[Possibilities and perspectives of quality management in radiation oncology]. / Möglichkeiten und Perspektiven des Qualitätsmanagements in der Radioonkologie.

The medical discipline radiation oncology and radiation therapy (treatment with ionizing radiation) has developed rapidly in the last decade due to new technologies (imaging, computer technology, software, organization) and is one of the most important pillars of tumor therapy. Structure and process quality play a decisive role in the quality of outcome results (therapy success, tumor response, avoidance of side effects) in this field. Since 2007 all institutions in the health and social system are committed to introduce and continuously develop a quality management (QM) system. The complex terms of reference, the complicated technical instruments, the highly specialized personnel and the time-consuming processes for planning, implementation and assessment of radiation therapy made it logical to introduce a QM system in radiation oncology, independent of the legal requirements. The Radiation Center Hamburg (SZHH) has functioned as a medical care center under medical leadership and management since 2009. The total QM and organization system implemented for the Radiation Center Hamburg was prepared in 2008 and 2009 and certified in June 2010 by the accreditation body (TÜV-Süd) for DIN EN ISO 9001:2008. The main function of the QM system of the SZHH is to make the basic principles understandable for insiders and outsiders, to have clear structures, to integrate management principles into the routine and therefore to organize the learning processes more effectively both for interior and exterior aspects.

[Therapeutic results of radioiodine therapy of hyperthyroid thyroid gland diseases]. / Therapieergebnisse der Radiojodtherapie hyperthyreoter Schildrüsenerkrankungen.

PATIENTS AND METHODS: The result of radioiodine treatment administered to 126 patients with hyperthyroidism between 1986 and 1991 were analysed retrospectively. The indications for radioiodine treatment were single hyperfunctioning nodules (n = 47), multinodular goitre (n = 33), diffuse goitre (n = 19) and Graves' disease (n = 27); the respective doses of 131I, calculated with the Doering and Kramer formula, were 300 Gy (30,000 rad), 150 to 200 Gy (15,000 to 20,000 rad), 100 to 120 Gy (100,000 to 120,000 rad) and 100 Gy (100,000 rad). The uptake of radioiodine was measured on a daily basis and in the case of 46 patients (36.5%) additional treatment given on the third day of treatment. RESULTS: For the patients undergoing regular follow-up, data were collected in 1992, at least six months post-therapy. Evaluation revealed a total applied dose of 131I of 20 +/- 12.4 mCi (median +/- SD) per patient. non-response to treatment making hospitalisation and renewed therapy necessary was observed in 1.6% of the group. In only two further patients did scintigraphy reveal compensated toxic adenoma. In 36% of patients with single hyperfunctioning nodules, 21% of those with multinodular goitre, 53% of those with diffuse goitre and 56% of those with Graves' disease hyperthyroidism was observed. In the great majority of cases, hypothyroidism occurred in the first year following treatment.

[Lung activity in 201Tl myocardial scintigraphy: distribution and correlation with hemodynamic parameters]. / Die Lungenaktivität in der 201Tl-Myokardszintigraphie: Verteilung und Korrelation zu hämodynamischen Parametern.

UNLABELLED: The aim of this study was 1. to investigate whether the pulmonary activity in 201Tl myocardial scintigraphy can be accurately quantified from the anterior SPECT projection, 2. to determine the pattern of the intrapulmonary Tl distribution, and 3. to assess the influence of parameters of left ventricular function on the lung/heart ratio (LHR). Scintigraphic images of 85 patients were analysed. In 24 patients planar anterior imaging of the thorax was performed in addition to myocardial SPECT, in 41 patients radionuclide ventriculography was performed within 4 weeks after Tl scintigraphy. IN CONCLUSION: 1. pulmonary Tl-content can be quantitated from the anterior SPECT projection with sufficient accuracy, 2. a lower thallium activity was registered over the apical part of the lung as compared to the basal part, and 3. in the multiple regression analysis the left ventricular ejection fraction (LVEF) during exercise and heart rate during exercise (HRex) exhibited the strongest relation to LHR. After correction with regard to HRex the elevated LHR points to a pathological LVEF during exercise.

Radioimmunoscintigraphy of squamous cell carcinoma in the head and neck region.

Radioimmunoscintigraphy (RIS) with a monoclonal antibody (SQ 174, Biomira, Inc, Canada) is introduced as a new diagnostic method for detection of squamous cell carcinoma in the head and neck region. RIS could detect eight of the 10 primary tumors. One patient had histopathologically proven nodal disease. This lymph node was seen in RIS. No false positive results were seen in RIS, whereas sonography, computed tomography, and magnetic resonance imaging showed several false positive results.

Use of amphotericin B aerosols for the prevention of pulmonary aspergillosis.

Invasive pulmonary Aspergillus infections are increasingly recognized among severely neutropenic and/or immunosuppressed individuals. As the infections are usually acquired through the inhalation of Aspergillus conidia, at present prevention of invasive pulmonary aspergillosis consists mainly of the reduction of environmental exposure to aspergillus conidia. More recently, prophylaxis with amphotericin B aerosols has been investigated. Inhalations with amphotericin B aerosols significantly delayed mortality in an animal model of invasive pulmonary aspergillosis and high pulmonary concentrations of amphotericin B could be achieved. In man, pulmonary deposition of amphotericin B could also be demonstrated using commercially available nebulizers. Inhalations were well tolerated with little systemic absorption of the drug. In order to evaluate the efficacy of aerosol amphotericin B administrations for the prevention of invasive pulmonary aspergillosis, a prospective randomized trial has been initiated.

Aerosol amphotericin B for prevention of invasive pulmonary aspergillosis.

The pharmacokinetics and applicability of aerosol amphotericin B administrations were studied in 40 neutropenic patients and 4 healthy volunteers. Particle size was measured and pulmonary deposition was demonstrated by radioisotope studies. Inhalations were easy to administer and were well tolerated, with minimal systemic absorption of the drug.

[Prophylactic inhalation of amphotericin B in invasive aspergillosis: a distribution study]. / Prophylaktische Inhalation von Amphotericin B bei invasiver Aspergillose: Verteilungsstudie.

Invasive pulmonary aspergillosis (IPA) during periods of immunosuppression or prolonged neutropenia is a serious condition with high mortality. Prophylaxis is unsatisfactory because of the low effectiveness of systemic administration of amphotericin B (AMB) and because of its side effects. Prophylactic inhalation of AMB by means of a nebulizing system may be able to reduce the incidence of IPA. Therefore, we studied the distribution of nebulized 99mTc-labeled AMB and estimated its particle size. AMB is homogeneously distributed in the lung and partly deposited in the terminal respiratory unit; it remains there with a half-life of at least 14 h. Therefore, prophylaxis of IPA with AMB nebulized as described can be recommended.

[Quantitative 201Tl-scintigraphy of the lower limb in arterial occlusive disease]. / Quantitative 201Tl-Szintigraphie der Unterschenkel bei arterieller Verschlusskrankheit.

201Tl scintigraphy is useful in evaluating the hemodynamic consequences of arterial stenoses in arterial occlusive disease. The aim of the present study was to determine normal values for absolute Tl uptake in the lower leg, for the quotient between left and right lower leg uptake as well as for the redistribution pattern after bicycle exercise. We examined as reference 49 patients without clinical evidence of peripheral or coronary artery disease: absolute Tl uptake in the lower leg in anterior scintigraphy (acquisition time: 120 sec) was 5.02 +/- 1.70 counts/pixel (left) and 5.21 +/- 1.53 counts/pixel (right), the quotient between right and left lower leg was 0.85 +/- 0.09 and the redistribution pattern (quotient of the mean activity exercise/rest) 0.82 +/- 0.17 (left) and 0.83 +/- 0.15 (right). The arithmetic mean minus 2 standard deviations was regarded as the lower limit of normal. In 8 patients with mechanical compression of the left femoral artery before injection at least two scintigraphic parameters were abnormal, in 7 patients with angiographically proven peripheral artery disease at least one scintigraphic parameter was below normal. Quantification of Tl redistribution offers diagnostic advantages in bilateral peripheral artery disease.

[Brain scintigraphy (SPECT) with thallium-201 in primary brain tumors]. / Hirnszintigraphie (SPECT) mit Thallium 201 bei primären Hirntumoren.

We evaluated the role of thallium-201 single-photon emission-computed tomography (SPECT) in diagnosis, differential diagnosis and follow-up of 33 patients with primary brain tumors. 27 of 33 lesions were detectable by Tl-201 SPECT because only two of eight low-grade (grade 1 and 2) astrocytomas showed Tl-201 accumulation up to a tumor to nontumor ratio of 2.6. High grade (grade 3 and 4) astrocytomas showed Tl-201 accumulation in the range of 2.2 up to 13.0 and were different from low-grade astrocytomas. Noninvasive grading of astrocytomas is therefore possible, whereas differential diagnosis of oligodendrogliomas and astrocytomas or meningiomas was not possible with Tl-201. In the follow-up of six patients, we could demonstrate, that tumor progression is correlated with increasing and tumor regression with decreasing Tl-201 accumulations. This functional changing proceed morphological findings in CT. But vanishing of Tl-201 accumulation during therapy does not mean vanishing of tumor as could be demonstrated by follow-up.

[The determination of cerebral dopamine (D2) receptor density by using 123I-IBZM-SPECT in Parkinson disease patients]. / Bestimmung der zerebralen Dopamin-(D2)-Rezeptoren-Dichte mit Hilfe der 123Jod-IBZM-SPECT bei Patienten mit Morbus Parkinson.

An alteration of the dopaminergic nigrostriatal system is believed to be the main pathogenetic factor of Parkinson's disease (PD). We report on our initial results on the determination of the post-synaptic dopamine-D2-receptor binding of 123I-IBZM in patients with PD. Drug-native patients showed a significantly higher IBZM binding in the basal ganglia as compared to patients on specific dopaminergic medication. Age, duration of the disease and the severity of the disease do not seem to influence the IBZM-receptor binding. We conclude that 123I-IBZM-SPECT is an extremely useful tool for the evaluation of the functional state of cerebral dopamine-D2-receptors.

[Radioimmunoscintigraphy: fundamentals (1)]. / Radioimmunszintigraphie: Grundlagen (Teil 1).

Radioimmunoscintigraphy (scintigraphy of benign and malignant diseases with radioactively labelled monoclonal antibodies) is being performed via clinically controlled studies in Germany since 1985. In this review the immunological fundamentals and diagnostic possibilities of this new diagnostic approach are given described.

[Radioimmunoscintigraphy of colorectal tumors: state of the art (2)]. / Radioimmunszintigraphie kolorektaler Tumoren: State of the Art (Teil 2).

Radioimmunoscintigraphy (RIS) of colorectal carcinomas is under investigation in controlled clinical studies in Germany since 1985. With the availability of 99mTc labelled monoclonal antibodies against the carcinoembryonic antigen (CEA), there is an increasing acceptance of this new technique; nevertheless, the merits of RIS in comparison to established methods of staging and restaging of patients with colorectal carcinomas as computed tomography, endoscopy and sonography are still under discussion. In this review the current "State of the Art" of radioimmunoscintigraphy of colorectal carcinomas is given in respect of whether there is additional information which can be gained only by Ris but not by the established diagnostic procedure.

[Radioimmunoscintigraphy of colorectal tumors with 99m-Tc marked CEA antibodies. Indications and clinical value]. / Radioimmunszintigraphie kolorektaler Tumoren mit 99m-Tc-markierten CEA-Antikörpern. Indikationen und klinische Wertigkeit.

In Germany, radioimmunoscintigraphy (RIS) (scintigraphic, specific imaging of benign and malignant diseases by radioactively labelled monoclonal antibodies) has been employed since 1985 in clinical trials involving patients with colorectal cancer. After proving successful for identifying primary tumors, RIS is now increasingly being used for the early diagnosis of recurrent and metastatic lesions. In this prospective study involving 75 patients with colorectal tumors confirmed by endoscopy and biopsy, it was shown that RIS using the SPECT technique with 99m-Tc-labelled monoclonal CEA antibodies has a sensitivity of 78% in the detection of local recurrent disease in cases in which diagnostic work-up has been inconclusive.

[Typical findings and erroneous findings in SPECT-radioimmunoscintigraphy using 99mTc-labeled CEA antibodies in colorectal tumors]. / Typische Befunde und Fehlbefunde in der SPECT-Radioimmunszintigrapie mit 99mTc-markierten CEA Antikörpern bei kolorektalen Tumoren.

Radioimmunoscintigraphy with 99mTc-labelled monoclonal antibodies against Carcino-Embryonic-Antigen (CEA) is increasingly accepted in the follow-up of patients suffering from colorectal carcinomas. However, interpretation of transversal, coronal and sagittal reconstructions of "Single Photon Emission Computed Tomography" radioimmunoscintigraphic studies is difficult due to physiological antibody accumulations and anatomical based variations of antibody distribution. In the following study we demonstrate therefore, the typical findings and "pitfalls" of radioimmunoscintigraphy with 99mTc-labelled CEA antibodies in comparison to findings in computed tomography, to help to avoid misinterpretations.

[Border-area cerebral ischemia--3D-SPECT for the imaging of the regional cerebral blood flow]. / Zerebrale Grenzzonenischämie--3D-SPECT zur Darstellung des regionalen zerebralen Blutflusses.

15 patients with suspected cerebral ischaemia were examined using 99mTc-HM-PAO-SPECT to assess cerebral blood flow. Results obtained from SPECT were correlated with CT and Doppler ultrasound findings. A 3D-display algorithm is proposed to enhance the lesion to non-lesion contrast compared to the standard 2D-image interpretation. In all cases contrast was superior on 3D-display to 2D-display (-0.38 versus -0.09). 3D-display of SPECT-data enhances lesion contrast due to postreconstructive data processing and may improve exact interpretation of cerebral blood flow studies.

[The place of radioimmunoscintigraphy in the diagnosis and follow-up of ovarian cancer in comparison with computed tomography and second-look surgery]. / Stellenwert der Radioimmunszintigraphie in der Diagnostik und Verlaufskontrolle des Ovarialkarzinoms im Vergleich zur Computertomographie und "Second Look"-Operation.

In this prospective study the diagnostic capability of radioimmunoscintigraphy (RIS) was compared with that of computed tomography (CT) and of "second look" surgery as primary diagnostic procedures in 27 patients and in the follow-up of 52 women suspected of suffering from ovarian cancer. The results were compared with immunohistochemical findings and CA125 serum levels. For primary diagnosis sensitivity, specificity and diagnostic accuracy of RIS was 100%, 60% and 90%, resp. In follow-up, sensitivity for local recurrencies was 75% and specificity 68%. Peritoneal carcinosis in the pelvis and lower abdominal region was better detectable by RIS, but for detection of liver metastases CT showed better results. CT and RIS could not replace "second look" surgery.

[The value of radioimmunoscintigraphy compared to computed tomography in the diagnosis and relapse diagnosis of colorectal tumors]. / Wertigkeit der Radioimmunszintigraphie im Vergleich zur Computertomographie in der Diagnostik und Rezidivdiagnostik kolorektaler Tumoren.

Radioimmunoscintigraphy (= RIS, scintigraphic "specific" imaging of benign and malignant diseases by means of radioactively marked monoclonal antibodies) has been performed in Germany in clinical studies since 1985 in patients suffering from colorectal cancer. After having been successfully proven in primary studies, RIS is now being used in the early diagnosis of recurrences and metastases. In the prospective study presented here the clinical usefulness of RIS was assessed in comparison against well-tried diagnostic methods including computed tomography in patients suffering from colorectal cancer. It was shown that RIS in SPECT technique (= single photon emission computed tomography) with 99mTc-labelled monoclonal CEA antibodies can visualise local recurrences if diagnostic findings are doubtful, with a sensitivity of 78% versus 50% for CT findings.