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Application of Intravenous Contrast in PET/CT: Does It Really Introduce Significant Attenuation Correction Error?

¹ Department of Nuclear Medicine and PET-CT, AmMed Cancer Center, Adventist Hospital, Hong Kong, China
² General Electric Medical Systems, Milwaukee, WI
³ The Hamamatsu/Queen’s PET Imaging Center, Honolulu, HI

The current perception of using contrast-enhanced CT (CECT) for attenuation correction (AC) is that of caution, as it might lead to erroneously elevated ¹⁸F-FDG uptake on the PET scan. This study evaluates in vivo whether an intravenous iodinated contrast agent produces a significant AC artifact in the level of standardized uptake value (SUV) changes in PET/CT. Methods: Fifty-four patients referred for whole-body (WB) PET/CT scans were enrolled and subdivided into 2 groups. In part I, 26 patients had a single WB PET scan that was corrected for attenuation using noncontrast and intravenous CECT obtained before and after the emission data, respectively. The final PET images were compared for any visual and SUV maximum (SUV_max) measurement difference. This allowed analysis of the compatibility of the scaling processes between the 2 different CTs and the PET. The SUV_max values were obtained from ascending aorta, upper lung, femoral head, iliopsoas muscle, spleen, liver, and the site of pathology (total, 193 regions). Part II addressed whether intravenous contrast also influenced the PET emission data. For that purpose, the remaining 28 patients underwent a limited plain CT scan from lung base to lower liver edge, followed by a 1-bed PET scan of the same region and then a WB intravenous contrast CT scan in tandem with a WB PET scan. SUV_max values were obtained at the lung base, liver, spleen, T11 or T12 vertebra, and paraspinal muscle (total, 135 regions). The data obtained from pre- and post-intravenous contrast PET scans were analyzed as in part I. Results: There was no statistically significant elevation of the SUV level in the measured anatomic sites as a whole (part I: mean SUV_max difference = 0.06, P > 0.05; Part II: mean SUV_max difference = –0.02, P > 0.05). However, statistically significant results as a group (mean SUV_max difference = 0.26, P < 0.05)—albeit considered to be clinically insignificant—were observed for areas of pathology in the part I study. No abnormal focal increased ¹⁸F-FDG activity was detected as a result of the intravenous contrast in both parts of this examination. Conclusion: No statistically or clinically significant spuriously elevated SUV level that might potentially interfere with the diagnostic value of PET/CT was identified as a result of the application of intravenous iodinated contrast.

Key Words: ¹⁸F-FDG PET • CT • intravenous contrast • PET artifact • attenuation correction • PET/CT

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