International EANM SNMMI ISMRM Consensus Recommendation For PET/MRI in Oncology

European Journal of Nuclear Medicine and Molecular Imaging
https://doi.org/10.1007/s00259-023-06406-x
GUIDELINES
International EANM‑SNMMI‑ISMRM consensus recommendation

for PET/MRI in oncology
Patrick Veit‑Haibach1,2 · Håkan Ahlström3,4 · Ronald Boellaard5,6 · Roberto C. Delgado Bolton7 · Swen Hesse8 ·
Thomas Hope9 · Martin W. Huellner10 · Andrei Iagaru11 · Geoffrey B. Johnson12 · Andreas Kjaer13 · Ian Law14 ·
Ur Metser15 · Harald H. Quick16,17 · Bernhard Sattler18 · Lale Umutlu19 · Greg Zaharchuk20 · Ken Herrmann21
Received: 30 June 2023 / Accepted: 16 August 2023

© The Author(s) 2023
Abstract
Preamble The Society of Nuclear Medicine and Molecular Imaging (SNMMI) is an international scientific and professional
organization founded in 1954 to promote the science, technology, and practical application of nuclear medicine. The European
Association of Nuclear Medicine (EANM) is a professional non-profit medical association that facilitates communication
worldwide between individuals pursuing clinical and research excellence in nuclear medicine. The EANM was founded
in 1985. The merged International Society for Magnetic Resonance in Medicine (ISMRM) is an international, nonprofit,
scientific association whose purpose is to promote communication, research, development, and applications in the field of
magnetic resonance in medicine and biology and other related topics and to develop and provide channels and facilities for
continuing education in the field.The ISMRM was founded in 1994 through the merger of the Society of Magnetic Resonance
in Medicine and the Society of Magnetic Resonance Imaging. SNMMI, ISMRM, and EANM members are physicians, tech-
nologists, and scientists specializing in the research and practice of nuclear medicine and/or magnetic resonance imaging.
The SNMMI, ISMRM, and EANM will periodically define new guidelines for nuclear medicine practice to help advance the
science of nuclear medicine and/or magnetic resonance imaging and to improve the quality of service to patients throughout
the world. Existing practice guidelines will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or
sooner, if indicated. Each practice guideline, representing a policy statement by the SNMMI/EANM/ISMRM, has under-
gone a thorough consensus process in which it has been subjected to extensive review. The SNMMI, ISMRM, and EANM
recognize that the safe and effective use of diagnostic nuclear medicine imaging and magnetic resonance imaging requires
specific training, skills, and techniques, as described in each document. Reproduction or modification of the published prac-
tice guideline by those entities not providing these services is not authorized.
These guidelines are an educational tool designed to assist practitioners in providing appropriate care for patients. They are
not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of
care. For these reasons and those set forth below, the SNMMI, the ISMRM, and the EANM caution against the use of these
guidelines in litigation in which the clinical decisions of a practitioner are called into question.
The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the physician
or medical physicist in light of all the circumstances presented. Thus, there is no implication that an approach differing from
the guidelines, standing alone, is below the standard of care. To the contrary, a conscientious practitioner may responsibly
adopt a course of action different from that set forth in the guidelines when, in the reasonable judgment of the practitioner,
such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge
or technology subsequent to publication of the guidelines.
The practice of medicine includes both the art and the science of the prevention, diagnosis, alleviation, and treatment of
disease. The variety and complexity of human conditions make it impossible to always reach the most appropriate diagnosis
or to predict with certainty a particular response to treatment.
Therefore, it should be recognized that adherence to these guidelines will not ensure an accurate diagnosis or a success-
ful outcome. All that should be expected is that the practitioner will follow a reasonable course of action based on current
Extended author information available on the last page of the article
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knowledge, available resources, and the needs of the patient to deliver effective and safe medical care. The sole purpose of
these guidelines is to assist practitioners in achieving this objective.
Keywords Consensus · Oncology · SNMMI · ISMRM · EANM · PETMR · PET · MRI
Introduction to share a basic technical acquisition groundwork and to pro-

vide a minimum agreeable standard imaging protocol for the
Positron emission tomography/magnetic resonance imaging main PET/MRI indications in oncology. This guideline will
(PET/MRI) is the latest combination of noninvasive diagnostic give not any fixed recommendations; instead, it will sug-
positron emission tomography (PET) imaging. As other PET- gest where PET/MRI should be used instead of PET/CT or
based imaging procedures, it provides tomographic images where PET/MRI should be used instead of MRI + PET/CT
of metabolic activity or other phenotypic characteristics of since there are no clear recommendations for such scenarios
target tissues and offers the option of (semi)quantification. available in the literature. The purpose of this guideline is
While most guidelines on PET imaging are radiopharmaceu- also to provide PET/MRI users with a common denominator
tical-focused (i.e., [ 18F]fluorodeoxyglucose-PET/CT imag- for recommending, performing, interpreting, and reporting
ing, [68Ga]Ga-DOTA-based PET-imaging), this PET/MRI the results of the most used PET/MRI indications. It is not
guideline is technology oriented. Also, the radiopharmaceuti- intended to prescribe users with fixed and inflexible proto-
cal and PET related part is mostly not significantly different cols. It is designed and meant to rather describe the techno-
from PET/CT and other radiopharmaceutical-based guidelines. logical possibilities and how to properly adapt the combined
Therefore, we will always refer for those parts to the respective acquisition techniques according to clinical indications.
PET/CT guideline. Thus, in opposition to other guidelines, the As in PET/CT, the user is able to use the PET component
authors more emphasize on the intersection of MRI and PET in PET/MRI as a (semi)quantitative imaging technique. In
imaging, the combined PET/MRI acquisition and its clinical addition, a variety of partly also quantitative MRI tech-
uses. The authors would also like to point out that this work niques can be acquired simultaneously. Thus, PET/MRI also
is constantly evolving, that this is not a definitive document, requires standardized quality control (QC)/quality assur-
and this document might well serve as the offspring for other ance (QA) procedures to maintain the accuracy and preci-
consecutive, disease-based and tracer-based and more indi- sion of quantitation for both procedures [1, 2]. These quality
vidualized PET/MRI guidelines. measures are essential preconditions to ensure repeatability
As for the approval process, this document went through the and reproducibility. Reliable repeatability and reproducibil-
standardized combined approval procedure of the European ity are necessary requirements for the clinical management
Association of Nuclear Medicine (EANM) and the Society of patients but also for comparability in multicenter trials.
of Nuclear Medicine (SNM). This includes submission to the Common and standardized combined imaging protocols are
respective committees within the EANM and SNM. After important to promote the appropriate use of this complex
review and revision based on the committees’ comments, the combined imaging procedure but also to increase the aware-
documents underwent review by the national delegates of the ness about the advantages of this first truly simultaneous
EANM. After iterative revision, the document was submit- hybrid, cross-modality molecular imaging method. It also
ted to the PET MR Study Group of the International Society ensures accurate evaluation of disease staging, response,
for Magnetic Resonance in Medicine (ISMRM) for approval. and follow-up. This guideline has no direct predecessor,
After that, it went through the Publications Committee and the however, especially the PET part is partly building on previ-
Board of Trustees of the ISMRM before final submission. The ously published guidelines, i.e., PET/CT for tumor imaging
authors from all mentioned societies participated in drafting and the SNMMI procedure guidelines for tumor imaging
and revision of the manuscript. 1.0 [1, 3, 4].
Goals PET/MRI technology fundamentals

and quality controls
Currently, there are multiple studies available on the evalu-
ation of different diseases with PET/MR. However, there Positron emission tomography and magnetic resonance
is an information gap on how to actually perform the PET/ imaging (PET and MRI) have been each in the arena of
MR itself in a somewhat harmonized way. The objective is clinical molecular tomographic imaging more than three
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decades. While MRI was originally aimed at imaging soft this method can be called digital photon counting (DPC).
tissue structures and PET was primarily aimed at imaging More technical details and performance characteristics can
physiologic and pathophysiologic processes using Fluoro- be found in the article by Seifert et al. as well as in the ref-
deoxyglucose (FDG), both gradually expanded. MRI gained erenced book [23].
molecular imaging capabilities beyond morphology and PET Depending on the legislation and organizational require-
increased its offer of radiopharmaceuticals to image onco- ments and settings, PET/MRI systems should usually be
logic and non-oncologic targets. installed in and managed by nuclear medicine, radiology,
After the proof of operability of specific light detectors or both departments altogether. If it is integrated in a full
such as avalanche photo diodes (APD) and silicon photo hybrid imaging molecular imaging PET center with a radi-
multipliers (SiPM) in a magnetic field, the way of combin- opharmaceutical production site including a cyclotron, the
ing PET and MRI to hybrid systems was paved. First, PET- system should be located in close proximity to this facil-
detector inserts for preclinical [5–11] and clinical MR–sys- ity. However, satellite PET/MRI units can also be installed
tems [12, 13] were developed to further proof the feasibility at specialized clinical sites such as pediatric, psychiatric,
of combining two imaging modalities without impairing the or neurology departments if the proper staffing level is
qualitative and quantitative imaging results intolerably. In available.
parallel, by using systems employing a single patient han-
dling system/table for either imaging modality, the clinical
utility of having the image data co-registered was thoroughly Qualifications and responsibilities
investigated. Regarding the latter, GE Healthcare devised a of personnel
two-room-setup where a clinical PET/CT and an MRI sys-
tem were installed in rooms right next to each other and the When PET/MRI as a cross-modality hybrid imaging system
patient handling system designed connectable to the patient is put into operation, the availability of adequately trained
ports/-bores of both of the systems [14, 15]. One step fur- personnel must also be planned in advance. This obviously
ther, Philips omitted the CT component and introduced a refers to both the PET and the MRI components of the
bi-planar system installing the PET- and the MRI-gantry in integrated system and to all professional groups involved
one room using a rotating patient table [16, 17]. Finally, the (physicians, physicists, technologists) [19]. Technologists in
first system fully integrating the APD based PET detector charge of running the daily operation should be well trained
system was designed by Siemens Healthineers and reached and experienced in operating both modalities. Depending
market maturity in 2010 [18–20]. This system offered the on the local workload and the level of training and expe-
option of true simultaneous whole-body measurement of rience, two individuals might be necessary to operate the
PET and MRI signals. However, the limited timing reso- system effectively. Curricula of technologist education are
lution of the APDs did not allow for time of flight (TOF) country dependent. While some countries may include train-
PET measurements as utilized in photomultiplier-based PET ing in understanding and the operation of all radiological
detector systems in state-of-the-art hybrid PET/CT systems. (including MRI), radiotherapy, and nuclear medicine (NM)
In 2013, GE healthcare introduced a TOF-PET-capable fully imaging as well as non-imaging equipment (academic or
integrated whole-body PET/MRI system employing SiPMs non-academic), other countries may only focus their training
as light detectors in the PET-detector system [21]. In a com- on the modality the technologist is obtaining licensure in.
prehensive overview, Quick and Boellaard summarized the However, the level of actual practical experience will depend
performance parameters of the three PET/MRI systems on the main site of deployment in one of the aforementioned
available for clinical use [16, 22]. SiPM based detectors are fields. So, for instance, technologists working mainly in the
also used in digital PET detector systems that are employed MRI field might not be fully aware of the issues with han-
in hybrid PET/CT to further increase timing resolution and dling radioactivity, the respective molecular imaging equip-
reduce the influence of noise by analog–digital conversion. ment and radiation protection, and, vice versa, technologists
“Digital” in this context means that each light photon is coming from the nuclear medicine molecular imaging and
detected by the SiPM and directly converted into a binary therapy field might not be fully aware of the issues and safety
output signal (i.e., output = 1 → photon detected, output = 0 precautions with high-field magnetism, radiofrequency
→ no photon detected). As a consequence, a considerable transmission as well as understanding, and adapting MRI
number of SiPM-microcells read out the scintillation light of sequences and protocols.
one particular detector crystal. Each individual crystal can In principle, all this is also true for physicians and other
be read out eliminating the need for localization electronics academic personnel involved. In general, to justify, conduct,
and arrays within the detector block electronics. Since there analyze, and report MRI and PET, physicians specialized in
is no analog–digital conversion involved in this process and those particular fields need to be involved. Generally, this
each light photon leads to a binary output of a SiPM cell, is achieved by completing the curricula in Radiology and
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Nuclear Medicine resulting in specialization as a radiolo- and national standards. In most countries, the basic QA/
gist, a nuclear medicine physician or both. The integration QC measures of PET systems are written in legislation and
of these specializations varies considerably from a full inte- mandatory before the system can be used for patient care.
gration into one curriculum to two separate specializations Sattler et al. extracted the most important QA/QC measures
from country to country. Once a hybrid oncology PET/MRI as applicable for combined/simultaneous PET/MRI systems
has been successfully acquired and analyzed, a joined read- [19]. The accuracy of PET quantification decisively depends
ing and reporting should be conducted. Ideally, this is done on the correct system calibration involving all corrections
in regular conferences of the MRI and PET-specialized that are implicitly necessary using the full ring PET detec-
physicians where results including a joined conclusion are tor setting in 3D mode. Basically, these are scatter, random,
finalized in one report. Additionally, the complexity of the attenuation, and dead-time corrections and detector normali-
methodology and the level of sophistication requires the zation on a regular basis. They are required for correct activ-
availability of physicists and/or engineers experienced and ity quantification in a lesion, organ, or phantom. Ultimately,
specialized in one or both fields from a physical-technical these measures are influenced by correct attenuation correc-
perspective. tion (AC). Dependent on the body region under investiga-
Another aspect is that in most of the countries fulfill- tion, there are several methods to generate a map of linear
ment of regulatory requirements, particularly when handling attenuation coefficients (LAC) [27, 28]. As an important QC
radioactive material in clinical and/or research settings, is measure, these maps are to be at least visually inspected for
mandatory. This includes specialization and licensing of the every investigation before reconstruction. Finally, analysis
involved non-academic (technologists, nurses) and academic and quantification of PET data can be approved.
(physicians, physicists, engineers, technologists) personnel
including documented regular knowledge refreshment and Quality control of MRI prior to scanning
continuing education.
In contrast to the requirements for the PET component of the
Quality assurance and control of PET (QA/QC) combined system, there is no legal requirement to perform
standardized QC/QA measures of the MRI part. However,
Generally, the quality control of the PET system should some regular (not daily as in PET-imaging) basic perfor-
follow the specifications of the manufacturer. The system mance tests are advisable to ensure appropriate imaging per-
should be turned off and rebooted daily to allow for a full formance and patient safety. A comprehensive set of tests is
reset of all hardware and software components. The daily described in the MRI Accreditation Program Requirements
reboot comprises a basic check of important parameters of the ACR [29]. Regarding the strong magnetic and electro-
of components, internal and external connections between magnetic fields involved in MRI, patient safety procedures
those as well as all precautions relevant to the operators and need to be established in the entire PET/MRI setting and in
patients’ safety. Right after the reboot, calibration check and the routine patient workflow. Here, we refer to the section
normalization of the PET detector system must follow. This on patient preparation and MRI safety below.
is usually carried out using a Gallium-68 filled cylindrical
phantom that is placed in the center of the PET FOV. This
quality check should follow a protocol predefined by the Procedure/specifications of the examination
manufacturer and result in an output of a sinogram for visual
inspection accompanied by information to the user to check Request/referral/justifying indications
if sensitivity and calibration of the PET detector system is
within acceptable levels. The results and the trend of this test Patient referral for PET/MRI is determined by the inter-
over time are stored internally and the user is only alerted if play and communication between the referring oncologic
the results are outside of certain specifications. It is advis- centers, institutions, and physicians. Due to the complexity
able to the user to read this trend periodically and keep it of the method, especially on the PET part, referring physi-
for their own records. Usually, the calibration and sensitivity cians should communicate with the PET/MRI responsible
are very stable and need to be recalibrated only on occasion physician(s) well in advance. Be it on the occasion of inter-
of planned maintenance by the manufacturer or on occa- disciplinary tumor boards or through other dedicated means
sion of major repair service events including replacement of of communication, agreement with regard to the eligibility
detector modules or electronics for instance. Less frequent of the particular patient should be reached based on previous
necessary QA/QC procedures can be found in the EANM clinical findings in order to justify the investigation and opti-
recommendations on routine quality control for nuclear med- mize the exam protocol. Thus, it is ensured an optimal com-
icine instrumentation [24], an IAEA publication on the topic prehensive answer to the clinical question by the PET/MRI
[25], the NEMA NU2 2012 publication [26], or international investigation. If patients need to be sedated or anesthetized
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for the imaging procedure, particular scrutiny is needed to of PET and MRI preparations and safety instructions. It is
optimally adapt the schedule of both procedures (anesthe- also advisable to have a responsible safety person per imag-
sia and imaging). All intensive care equipment that has to ing modality (in PET and MRI separately). If not possible,
be brought in the PET/MRI suite must be certified as MRI a “combined” safety officer can be established.
compatible. The request or referral for a PET/MRI should be
directed to the department which is responsible for the PET/
MRI operations. As in PET/CT, it should contain appro- Patient positioning and tracer and contrast
priate medical information to justify the medical need for administration schemes
the examination, including diagnosis, the specific medical
question, and a brief medical history. Especially the specific The tracer administration scheme follows PET/CT recom-
medical question is of utmost importance in PET/MRI since mendations. However, current PET/MRI systems incorpo-
it defines the acquisition protocol. In patients with suspected rate highly efficient and sensitive PET detectors which allow
(pregnancy test needed) or confirmed pregnancy, a decision for significant reduction of the activity of injected radiop-
has to be taken weighing carefully the risks versus potential harmaceutical, at least for 18F-based tracers [35–37]. This
benefits of the examination. Generally, it should be stated should be considered and incorporated in local protocols in
that there are no established emergency indications for PET/ accordance with the imaging time of the MRI.
MRI. Concerning the radiation exposure caused by the PET- Contrast agent administration is not influenced or altered
tracer application, please refer to the EANM PET/CT proce- by the concomitant PET acquisition. Thus, the standard
dure guideline for tumor imaging as well as the International MR-contrast choice (vendor) and injection protocol is in
Commission on Radiological Protection (ICRP) [1, 30] or general not different from stand-alone MRI and depends
respective safety data that has been published for the par- on the institution’s preference. However, it has to be noted
ticular tracer in use. Generally, and as long as the PET-tracer that the acquisition of all MR-based AC (MR-AC) has to be
is labeled with 18F the exposure depends on the amount of completed before commencing MRI contrast agent injection.
radioactivity applied and ranges between 5 and 10mSv [31]. Otherwise, tissue segmentation based on MRI images may
It should be noted that the overall exposure by a PET/MRI lead to faulty results in MR-based AC methods [38].
examination is significantly lower than by PET/CT since the Dependent on the tracer and investigational protocol
radiation from the CT examination is omitted. involved, patients should arrive to the PET/MRI site between
60 to 90 min prior to the scheduled procedure start, allowing
Patient preparation and MRI safety sufficient time for final anamnesis and to obtain informed
consent of the patient or the care giver. Depending on the
Preparation and instructions to patients depend on the tracer radiopharmaceutical and the investigational protocol, the
being injected and (at least for FDG imaging) are similar to patient gets the tracer injected either in advance to being
PET/CT [1]. positioned on the system or after it in the case of dynamic
Additional specific instructions concerning MRI safety imaging studies. In the former case, imaging can start as
and patient preparation for MRI are defined by several inter- soon as the accumulation and resting time has elapsed, the
national guidelines/papers [32–34]. All safety regulations patient was asked to void, and the preparation of the system
and guidelines for MRI safety also apply to PET/MRI hybrid with all peripheral equipment is completed.
imaging. More specific, all established guidelines, patient Then, the patient is positioned head first supine (at least
questionnaires, and checklists for MRI safety need to be fol- mostly for whole body cases) on the patient bed, the radiof-
lowed prior to an MRI or PET/MRI exam. This includes requency (RF) head/neck coil and the flexible receiver coils
screening for potential MRI safety contraindications (e.g., and ear protectors are mounted and the patient is (again)
claustrophobia, passive and active implants, metallic inclu- instructed to keep still during imaging acquisition. The spe-
sions, pregnancy) [32–34]. Regarding MRI safety, it has cific requirements in preparation for PET can generally be
to be noted that all current PET/MRI systems operate at obtained from the respective clinical guidelines [16, 39].
3-Tesla static magnetic field strength. This may have practi- Otherwise, patient positioning will depend on the clincal
cal impact on MRI safety when scanning patients with MRI scenario, i.e., prone positioning of the patient in breast can-
conditional cardiac pacemakers or other active implants is cer cases.
planned. Additional local rules regarding MRI and/or PET In several cases, it is also possible that the MR-acqui-
safety may apply. sition time might already start during the PET acquisition
Regarding safety, there is actually no overlap between the time so optimize the scanner room time, i.e., MR scanning
imaging modalities, which would save any preparation or can start at minute 40 with non contrast sequences during
safety step in PET or in MRI. However, it is crucial that all the PET-uptake time and the PET-acquisition is then started
personnel involved in PET/MRI is familiar with both sides at minute 60.
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Attenuation correction and other correction limited to tracers like [ 18F]FDG that peripherally distribute
methods throughout the body. A more recent and fully MR-based
method for truncation correction is magnetic field homog-
Different concepts and methods for scatter correction (SC) enization using gradient enhancement (HUGE) [45, 49].
and AC in PET/MRI have been developed over the recent
years. MR-based AC relies on the segmentation of MRI Execution of examination (simultaneous
images into different tissue classes (e.g., background air, fat, procedures)
muscle, lung tissue), based on their image-based grey scales.
Following segmentation, the individual tissue compartments There are general types of investigational protocols for
are then assigned a predefined LAC for the corresponding simultaneous PET/MRI. These are basically designed for
tissue [20]. Dedicated fast MRI sequences, mostly using the simultaneous oncologic, neurologic, cardiologic, and inflam-
Dixon-technique providing fat and water images, are used matory disease PET/MRI. Mostly in oncology but also in the
to obtain images of tissue distribution and subsequent seg- other areas, there are special protocols adapted for pediatric
mentation. This general method of tissue segmentation from PET/MRI. Moreover, there are protocol adaptions for spe-
MRI images is widely used in all currently available PET/ cific body regions and disease entities like prostate cancer,
MRI systems [40]. breast cancer, or neuro-oncologic diseases. A comprehen-
The method for AC of hardware components such as the sive overview of oncologic indications that can profit from
patient table and RF coils for MRI signal reception is estab- being diagnosed, staged, and monitored can be found in
lished by applying CT-based attenuation templates of the Umutlu and Hermann (eds.) [50] and there is, moreover,
respective hardware components during PET data recon- a multitude of clinical guidelines describing patient selec-
struction [20, 41]. Such CT-based AC templates for the AC tion, preparation of imaging protocols, and analysis for/of
of most commercial RF coils are available on the current oncologic PET investigations. In simultaneous PET/MRI,
PET/MRI systems and are automatically considered during the PET part of the investigation will mostly be carried out
PET data reconstruction [20, 41]. as described in those aforementioned resources. Generally,
Dedicated AC methods and MRI sequences have been the preparation starts with a thorough explanation of the
developed to account for the increased attenuation of bone imaging procedure to the patient and/or his/her caregivers.
as additional tissue compartment as studies have suggested If claustrophobia related problems are to be expected, this
that not including bone could lead to errors in SUV deter- might also include showing the system beforehand. In pedi-
mination of up to 25% [28]. In brain PET/MRI studies, atric imaging [51] but also in some situations as described
the use of ultrashort echo time (UTE) or zero echo time above as sedation or anesthesia might be necessary and the
(ZTE) sequences enables the consideration of skull bones in respective MRI-compatible equipment should be available.
MR-based AC [42, 43]. For whole-body PET/MRI studies, Depending on the tracer employed and the imaging protocol
the integration of bone-models allows AC of major bones (static or dynamic PET imaging), the tracer is injected either
[44–46]. More recently, deep learning methods have been before or immediately at the time the PET imaging protocol
developed to generate patient-specific synthetic CT images starts. Usually, the patient is positioned head-first supine on
with bone information purely from MRI images [47]. These the system. In protocols other than just head/neck/brain, the
developments are currently very dynamic and will find their RF spine coil, usually located in the patient bed, is always
implementation into commercially available AC methods used. If the head region is of interest, the head should be
and applications in the near future. placed and fixed inside the RF head coil. Moreover, region-
To complete MR-based AC maps in whole-body PET/ specific, PET/MRI-compatible rigid or flexible receiver coils
MRI examinations, methods for truncation correction are have to be fixed as close as possible to the body regions of
applied. These supplement the limited field-of-view in MRI interest. The imaging session usually starts with a localizer
that may lead to truncation of MRI signal along the patient sequence with continuously moving table to plan the MRI
arms in the MR-based AC maps. If not corrected, such trun- sequences and the PET imaging. If tracer amounts accord-
cations may cause faulty PET quantification following MR- ing to diagnostic reference levels are used, the duration of
based AC of PET data. Two general methods are used for PET imaging at one bed position or station usually is several
truncation correction in PET/MRI. The maximum-likelihood minutes up to about 5 min. If dynamic imaging at only one
reconstruction of attenuation and activity (MLAA) algo- bed-position is desired (i.e., in brain imaging), PET data
rithm [48] estimates the outer contours of the patient body acquisition in list mode would be the preferred methodol-
from non-AC PET images. Truncated areas in the MR-based ogy in order to be able to select time frames and durations
AC map can thus be completed with information from PET later on while reconstruction. A basic oncologic set of MRI
images. This method for truncation correction is established sequences should be for example comprised of a transverse
on all currently available PET/MRI systems. However, it is half-fourier acquisition single-shot turbo spin-echo sequence
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(i.e., TE = 90 ms), a transverse diffusion-weighted imaging the target structures based on the molecular imaging results
(i.e., b = 800 s/mm2), a coronal turbo inversion recovery and sends those off to the treatment planning system along
magnitude (TIRM) sequence (i.e., TI = 220 ms) and possibly with the structural MR-imaging data set using the DICOM-
a three-dimensional magnetization prepared rapid acquisi- RT structure set format. The patient can be released to the
tion gradient echo (T1) sequence. In the bed position of the public and/or the referring ward after initial quality control
thorax, a respiratory navigator is placed (manually or auto- of the acquired data are complete and satisfying.
matically, depending on the vendor) on the diaphragm and
used for the MRI acquisition. Depending on the patient’s Motion correction
size, a scan of the whole body-trunk can thus be done within
20–30 min. Several modified whole-body protocols can be One of the potential advantages of PET/MRI over PET/CT
used as outlined in the individual indications below. is that simultaneous and independent PET and MRI data
acquisition both require several minutes per bed position.
Ending of examination, reconstruction, archive What looks like a disadvantage at first sight can be turned
transfer, and releasing the patient into an advantage, namely providing motion correction
of moving organs such as lungs and heart [59, 60]. Here,
Immediately after the end of the simultaneous acquisition time-resolved MRI data can be used as a prior to correct for
— i.e., while the patient is still on the table — visual qual- motion in PET data [59, 60]. Subsequent fusion of both data
ity checks of the acquired image data should be carried out sets allows for display and reading of time-resolved lung and
to ensure and enable sufficient reporting and correct further cardiac studies with the advantage that moving structures
data analysis. In particular, MRI images have to be checked are depicted with less blurring and motion artifacts and with
for artifacts originating from patient motion, metal artifacts higher sharpness [60–62]. Best results in this context are
or RF artifacts. This also includes a thorough visual check obtained, when also the AC map is generated using motion
of the generated attenuation map (µ-map) of LAC that is the correction. Then, the moving organs are considered in AC
basis for a quantitatively valid reconstruction of the PET with each appropriate motion phase of the respective breath-
data set. Meanwhile, there is a lot of different methods avail- ing and/or cardiac cycle.
able that sufficiently solve the problem that structural MRI In view of the relative complexity of PET/MRI attenua-
cannot directly deliver a µ-map as it does not yield an elec- tion correction and of the multitude and ever-growing num-
tron density signal [28, 41, 44, 52–58]. The aforementioned ber of AC methods available, it is recommended to always
influences could generate artifacts that also could hamper the use the latest available software version and AC protocols on
generation of a correct µ-map and, thus, impair the quantita- the respective PET/MRI system. Users are advised, further-
tive validity of the attenuation corrected reconstructed PET more, to strictly follow the most current recommendations
data set. If the acquired data are of good quality, the patient of the manufacturers regarding AC methods and protocols.
can be unloaded from the table. The patient should stay in Finally, PET/MRI users are advised to carefully inspect non-
the department waiting room as long as the reconstruction AC PET data and the MR-based AC maps along with the
is not finished (only a few minutes). The PET reconstruc- AC PET data during image reading and reporting. Thereby,
tion employs iterative reconstruction methods involving obvious motion artifacts [63] and artifacts around metallic
the attenuation and other corrections to the data using — if implants are detected. If left unattended they may lead to
available — time-of-flight information in the PET event- faulty segmentation in the MR-based AC data, which then
protocols (sinograms). Moreover, recent software versions may result in local bias in PET data quantification or even
of the vendors enable truncation correction in outer body visible artifacts in the PET data [64, 65]. Where available,
regions and use co-registered anatomical atlases, sometimes TOF-PET detection shall be used to mitigate the quantitative
in combination with trained neuronal networks. That way, impact of artifacts caused by metallic implants [66]. Further
it improves tissue segmentation for MRI-based attenuation comments and insights on artifacts will be discussed below
correction of PET data up to a level that in certain body in the manuscript in the dedicated section.
regions performs as good and stable as the CT standards.
This allows for a good representation of the actual body Protocol/image acquisition/workflow
structure and property and, thus, its attenuation behavior
against the 511 keV photons of the PET signal. The results Like in PET/CT, there are several workflow options espe-
(images) relevant to the clinical report should be transferred cially on the MRI part of PET/MRI. First, it has to be
to a DICOM-compatible PACS system to be permanently decided if whole body PET/MRI (skull to upper thighs or
stored. If the PET/MRI has been planned and carried out in even down to the distal lower limbs) or single station/partial
the scenario of planning an external beam radiation treat- body (between one and several PET positions) is needed to
ment, ideally, the responsible physician immediately marks answer the clinical question. Single station (or few stations)
13
imaging is possible even in oncologic indications (in con- contrast-enhanced PET/CT, to very short non-contrast pro-
trast to cardiac and brain imaging where single station imag- tocols. Overall, within this category, protocol acquisitions
ing is the default) since the injected tracer activities can be have been divided in the literature into “ultrafast” or “basic”
reduced and acquisition time for the PET can be adapted and “abbreviated” protocols which only use a fraction of the
depending on the MRI protocol being used. Therefore, the diagnostic MRI sequences which would normally be used in
current argument that once a tracer is injected (with its standalone MRI protocols [68–71].
consecutive radiation exposure), the entire body should be Those protocols focus mainly on the information from
imaged is, depending on the clinical question/area examined, PET component with only minimal basic MRI sequences
partly not valid anymore. simultaneously acquired [68] and thus comparable to a low-
Diagnostic MRI protocols should encompass all dose unenhanced PET/CT. The literature has reported such
sequences and contrast weightings needed to answer the spe- protocols being used for quick whole-body staging in ana-
cific diagnostic question. In general terms, high quality MRI tomically “simple” diseases (i.e., lymphoma) or in patients
images should provide high soft tissue contrast, high spatial with possibly low compliance or pain. Also, these protocols
in-plane resolution, high spatial through-plane resolution can be used for whole-body overview/metastases search inte-
(e.g., thin slices), homogeneous signal distribution and low grated into more diagnostic/advanced protocols (see below).
image noise, and be free of any metal and motion artifacts. Basically, such acquisitions comprise of the Dixon-based
In integrated PET/MRI systems, MRI data is acquired simul- attenuation sequences, possible additional higher resolution
taneously to PET data acquisition. For most efficient work- T1-sequences (Dixon or gradient echo sequences) and fast
flow, the data acquisition times for PET and MRI should T2-sequences (with or without fat saturation).
match as closely as possible. This implies to reduce the Those protocols (Fig. 1) are making maximal use of
number of MRI contrast weightings and sequences per bed the complementary nature of the MRI and PET-derived
position to the diagnostically necessary minimum. information.
The currently used PET/MRI protocols share several The next category has been called “fast” or also “basic”
common technical aspects. MRI localizers are always protocols in the literature [72]. Those still contain only
required for the MRI acquisition planning. This initial plan- whole-body sequences but with certain additions, i.e., fast
ning process defines the axial range for the simultaneous T1 gradient-echo sequences post contrast, additional whole-
PET/MRI examination. Current PET/MRI systems use sin- body diffusion or additional fast T2-sequences in multiple
gle bed positions of about 25 cm, with a certain percentage planes. The extra sequences can be used to screen for small
of overlap between bed positions (depending on the vendor). lesions otherwise possibly overlooked on other sequences,
Then, specific MRI sequences for attenuation correction diffusion imaging being the most prominent example. Addi-
have to be acquired, please refer to the respective section tional sequences in other planes (sagittal or coronal) con-
above. Finally, diagnostic MRI sequences for either whole- tribute to localization of lesions/findings in anatomically
body or partial body imaging are the longest part of the challenging body compartments.
protocol. The next category is comprised of “fully diagnostic”,
As indicated above, acquisition time can be adapted based “advanced” or “dedicated” whole-body PET/MRI proto-
on the MRI acquisition time and counterweighed vs. the cols. Those protocols would include again a “basic” whole-
injected activity. Since the MRI time is usually the dominant body overview, but specific additional fully diagnostic MRI
factor for the overall imaging time, it is expected that the sequences in the respective anatomical area (i.e., head and
injected tracer activity can be reduced significantly. neck cancer protocols, chest protocols with gated sequences
However, overall current literature suggests that the and/or UTE/ZTE, liver and pelvic protocols). It should be
standard imaging time used in PET/MRI can be similar to noted that even those fully dedicated MR-protocols can
PET/CT (2–4 min per bed position) with significant varia- partly be abbreviated compared to their stand-alone MR-only
tions depending on the protocol [67]. counterparts [73]. Reasoning is that MR-only protocols are
The more frequently used protocol options are as follows: designed to provide the highest specificity and sensitivity for
one imaging modality whereas hybrid imaging offers addi-
First, the general whole-body PET/MRI protocols, which tional complementary information. As those fully diagnostic
should answer the most current and frequent medical MR-protocols take somewhat longer based on the required
questions. They are referred to as “standard PET/MRI” MR-sequence acquisition time (even when shortened), they
protocols. offer at the same time the possibility to acquire high-count,
higher quality PET-imaging as well. These dedicated PET-
These examinations can range from fully diagnostic images offer increased diagnostic accuracy especially in ana-
PET/MRI protocols (e.g., with contrast media, longer scan tomical areas prone to breathing artifacts (chest, upper abdo-
times on specific organs), comparable to fully diagnostic men), where there is significantly increased physiological
13
Fig. 1 PET/MR workflow schematic. On the left of the PET/MR exploit PET/MRs full potential are given. The latter, as explained in
fusion image, the basic protocol similar in time and functionality the text, would add time to the study making it longer than standard
to PET/CT is shown. To the right of the fusion image, examples of PET/CT
extra MR sequences and accompanying PET acquisitions that would
background activity (liver, lymphproliferative tissue of the the heart or liver region, there are dynamic PET-imaging
head and neck) or where multiple areas of physiological protocols available. Time resolution is achieved by sub-
uptake can make diagnosis challenging (pelvic exams with dividing the acquisition into predefined frames of time
uptake in the bladder and bowel loops). or acquiring in listmode to be able to decide on the time
A further option is acquiring a specific, “local PET/MR” framing of the PET acquisition later on. In such dynamic
after a PET/CT in cases where specific questions are left PET acquisition protocols, the i.v. application of the tracer
unanswered. This could be, e.g., local extent of soft tissue is performed parallel to the start of the PET-acquisition;
tumors (where the MRI component has its clear advantages) although in practice, it is advisable to start the PET acqui-
or better PET image quality in previously questionably PET- sition first and inject the tracer 1 min later to validate the
positive lesions based on the potentially significantly longer positioning prior to tracer injection. Reconstruction can
PET acquisition time which can be used in such protocols. then be performed with 1 min delay. Depending on the
A particular focus shall be given to dynamic PET/ intended data analysis, the application is performed as a
MRI protocols. In these situations — as stated before — bolus or continuous infusion using an infusion pump to
patients are positioned with the body region of interest ensure a stable infusion rate. If desired, it might be neces-
both axially and transaxially centered in the PET FOV. sary to simultaneously take samples of arterial blood to
The goal is to follow the tracer distribution and metabo- enable full kinetic modeling of the tracer to characterize
lism over time in regions or organsof interest. There is a its pharmacokinetics. In neuro oncology, it is of impor-
focus on dynamic brain PET but also for investigations of tance to characterize the pharmacokinetic behavior of
13
particular tracers as a parameter in staging the risk poten- adjacent to metal implants or other artifact causing struc-
tial of tumors, such as for instance glioma [39, 74]. tures in the MR-based AC maps.
The last major option refers to “CT/MR-guided PET/ More technical details on the topics above can be found
MRI” protocols. Those are cases where a PET is warranted/ in a comprehensive review by Vandenberghe and Marsden
indicated, but where there is already previous imaging for [75] or Sattler [76].
staging purposes available, and only very specific questions
are left for PET/MRI. Thus, one can focus on the PET part MRI image reconstruction
for the whole-body examination (“low-dose PET/MRI”) and
only add few specific MRI sequences on the region of inter- As mentioned in the “attenuation correction” section,
est, like the case of brain imaging in primary staging for MR-AC should be acquired and reconstructed according to
lung cancer. the most current available version and according to the rec-
ommendations of the manufacturer. MR-AC µ-map should
be carefully inspected during the PET data reading and
PET image reconstruction reporting process.
Reconstruction of MRI images can be performed in any
With PET being a quantitative imaging method with high spatial orientation that is needed to match and overlay the
sensitivity, PET data acquisition and reconstruction needs PET data during PET/MRI hybrid image reading. It has to
to fulfill numerous preconditions in order to provide accu- be noted, however, that for most 2D sequences, the orienta-
rate and quantitative results. PET data needs to be corrected tion of MRI data acquisition (e.g., transaxial, coronal, sag-
regarding radiotracer decay over time, photon scatter, field- ittal, oblique) determines the direction of the highest spa-
of-view truncation, and photon attenuation. Various methods tial resolution. That is, a stack of transaxial 2D slices will
for PET data correction have been established. We refer the provide high spatial in-plane (transaxial) resolution while
interested reader to the section on attenuation correction of the through-plane resolution in slice direction is reduced.
this paper and also refer to the detailed description on PET Consequently, a sagittal or coronal reconstruction or refor-
corrections and PET image reconstruction in the PET/CT matting of a transaxial 2D stack will show reduced spatial
guideline [1]. resolution that might hamper accurate anatomic assessment
In the context of PET/MRI, specific topics have to be of findings in PET. Accordingly, the diagnostic MRI proto-
considered regarding PET image reconstruction. PET image col for each bed position should include 2D MRI sequences
reconstruction should be performed according to the manu- with thin slices or 3D sequences with nearly isotropic spatial
facturers recommended standard reconstruction parameters resolution.
(e.g., OSEM with appropriate number of iterations and pre-
filtering). Furthermore, resolution modeling (point-spread-
function (PSF) modeling) or other image processing and PET/MRI protocols based on clinical
reconstruction methods may be applied depending on the indications
scanner capabilities. Time-of-flight (TOF) PET informa-
tion should be used during reconstruction, when available. Neuro‑oncology applications
It has to be noted, however, that all listed PET reconstruction
parameters (e.g., OSEM, number of iterations, PSF mod- In general, simultaneity is a convenient one stop-shopping
eling, TOF information) may have potential impact on PET approach, but not mandatory for neurological indications, as
quantification. This may have clinically relevant impact in vendor provided co-registration software solutions between
repeated PET/MRI studies, where patients undergo repeated PET and MRI (if done in close temporal proximity) are usu-
PET/MRI examinations for therapeutic monitoring or other ally sufficiently robust for clinical use in oncology cases.
indications. Similarly to PET/CT [1], in such PET/MRI One exception to this might be the need for anesthesia, in
studies, identical acquisition protocols and reconstruction which case sequential studies could entail either longer or
parameters should be used. repeated anesthesia, increasing patient risk [77, 78].
As in PET/CT [1] and as mentioned above, it is good The most used PET tracers for brain tumors are described
clinical practice to perform reconstructions with and within Table 1.
out attenuation correction to be able to visually identify Usually, a static amino-acid PET image acquisition of
potential reconstruction artifacts caused by MR-based AC. 10–20 min is sufficient for clinical use, while a 40–50 min
Both attenuation-corrected (AC-PET) and non-attenuation- dynamic acquisition for FET may provide additional diag-
corrected (NAC-PET) images should be available for inter- nostic information (see imaging protocol below). Of course,
pretation and lesions seen on the AC-PET images may need if MRI acquisition is longer than 10–20 min, continued
to be checked on the NAC-PET images, particularly when acquisition of PET information throughout the entire study
13
can improve the quality of the PET images, depending on the An additive diagnostic advantage of combining advanced
properties of the used radiopharmaceutical. Further details MRI techniques to standard PET and MRI has been sug-
on FDG and amino acid tracer patient preparation, image gested in smaller patient series [86], but has not been
acquisition, reconstruction, semi-quantitative parameters, consistently documented. The challenges are the lack of
interpretation, reporting, and pitfalls are presented elsewhere standardization and availability of MRI techniques, both
[39]. A wide range of PET attenuation correction techniques for acquisition and post-processing, and the limited tissue
in neuro PET/MRI has been suggested. The reported impair- coverage because of susceptibility to patient movement and
ment of PET quantification by AC-artifacts in brain PET/ artifacts on postsurgical MRI [87, 88].
MRI is, except for close proximity to bony structures or air Other useful advanced MRI techniques for multipara-
cavities as low as known from PET/CT, on the order of up metric use in neurooncology PET/MRI have recently been
to 4%. Depending on the proximity to bony structures or reviewed and published in a position paper by the European
air cavities, this may lead to systematic differences in the Cooperation in Science Technology (COST) Glioma MRI
activity distribution and calculated semi-quantitative tumor Imaging 2.0 (GliMR) initiative.
metrics [79], which should carefully be considered during
PET image interpretation [28, 80]. Head and neck
The MRI sequences required may depend on whether
the patient has recently had extensive imaging, in which For head and neck tumors, mainly FDG is indicated as
case an abbreviated protocol, possibly even only sequences radiotracer. Exceptions apply to neuroendocrine tumors,
for MRAC, might be acquired. Ellingson et al. [81] have paraganglioma, and medullary thyroid carcinoma (DOTA-
proposed consensus guidelines for MRI of brain tumors for conjugated somatostatin receptor targeting peptides, DOPA)
clinical trials, to assure reproducibility and inter-trial com- [89–91], extracranial meningiomas (DOTA-conjugated
parisons. They suggest 5 key sequences (3D T1 pre, Ax T2 somatostatin receptor targeting peptides) [92], differentiated
FLAIR, Ax DWI, Ax T2 post-contrast, and 3D T1 post- thyroid cancer (I124), and parathyroid neoplasia (choline-
contrast) as minimum standards [82]. To acquire all these based radiotracers) [93]. However, the use of non-FDG radi-
sequences, an imaging duration of about 30 min is required. otracers in these indications is partly off-label in the USA
Examples of pediatric neurooncology PET/MRI protocols and in Europe.
can be found in the literature [77, 78, 82, 83]. PET/MRI can contain a dedicated MRI protocol tailored
A number of advanced functional MRI techniques that to the head and neck region. PET/MRI can be used for the
may be useful in neurooncology in a multiparametric set- staging of head and neck carcinomas greater than clinical
ting that are available for measurement of tumor perfusion stage T2 / N2a. Also, lower neck tumor location (e.g., in the
by arterial spin labeling (ASL), tumor biochemistry by MRI hypopharynx) and the presence of lower neck level (III, IV)
spectroscopic imaging (MRSI), and tumor angiogenesis by nodal metastases should prompt whole-body staging (which
relative cerebral blood volume (rCBV) using dynamic sus- can be done with PET/MR), owing to the higher risk of
ceptibility contrast (DSC) or dynamic contrast enhancement distant metastases in these patients [94]. Furthermore, in a
(DCE) have been reviewed recently [84, 85]. Also, dedi- study conducted by Chan et al. [95], PET/MRI outperformed
cated fMRI techniques can be performed for evaluation of MRI and PET/CT in T and N staging while providing simi-
feasibility of surgical resection in one setting together with lar performance for M staging. Whole-body imaging should
PET-imaging. cover the area from the skull vertex to the upper thighs and is
usually accomplished with an axial T1-weighted Dixon-type
sequence, which takes approximately 3 min. With the lung
Table 1 Most commonly used PET tracers for brain tumors being the most common site for distant metastatic disease,
the acquisition of specific lung MRI sequences is recom-
Tracer Pathologies
mended [96–98].
2-deoxy-2-[18F]fluoro-D-glucose (FDG) First choice: PET/MRI is useful for detecting residual disease in
• CNS lymphoma patients after non-surgical therapy, with optimal diagnostic
Alternative use: reassurance at 12 weeks after therapy [99, 100]. Recurrent
• Glioma
• MTS
disease after different kinds of therapy can reliably detected
O-(2-[18F]fluoroethyl)-L-tyrosine (FET) First choice:
with PET/MRI, as shown by Queiroz et al. [101].
L-[methyl-11C]methionine (MET) • Glioma PET/MRI for head and neck cancers can be safely per-
3,4-dihydroxy-6-[18F]fluoro-L-phenylalanine formed without the use of gadolinium-based contrast agents.
(FDOPA) As shown by Kuhn et al. [102], this is still as accurate as
[68 Ga]DOTA-conjugated peptides First choice: contrast-enhanced PET/CT imaging, provided fat-sup-
• Meningioma
pressed T2-weighted pulse sequences are used in the head
13
and neck region. However, for optimal results in the head and studies have shown, for example, that even in small pul-
neck — and to obviate a separate MRI acquisition — PET/ monary nodules, the lung parenchyma and mediastinal and
MRI should additionally contain at least a non-suppressed pleural infiltration can be evaluated with advanced PET/
T1-weighted sequence before contrast and a fat-suppressed MRI techniques (gating, UTE/ZTE, motion correction,
post-contrast T1-weighted sequence [94, 103]. As shown radial Fourier plane acquisitions) [61, 107–112]. How-
by Sekine et al. [103], such a protocol might be useful to ever, overall imaging time in the latter scenario will be
determine the resectability of tumors. After contrast admin- significantly longer than that of standard PET/CT. Finally,
istration, the whole-body T1-weighted MRI scan might be data-driven motion correction techniques for PET recon-
repeated in patients with known or suspected distant meta- struction are also on the horizon [113–115].
static disease or with other primary tumors. Small initial studies comparing PET/MRI with PET/
During the MRI acquisition in the head and neck region, CT in local thoracic staging of malignant pleural meso-
which takes approximately 20 min using the minimum pro- thelioma (MPM) found a comparable diagnostic accuracy.
tocol outlined above, one may keep the PET camera active Radiologists partly felt more confident staging with PET/
to obtain a dedicated regional PET dataset with higher SNR. MRI compared to PET/CT [116]. Overall, it was suggested
Functional MRI techniques aid in the characterization of that MPM can be staged using PET/MRI which is, how-
tumors, lymph nodes, and suspected recurrences. However, ever, always dependent on the local/jurisdictional circum-
their value in the setting of FDG-PET/MRI has not been stances [111].
studied in detail. Diffusion weighted imaging (DWI) as part
of a PET/MRI protocol appears useful to detect unknown
primaries and recurrent tumors after radiotherapy [100, 104, Breast cancer
105], but not for the staging of tumors [106]. The benefit of
other functional MRI techniques as part of a head and neck PET/MRI has the advantage of being able to perform an
PET/MRI protocol remains to be determined. accurate local staging in addition to regional and dis-
tant staging as discussed above. Dedicated breast MRI
Chest sequences and PET-compatible RF breast coils are avail-
able [117, 118]. Moreover, the physicians’ confidence in
When the local staging is already evaluated via the avail- their diagnosis when interpreting co-registered PET and
able chest CT, the PET/MRI protocol can be acquired with MRI images together can be increased [119–121]. Also,
previously described “basic” or “fast” whole body proto- local staging can be achieved with significantly reduced
cols, including contrast media application [70, 71]. The PET radiation exposure [37]. It is currently of debate whether
acquisition time per bed position for those basic protocols the dedicated breast acquisition with a dedicated breast
have been described with usually 2–3 min which brings the coil in prone position should be performed in PET/MR.
PET/MRI acquisition time closely down to standard PET/ While this is the standard in MR-imaging, it might, how-
CT imaging. ever, not always be possible in PET/MR based on the more
The brain MRI can be done as a standard brain MRI met- narrow patient tunnel.
astatic protocol, using the already applied contrast media There is also still debate if there is actually clinically
for the whole-body acquisition. The PET-imaging time for added value of dedicated breast 18F-FDG PET/MRI for the
the brain acquisition can be adapted to the MRI acquisi- evaluation of the primary breast cancer when compared
tion time. Alternatively, in cases of high-throughput PET/ to dedicated breast MRI. Newly developed FAP-imaging
MRI prioritization, an abbreviated brain MRI protocol can might offer new insights and improved diagnostic accuracy
be acquired to limit scanner time on the PET/MRI. In case in breast cancer, also for the evaluation of the primary breast
there is a positive brain finding which explicitly needs fur- cancer [122–125]. There is already, however, consensus in
ther characterization, an extended brain MRI protocol can the literature that 18F-FDG PET/MRI can provide added
be acquired on a stand-alone MRI since the PET component value for whole-body breast cancer staging and for treat-
usually does not add any advantage to the diagnostic accu- ment monitoring.
racy in this scenario. With this approach, patients would [18F]FDG PET/CT is more sensitive and MRI is more
have, in most instances, only one staging procedure instead specific in predicting pathological complete response at the
of several different procedures. This is especially evident end of neoadjuvant chemotherapy, and therefore, both could
in health care systems with limited access to MRI and its be combined in order to improve such assessments.
consecutive waiting times. Future directions include the use on other radiophar-
Advanced PET/MRI protocols might be applied for maceuticals targeting estrogen and Her-2 receptor status,
local staging purposes in bronchial carcinoma and other angiogenesis, or gastrin-releasing peptide receptor expres-
chest malignancies (i.e., esophageal cancer). Several sion [126].
13
Liver was found to be an independent predictor of progression-free

survival when done after treatment [134].
Whole-body PET/MRI protocol can be combined with a
liver specific PET/MRI protocol, which includes an addi- Neuroendocrine tumors
tional, single-bed and (ideally) respiratory compensated PET
acquisition of liver with simultaneous acquisition of liver MRI-only is an important modality for NET patients, as a
specific MRI sequences. The MRI sequences have to be opti- large percentage of NET patients have liver dominant disease
mized for the specific indication, taking also into account the [135]. Gastro-entero-pancreatic NET primarily metastasize
complexity and time constraints of simultaneous PET/MRI to the mesenteric lymph nodes and to the liver. The evalua-
acquisition. Institutions may use gadoxetate (a paramagnetic tion/characterization of liver metastases from NET should
contrast agent) for liver PET/MRI, depending on the indica- rely on a somatostatin receptor targeting radiopharmaceu-
tion and based on the higher accuracy of the hepatobiliary tical [136–138]. Indeed, SSTR-PET/MRI incorporating
phase for oncologic liver imaging [127, 128]. hepatobiliary phase imaging is a useful modality in patients
There has been significant potential being demon- with liver dominant NET. However, there is only very lit-
strated for [ 18F]FDG PET/MRI for imaging of hepatic tle data in NET and PET/MRI available [128, 139–143].
metastases and to provide a potential one-stop-shop [68 Ga]Ga-DOTATOC PET/MRI can depict the anatomic
imaging solution for patients with known or suspected correlates possibly better on the MRI component. However,
hepatic metastases [129, 130]. PET/MRI may improve lung lesions might be better seen with the CT component
reader confidence and the MRI component can improve of the PET/CT.
characterization of focal hepatic lesions, especially PET There are currently no publications available concerning
negative metastases [131, 132]. detection/characterisation of the primary tumor; however,
However, there are only selected studies showing the for pancreatic tumors, this would not differ from what was
advantage of PET/MRI in characterization of primary described above. For NET’s of the small bowel, a specific
hepatic tumors. The main indication for [18F]FDG is the MR-enterography protocol could be used in addition to the
evaluation of tumor differentiation, i.e., in HCC and to described basic whole-body PET/MRI.
predict hepatoma relapse after transplant. Thus, the main Another potential role of SSTR-PET/MRI is in patients
potential of PET/MRI for characterisation of primary hepatic who have higher grade tumors. In higher grade NETs
tumors is likely to be realized with non-FDG radiotracers, (increasing Ki-67 of 10% and higher), expression of the
i.e., choline, prostate specific membrane antigen (PSMA), SSTR declines [144]. In this setting, diffusion weighted
FAPI, or CXC chemokine receptor type 4 (CXCR4)-based imaging can be helpful for lesion detection and characteriza-
radiotracers. tion. Some facilities may perform both FDG and SSTR-PET-
imaging for evaluation as the differential uptake can pro-
Pancreas vide insight into tumor aggressiveness as well as response
to SSTR-targeted therapies [145–148].
In pancreatic ductal adenocarcinoma (PDAC), MRI is equiv-
alent to CT for the evaluation of local extension, vascular Colon/rectal cancer
invasion, and nodal involvement. However, MR, compared
to CT, has a higher sensitivity for the detection of small By integrating the quantitative parameters SUV and ADC
metastatic liver lesions (see above). Protocol requirements from PET/MRI, an improved prediction and evaluation of
are relatively similar to PET/MRI of the liver. A whole- therapy effect, compared with RECIST size measurements,
body PET/MRI overview can be followed by a single sta- may be achieved [149, 150].
tion/dual station PET-acquisition with simultaneous acquisi- In addition to the standard, above-described preparation,
tion of pancreas (and liver) specific MRI sequences as per scopolamine butylbromide or glucagon can be addition-
departmental guideline/as per published recommendations ally injected immediately before the start of investigation
for MRI. The combination of PET and MRI, however, may to minimize bowel motion and is used as a clinical stand-
be useful in assessing advanced imaging biomarkers. For ard in many institutions [151, 152]. FDG-PET/MRI in
example, regarding the evaluation of tumor aggressiveness, patients with colon tumors should contain a prolonged PET
there is evidence of an inverse correlation between standard- scan (12–15 min) in the area of interest in parallel with a
ized uptake value (SUV) and apparent diffusion coefficient detailed transverse DWI (at least 3 b-factors) and T1w and
(ADC) in many malignant tumors as well as in pancreatic T2w sequences (with high spatial resolution) of the primary
cancer [133]. In other studies, the metabolic tumor volume tumor.
(MTV)/minimum ADC score ratio demonstrated the highest Thereafter, a standardized protocol for whole-body MRI
predictive ability for estimating the clinical TNM stage and simultaneously with a whole-body FDG-PET acquisition
13
(2–3 min. for each station) can be acquired for detection The Lugano classification, a consensus document devel-
of distant colorectal metastases. DWI can be added to oped following workshops at the International Conference
the standardized whole-body protocol, when the abdomi- on Malignant Lymphoma [167] has incorporated PET in the
nal cavity is scanned, to improve detection of peritoneal staging of all FDG-avid lymphomas.
carcinomatosis. The main purpose of initial staging is to accurately assess
Contrast-enhanced MRI of the liver including T2w and disease extent, at nodal and extra-nodal sites and to identify
DWI with 3b-factors using navigators for respiratory gating sites of bulky disease. Bulk has prognostic and therapeutic
and T1w 3D fat saturated (breath hold) sequences before and implications and therefore baseline maximal tumor diameter
after standard i.v. contrast or hepato-biliary specific contrast should be recorded.
during arterial, portal phase and 4 and 10 min after contrast PET-imaging based therapy response assessment criteria
injection should be acquired. have a high negative predictive value of 95–100% for HL
Patients with rectal cancer are investigated with a stand- and 80–100% for aggressive NHL [168]. Residual lesions
ard clinical protocol according to the departmental guide- at interim assessment or after therapy are assessed with the
lines but should include at least a T2-weighted sequence (in Deauville score. Patients who do show residual disease at
3 planes) and DW (3 b-factors) images of the primary tumor end of therapy, sites of positivity on PET may be used to
in parallel with a prolonged PET scan in this bed position. guide biopsy to confirm residual disease prior to salvage
The PET acquisition time can be adapted to the rectal MRI therapy. Interim PET performed after 2 or 3 cycles of chem-
protocol. This again will be followed by the standard whole- otherapy offers a window to the chemosensitivity of the
body protocol [153, 154]. tumor. A negative interim PET in Hodgkin’s lymphoma has
been shown to indicate favorable response at end of therapy
Gynecological cancers and in patients with advanced-stage HL, interim PET can be
used to tailor management [169].
PET/MR has been shown to be beneficial for evaluation of Routine PET/MRI protocol for staging of patients with
cervical cancer, endometrial cancer, and ovarian lesions lymphoma could include Dixon based attenuation correc-
[155–160]. tion sequences, a secondary plane with T2-sequence (with
For gynecological cancers, the imaging protocol should or without fat sat) and a 3D (fat suppressed) post contrast
be set up in consideration of the following aspects: (1) tumor sequence. Overall acquisition time would be 25 min [72].
entity (e.g., cancer of the uterine cervix or endometrial can- However, depending on the sequences used, this can be done
cer); (2) desired coverage and clinical question — (a) pri- also < 20 min. Unless contraindicated, there may be added
mary local staging (pelvis only), (b) primary local and addi- value for contrast enhanced MR-imaging or DWI for bet-
tional whole-body staging, and (c) whole-body restaging. ter delineation of disease at extranodal sites, especially in
MRI protocols for local staging of primary tumors of bone marrow where MR-imaging has clear advantages over
the female pelvis (a) comprise a combination of T1- and CT-imaging. Also, other extranodal lymphoma manifesta-
T2-weighted sequences, dynamic imaging as well as poten- tions, i.e., brain or liver manifestations can be evaluated with
tially of diffusion-weighted imaging (exemplary protocol improved accuracy on MR-imaging over CT-imaging.
shown in Fig. 1). Optimal assessment of the different tumor Also, a special consideration for osseous involvement of
entities (e.g., cervical cancer, endometrial cancer) requires hematological malignancies applies to PET/MR imaging in
protocol adaptations such as T2-weighted axial oblique multiple myeloma [170]. The predominant bone marrow
plane imaging in case of cervical cancer to identify potential involvement in this disease makes PET/MR a well-suited
parametrial invasion [161, 162]. These protocol adaptations combined imaging method for evaluation of this disease and
may be applied in accordance with current guidelines. PET- as well as MR-imaging are now already suggested in
In case whole-body staging is desired in addition to local multiple myeloma classification [171].
primary staging or for whole-body tumor relapse assess- For response assessment, protocols may be abbrevi-
ment, fast-whole body sequences as discussed above may ated even further, if a baseline scan exists. Dixon-based
be acquired for whole-body coverage [163, 164]. sequences for attenuation correction and the additional
T2-sequence or 3D post contrast T1-imaging may suffice in
Lymphoma identifying and measuring residual masses and assigning the
appropriate Deauville score from the PET datasets. Since a
PET/CT-imaging is generally done for the following clini- decrease in size of mass along with negative PET has a bet-
cal indications: staging of FDG avid lymphoma (baseline), ter predictive of a favorable outcome as compared to either
interim response assessment, and end of therapy response test alone, it is important to note and measure all residual
assessment [165, 166]. masses along with metabolic response score [172].
13
Prostate cancer suspicious anatomical findings that correlate with frequently

subtle metabolic findings in patients with early biochemical
PET/MRI imaging is increasingly used in prostate cancer. recurrence [186].
The two main applications are detection and characterisation
of primary disease within the prostate (mostly in high risk or Carcinoma of unknown primary (CUP)
the intermediate unfavorable risk group). Additional whole
body imaging may be indicated for primary staging or in There is broad evidence of the utility of FDG PET/CT in
patients with biochemical recurrence [173–177]. PET/MRI patients with CUP [187, 188]. There are only two studies on
acquisition is tailored according to the indication: primary PET/MRI in CUP [104, 189]. The studies found either com-
staging, re-staging in cases of biochemical recurrence, and parable diagnostic accuracy between PET/MRI and PET/CT
follow up after established diagnosis. For primary staging, or higher detection rate for the actual primary tumor. It has
a dedicated MRI of the prostate (see below) with adapted to be noted that studies on CUP usually (as in this two cited
PET-acquisition time of the pelvis plus a fast whole-body studies) are studies about head and neck cancer. In those
acquisition should be performed. For cases with biochemical cases, as above described, a “fully diagnostic,” “advanced,”
recurrence (post prostatectomy), fast whole-body sequences or “dedicated” PET/MR of the head and neck is recom-
and similar pelvic sequence types can be used but have to mended as described above. Given the time required by the
be adapted to the pelvis instead of the prostate. For follow MR for the diagnostic MR-sequences for the head and neck,
up of cases with established diagnosis, a fast whole-body the prolonged imaging time in PET allows how increased
overview might be sufficient. sensitivity and therefore possible detection of smaller pri-
[18F]Fluciclovine is widely used in the USA for prostate mary head and neck tumors (i.e., in the tonsils).
PET/CT and PET/MRI. However, the majority of imaging However, other indications can occur as well, i.e., liver
sites currently work with PSMA (either 18F or 68 Ga-labeled) or lung metastases without an immediately found primary.
and a recent publication with a head-to-head comparison Thus, the specific PET/MRI protocols in the respective ana-
suggested that PSMA-imaging might be the favorable imag- tomical areas as discussed in this guideline should then be
ing compound [178, 179]. Moreover, PSMA has recently used.
been approved in the USA as well.
A problem with all radiopharmaceuticals for prostate
imaging is that they are not prostate/prostate cancer spe- Image interpretation, quantification,
cific and thus uptake in benign lesions such as benign pros- and reporting
tatic hyperplasia (BPH) might represent a pitfall. However,
with the addition of dedicated MR-sequences in PET/MRI Artifacts in PET/MRI and their correction
specificity can be significantly increased up to 0.96 [180,
181]. Those dedicated protocols should include dedicated The complexity of integrated PET/MRI hybrid imaging
T2 sequences, dynamic contrast enhanced T1 imaging and bears high potential for the occurrence of either PET, MRI,
diffusion weighted imaging (DWI). or PET/MRI-related artifacts [16, 190]. Beyond the mere
Another pitfall is urinary excretion of most of the PSMA visual affection of hybrid images, artifacts in PET/MRI may
tracers (except for the 1007 compound, [18F]fluciclovine, also have a significant effect on quantification of PET data.
[64Cu]Cu-PSMA, and [ 18F]methyl/ethyl choline) that may Since attenuation correction in PET/MRI is mostly based
lead to scatter impaired image quality [182]. Thus, updated on MRI sequences, all artifacts in the MR-AC images will
PET data reconstruction algorithms that can correct for this ultimately translate into inaccurate values in PET quantifica-
are available today and need to be used in the context of tion following MR-AC [64, 191].
PSMA prostate PET/MRI [183, 184]. Typical artifacts in PET/MRI hybrid imaging are the fol-
When using PET/MRI in the setting of biochemical lowing: motion artifacts and local misalignments between
recurrence, the local/pelvic imaging needs to be adapted PET and MRI data due to patient and organ motion [192];
accordingly and is different than prostate MRI for primary faulty tissue segmentation with assignment of wrong LAC
staging. DCE-MRI can aid in the detection of local recur- in MR-based AC [64]; signal truncations along the patient’s
rence, which is a common location for recurrence in patients arms where the patient anatomy often exceeds the spatial
with post-radical prostatectomy or radiation therapy [185]. constraints of the MRI field-of-view [40, 193, 194]; and den-
Additionally, diffusion-weighted imaging can be helping in tal and metal implants that are found in a large and increas-
cases of local recurrence. It might, however, be limited by ing group of patients [79, 195–197]. Apart from the safety
artifacts in patients post-brachytherapy. It has been shown aspects of metal implants that have to be clarified before any
that the complementary information from PET and MRI MRI and PET/MRI examination (see section on MRI safety
can increase confidence in interpretation by delineating above), all metal implants might cause signal voids or local
13
distortions in diagnostic MRI images and in MRI-based AC for the analysis of FDG uptake in case of vascular diseases
that exceed the physical implant volume. and for brain imaging are available and should be applied to
Recent studies now report about new developments to PET/MRI studies as well [39]. In all cases when quantita-
correct for artifacts. To reduce the quantitative impact of tive reads are desired, all necessary corrections to allow for
metal artifacts in MRI based AC on PET quantification, a quantitative reads should be included during the PET image
method has been suggested to complete signal voids in the acquisition and reconstruction process, such as normaliza-
MR-AC caused by implants by deriving the shape and AC tion, dead time, decay, randoms, scatter, and attenuation
values of metal implants from PET emission data [198]. correction. Dedicated sequences and procedures to derive
Truncation artifacts can be corrected by estimating the MR-AC available on each PET/MRI system and as provided
patient body contours from PET data using the MLAA algo- by the vendor should be applied.
rithm [199]. A second method for correction of truncation
artifacts is fully MR-imaging based and applies B0-HUGE Reporting content and image interpretation
to effectively increase the lateral field-of-view in MR-based
AC [1, 45, 49]. In the context of metal artifact reduction in Detailed recommendations for reporting FDG findings have
PET/MRI, it has been shown that TOF PET detection with been published [1]. Niederkohr et al. published a reporting
fast PET detectors allows for a significant visual reduction guidance listing the essential elements of a concise and com-
of artifacts in the µ-map [66, 200], albeit PET quantification plete oncologic [18F]FDG PET/CT report [204]. Recommen-
may still be biased. dations are also provided in the European Guideline for FDG
Regarding the management of artifacts in a current clini- PET/CT oncology imaging. These recommendations refer to
cal PET/MRI setting, clinical users of PET/MRI are advised PET/CT but are equally applicable to PET/MRI regarding
to always use the newest available generation of software the reporting of patient history, details of the FDG imaging
and MR-AC methods. Time-of-flight detection shall be used procedure, and any clinical findings and conclusions derived
were applicable to reduce the visual and quantitative influ- from the FDG PET/MRI study. In case of FDG brain imag-
ence of artifacts. Furthermore, image readers are advised to ing studies, recommendations have been published before
always carefully check the MR-based AC image data for arti- and are similarly applicable to PET/MRI [39, 205].
facts during PET/MRI image reading. Tissue segmentation In case of image interpretation of PET/MRI studies, par-
errors, Dixon technique related fat/water swaps, truncation ticular attention is needed to potential MR-AC artifacts and
artifacts, and large volume artifacts around metal implants pitfalls, as explained before. For both PET/CT and PET/
are well detectable in the AC maps and indicate anatomic MRI, attenuation correction artifacts may occur, although
regions were the PET quantification may be hampered. different in cause and nature. It is therefore recommended
to not only inspect both the attenuation and non-attenuation
PET quantification corrected PET images but also to inspect the generated MR-
based attenuation coefficient image (µ-image or µ-map) for
PET quantitative reads may be required or are part of the any unexpected artifacts [1]. Due to differences in MR-AC
PET/MRI study objectives. Although fully quantitative versus CT-AC, differences in apparent tracer uptake distribu-
analysis using kinetic modeling approaches implying the tion may occur. FDG uptake in and near bone may appear
ultimate need for dynamic PET imaging protocol (see above) lower in PET/MRI than this seen in PET/CT. Furthermore,
may be considered most accurate, these studies are — apart due to the assignment of a uniform attenuation coefficient
from some neuro oncologic PET investigations — com- to lung tissue, uptake in the healthy lung tissue may have
monly not performed due to their complexity. Nevertheless, a slightly different appearance. Several techniques became
full quantitative studies may be required, e.g., to validate meanwhile available to correct for different MR-AC aspects.
use of more simplified metrics derived from static imaging Irrespective which is used and despite potential differences
procedures as recently explained by Lammertsma et al. [201] in the quality and accuracy of MR-AC versus CT attenuation
and/or shown before by Cheebsumon et al. [202]. correction, clinical PET/MRI images show a very compa-
Typically, FDG uptake quantification is based on SUV rable physiological FDG distribution as those seen in PET/
or tumor/lesion background ratios (TBR). In these cases, CT [1, 3].
tracer uptake in the tumor or lesion is normalized to injected
activity over patient weight (or lean body mass [203]) in RADS/other reporting classifications
case of SUV or normalized to the uptake in a background
region for TBR. The most applicable uptake metrics and While there is no standard template to report hybrid imag-
how to obtain these have already been identified and rec- ing (PET/MRI or PET/CT for that matter), there is a wealth
ommended for oncology FDG PET/CT studies [1], but are of (structured) reporting systems available in CT, MRI, and
equally applicable to PET/MRI. Similarly, recommendation ultrasound. There are several RADS (Reporting and Data
13
System) available (i.e., for HCC, prostate cancer, thyroid honoraria from GE Healthcare, a fund by the Alfred and Annemarie
cancer, and many more). Although it has been shown that von Sick legacy and a grant from the clinical research priority program
(CRPP) Artificial Intelligence in Oncological Imaging Network of the
there is no influence on reporting quality or sensitivity of University of Zurich. Author AI is an unpaid consultant to GE Healthcare
detection of the disease itself, RADS harmonizes the imag- and Lantheus, paid consultant to Amgen, IRE, Curium (EU), ITM,
ing/reporting output. The major values of such reporting and Novartis, Rayzebio and Telix, and a member of the scientific advisory
data systems are that it provides consistency in terminology, board at Clarity Pharmaceuticals and Alpha9 Theranostics. Mayo Clinic
receives funding from Novartis, Pfizer, MedTrace, Clarity, Clovis, and
which makes the reporting more reliable and better under- ViewPoint/Perspective for research conducted by author GBJ. Mayo
standable for the referring physicians. Clinic receives funding for consulting with Pfizer, Novartis, Curium,
Since there are several reporting systems available for Blue Earth, AstraZeneca and Lantheus conducted by author GBJ.
PET as well as for MR, either stratified by disease or even by Companies founded by author GBJ include Nucleus RadioPharma and
The Green Clinic. Mayo Clinic and author GBJ hold patents pending on
therapy, it is not possible to give a concise recommendation radionuclide theragnostic technologies. Author UM is a consultant for
which reporting system to use. However, it is justified that POINT Biopharma inc. Author HHQ has received research grants from
standardized reporting is used for both components (if avail- Siemens Healthcare GmbH, Erlangen. Author BS has received speaker
able) in PET/MRI within the institutions’ preferences. This honoraria from SIEMENS Healthineers and is a member of the policy
and regulatory affairs committee of EANM. Author GZ has received
(institutional) standard shall comprise a joint final assess- research grants from GE Healthcare and Bayer, consulting fees from
ment and conclusion of each report including the approval Biogen, and equity in Subtle Medical, Inc. Author KH reports personal
of both the MRI- and PET-specialized MD. fees from: Bayer, SIRTEX, Adacap, Curium, Endocyte, IPSEN, Siemens
Heatlhineers, GE Healthcare, Amgen, Fusion, Immedica, Onkowissen.
Acknowledgements We thank the EANM Oncology and theranostic de, Novartis, Molecular Partners, ymabs, Aktis Oncology, Theragnostics,
Committee, EANM National Societies and the ISMRM and SNMMI Pharma15, Debiopharma, AstraZeneca and Janssen. Author KH also has
bodies for their review and contribution. We also thank Andres Kohan personal fees and other from Sofie Biosciences, non-financial support
from the Joint Department of Medical Imaging at University Health from ABX and grants and personal fees from BTG. Authors RB, RCDB,
Network in Canada for his great support during the development of AK, IA, and LU declared no conflict of interest.
this guideline.
Liability statement This guideline summarizes the views of the EANM
Author contribution All authors contributed to the study conception Oncology-Theranostic Committee, SNMMI and ISMRM. It reflects
and design. The first draft of the manuscript was written by Patrick recommendations for which the EANM, SNMMI and ISMRM cannot
Veit-Haibach compiling all the authors’ contributions and all authors be held responsible. The recommendations should be taken into context
commented on previous versions of the manuscript. All authors read of good practice of nuclear medicine and do not substitute for national
and approved the final manuscript. and international legal or regulatory provisions.
Funding Open Access funding enabled and organized by Projekt Open Access This article is licensed under a Creative Commons Attri-
DEAL. bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
Data availability Data sharing is not applicable to this article as no as you give appropriate credit to the original author(s) and the source,
datasets were generated or analysed during the current study. provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
Declarations included in the article's Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
Ethics approval This is a guideline and does not contain any studies the article's Creative Commons licence and your intended use is not
with human participants performed by any of the authors. permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
Conflict of interest Author PVH has IIS grants from: Bayer Switzerland, copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
Roche Pharmaceuticals, Siemens Healthineers, GE Healthcare and Point
Biopharma. Author PVH has an Industry Sponsored Theranostic Trial:
AAA. Author PVH has speaker fees and travel support from Siemens
Healthineers and GE Healthcare. Author PVH has speaker fees from: References
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Authors and Affiliations
Patrick Veit‑Haibach1,2 · Håkan Ahlström3,4 · Ronald Boellaard5,6 · Roberto C. Delgado Bolton7 · Swen Hesse8 ·
Thomas Hope9 · Martin W. Huellner10 · Andrei Iagaru11 · Geoffrey B. Johnson12 · Andreas Kjaer13 · Ian Law14 ·
Ur Metser15 · Harald H. Quick16,17 · Bernhard Sattler18 · Lale Umutlu19 · Greg Zaharchuk20 · Ken Herrmann21
11
* Ken Herrmann Department of Radiology, Division of Nuclear Medicine,
[email protected] Stanford University Medical Center, Stanford, CA, USA
12
1 Division of Nuclear Medicine, Department of Radiology,
Joint Department Medical Imaging, University Health
Mayo Clinic, Rochester, MN, USA
Network, Mount Sinai Hospital and Women’s College
13
Hospital, Toronto General Hospital, 1 PMB‑275, 585 Department of Clinical Physiology, Nuclear Medicine &
University Avenue, Toronto, Ontario M5G 2N2, Canada PET and Cluster for Molecular Imaging, Rigshospitalet
2 and University of Copenhagen, Copenhagen, Denmark
Joint Department of Medical Imaging, University of Toronto,
14
Toronto, Canada Department of Clinical Physiology, Nuclear Medicine &
3 PET, Rigshospitalet, Copenhagen, Denmark
Department of Surgical Sciences, Uppsala University,
15
751 85 Uppsala, Sweden Joint Department of Medical Imaging, University Health
4 Network, Mount Sinai Hospital and Women’s College
Antaros Medical AB, BioVenture Hub, 431 53 Mölndal,
Hospital, University of Toronto, Toronto, Ontario, Canada
Sweden
16
5 High‑Field and Hybrid MR Imaging, University Hospital
Department of Nuclear Medicine and Molecular Imaging,
Essen, University of Duisburg-Essen, Essen, Germany
University Medical Center Groningen, Groningen,
17
The Netherlands Erwin L. Hahn Institute for MR Imaging, University
6 of Duisburg-Essen, Essen, Germany
Department of Radiology and Nuclear Medicine, VU
18
University Medical Center, Amsterdam, The Netherlands Department of Nuclear Medicine, University Hospital
7 Leipzig, Leipzig, Germany
Department of Diagnostic Imaging (Radiology) and Nuclear
19
Medicine, University Hospital San Pedro and Centre Department of Diagnostic and Interventional Radiology
for Biomedical Research of La Rioja (CIBIR), Logroño, and Neuroradiology, University Hospital Essen, Essen,
La Rioja, Spain Germany
8 20
Department of Nuclear Medicine, University of Leipzig Division of Neuroradiology, Department of Radiology,
Medical Center, Leipzig, Germany Stanford University, 300 Pasteur Drive, Room S047,
9 Stanford, CA 94305‑5105, USA
Department of Radiology and Biomedical Imaging,
21
University of California San Francisco, San Francisco, CA, Department of Nuclear Medicine, University
USA of Duisburg-Essen and German Cancer Consortium (DKTK),
10 University Hospital Essen, Essen, Germany
Department of Nuclear Medicine, University Hospital
Zürich, University of Zürich, Rämistrasse 100, 8091 Zurich,
Switzerland
13

International EANM SNMMI ISMRM Consensus Recommendation For PET/MRI in Oncology

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International EANM SNMMI ISMRM Consensus Recommendation For PET/MRI in Oncology

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European Journal of Nuclear Medicine and Molecular Imaging

International EANM‑SNMMI‑ISMRM consensus recommendation

Received: 30 June 2023 / Accepted: 16 August 2023

Extended author information available on the last page of the article

Keywords Consensus · Oncology · SNMMI · ISMRM · EANM · PETMR · PET · MRI

Introduction to share a basic technical acquisition groundwork and to pro-

Goals PET/MRI technology fundamentals

Liver was found to be an independent predictor of progression-free

Prostate cancer suspicious anatomical findings that correlate with frequently

Authors and Affiliations

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