Lung cancer is the leading cause of cancer-related deaths globally. According to the most recent estimates, nearly 2.5 million people were diagnosed with lung cancer in 2022, and over 1.8 million died from the disease.1,2 NSCLC, representing approximately 80%-85% of lung cancer cases, poses a significant challenge due to its typically late-stage diagnosis and poor prognosis. Imaging plays a critical role in screening, diagnosis, staging, treatment planning, and follow-up.

While CT remains the gold standard for lung cancer screening and T-staging, it has limitations, such as differentiating postobstructive lung collapse from the tumor and evaluating soft tissue infiltration, disease spread, and lymph node involvement.3 Moreover, although CT is highly effective in assessing the size and extent of disease, it does not account for the biological or functional processes occurring within the tumor. It is well known that new lung cancer therapies (eg, antiangiogenic drugs) are cytostatic rather than cytoreductive. Therefore, a technique that also considers the functional aspects of tumors is indeed desirable.

PET imaging is of paramount importance in oncology imaging, providing accurate information particularly in borderline adenopathy, distant metastases and in evaluating therapeutic metabolic/functional response. Nonetheless, challenges persist, as CT is an ionizing radiation technique, and PET/CT has an even higher cumulative radiation dose, which may become an issue especially when several scans are required with repeated radiation exposure.4

A further limitation of both techniques - especially PET/CT when using low-resolution CT for attenuation correction - is the limited soft tissue contrast in common sites of lung metastasis, such as the brain, bones, adrenal glands, and liver.

MRI is radiation free technique that is not frequently used for lung imaging; however, it offers undeniable advantages. First, it eliminates radiation exposure of the CT component of the study. Second, it provides superior contrast resolution, particularly in soft tissues, allowing for a more accurate assessment of potential chest wall infiltration in lung cancer. Lastly, it offers functional information through specific sequences (eg, diffusion-weighted and perfusion sequences). As a result, MRI can provide both qualitative and quantitative insights into cell membrane integrity and tissue consistency, reflecting changes at a cellular level.5 These potential benefits have been put forward in the past few years for evaluating nodal involvement and follow up patients treated with new angiogenic therapies.

PET/MR has emerged as a promising imaging technique, offering a one-stop-shop modality for lung cancer evaluation by combining the metabolic capabilities of PET with the superior soft tissue contrast of MRI, all while significantly reducing radiation exposure. This hybrid modality has been developed for assessing various cancers, including lung cancer. This review aims to explore the potential value of PET/MR in NSCLC, highlighting its clinical applications, challenges, and future directions.