FDG Dose Extravasations in PET/CT: Frequency and Impact on SUV Measurements

Medhat M Osman, Razi Muzaffar, M Erkan Altinyay, Cyrus Teymouri, Medhat M Osman, Razi Muzaffar, M Erkan Altinyay, Cyrus Teymouri

Abstract

Objectives: Positron emission tomography (PET)/CT with 18F-FDG has proven to be effective in detecting and assessing various types of cancers. However, due to cancer and/or its therapy, intravenous (IV) FDG injection may be problematic resulting in dose extravasations. In the most frequently used field of view (FOV), arms-up, and base of skull to upper thigh [limited whole body (LWB)], the injection site may not be routinely imaged. The purpose of this study was to evaluate the frequency of dose extravasations in FDG PET and the potential impact on standard uptake value (SUV) measurements.

Methods: True whole body FDG PET/CT scans (including all extremities) of 400 patients were retrospectively reviewed. A log recorded cases of IV dose extravasations. When possible, SUVs were measured in two frequently used reference locations: mediastinum and liver. The SUVs were obtained in the same patients who had studies with and without FDG extravasations within an average of 3 months without interval therapy.

Results: Of the 400 scans, 42 (10.5%) had extravasations on the maximum intensity projections images. In scans with or without dose infiltration, FDG injection site was at or distal to the antecubital fossa in 97% of studies. Of those 42 cases, dose infiltration was within the LWB FOV in 29/42 (69%) and outside in the remaining 13/42 (31%). Of those 42 patients, 5 had repeat PET studies with no interval therapy. For those 5 patients, liver maximum SUV was 11.7% less in patients with infiltration than those without (2.22 ± 0.54 vs. 2.48 ± 0.6). Mediastinum SUVmax was 9.3% less in patients with infiltration than those without (1.72 ± 0.54 vs. 1.88 ± 0.49).

Conclusion: We conclude dose extravasations were commonly encountered (10.5%) in PET/CT. However, it is underreported by at least 31% due to omitting injection site from the FOV. When present, extravasations may lead to underestimation of SUVmax. Therefore, it should not only be avoided but also reported in order to avoid false interpretations of the exam.

Keywords: FDG dose extravasations; FOV; PET/CT; whole body PET.

Figures

Figure 1
Figure 1
Maximum intensity projection (MIP) PET image of a 63-year-old male with a history of esophageal cancer. Patient was injected in the left antecubital fossa (LAC) with dose extravasation (SUVmax 196) within the LWB FOV.
Figure 2
Figure 2
MIP PET image of an 83-year-old female with metastatic disease from an unknown primary. Patient was injected in the right antecubital fossa (RAC) with dose extravasation (SUVmax 7) outside the LWB FOV (right).
Figure 3
Figure 3
Patient is a 46-year-old male with a history of melanoma. Left MIP shows extravasation in the right wrist and a repeat PET was performed 5 months later with no extravasation. The top row shows SUV measurement of the mediastinum with extravasation and the second row shows SUV of the mediastinum without extravasation. The third row shows SUV of the liver with extravasation and the bottom row shows SUV of the liver without extravasation.
Figure 4
Figure 4
Maximum intensity projections PET image (LWB FOV) of a patient with a history of lung cancer. Dose extravasation in the LAC at the edge of the image field with SUVmax 1297.

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