title: PET/CT with intravenous contrast can be used for PET attenuation correction in cancer patients.
abstract: OBJECTIVE
  If the CT scan of a combined PET/CT study is performed as a full diagnostic quality CT scan including intravenous (IV) contrast agent, the quality of the joint PET/CT procedure is improved and a separate diagnostic CT scan can be avoided. CT with IV contrast can be used for PET attenuation correction, but this may result in a bias in the attenuation factors. The clinical significance of this bias has not been established. Our aim was to perform a prospective clinical study where each patient had CT performed with and without IV contrast agent to establish whether PET/CT with IV contrast can be used for PET attenuation without reducing the clinical value of the PET scan.
  
  
  METHODS
  A uniform phantom study was used to document that the PET acquisition itself is not significantly influenced by the presence of IV contrast medium. Then, 19 patients referred to PET/CT with IV contrast underwent CT scans without, and then with contrast agent, followed by an 18F-fluorodeoxyglucose whole-body PET scan. The CT examinations were performed with identical parameters on a GE Discovery LS scanner. The PET data were reconstructed with attenuation correction based on the two CT data sets. A global comparison of standard uptake value (SUV) was performed, and SUVs in tumour, in non-tumour tissue and in the subclavian vein were calculated. Clinical evaluation of the number and location of lesions on all PET/CT scans was performed twice, blinded and in a different random order, by two independent nuclear medicine specialists.
  
  
  RESULTS
  In all patients, the measured global SUV of PET images based on CT with IV contrast agent was higher than the global activity using non-contrast correction. The overall increase in the mean SUV (for two different conversion tables tested) was 4.5+/-2.3% and 1.6+/-0.5%, respectively. In 11/19 patients, focal uptake was identified corresponding to malignant tumours. Eight out of 11 tumours showed an increased SUVmax (2.9+/-3.1%) on the PET images reconstructed using IV contrast. The clinical evaluation performed by the two specialists comparing contrast and non-contrast CT attenuated PET images showed weighted kappa values of 0.92 (doctor A) and 0.82 (doctor B). No contrast-introduced artefacts were found.
  
  
  CONCLUSIONS
  This study demonstrates that CT scans with IV contrast agent can be used for attenuation correction of the PET data in combined modality PET/CT scanning, without changing the clinical diagnostic interpretation.
authors.affiliation: Department of Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital, Copenhagen, Denmark.
authors.forename: A K
authors.initials: AK
authors.lastname: Berthelsen
authors.forename: S
authors.initials: S
authors.lastname: Holm
authors.forename: A
authors.initials: A
authors.lastname: Loft
authors.forename: T L
authors.initials: TL
authors.lastname: Klausen
authors.forename: F
authors.initials: F
authors.lastname: Andersen
authors.forename: L
authors.initials: L
authors.lastname: Højgaard
mesh_terms: D000328:Adult; D000368:Aged; D016477:Artifacts; D003287:Contrast Media / Q000008:administration & dosage; D005260:Female; D019788:Fluorodeoxyglucose F18; D006801:Humans; D007089:Image Enhancement / Q000379:methods*; D007275:Injections, Intravenous; D007483:Iothalamic Acid / Q000008:administration & dosage / Q000031:analogs & derivatives*; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000175:diagnosis*; D019047:Phantoms, Imaging; D049268:Positron-Emission Tomography / Q000295:instrumentation / Q000379:methods*; D019275:Radiopharmaceuticals; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D016037:Single-Blind Method; D013382:Subtraction Technique; D014057:Tomography, X-Ray Computed / Q000295:instrumentation / Q000379:methods*
chemical_list: D003287:Contrast Media; D019275:Radiopharmaceuticals; D019788:Fluorodeoxyglucose F18; D007483:Iothalamic Acid; C002587:ioxitalamic acid