MR-based attenuation correction methods for clinical PET/MR brain imaging
My research interest lies in the application of machine learning for attenuation correction methods in combined Positron Emission Tomography (PET) and Magnetic Resonance Imaging (MRI) for brain imaging.
Attenuation correction is an important challenge in combined PET/MRI.
Bone structures, which are prominent in the anatomy of the human head, contribute significantly to the attenuation of the PET photons.
Their accurate identification is therefore essential for quantitative brain PET imaging.
However, bone is invisible in conventional MRI sequences.
Several MR-based attenuation correction methods have been published for PET/MR brain imaging.
This project studies the effect of MR-based attenuation correction methods using data acquired on a combined PET/MRI scanner, the Siemens BrainPET.
Journal of Nuclear Medicine, 54(10):1768-1774, 2013 (article)
Hybrid PET/MR systems have recently entered clinical practice. Thus, the accuracy of MR-based attenuation correction in simultaneously acquired data can now be investigated. We assessed the accuracy of 4 methods of MR-based attenuation correction in lesions within soft tissue, bone, and MR susceptibility artifacts: 2 segmentation-based methods (SEG1, provided by the manufacturer, and SEG2, a method with atlas-based susceptibility artifact correction); an atlas- and pattern recognition–based method (AT&PR), which also used artifact correction; and a new method combining AT&PR and SEG2 (SEG2wBONE). Methods: Attenuation maps were calculated for the PET/MR datasets of 10 patients acquired on a whole-body PET/MR system, allowing for simultaneous acquisition of PET and MR data. Eighty percent iso-contour volumes of interest were placed on lesions in soft tissue (n = 21), in bone (n = 20), near bone (n = 19), and within or near MR susceptibility artifacts (n = 9). Relative mean volume-of-interest differences were calculated with CT-based attenuation correction as a reference. Results: For soft-tissue lesions, none of the methods revealed a significant difference in PET standardized uptake value relative to CT-based attenuation correction (SEG1, −2.6% ± 5.8%; SEG2, −1.6% ± 4.9%; AT&PR, −4.7% ± 6.5%; SEG2wBONE, 0.2% ± 5.3%). For bone lesions, underestimation of PET standardized uptake values was found for all methods, with minimized error for the atlas-based approaches (SEG1, −16.1% ± 9.7%; SEG2, −11.0% ± 6.7%; AT&PR, −6.6% ± 5.0%; SEG2wBONE, −4.7% ± 4.4%). For lesions near bone, underestimations of lower magnitude were observed (SEG1, −12.0% ± 7.4%; SEG2, −9.2% ± 6.5%; AT&PR, −4.6% ± 7.8%; SEG2wBONE, −4.2% ± 6.2%). For lesions affected by MR susceptibility artifacts, quantification errors could be reduced using the atlas-based artifact correction (SEG1, −54.0% ± 38.4%; SEG2, −15.0% ± 12.2%; AT&PR, −4.1% ± 11.2%; SEG2wBONE, 0.6% ± 11.1%). Conclusion: For soft-tissue lesions, none of the evaluated methods showed statistically significant errors. For bone lesions, significant underestimations of −16% and −11% occurred for methods in which bone tissue was ignored (SEG1 and SEG2). In the present attenuation correction schemes, uncorrected MR susceptibility artifacts typically result in reduced attenuation values, potentially leading to highly reduced PET standardized uptake values, rendering lesions indistinguishable from background. While AT&PR and SEG2wBONE show accurate results in both soft tissue and bone, SEG2wBONE uses a two-step approach for tissue classification, which increases the robustness of prediction and can be applied retrospectively if more precision in bone areas is needed.
PURPOSE: Our objective was a multifunctional imaging approach of chronic sclerodermatous graft-versus-host disease (ScGVHD) and its course during therapy using PET/MRI.
METHODS: We performed partial-body PET/CT and PET/MRI of the calf in 6 consecutively recruited patients presenting with severe ScGVHD. The patients were treated with different immunosuppressive regimens and supportive therapies. PET/CT scanning started 60.5 +/- 3.3 minutes, PET/MRI imaging 139.5 +/- 16.7 minutes after F-FDG application. MRI acquisition included T1- (precontrast and postcontrast) and T2-weighted sequences. SUVmean, T1 contrast enhancement, and T2 signal intensity from region-of-interest analysis were calculated for different fascial and muscular compartments. In addition, musculoskeletal MRI findings and the modified Rodnan skin score were assessed. All patients underwent imaging follow-up.
RESULTS: At baseline PET/MRI, ScGVHD-related musculoskeletal abnormalities consisted of increased signal and/or thickening of involved anatomical structures on T2-weighted and T1 postcontrast images as well as an increased FDG uptake. At follow-up, ScGVHD-related imaging findings decreased (SUVmean n = 4, mean T1 contrast enhancement n = 5, mean T2 signal intensity n = 3) or progressed (SUVmean n = 3, mean T1 contrast enhancement n = 2, mean T2 signal intensity n = 4). Clinically modified Rodnan skin score improved for 5 follow-ups and progressed for 2. SUVmean values correlated between PET/CT and PET/MRI acquisition (r = 0.660, P = 0.014), T1 contrast enhancement, and T2 signal (r = 0.668, P = 0.012), but not between the SUVmean values and the MRI parameters.
CONCLUSIONS: PET/MRI as a combined morphological and functional technique seems to assess the inflammatory processes from different points of view and provides therefore in part complementary information
Schmidt, H., Schwenzer, N., Bezrukov, I., Kolb, A., Mantlik, F., Kupferschläger, J., Lois, C., Sauter, A., Brendle, C., Pfannenberg, C., Pichler, B.
2011(J2-8), 2011 IEEE Nuclear Science Symposium, Medical Imaging Conference (NSS-MIC), October 2011 (talk)
First clinical fully integrated whole-body PET/MR scanners are just entering the field. Here, we present studies toward quantification accuracy and variation within the PET field of view of small lesions from our BrainPET/MRI, a dedicated clinical brain scanner which was installed three years ago in Tbingen. Also, we present first results for patient and phantom scans of a fully integral whole-body PET/MRI, which was installed two months ago at our department. The quantification accuracy and homogeneity of the BrainPET-Insert (Siemens Medical Solutions, Germany) installed inside the magnet bore of a clinical 3T MRI scanner (Magnetom TIM Trio, Siemens Medical Solutions, Germany) was evaluated by using eight hollow spheres with inner diameters from 3.95 to 7.86 mm placed at different positions inside a homogeneous cylinder phantom with an 9:1 and 6:1 sphere to background ratio. The quantification accuracy for small lesions at different positions in the PET FoV shows a standard deviation of up to 11% and is acceptable for quantitative brain studies where the homogeneity of quantification on the entire FoV is essental. Image quality and resolution of the new Siemens whole-body PET/MR system (Biograph mMR, Siemens Medical Solutions, Germany) was evaluated according to the NEMA NU2 2007 protocol using a body phantom containing six spheres with inner diameter from 10 to 37 mm at sphere to background ratios of 8:1 and 4:1 and the F-18 point sources located at different positions inside the PET FoV, respectively. The evaluation of the whole-body PET/MR system reveals a good PET image quality and resolution comparable to state-of-the-art clinical PET/CT scanners. First images of patient studies carried out at the whole-body PET/MR are presented highlighting the potency of combined PET/MR imaging.
2011(MIC18.M-96), 2011 IEEE Nuclear Science Symposium, Medical Imaging Conference (NSS-MIC), October 2011 (poster)
Combined PET/MR provides simultaneous molecular and functional information in an anatomical context with unique soft tissue contrast. However, PET/MR does not support direct derivation of attenuation maps of objects and tissues within the measured PET field-of-view. Valid attenuation maps are required for quantitative PET imaging, specifically for scientific brain studies. Therefore, several methods have been proposed for MR-based attenuation correction (MR-AC). Last year, we performed an evaluation of different MR-AC methods, including simple MR thresholding, atlas- and machine learning-based MR-AC. CT-based AC served as gold standard reference. RoIs from 2 anatomic brain atlases with different levels of detail were used for evaluation of correction accuracy. We now extend our evaluation of different MR-AC methods by using an enlarged dataset of 23 patients from the integrated BrainPET/MR (Siemens Healthcare). Further, we analyze options for improving the MR-AC performance in terms of speed and accuracy. Finally, we assess the impact of ignoring BrainPET positioning aids during the course of MR-AC. This extended study confirms the overall prediction accuracy evaluation results of the first evaluation in a larger patient population. Removing datasets affected by metal artifacts from the Atlas-Patch database helped to improve prediction accuracy, although the size of the database was reduced by one half. Significant improvement in prediction speed can be gained at a cost of only slightly reduced accuracy, while further optimizations are still possible.
2011(MIC18.M-116), 2011 IEEE Nuclear Science Symposium, Medical Imaging Conference (NSS-MIC), October 2011 (poster)
With the recent availability of clinical whole-body PET/MRI it is possible to evaluate and further develop MR-based attenuation correction methods using simultaneously acquired PET/MR data. We present first results for MRAC on patient data acquired on a fully integrated whole-body PET/MRI (Biograph mMR, Siemens) using our method that applies atlas registration and pattern recognition (ATPR) and compare them to the segmentation-based (SEG) method provided by the manufacturer.
The ATPR method makes use of a database of previously aligned pairs of MR-CT volumes to predict attenuation values on a continuous scale. The robustness of the method in presence of MR artifacts was improved by location and size based detection. Lesion to liver and lesion to blood ratios (LLR and LBR) were compared for both methods on 29 iso-contour ROIs in 4 patients.
ATPR showed >20% higher LBR and LLR for ROIs in and >7% near osseous tissue. For ROIs in soft tissue, both methods yielded similar ratios with max. differences <6% . For ROIs located within metal artifacts in the MR image, ATPR showed >190% higher LLR and LBR than SEG, where ratios <0.1 occured. For lesions in the neighborhood of artifacts, both ratios were >15% higher for ATPR.
If artifacts in MR volumes caused by metal implants are not accounted for in the computation of attenuation maps, they can lead to a strong decrease of lesion to background ratios, even to disappearance of hot spots. Metal implants are likely to occur in the patient collective receiving combined PET/MR scans, of our first 10 patients, 3 had metal implants. Our method is currently able to account for artifacts in the pelvis caused by prostheses. The ability of the ATPR method to account for bone leads to a significant increase of LLR and LBR in osseous tissue, which supports our previous evaluations with combined PET/CT and PET/MR data. For lesions within soft tissue, lesion to background ratios of ATPR and SEG were comparable.
Wagenknecht, G., Rota Kops, E., Mantlik, F., Fried, E., Pilz, T., Hautzel, H., Tellmann, L., Pichler, B., Herzog, H.
In pages: 2261-2266 , IEEE, Piscataway, NJ, USA, IEEE Nuclear Science Symposium and Medical Imaging Conference (NSS/MIC), October 2011 (inproceedings)
Our method for attenuation correction (AC) in MR-BrainPET with segmented T1-weighted MR images of the pa-tient's head was applied to data from different MR-BrainPET scanners (Jülich, Tübingen) and compared to CT-based results. The study objectives presented in this paper are twofold. The first objective is to examine if the segmentation method developed for and successfully applied to 3D MP-RAGE data can also be used to segment other T1-weighted MR data such as 3D FLASH data. The second aim is to show if the similarity of segmented MR-based (SBA) and CT-based AC (CBA) obtained at HR+ PET can also be confirmed for BrainPET for which the new AC method is intended for. In order to reach the first objective, 14 segmented MR data sets (three 3D MP-RAGE data sets from Jülich and eleven 3D FLASH data sets from Tubingen) were compared to the resp. CT data based on the Dice coefficient and scatter plots. For bone, a CT threshold HU>;500 was applied. Dice coefficients (mean±std) for the upper cranial part of the skull, the skull above cavities, and in the caudal part including the cerebellum are 0.73±0.1, 0.79±0.04, and 0.49±0.02 for the Jülich data and 0.7U0.1, 0.72±0.1, and 0.60±0.05 for the Tubingen data. To reach the second aim, SBA and CBA were compared for six subjects based on VOI (AAL atlas) analysis. Mean absolute relative difference (maRD) values are maRD(JUFVBWl-FDG): 0.99%±0.83%, maRD(JüFVBW2-FDG): 0.90%±0.89%, and maRD(JUEP-Fluma- zenil): 1.85%±1.25% for the Jülich data and maRD(TuTP02- FDG): 2.99%±1.65%, maRD(TuNP01-FDG): 5.37%±2.29%, and maRD(TuNP02-FDG): 6.52%±1.69% for the three best-segmented Tübingen data sets. The results show similar segmentation quality for both Tl- weighted MR sequence types. The application to AC in BrainPET - hows a high similarity to CT-based AC if the standardized ACF value for bone used in SBA is in good accordance to the bone density of the patient in question.
Journal of Nuclear Medicine, 52(9):1392-1399, September 2011 (article)
PET/MRI is an emerging dual-modality imaging technology that requires new approaches to PET attenuation correction (AC). We assessed 2 algorithms for whole-body MRI-based AC (MRAC): a basic MR image segmentation algorithm and a method based on atlas registration and pattern recognition (AT&PR).
Eleven patients each underwent a whole-body PET/CT study and a separate multibed whole-body MRI study. The MR image segmentation algorithm uses a combination of image thresholds, Dixon fat-water segmentation, and component analysis to detect the lungs. MR images are segmented into 5 tissue classes (not including bone), and each class is assigned a default linear attenuation value. The AT&PR algorithm uses a database of previously aligned pairs of MRI/CT image volumes. For each patient, these pairs are registered to the patient MRI volume, and machine-learning techniques are used to predict attenuation values on a continuous scale. MRAC methods are compared via the quantitative analysis of AC PET images using volumes of interest in normal organs and on lesions. We assume the PET/CT values after CT-based AC to be the reference standard.
In regions of normal physiologic uptake, the average error of the mean standardized uptake value was 14.1% ± 10.2% and 7.7% ± 8.4% for the segmentation and the AT&PR methods, respectively. Lesion-based errors were 7.5% ± 7.9% for the segmentation method and 5.7% ± 4.7% for the AT&PR method.
The MRAC method using AT&PR provided better overall PET quantification accuracy than the basic MR image segmentation approach. This better quantification was due to the significantly reduced volume of errors made regarding volumes of interest within or near bones and the slightly reduced volume of errors made regarding areas outside the lungs.
Sauter, A., Schmidt, H., Gueckel, B., Brendle, C., Bezrukov, I., Mantlik, F., Kolb, A., Mueller, M., Reimold, M., Federmann, B., Hetzel, J., Claussen, C., Pfannenberg, C., Horger, M., Pichler, B., Schwenzer, N.
(T110), 2011 World Molecular Imaging Congress (WMIC), September 2011 (talk)
Hybrid imaging modalities such as [18F]FDG-PET/CT are superior in staging of e.g. lung cancer disease compared with stand-alone modalities. Clinical PET/MRI systems are about to enter the field of hybrid imaging and offer potential advantages. One added value could be a deeper insight into the tumor metabolism and tumorigenesis due to the combination of PET and dedicated MR methods such as MRS and DWI. Additionally, therapy monitoring of diffucult to diagnose disease such as chronic sclerodermic GvHD (csGvHD) can potentially be improved by this combination. We have applied PET/MRI in 3 patients with lung cancer and 4 patients with csGvHD before and during therapy. All 3 patients had lung cancer confirmed by histology (2 adenocarcinoma, 1 carcinoid). First, a [18F]FDG-PET/CT was performed with the following parameters: injected dose 351.7±25.1 MBq, uptake time 59.0±2.6 min, 3 min/bed. Subsequently, patients were brought to the PET/MRI imaging facility. The whole-body PET/MRI Biograph mMR system comprises 56 detector cassettes with a 59.4 cm transaxial and 25.8 cm axial FoV. The MRI is a modified Verio system with a magnet bore of 60 cm. The following parameters for PET acquisition were applied: uptake time 121.3±2.3 min, 3 bed positions, 6 min/bed. T1w, T2w, and DWI MR images were recorded simultaneously for each bed. Acquired PET data were reconstructed with an iterative 3D OSEM algorithm using 3 iterations and 21 subsets, Gaussian filter of 3 mm. The 4 patients with GvHD were brought to the brainPET/MRI imaging facility 2:10h-2:28h after tracer injection. A 9 min brainPET-acquisition with simultaneous MRI of the lower extremities was accomplished. MRI examination included T1-weighted (pre and post gadolinium) and T2-weighted sequences. Attenuation correction was calculated based on manual bone segmentation and thresholds for soft tissue, fat and air. Soleus muscle (m), crural fascia (f1) and posterior crural intermuscular septum fascia (f2) were surrounded with ROIs based on the pre-treatment T1-weighted images and coregistered using IRW (Siemens). Fascia-to-muscle ratios for PET (f/m), T1 contrast uptake (T1_post-contrast_f-pre-contrast_f/post-contrast_m-pre-contrast_m) and T2 (T2_f/m) were calculated. Both patients with adenocarcinoma show a lower ADC value compared with the carcinoid patient suggesting a higher cellularity. This is also reflected in FDG-PET with higher SUV values. Our initial results reveal that PET/MRI can provide complementary information for a profound tumor characterization and therapy monitoring. The high soft tissue contrast provided by MRI is valuable for the assessment of the fascial inflammation. While in the first patient FDG and contrast uptake as well as edema, represented by T2 signals, decreased with ongoing therapy, all parameters remained comparatively stable in the second patient. Contrary to expectations, an increase in FDG uptake of patient 3 and 4 was accompanied by an increase of the T2 signals, but a decrease in contrast uptake. These initial results suggest that PET/MRI provides complementary information of the complex disease mechanisms in fibrosing disorders.
European Journal of Nuclear Medicine and Molecular Imaging, 38(5):920-929, May 2011 (article)
Clinical PET/MR requires the use of patient positioning aids to immobilize and support patients for the duration of the combined examination. Ancillary immobilization devices contribute to overall attenuation of the PET signal, but are not detected with conventional MR sequences and, hence, are ignored in standard MR-based attenuation correction (MR-AC). We report on the quantitative effect of not accounting for the attenuation of patient positioning aids in combined PET/MR imaging.
We used phantom and patient data acquired with positioning aids on a PET/CT scanner (Biograph 16, HI-REZ) to mimic PET/MR imaging conditions. Reference CT-based attenuation maps were generated from measured (original) CT transmission images (origCT-AC). We also created MR-like attenuation maps by following the same conversion procedure of the attenuation values except for the prior delineation and subtraction of the positioning aids from the CT images (modCT-AC). First, a uniform 68Ge cylinder was positioned centrally in the PET/CT scanner and fixed with a vacuum mattress (10 cm thick) and, in a repeat examination, with MR positioning foam pads. Second, 16 patient datasets were selected for subsequent processing. All patients were regionally immobilized with positioning aids: a vacuum mattress for head/neck imaging (nine patients) and a foam mattress for imaging of the lower extremities (seven patients). PET images were reconstructed following CT-based attenuation and scatter correction using the original and modified (MR-like) CT images: PETorigCT-AC and PETmodCT-AC, respectively. PET images following origCT-AC and modCT-AC were compared visually and in terms of mean differences of voxels with a standardized uptake value of at least 1.0. In addition, we report maximum activity concentration in lesions for selected patients.
In the phantom study employing the vacuum mattress the average voxel activity in PETmodCT-AC was underestimated by 6.4% compared to PETorigCT-AC, with 3.4% of the PET voxels being underestimated by 10% or more. When the MR foam pads were not accounted for during AC, PETmodCT-AC was underestimated by 1.1% on average, with none of the PET voxels being underestimated by 10% or more. Evaluation of the head/neck patient data showed a decrease of 8.4% ([68Ga]DOTATOC) and 7.4% ([18F]FDG) when patient positioning aids were not accounted for during AC, while the corresponding decrease was insignificant for the lower extremities.
Depending on the size and density of the positioning aids used, a regionally variable underestimation of PET activity following AC is observed when positioning aids are not accounted for. This underestimation may become relevant in combined PET/MR imaging of patients with neuropsychiatric indications, but appears to be of no clinical relevance in imaging the extremities.
2010(M08-4), 2010 Nuclear Science Symposium and Medical Imaging Conference (NSS-MIC), November 2010 (talk)
Combined PET/MR provides at the same time molecular and functional imaging as well as excellent soft tissue contrast. It does not allow one to directly measure the attenuation properties of scanned tissues, despite the fact that accurate attenuation maps are necessary for quantitative PET imaging. Several methods have therefore been proposed for MR-based attenuation correction (MR-AC). So far, they have only been evaluated on data acquired from separate MR and PET scanners. We evaluated several MR-AC methods on data from 10 patients acquired on a combined BrainPET/MR scanner. This allowed the consideration of specific PET/MR issues, such as the RF coil that attenuates and scatters 511 keV gammas. We evaluated simple MR thresholding methods as well as atlas and machine learning-based MR-AC. CT-based AC served as gold standard reference. To comprehensively evaluate the MR-AC accuracy, we used RoIs from 2 anatomic brain atlases with different levels of detail.
Visual inspection of the PET images indicated that even the basic FLASH threshold MR-AC may be sufficient for several applications. Using a UTE sequence for bone prediction in MR-based thresholding occasionally led to false prediction of bone tissue inside the brain, causing a significant overestimation of PET activity. Although it yielded a lower mean underestimation of activity, it exhibited the highest variance of all methods. The atlas averaging approach had a smaller mean error, but showed high maximum overestimation on the RoIs of the more detailed atlas. The Nave Bayes and Atlas-Patch MR-AC yielded the smallest variance, and the Atlas-Patch also showed the smallest mean error.
In conclusion, Atlas-based AC using only MR information on the BrainPET/MR yields a high level of accuracy that is sufficient for clinical quantitative imaging requirements. The Atlas-Patch approach was superior to alternative atlas-based methods, yielding a quantification error below 10% for all RoIs except very small ones.
Journal of Nuclear Medicine, 51(Supplement 2):1418 , June 2010 (poster)
Objectives: We study the quantitative effect of not accounting for the attenuation of patient positioning aids in combined PET/MR imaging.
Methods: Positioning aids cannot be detected with conventional MR sequences. We mimic this effect using PET/CT data (Biograph HiRez16) with the foams removed from CT images prior to using them for CT-AC. PET/CT data were acquired using standard parameters (phantoms/patients): 120/140 kVp, 30/250 mAs, 5 mm slices, OSEM (4i, 8s, 5 mm filter) following CT-AC. First, a uniform 68Ge-cylinder was positioned centrally in the PET/CT and fixed with a vacuum mattress (10 cm thick). Second, the same cylinder was placed in 3 positioning aids from the PET/MR (BrainPET-3T). Third, 5 head/neck patients who were fixed in a vacuum mattress were selected. In all 3 studies PET recon post CT-AC based on measured CT images was used as the reference (mCT-AC). The PET/MR set-up was mimicked by segmenting the foam inserts from the measured CT images and setting their voxel values to -1000 HU (air). PET images were reconstructed using CT-AC with the segmented CT images (sCT-AC). PET images with mCT- and sCT-AC were compared.
Results: sCT-AC underestimated PET voxel values in the phantom by 6.7% on average compared to mCT-AC with the vacuum mattress in place. 5% of the PET voxels were underestimated by >=10%. Not accounting for MR positioning aids during AC led to an underestimation of 2.8% following sCT-AC, with 5% of the PET voxels being underestimated by >=7% wrt mCT-AC. Preliminary evaluation of the patient data indicates a slightly higher bias from not accounting for patient positioning aids (mean: -9.1%, 5% percentile: -11.2%).
Conclusions: A considerable and regionally variable underestimation of the PET activity following AC is observed when positioning aids are not accounted for. This bias may become relevant in neurological activation or dementia studies with PET/MR
Sauter, A., Horger, M., Boss, A., Kolb, A., Mantlik, F., Kanz, L., Pfannenberg, C., Stegger, L., Claussen, C., Pichler, B.
Journal of Nuclear Medicine, 51(Supplement 2):1001 , June 2010 (poster)
Objectives: The study purpose is the evaluation of patients, suffering from hemato-oncological disease with complications at the lower extremities, using simultaneous PET/MRI.
Methods: Until now two patients (chronic active graft-versus-host-disease [GvHD], B-non Hodgkin lymphoma [B-NHL]) before and after therapy were examined in a 3-Tesla-BrainPET/MRI hybrid system following
F-18-FDG-PET/CT. Simultaneous static PET (1200 sec.) and MRI scans (T1WI, T2WI, post-CA) were acquired.
Results: Initial results show the feasibility of using hybrid PET/MRI-technology for musculoskeletal imaging of the lower extremities. Simultaneous PET and MRI could be acquired in diagnostic quality.
Before treatment our patient with GvHD had a high fascia and muscle FDG uptake, possibly due to muscle encasement. T2WI and post gadolinium T1WI revealed a fascial thickening and signs of inflammation.
After therapy with steroids followed by imatinib the patients symptoms improved while, the muscular FDG uptake droped whereas the MRI signal remained unchanged. We assume that fascial elasticity improved
during therapy despite persistance of fascial thickening. The examination of the second patient with B-NHL manifestation in the tibia showed a significant signal and uptake decrease in the bone marrow and
surrounding lesions in both, MRI and PET after therapy with rituximab. The lack of residual FDG-uptake proved superior to MRI information alone helping for exclusion of vital tumor.
Conclusions: Combined PET/MRI is a powerful tool to monitor diseases requiring high soft tissue contrast along with molecular information from the FDG uptake.
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