PET/MR Strategic Plan for SNMMI
Introduction
During the 2011 PET Center of Excellence Board of Directors retreat, it was agreed that
the center should create a PET/MR Task Force in order to prepare the SNMMI members
for the future. This task force, was charged with developing a comprehensive PET/MR
Strategic Plan that should include all aspects that the Society must focus on for the
implementation of PET/MR into everyday practice.
Subsequently, PET/MR was announced as one of the banner issues for the Society.
Banner issues are priority points for the society and are intended to provide focus on
various efforts within the organization.
The information below is an overview of the various initiatives proposed by the PET
Center of Excellence to develop content, provide education and ensure that the
membership and field are prepared for the implementation of PET/MR into everyday
nuclear medicine and molecular imaging.
PET/MR Task Force Members:
Chair: Heiko Schoder, MD
Otto Hoekstra, MD, PhD
Hossein Jadvar, MD, PhD, MPH, MBA, FACNM
Ryan Niederkohr, MD
J. Anthony Parker, MD, PhD – Education Committee Chair
Lalitha Ramanna, MD, FACNM – Correlative Imaging Council Representative
Ruth Tesar, CNMT
Katherine Zukotynski, MD
Timeline
The PET CoE would like to implement the complete plan below within the next year and
a half (January 2014).
Market Analysis
As of spring 2012, there are currently two hybrid PET/MR machines available in the
United States; the Siemens Healthcare Biograph mMR (approved by the FDA in June
2011) and the Philips Ingenuity TF System (approved by the FDA in November 2011). In
addition, General Electric (GE) has a GE PET/CT + MRI machine that works to combine
data only (not integrated equipment).
Currently there are 2,085 sites performing PET imaging studies in the United States . Of
the 2,085 sites, 300 or 14% anticipate acquiring (through purchase or otherwise) PET
systems over the next three years – inclusive of PET/CT, PET and PET/MR. This data,
from IMV PET Market Analysis 2011, shows a significant decrease from the 2008 IMV
PET Market Analysis which indicated 22% of sites would be purchasing PET imaging
systems. (pg.94) In addition, “if all sites that are currently planning to use PET/MR do so,
4% of the fixed PET/CT sites, 2% of the fixed PET sites, and 4% of the mobile users,”
will be utilizing PET/MR technology by 2014. (IV-31) (IMV - 2011 PET Imaging Market
Summary Report)
In a February 29, 2012 Diagnostic Imaging article, it was reported that in a survey
conducted summer 2011 amongst readers, “21 percent said they planned to purchase a
PET/MR machine in the next six to 12 months, and 24 percent said that purchasing would
depend on reimbursement. Another 16 percent planned to wait and see, while 38 percent
had no purchase plans” (Diagnostic Imaging – February 29, 2012).
Existing/Planned PET/MR Education
Various special interest groups within SNMMI are currently working on programs
and/or initiatives with regard to PET/MR or MRI education. Below is a summary of the
previously held educational programs and the upcoming planned programs for 2013.
Previously held in 2012…
The following continuing education courses were held during the 2012 Mid-Winter
Meeting. If approved by the speaker, the slides from the various presentations are now
available online.
 Clinical Evaluation and Overview of Alzheimer's Disease
 MRI Correlative Imaging for the nuclear medicine physician
 Advances in Neuroimaging
 Basic MRI Anatomy 101
 How to image scar, hibernation and viability with echo and MRI
Webinar - Magnetic Resonance Imaging and Spectroscopy, Including MR Contrast
Agents and fMRI (Speaker: Drew Torigian) – now available on demand. The purpose of
this webinar is to provide basic information about MRI, common MRI sequences
including MRS and fMRI, and MR contrast agents with regards to how they work and
how they can be used practically in the clinical setting for human use. The emphasis will
primarily be on clinical knowledge, and the intended audience is anyone with a desire to
learn about MRI (in particular, nuclear medicine residents, radiology residents, and other
professionals). Attendees will learn about the fundamentals of MRI that can be used as a
starting point for future study and for purposes of practical application, whether for
research or clinical purposes in humans. It is expected that this webinar presentation will
enable attendees to become familiar with the basics of MRI and lead to an improvement
in diagnostic performance and patient outcomes.
The following continuing education sessions were held during the 2012 Annual Meeting
and are now available on-demand through the SNMMI Virtual Meeting.
 PET/MRI: Defining Potential Clinical Applications
 RWE: Multimodality SPECT, PET, CT, and CMR
 Multimodality Breast Imaging
 GI Tumors and Metastases: MRI, Multiphasic Spiral CT, and PET/CT
 Correlation of Anatomical and Functional Imaging in Skeletal Malignancy
 A106/107 Hybrid Nuclear-Magnetic Resonance Imaging Technologies




Advanced Hybrid Imaging in Pediatrics - Neurologic and Musculoskeletal
PET Boot Camp: Mind, Body, and Spirit
Advances in Molecular Neuroimaging: From Bench to Bedside, FDG and Beyond
Update in Cardiovascular Molecular Imaging: Part I: Emerging Technology,
Applications and Controversies in Cardiovascular Molecular Imaging. Part II:
Emerging Concepts in Cardiovascular Perfusion and Molecular Imaging
Coming in 2013…
The PET Center of Excellence in conjunction with the Center for Molecular Imaging
Innovation and Translation (CMIIT) will be hosting a PET/MR Symposium during the
2013 Mid-Winter Meeting in New Orleans, LA. The symposium is entitled “A Different
Spin on Nuclear Imaging: The Role of PET/MRI in Molecular Imaging” and will be held
on Thursday, January 24, 2013. The purpose of the session is to provide a review of the
issues related to PET/MRI technology including brief primers on physics and
instrumentation, emerging dual imaging biomarkers, and potential clinical applications in
neurologic, cardiovascular, oncologic, and musculoskeletal disorders.
Learning Objectives:
1. Recognize the fundamentals of MR physics relevant to PET/MRI imaging.
2. Identify the basic principles of MR data acquisition protocols.
3. Describe current MR imaging applications in relationship to disease
presentations.
4. Identify advantages of MRI and its complementary role in diagnostic imaging.
5. Discuss the molecular imaging agents that may be associated with PET/MRI.
6. Discuss the benefits and challenges of combined PET/MRI.
7. Recognize clinical conditions that may benefit most from combined
PET/MRI.
In addition, the Correlative Imaging Council (CIC) will be hosting a 2.5 hour / 30 case
MR Workshop & Review during the 2013 Mid-Winter Meeting. Title of session: MR
case based review of anatomy (Moderator/ organizer: Claudia G. Berman, MD - Content
category & Modality: MRI – Neurology, Oncology). Description of course: PET/MR is
becoming an important new technology and advancement in Nuclear Medicine and
Molecular Imaging. Nuclear Medicine professionals (physicians and technologists) need
basic training in how to perform technically adequate MR studies/ sequences, how to
evaluate studies for normal findings and pathologies and how to interpret and
communicate results. Two expert MR readers will present a total of 30 cases over a 3
hour session. The MR imaging parameters will be reviewed and explained. The basic
anatomy and pathologic findings will be reviewed. A question for each case will be
discussed with participants and SAM’s questions will be offered.
Learning objectives/outcomes:
1. The participants will understand the basic MR sequences that will be useful in
PET/MR.
2. The enhanced anatomy seen with MR in different parts of the body will be
reviewed.
3. The participants will be exposed to the MR appearance of common
pathologies.
4. The relative advantages and disadvantages of MR imaging with reference to
different parts of the body will be discussed.
Lastly, the PET Center of Excellence, Brain Imaging Council and Correlative Imaging
Council will be proposing PET/MR sessions for the 2013 Annual Meeting. The final
educational program has not been determined.
MRI Education Proposal
The Correlative Imaging Council developed a 5- year MRI education program plan that
would incorporate didactic and case-based MRI education. The proposed plan would
include 200 didactic hours of MRI physics and related topics and a total of 1500 MRI
case reviews; (300/year for 5 years). The case- based education would cover brain,
head/neck, chest, breast, abdomen/pelvis and musculoskeletal system. Additionally the
CIC Board recommends that the credential requirements for MRI education follow the
guidelines of CT education; 500 MRI case reviews under the supervision of an expert
MRI Radiologist and 200 didactic hours. The CIC is currently working to implement this
program and provide the MRI cases through their allotted sessions during the Mid-Winter
and Annual Meetings. (Appendix A)
Proposed “NEW” PET/MR Education
It is recommended that additional education be created focused on PET/MR. Specific
areas of interest include online education modules, Self Assessment Modules (SAM’s)
and continuing education articles for the Journal.
Recommendation: The PET/MR Task Force has recommended that additional plans for
education be discussed following the completion of the 2013 Mid-Winter Meeting
PET/MR Symposium. The Task Force believes that the feedback from the symposium
will provide a greater focus for the education needed.
The Task Force will reach out to the Journal of Nuclear Medicine Editor to determine if it
would be possible to include a focused article on PET/MRI in at least three issues over
the next year, similar to the focus on MI section that was created during the Bench to
Bedside Campaign.
PET/MR Procedure Guideline
Currently no standard procedure or guideline exists for PET/MRI. As it stands, in some
instances, the PET and MRI are done separately and then read overlaid. However, in
other instances, the PET/MRI is combined and special procedures must be followed
during the imaging process.
Recommendation: The PET Center of Excellence recommends SNMMI Committee on
Guidelines begin developing the PET/MRI Guideline. The PET Center of Excellence is
willing to assist in providing the expertise regarding the PET portion of the procedure.
However, it is recommended that the SNMMI collaborate with the International Society
for Magnetic Resonance in Medicine (ISMRM).
PET/MR Reimbursement
According to the SNMMI Coding Corner, there are no CPT codes that describe the
software or hardware fusion of PET with non-concurrently or concurrently acquired MRI.
If separately ordered, clinically indicated and if separate interpretations are given, it may
be appropriate to code for the PET, MRI and the concurrently (hybrid scanner) or nonconcurrently (software) fused anatomic localization studies separately. To code, we
would suggest using the appropriate PET and MRI codes plus an "unlisted nuclear
medicine procedure" code –99 (e.g. CPT 78999) for the fused procedure. Again, the PET
and the MRI studies are coded and charged for separately from the “fusion” procedure.
Currently, Medicare has no reimbursement policy regarding software or hardware fusion
of PET/MRI data. Additionally, since the PET National Coverage Determination (NCD)
is an exclusionary policy, Medicare may consider this a non-covered procedure. If
performed for oncology indications, Medicare may consider this covered under NOPR.
Recommendation: While PET/MR is not widespread, it does have the possibility of
growing quickly if appropriate reimbursement is identified. The Task Force recommends
that the SNMMI review the information above and determine if there are any changes or
updates to the current procedure for requesting reimbursement. The Task Force is also
requesting that SNMMI determine it is possible to charge for 2 separate studies (in this
case PET and MRI) if a patient were to undergo these scans as part of a single imaging
(PET/MR) session.
Content Development (Website)
There is a need to develop specific information regarding PET/MR on the SNMMI
website. Specific information of interest includes; institutions with PET/MR, contact
names and numbers at these facilities, a list of clinical PET/MR indications, procedures
and protocols.
In addition, task force members suggested that as PET/MR is still an evolving modality,
that references and information be gathered and populated on the website for others to
view. These items include; journal articles, press releases, updates from PET/MR
manufacturers, and research.
Recommendation: The Task Force will begin work to develop this content over the next
year and will seek the assistance of the councils and centers who have interest in
PET/MR; specifically, the Brain Imaging Council, Correlative Imaging Council, and the
Center for Molecular Imaging Innovation and Translation.
International Society for Magnetic Resonance in Medicine
While the SNMMI members may have some expertise in MR Imaging, the PET Center of
Excellence believes that it is important to collaborate with the ISMRM. No direct contact
has bee made on the physician side, however, the technologist section has worked jointly
with the Society Magnetic Resonance Technologists (SMRT) for the past two years.
The 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. Its multidisciplinary
membership of over 6,000 consists of clinicians, physicists, engineers, biochemists, and
technologists. In addition to its large scientific meetings, the Society holds workshops
and publishes two journals, Magnetic Resonance in Medicine and the Journal of
Magnetic Resonance Imaging, and a newsletter, MR Pulse. It also sponsors study groups
on specific areas of scientific interest and chapters based on geographical location.
Recommendation: The Task Force recommends that the SNMMI leadership invite the
ISMRM leadership to attend the 2013 Mid-Winter Meeting and meet with the leadership
to discuss possible collaborative opportunities. In addition, it is also recommended that
the SNMMI and ISRMS host joint sessions at each others meetings in the future. The
Task Force believes that collaboration with the ISMRM is very important to the
development of PET/MR education and research.
Technologist Section Efforts
During the SNMMI Annual Meeting in June 2011, the SNMMI-Technologist Section
(SNMMI-TS) and the Section for Magnetic Resonance Technologists (SMRT) leadership
met to discuss possible collaboration opportunities. Through these discussions, it became
clear that PET/MR, as an emerging technology, is moving quickly to the market place.
Both MR and Nuclear Medicine technologists will need to garner the education necessary
to perform this procedure. It is evident, also from the leadership discussion, that neither
the SNMTS nor the SMRT can successfully educate its members, independently, about
the intricate details of PET/MR. With this in mind, a PET/MR Task Force was formed
and charged with (1) reviewing both the nuclear medicine entry level curriculum as well
as the MR entry level curriculum to determine areas of overlap (2) provide outreach to
the SNMMI-TS and SMRT communities, (3) develop a white paper focused on the
importance of collaboration among organizations to better prepare technologists for the
future of hybrid imaging. The co-chairs of the task force are Cindy Comeau, BS, CNMT,
RT(N)(MR), FSMRT, from SMRT and David Gilmore, MS, CNMT, RT(R)(N),
FSNMTS, from SNMMI-TS.
The white paper has been drafted and will be finalized later this year and published in the
Journal of Nuclear Medicine Technology (JNMT).
In addition, the SMRT and SNMMI-TS held their first joint session during the 2012
Annual Meeting and will be hosting another joint continuing education session in 2013.
The SNMMI-TS provided one speaker for the 2012 ISMRM meeting in Australia and
will be sending another representative again in 2013.
Technologists also have the opportunity to purchase the MR101: Basic Principles of
Magnetic Resonance Imaging Combo, an online lecture series, which includes the
following areas of interest:
 MR Hardware
 MR Safety and Clinical Procedures
 Producing an MR Image
 Producing an MR Signal
Recommendation: The Task Force would like to add a representative from the SNMMITS PET/MR Task Force to the PET CoE PET/MR Task Force to provide updates and
discussion on what the SNMMI-TS is working on with regard to PET/MR.