PET/MR imaging of the pelvis in the presence of endoprostheses: reducing image artifacts and increasing accuracy through inpainting

In combined whole-body PET/MR, attenuation correction (AC) is performed indirectly using the available MR image information and subsequent segmentation. Implant-induced susceptibility artifacts and subsequent signal voids may challenge MR-based AC (MR-AC). We evaluated the accuracy of MR-AC in PET/MR in patients with metallic endoprostheses, and propose a clinically feasible correction method.

We selected patients with uni- or bilateral endoprostheses from 61 consecutive referrals for whole-body PET/MR imaging (mMR; Siemens Healthcare). Simultaneous whole-body PET/MR imaging was performed at 120 min after injection of about 300 MBq [¹⁸F]FDG. MR-AC was performed using (1) original MR images and subsequent Dixon water–fat segmentation, (2) as method 1 with implant-induced signal voids filled with soft tissue, (3) as method 2 with superimposed coregistered endoprostheses from the CT scan, and (4) as method 1 with implant-induced signal voids filled with metal. Following MR-AC (methods 1–4) PET emission images were reconstructed on 344 × 344 matrices using attenuation-weighted OSEM (three iterations, 21 subsets, 4 mm gaussian). Maximum body-weight normalized standardized uptake values (SUVmax) were obtained for both hips. Mean SUV (SUVmean) in homogeneous reference regions in the gluteal muscle and bladder following MR-AC (methods 1–4) are also reported.

In total, four patients presented with endoprostheses, unilateral in two and bilateral in two. The fraction of voxels in MR images affected by the implant was at least twice that of the voxels representing the actual implants. MR-AC using methods 2 and 3 recovered the FDG distribution pattern compared to uncorrected PET images and method 1, while method 4 resulted in severe overestimation of FDG uptake (>460 % SUVmax). When compared to method 1, relative changes in SUVmean in the reference regions from method 2 and 3 were generally small albeit not correlated with the fraction of the attenuation image affected by implant-induced artifacts.

Endoprostheses cause PET/MR artifacts that exceed the volume occupied by the implants, and bias PET quantification. Artifacts and bias can be corrected by semiautomated inpainting with soft tissue with a single composition prior to MR-AC, thus restoring quantitative activity distribution.