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PET/MRI: Radiologists Are Exploring the Clinical Role of What Is Still Seen Primarily as a Research Tool
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April2015
PET/MRI:RadiologistsAreExploringtheClinicalRoleofWhatIs
StillSeenPrimarilyasaResearchTool
ByBethW.Orenstein
RadiologyToday
Vol.16No.4P.12
Sinceitsintroductionintheearly2000s,PET/CThasreplacedstand
alonePETasthetoolformanycancerdiagnoses,staging,and
treatments.Since2001,therehavebeenmorethan400installations
ofPET/CTscannersannuallyworldwide.Overthepastfouryears,
PET/MRIhasbeenmakinginroadsaswellandsomebelieveitcould
eventuallysupplantPET/CTasthemodalityofchoiceinsomeareas
ofoncology,neurology,andcardiology.

PET/MRisstilllargelyresearchbased,saysFrankDiLallaofPhilipsImaging,whichisoneofthe
threemanufacturersthatmakethehybridmodalitymachines,alongwithSiemensHealthcareand
GEHealthcare.(Afourthisindevelopment.)"Wearestilltryingtodeterminewhichclinical
applicationswillemergeassignificantlybetterthanitsbrethrenPET/CT,"DiLallasays.Currently,he
says,"It'samixedbag.Honestly,itdependsonwhomyoutalkto."Theearlyadoptersareworking
todeterminewhereandwhenPET/MRIshouldbethehybridmodalityofchoice."Thenextlevelof
adoptersarewatchingthemclosely,"DiLallasays.
EricStahre,presidentandCEOofglobalMRIforGEHealthcare,saysPET/MRissomethingthat
hascertainlycapturedtheimaginationofacademicresearchersandisslowlymovingintothe
clinicalrealm."Itisnotsomethingthatwillbeubiquitous,butitisstartingtogetsomereallynice
tractioninclinicalsettings,"Stahresays.
AbeVoorhees,PhD,abusinessmanagerforSiemens,sayswhenitsBiographmMRwas
introducedin2011,thefirstinstallationswereallforresearchpurposes.ButSiemensisbeginning
toseemoreadoptionintheclinicalrealm."Fourofthelastfivescannersweinstalledwillhavea
heavyfocus,ifnotexclusive,onclinicalimaging,"Voorheessays.
Atthispoint,StanfordUniversityisusingitsGEwholebodyPET/MRscannerforresearchonly,
saysAndreiIagaru,MD,whopracticesinStanford'sdivisionofnuclearmedicineandmolecular
imaging."Oureffortsarefocusedonidentifyingwhichdiseasesandwhichpatientsaremost
appropriateforPET/MRIandwherewecanuseittoseeearlyifatreatmentisworkingornot.We
arealsomakingprogressdevelopingefficientworkflowsforthevariousindicationsforthePET/MR,"
Iagarusays.
NumerousProjects
Likewise,theUniversityofCalifornia,SanFrancisco(UCSF)isusingitsGEhybridscannerfor
researchonlyatthistime.UCSFhas16researchprojectsinvolvingitsuse,saysSpencerBehr,
MD,anassistantprofessorofclinicalradiology.ThatincludesBehr'sprojectontheuseofPET/MR
forprostatecancer.He'shopingtoshowthatonePET/MRscancouldreplacethemultipletests
(MRoftheprostate,abonescan,andCToftheabdomenforlymphnodes)currentlyneededto
stageprostatecanceranddetermineifit'slocalizedandsurgicallyresectableorasystemicdisease
thatrequiresadifferenttreatmentplan.Theissue,Behrsays,isfindingthetracerthatworksforthe
prostate.FDGisnonfunctionalinpatientswithprostatecancer."Ifwecanfindthatoneagent,you
coulddoonescanandyou'redone,"Behrsays.However,he'snotsure"wherePET/MRisgoing
becausemedicineischangingsofast."
Othershavebeguntousetheirhybridscannerforclinicalapplications.StonyBrookMedicinein
LongIsland,NewYork,wasamongthefirstsitesintheUnitedStatestooffersimultaneous
PET/MRItechnologyforclinicaluse.ItinstalledtheSiemensBiographmMRhybridimagingsystem
initsLisaandRobertLourieImagingSuiteattheStonyBrookUniversityCancerCenterin2013.
MarkSchweitzer,MD,FRCPSC,chiefofdiagnosticimagingandchairofthedepartmentof
radiologyatStonyBrook,believesthejuryisstilloutonwhetherPET/MRIisbetterthanPET/CTfor
stagingandrestagingcancer.It'smoreamatteroftimethananythingelse,hesays."Youneeda
bodyofresearchtoshowyouhowit'sbetterandinwhatsituations,"hesays."That'sthenatural
history.Toexpectotherwiseisnotrealistic.PET/MRIhasonlybeenoutforafewyears,andyou
couldn'texpectustoknowmorethanweknownow."
RadiologistsatClevelandClinicarefindingthattheyareusingtheirPET/MRIresource,whichthey
installedinJuly2013,forclinicalapplicationsmuchmorethantheyanticipated,saysShetalN.
Shah,MD,anabdominalimageranddirectorofitsPET/MRprogram.Tomakeitfinancially
feasible,thedepartmentestimateditneededtodo128PET/MRIscansand600MRIs(without
PET)inthefirstyear.Withinthefirst10months,ithadperformed185PET/MRIscansandcloseto
1,000MRIswithoutPET.ShahisconvincedPET/MRIisnotafadbutamodalitythatisheretostay
whenfullyintegratedintoclinicalcarepaths.ThephysiciansatClevelandClinicarefindingit
particularlyusefulforcancersofthehead,neck,pelvis,rectum,andliverforepilepsycareandin
thepediatricpopulation.
Shahrecallsonepatientwithovariancancerwherehertumormarkerswererisingbutherdoctors
couldfindnometastases.SheunderwentaPET/MRIandsureenoughshehada6cmmassinher
brainthathadnotbeendetectedtodate,hesays.Thefindingwassurprisingbecausethepatient
didnothaveneurologicalsymptomsandovariancancerdoesn'ttypicallymetastasizetothebrain,
Shahsays.

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PET/CTReplacement?
WillPET/MRIeverreplacePET/CT?Shahdoesn'tthinkso."ButthesynergismofMRIandPETcan
offervastlysuperioranatomicdetailandbiologicdatathatareextremelyvaluableinadvanced
evaluationofcancer,particularlywithrespecttosurgicalandradiationplanningaswellasin
assessingtherapyresponse,"headds.LikeBehr,Shahbelievesitwilltakesometime,education,
andexperiencetobuildupusageanduntilphysiciansarecomfortableorderingaPET/MRI."Inthe
meantime,earlyadoptersoughttofocusoncollaboratingtodiscoverrobustapplications,"Shah
says.

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3/1/2016

PET/MRI: Radiologists Are Exploring the Clinical Role of What Is Still Seen Primarily as a Research Tool
Othersaremoreencouragedbytheresultstheyhaveseeninthelasttwoyears.Steven
Mendelsohn,MD,CEOandmedicaldirectorofZwangerPesiri,isperhapsthemostenthusiasticof
PET/MRIusers.ZwangerPesiriacquiredSiemensBiographmMRinNovember2014forits
Lynbrook,NewYork,facility.ZwangerPesiri,whichhasnumerouslocationsonLongIsland,isthe
firstprivateradiologyclinicintheUnitedStatestoacquireaPET/MRI.Mendelsohnbelieves
"PET/MRIisthebiggestgamechangerinradiologyinthelast25years."Hisfacilityadvertisesits
hybridscanneras:"Radiology'sanswertocancer."
AhugeadvantagetoPET/MRoverPET/CTisthatpatientshavemuchlessradiationexposure,
Mendelsohnsays.MRinvolvesnoradiationandthetracerdosewithPET/MRisonehalfwhatitis
withPET/CT."You'resavingpatientsapproximately100chestXrays'worthofradiation,"
Mendelsohnsays.Loweringradiationexposureisahugeconcerninthefieldofradiologythese
days,particularlyforchildrenandwomen,Mendelsohnsays.Manytimescancerpatientsmust
undergorepeatstudies,andbeingabletodosowithlessradiationcouldbeakeytotheirlongterm
survival,hesays.
Patientconvenienceisanotheradvantage,Mendelsohnsays.WithSiemensBiographmMR,it
takesabout45minutestoacquireawholebodyPET/MRI.That'sfareasierforpatientsthanhaving
togoforaPETscanandMRseparatelyandfarlesstimeconsuming.Butperhapsthemost
importantadvantage,Mendelsohnsays,isthesuperiorinformationthatcanbeacquiredduringa
PET/MRstudy."It'sprofoundlyscaryhowmuchmetastaticdiseasewe'repickinguponthis
machine,"Mendelsohnsays.APET/MRstudycanfindmetastases,especiallyinthebrain,that
wouldnototherwisebedetecteduntiltheygrewlargerandsymptomatic,hesays.
Mendelsohn'stheoryisthataPET/MRmayprovetobetheonlystudyanoncologypatientneedsin
manycases."Mycontentionisthisonetestwillreplaceahugenumberoftestsandcondensethe
wholeworkupintoonevisitandyouwillgettheansweryou'relookingfor80%to90%ofthetime,
savingpatientsweeksofanxietycomingbackandforthforadditionaltesting,additionaltesting,"he
says.Also,Mendelsohnsays,detectingcancerearlierbeforeitissymptomaticmeanstreatment
canbepreemptiveand,perhaps,moresuccessful.Eventually,Mendelsohnexpectstohave
enoughcasestobeabletopublishthecenter'sresults,butitsradiologistshavefoundtheyhavenot
neededtosuggestafollowupstudyinanypatientswhohaveundergoneaPET/MRforcancer
stagingorrestaging.

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PossibleWeakness
TheoneapplicationwhereMendelsohnseesaslightweaknessofthehybridmodalityisforlung
nodules."Ifthenodulesaresmallerthan5mm,theFDGisnotparticularlygood,"hesays."We
mightmisstinylungnodulesonPET/MR."Currently,thosepatientswouldneedaPET/CTscan.
However,MendelsohnisoptimisticthatSiemenscansolvethisweakness."Siemenshasa
phenomenalbreathholdsequencethatoverthenextfewmonthsorayearcouldmigratetoits
PET/MRplatformandshowtinypulmonarynodules,"headds.
ShahagreesthatadvancedtoolsandanadjustablefieldofviewonPET/MRIcanbeoftremendous
valueinassessingsmallvolumeandnodaldiseaseincancerpatients,oftenalimitationwith
PET/CT.
Voorheessaysthatthere'snodoubtthequalityofthePET/MRscanisenablingclinicianswhouse
itto"calltheircaseswithgreaterconfidence."
PET/MRisalsoprovingusefulincardiacimagingandneurologicalimaging.Muchoftheworkisstill
intheresearchphase,butradiologistsarelookingatPET/MRasthebestmodalityforexamining
heartwallmotionandbloodperfusion.Italsoshowspotentialfordetectingabroadrangeofcentral
nervoussystemconditionsincludingAlzheimer'sdisease.Mendelsohnsayshisradiologistsare
verycomfortablewithcardiacPET/MRanduseitwhereappropriate.Schweitzersaysusing
PET/MRtodeterminemyocardialviabilityisonStonyBrook'sradarforlaterthisyear.Behrsaysthe
cardiacsurgeonsandneurologistsatUCSFareexcitedaboutthepossibilitiesofPET/MR"because
theyseeithasthepotentialtochangethewaywetreatpatients."
MultipleReaders
AsPET/MRmakesinroadsinclinicalsettings,someissuesremaintoberesolved.Whoreadsthe
hybridstudies?Whatwillinsurancecompaniesreimburseforthem?Iagaruthinksthishybrid
modalityaddsalevelofcomplexitytointerpretingexams."WewillneedoneMRspecialistandone
PETspecialistforthespecificindicationoftheexam(eg,neuro,cardiac,MSK,pediatric),"Iagaru
says.AtZwangerPesiri,everyPET/MRscanisreadbyatleastthreeradiologists,each
specializingamodalityordisciplinepertinenttotheexam,andittakesatleastthreehoursof
aggregatedtime."IwishIcouldtellyouthatonepersoniscapableofreadingallthosemodalities,
butIcan't,"Mendelsonsays.Admittedly,Mendelsohnsays,havingthree,andsometimesfour,
readersforeachexamistimeconsumingandnotcosteffective,especiallygiventhatinsurance
doesnotreimburseaccordingly.Thefacilitybillsthepatient'sinsurerforthePETandtheMRI,but
mayonlybereimbursedforoneortheotherdependingonwhichstudyorstudiesthepatientwas
authorizedtohave."ItiseconomicsuicidegettingpaidthesameasaPETscaninmostcases,"
Mendelsohnsays.Hisjob,headds,istoconvincephysiciansandinsurancecompaniesthatit's
betterandmoreeconomicaltoorderthisoneexamthanseveralinsequence.And,hebelieves,
thatdaywillbehereeventually.
MendelsohnremembersthatwhenMRImachinesfirstcameonthemarketinthelate'80sandearly
'90s,itwasachallengetogettheminuse.PET/MRisnodifferent,hesays.Still,hebelieves,that
withinfiveto10years,PET/MRwillbecomethegoldstandard."Peoplewillknowaboutit,"hesays.
"Therewillbeenoughpublications,anditwillbeanobrainertoorderaPET/MRvsaPET/CTand
savepatientsexposuretoradiation,especiallyyoungstersinneedofPETscans."
BethW.OrensteinisafreelancewriterbasedinNorthampton,Pennsylvania.Sheisafrequent
contributortoRadiologyToday.

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