized salt (p = 0.01) were the major determinants for goiter, whereas age (p = 0.18), oral contraceptives (p = 0.82), family history of goiter (p = 0.33), and smoking (p = 0.09) did not affect goiter prevalence. In 483 males, smoking (p < 0.0001) and age (p < 0.001) affected goiter prevalence, but not family history of goiter (p = 0.39), and the iodine status failed just to reach the significant level (p = 0.08) in this analysis. Gender-specific determinants of goiter are parity and iodine status in females and smoking and increasing age in males.

Radiosynovectomy in rheumatology, orthopedics, and hemophilia.

Radiosynovectomy (RSV) is a local intraarticular injection of radionuclides in colloidal form for radiotherapy. First used by Fellinger et al. in 1952, the technique has now been applied for more than 50 y for treatment of resistant synovitis of individual joints after failure of long-term systemic pharmacotherapy and intraarticular steroid injections. RSV relieves pain and inflammation from rheumatoid arthritis (RA), for which it initially was used, and is accepted as an alternative to surgical synovectomy in cases of RA or other inflammatory arthropathies such as osteoarthritis and hemophiliac arthropathy. A good understanding of the clinical pathophysiology of the disease processes is mandatory, and close interdisciplinary collaboration with other clinicians who diagnose and treat patients is strongly suggested. Reported success rates range from 40% to 90% for the different joints and underlying diseases. A few well-designed prospective double-blind trials have evaluated the efficacy of RSV and justified the procedure as a viable option for treating chronic synovitis in RA or secondary to inflammatory arthropathies. In comparison with surgical synovectomy, RSV produces equivalent results, costs less, allows the patient to remain ambulatory, and is repeatable. RSV has to be considered the initial procedure of choice for the treatment of patients with hemarthrosis in hemophilia. In addition, local instillation of radiopharmaceuticals can effectively reduce effusions after implantation of a prosthesis.

Changing trends of incidence and prognosis of thyroid carcinoma in lower Franconia, Germany, from 1981-1995.

BACKGROUND: A population-based registry (PBR) in Lower Frankonia in southern Germany was conducted to evaluate the changes of incidence and prognosis of thyroid carcinoma (TC) in this area. METHODS: The study comprised 476 patients with differentiated thyroid carcinoma (DTC) from Lower Franconia (1.3 x 10(6) inhabitants) registered between 1981 and 1995 at the Regional Tumor Center. The incidence was assessed with respect to gender, age, histology, tumor stage, lymph node involvement and distant metastases in 5-year intervals (1981-1985, 1986-1990, and 1991-1995). RESULTS: An increasing rate of papillary thyroid carcinoma PTC and a decreasing rate of follicular thyroid carcinoma (FTC) were observed over the three time periods (1981-1985, 1986-1990, and 1991-1995). The overall incidence revealed no significant change with time for both females from 3.22 to 3.25 and 3.73 and males (1.07 to 1.54 and 1.69) between the three time periods. There was a significant improvement in outcome of patients with DTC with respect to life expectancy. CONCLUSIONS: Iodine prophylaxis does influence the distribution of the histologic types of thyroid cancer and leads to an increase in the ratio of papillary versus follicular carcinoma. Our study supports the hypothesis that the benefits of correcting iodine deficency outweigh the risks of iodine supplementation.