AIM: As first-line therapy of hyperthyroidism caused by Graves' disease antithyroid drugs are favoured in Europe, while radioiodine therapy is favoured in the USA. Radioiodine therapy has become more economic in Germany since the new recommendations by the Federal German Radiation Protection Committee (SSK) for patient discharge guidelines. METHOD: Sensitivity analyses took into account the long-term relapse rate of conservative or radioiodine therapy, use of diagnostic tests, level of health insurance, drops in productivity and a discount factor. Costing models included the costs of follow-up care over 30 years. The costs of the hospitalisation for radioiodine therapy were calculated for 300 patients, discharged with 250 MBq 1-131 residual activity. RESULT: Antithyroid drugs were considered cost-effective when they achieved relapse rate of 50% or less, a cut in the number of tests needed and reduced working hours. Failure to meet any one of these conditions makes primary radioiodine therapy more cost-effective in 1593 of 1944 calculated costing models. Repeated conservative therapies will increase clearly the overall costs. CONCLUSION: Radioiodine is a cost-effective, first-line therapy in patients with a special risk of relapse after primary conservative therapy (goitre, younger patient, persistent elevated TSH-receptor-antibodies or Tc-uptake).

Antithyroid Agents↗

PubMed1998

Treatment of toxic nodular goitres: Comparative costing of radioiodine therapy and surgery.

Cost accounting has shown that the volume of tissue to be treated is the decisive factor in determining the cost of radioiodine therapy (RAITh). In the case of large goitres, the costs of excision (5.185 DM) and radioiodine therapy (5.562 DM) are, to a large extent, equivalent. Under the 1993 regulations for radiation protection, RAITh was cost-effective for treatment of toxic multinodular goitres up to volumes of 57 ml. However, new maximum permissible levels of radioactivity on discharge from hospital (250 MBq iodine-131 residual activity) have raised this threshold volume to 90 ml. In Germany, remuneration for a goitre resection is calculated from standard charges for total treatment without any consideration of the size and spectrum of medical services offered by different clinics, while remuneration for RAITh comes from payments for basic and specific, departmental medical services. University clinics with departments of nuclear medicine have relatively high basic costs. In the first quarter of 1998, the length of hospitalisation after RAITh (for all indications combined) was 4.6 days in university hospitals in Germany. Owing to this shorter length of hospitalisation, the payments received in some clinics fell far short of the total costs of this treatment calculated by cost accounting.

Cost Control↗

PubMed1998

Follow-up of differentiated thyroid cancer: what is the value of FDG and sestamibi in the diagnostic algorithm?

AIM: FDG-PET and MIBI-scintigraphy with SPECT were compared to [131I]-whole-body scintigraphy (WBS) and morphologic imaging in the follow-up of differentiated thyroid cancer. Their influence of therapy-planning was analysed. METHODS: In 50 consecutive patients (papillary/ follicular/variants of a follicular carcinoma: 33/13/4; primary status: pT1/2/3/4: 3/16/9/22) FDG-PET of neck/chest and MIBI-whole-body scan including SPECT were performed during hypothyreosis and before WBS. Morphologic imaging was done by MRI in all and by CT of the lung without contrast media in 21 patients. RESULTS: The complete extent of metastases was detected by FDG-PET in 11 and by MIBI-scintigraphy also in 11 of 22 patients with evidence of disease. The combined evaluation of WBS and FDG-PET as well as of WBS and MIBI-scintigraphy held true in 18 of 22 patients. Limiting FDG-PET or MIBI-scintigraphy to patients with elevated thyroglobulin (Tg)-levels and negative WBS only, would not, therefore, alter the sensitivity of this algorithm. The diagnostic benefit of FDG-PET and MIBI-scintigraphy was confined to lymph node metastases. The 1 cm limit for lymph node size in morphologically based imaging did not apply to FDG-PET and MIBI-scintigraphy. None of the 6 patients with small (< 1 cm) pulmonary metastases showed either FDG- or MIBI-uptake, but could be diagnosed by spiral-CT. CONCLUSION: WBS cannot be replaced by FDG-PET or MIBI-scintigraphy; neither of the latter was better than the other. Rising Tg-levels, negative WBS and the exclusion of pulmonary metastases by spiral-CT define the constellation in which FDG-PET and MIBI-scintigraphy can provide data of therapeutic relevance.

Adult↗

PubMed1998

[Consequences of new patient discharge guidelines on the cost structure of radioiodine therapy].

AIM: Consequences of the new recommendations by the Federal German Radiation Protection Committee (SSK) for patient discharge guidelines (residual activity of 250 MBq for I-131) were calculated for duration of stay and radioiodine therapy cost management. METHODS: For 601 consecutively admitted patients with hyperthyreosis, actual duration of stay and duration of stay according to previous guidelines (from 1993) were calculated, as well as duration of stay according to recommended values. Following BPflV statutes, cost-analysis considered the cause and volume of goitre, and by using sensitivity analyses included a range of diagnostics, service assessment, and duration of stay. RESULTS: Duration of stay following I-131 therapy (in Germany) is expected to fall by 35-50% (average future stay 4.0 +/- 2.8 days), average costs from DM 4,452 to DM 3,680 (-17.4%). Not including pretreatment diagnostics, cost reduction (service assessment 17-24%) was estimated at 21-25%. Compared to strumectomy, I-131 therapy costs are expected to be lower for goitres (Graves' disease) up to at least 60 ml, toxic nodules of at least 25 ml, and toxic multinodular goitres of at least 90 ml. CONCLUSION: In the future, I-131 therapy will be more cost-effective even with larger goitres. Since reimbursement is determined by the duration of stay, new reimbursement procedures are discussed in this paper.

Cost-Benefit Analysis↗

PubMed1997

[Polyneuropathies in monoclonal gammopathy of undetermined significance: initial manifestation of a lymphoma].

BACKGROUND: Monoclonal gammopathies-including so-called monoclonal gammopathies of undetermined significance-MGUS-may cause polyneuropathies, even if immunoglobulin concentrations are within a normal range. CASE REPORT: We report on a patient with a rapidly progressive polyneuropathy with severe motor disturbances in whom a small amount of a monoclonal IgM kappa cryoglobulin was found. Only by extensive, repeatedly performed diagnostic procedures could scattered lymphoma cells be detected. Nonspecific immunosuppression had been unsuccessful but eventually a more specific chemotherapy led to an almost complete, sustained recovery. CONCLUSION: This case shows that in patients with a polyneuropathy of uncertain etiology monoclonal immunoglobulins should be looked for and that a MGUS can precede a lymphoma. Therefore these, patients with a MGUS and clinical deterioration despite conventional immunosuppressive treatment should undergo large-scale diagnostic check-up to make sure that the chance for an adequate chemotherapy is taken.

Aged↗

PubMed1997

[99mTc-MDP-SPECT for detection of subclinical mandibular infiltration of squamous epithelial carcinoma].

UNLABELLED: A prospective study was performed to compare the sensitivity and accuracy of ultrasound (US), computed tomography (CT), and single photon emission computed tomography (SPECT) as a bone scan to detect subclinical invasion of the mandible by squamous cell carcinoma of the oral cavity and floor of mouth. METHODS: The present study reports data on 35 patients with squamous cell carcinoma of the oral cavity. SPECT, mandibular orthopantomography (OPG), US, CT and magnetic resonance imaging (MRI) were performed as well as histologic examination of resected mandibles. Transverse slices of 12 mm thickness were reconstructed for SPECT and semi-quantitative assessment of radionuclide uptake was performed with a scoring system based on comparisons of tracer uptake in the mandible to that in an unaffected part of the mandible. Lesion to non-lesion count ratios in the mandible in 3 h SPECT images were calculated. OPG, US and CT were evaluated for comparison. RESULTS: In 12/35 patients, histologic examination showed carcinoma infiltrating mandibular bone. SPECT correctly predicted mandibular invasion in 11/12 cases, with no false-positive results. CT detected correctly 3/12 lesions, while OPG and ultrasound each demonstrated 2/12 tumors. CONCLUSION: Bone SPECT was found to provide an accurate means for assessing tumor invasion to the mandible by intraoral squamous cell carcinoma. As a complementary study to one of the other imaging modalities it was shown to have a high specificity, indicating that it should be performed routinely in patients with suspect mandibular bone involvement by causes.

Adult↗

PubMed1997

Fluorine-18 fluorodeoxyglucose positron emission tomography and iodine-131 whole-body scintigraphy in the follow-up of differentiated thyroid cancer.

Metastases of differentiated thyroid cancer may show different uptake patterns for fluorine-18 fluorodeoxyglucose and [131I]NaI. FDG positron emission tomography (PET), iodine-131 whole-body scintigraphy (131I WBS) and magnetic resonance imaging were performed in 58 unselected patients, and spiral computed tomography (CT) of the lung in 25 patients. Thirty-eight patients presented with papillary carcinomas, 15 patients with follicular carcinomas and five patients with variants of follicular carcinoma. Primary tumour stage (pT) was pT1 in 3, pT2 in 19, pT3 in 11 and pT4 in 25 cases. For the detection of metastases, FDG PET was found to have a sensitivity of 50%, 131I WBS a sensitivity of 61%, and the two methods combined a sensitivity of 86%. When FDG PET was limited to patients with elevated thyroglobulin (Tg) levels and negative 131I WBS, the sensitivity of this algorithm was 82%. Of the 21 patients with lymph node metastases, seven presented with FDG uptake but no iodine uptake. In four of them, a second FDG hot spot appeared in a lymph node metastasis of normal size. Five of the seven patients underwent surgery. None of the eight patients with pulmonary metastases smaller than 1 cm exhibited FDG uptake, while five of them had iodine uptake. All had positive results on spiral CT. In conclusion, FDG PET cannot be substituted for 131I WBS. If the Tg level is elevated and 131I WBS is negative, FDG PET can be used to detect lymph node metastases and complements anatomical imaging. A spiral CT of the lung is useful to exclude pulmonary metastases before planning a dissection of iodine-negative lymph node metastases.

Adult↗

PubMed1997

[Radioiodine therapy in differentiated thyroid gland carcinoma].

The current level of knowledge about radioiodine therapy (RITh) for well-differentiated thyroid carcinoma under consideration of the recent literature is summarised. In RITh for thyroid carcinoma two major fields can be distinguished: the ablation of the thyroid remnant and the therapy of recurrences resp. local and distant metastases. New large American studies indicate, that the prophylactic post operative ablation of the thyroid remnant in primary tumours over 1.5 cm in diameter is linked with a distinct improvement of the long-term prognosis. The RITh is effective also in distant metastases, if applied early, when the tumour volume is still small. The prerequisite is an appropriate follow-up. Surveys about the application of RITh for well-differentiated thyroid carcinoma in Europe and in the USA reveal that uniform treatment recommendations designed to conform interdisciplinary demands are urgently required.

Adolescent↗

PubMed1997

[Cost minimization analysis for the definitive therapy of hyperthyroidism: comparison of goiter resection with radioiodine therapy].

AIM: Cost-analysis of strumaresection and radioiodine treatment in patients with hyperthyreosis. METHOD: Matched by age, sex, comorbidity, volume of goiter, and entity of hyperthyreosis 18 patients of a clinic of surgery, and 28 patients of a clinic of nuclear medicine were analysed by the reimbursed costs, and by a retrospective calculation of the real costs. RESULTS: Based on the rate for the reimbursed costs the radioiodine treatment (6450 DM) was more favourably than the strumaresection (7562 DM); based on the calculation of the real costs including regional specialities there was a minimal difference in favour of the strumaresection (5185 DM versus 5562 DM) because of the selection of large goiters (median 53 ml), the longer hospitalisation after radioiodine treatment due to legal reasons (12.5 days), and the frequent controls before and after the radioiodine treatment. Most important cost-factor of the radioiodine treatment was the volume of goiter, most important cost-factor of the strumaresection was the age of the patient. The treatment of Graves disease was more expensive than that of autonomy in surgery as well as in nuclear medicine. CONCLUSION: In order to achieve cost-minimization, radioiodine treatment should be prefered in cases of small goiters or in older patients.

Cost-Benefit Analysis↗

PubMed1993

[X-ray studies of the peripheral joints: a comparison of digital luminescence radiography (DLR) and film-screen systems].

175 matched skeletal x-ray examinations were carried out by digital luminescent radiography (DLR) and conventional screen-film system combinations. In digital luminescent radiography (DLR) two differently postprocessed images were obtained from one x-ray exposure: A display with low spatial frequency enhancement was opposed to a second display with high edge enhancement. Conventional and digital images were evaluated randomly and separately by four radiologists using a questionnaire. DLR proved to be diagnostically equivalent to the conventional technique except for a diminished visibility of subtle erosions and fissures. As major advantages of DLR maybe pointed out that faulty exposures were avoided by the automatic adjustment of image brightness and that the soft tissue margins could be more easily delineated in displays with high edge enhancement than in conventional radiography. However, digital displays with high edge enhancement did not provide additional diagnostic information and led to artifacts at the edges of metal prostheses.

Adult↗

PubMed1992

Dysplastic gangliocytoma of cerebellum in a newborn. Diagnosis by ultrasonography and MRI.

A cerebellar lesion was detected by ultrasonography (US) in a symptomatic newborn. Magnetic Resonance Imaging (MRI) demonstrated this lesion as a gyriform structure. Therefore a rare dysplastic gangliocytoma was suspected, which was compatible with histopathology. Immunohistochemical studies (monoclonal antibody Ki-67) showed signs of progression.

Cerebellar Neoplasms↗

PubMed1992

The fibrous metaphyseal defect in early stage. Differential diagnosis to metaphysitis.

In a 22-month-old boy a fibrous metaphyseal defect (FMD) was diagnosed by radiological follow-up examinations. The initial radiological finding could not be differentiated from metaphysitis because of its early manifestation and stage. Eleven months later, magnetic resonance imaging (MRI) with Gadolinium (Gd)-DTPA demonstrated a small central area of increased signal intensity. Based on known angiographic findings with fibrous metaphyseal defects, one may hypothesize that this is best explained by a hypervascularized area.

Bone Diseases, Developmental↗