For initial evaluation, ⁶⁸Ga-DOTA-TOC PET was performed for accurate staging and evaluation of the SSTR status of the lesions (Gabriel et al. 2007, 2009).

If PET is positive, either with ⁶⁸Ga-DOTA-TOC or ⁶⁸Ga-DOTA-LAN (in case of a negative or insufficient ⁶⁸Ga-DOTA-TOC binding) and visual scoring revealed higher uptake in the lesions as compared to the normal liver uptake, patients are included for PRRT. Dosimetry using the ¹¹¹In-labelled compound is followed to calculate tumour and organ doses.

Normally, the ⁹⁰Y-labelled compound is used as the first treatment choice. However, if individual lesions are smaller than 2 cm in diameter ¹⁷⁷Lu-DOTA-TATE is preferred for PRRT. This compound is also used in patients who have already undergone PRRT with ⁹⁰Y-DOTA-TOC and progression as second choice tracer due to lower radiation dose to the kidneys (Forrer et al. 2005).

The reference standard for the clinical outcome after PRRT is based on follow-up controls with all available patient records including laboratory parameters and the correlation of PET and CT/MRI findings according to Response Evaluation Criteria in Solid Tumours(RECIST) (Öberg and Jelic 2008; Duffaud and Therasse 2000). If necessary, other imaging modalities such as lesion guided MRI, and ¹⁸F-fluorodesoxyglucose (¹⁸F-FDG) PET, endoscopy and ultrasonography are also used to assess response to PRRT (Gabriel et al. 2009; Putzer et al. 2009).

Findings are summarized to three categories: response to therapy, stable disease (SD) and progressive disease (PD). Complete response, minor (MR), i.e. tumour shrinkage of less than 30 %, and partial response (PR).

Adverse effects of PRRT (evidence for thrombocytopenia, leukopenia, haemoglobinaemia, anaemia and elevation of creatinine) during the therapy course are reported.

In recent years, different therapeutic approaches have emerged for individualised targeted therapy in tumour patients. The expression of SST receptors on NETs has proven useful for imaging of NETs in different clinical situations, e.g. for initial diagnosis, staging and follow-up, with high diagnostic efficacy. Based on these findings tumours were also treated by SST-based radiopharmaceuticals showing promising overall results.

In our department patients are selected for PRRT by their inherent biological characteristic which can be evaluated by scintigraphy using either DOTA-TOC or, if this scan is negative, with DOTA-LAN. Recently, these compounds have also been labelled with gallium-68 for PET imaging providing higher diagnostic quality for initial evaluation as well as for the follow-up scanning after PRRT (Gabriel et al. 2007, 2009). Individualised therapy in nuclear medicine especially requires optimal functional imaging techniques with PET for visual evaluation and scintigraphy with ¹¹¹In labelled compounds for dosimetry.

PRRT can be considered in patients with inoperable metastatic disease and a positive SSTR scan. Although several studies have shown promising overall results, reported anti-tumour effects vary considerably. The individualised treatment regime applied at our department is based on various patient-related factors applying sometimes reduced standard doses. Nevertheless, our approach shows response to therapy in 75 % of patients which is basically comparable to published data of other centres (for review see Virgolini et al. 2009, van Essen et al. 2009) In addition, half of our patient population showed SD, and even in the patients with PD under therapy some palliation of tumour-related symptoms can be observed. In patients with advanced disease stages, older age, poor Karnovsky performance index and diminished organ function due to pre-treatment with chemotherapy, treatment doses are adapted according to clinical and laboratory parameters, so that severe, mostly intermittent, side effects (WHO grade 3 and 4) of PRRT are only rarely seen.

An other explanation for rather good tolerance of this regime might be based on the combination of PRRT with the cold SST analogue which could be a protective factor for kidney function. Furthermore, in about 30 % of patients a further improvement of the objective therapy response was also observed up to 12 months after finalization of PRRT. This might be in part contributed by the continuous application of the cold analogue to make the application of the non-labelled SST analogue an integral component of our regimen.

“Restitutio ad integrum” (lat. integritas) means “full healing” or “complete recovery”. NET Patients undergoing PRRT are mostly heavily metastasised and put a lot of hope into this new therapy modality. However, the treatment with high dose radioactivity is not so common and may cause a certain anxiety level. There is a lot of misinformation around and only a few studies exist in the area of external beam radiation therapy linking radiation to the patient general well-being or anxiety level (Smith et al. 2001). For nuclear medicine therapy, to our knowledge, there exist even less published data in this area. In NET patients undergoing PRRT, some authors (Teunissen et al. 2004) have reported significantly improved quality of life using the questionnaire from the European Organisation of Research and Therapy in Cancer Quality of Life Questionnaire C30, EORTC QLQ-C30 (Therasse et al. 2000). This questionnaire covers the global well-being of the patient. Other centres have also reported similar improvement of quality of life parameters in NET patients. In general, our view gets more and more accepted that for a NET patient a good clinical condition with stable tumour disease is better than a reduction in tumour size with reduced quality of life by high dose PRRT.

Healing, assessed physically, is the process by which the cells in the body regenerate and repair to reduce the size of a damaged or necrotic area. Healing incorporates both the removal of necrotic tissue, and the replacement of this tissue. Healing, assessed spiritually, emotionally, mentally or otherwise, is a process which involves more than just the action of cells (http://​psychology.​wikia.​com/​wiki/​Healing).

When building the therapy unit at the Department of Nuclear Medicine at the University of Innsbruck we aimed to establish a division in which the patient is treated not only by high standard nuclear medicine care but we also wanted to integrate other aspects of patient care.

The principle of architecture and healing (http://​nuklearmedizin.​i-med.​ac.​at/​, www.​youtube.​com/​watch?​v=​D15LOMR-aJY) was adapted to our therapy unit. The emphasis of healing, as mentioned above, was based on John 8,12 “I am the light of the world…. He, who follows Me, shall not walk in darkness, but have the light of life” as well as on Wolfgang Goethe` s last words “light, more light”. Consequently, the logo of our department (Fig. 3) depicts a severe sick patient who is in dark and who becomes enveloped by healing light, so that he can be transformed into well-being strength and joy. The various wall colours of our rooms where our NET patients are treated by PRRT (Fig. 4) are in perfect harmony with many Tyrolean Swarowski stones placed on the walls.

The ubiquity of music in human culture is indicative of its ability to produce pleasure and reward value. Recent PET studies have indicated that activity in paralimbic brain regions correlate with unpleasant or mildly pleasant emotions elicited by varying amounts of musical dissonance (Blood and Zatorre 2001), while subject-selected music that “chills” is accompanied by changes in heart rate, electromyogram and respiration and is correlated to brain regions thought to be involved in reward/motivation, emotion, and arousal (such as ventral striatum, midbrain, amygdala, orbitofrontal cortex, ventral medial prefrontal cortex). This brain structures are known to be active in response to other euphoria-inducing stimuli such as food, sex, etc., and link music with biologically relevant stimuli via their common recruitment of brain circuitry involved in pleasure and reward.

Anxiety is an understandable response to a diagnosis of cancer and its treatment. Two distinct types of anxiety are often presented, either acute or chronic. Roughly, half the cancer patients present with anxiety at varying levels and anxiety is simply underestimated. The stage of the cancer is a particularly important factor influencing anxiety. Specific music selections or types of music may have different effects for different people, and may have different effects for the same person at different times. Self-administered music interventions allow patients freedom to schedule their music intervention at times when it is most convenient (see Sect. 4) (Siedliecki et al. 2006; Blood et al. 2001)