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The recommendations outline how to perform and interpret bone marrow MRI in cancer patients, positioning MRI as the primary modality and detailing tailored protocols, whole-body versus axial skeleton approaches, standardized sequences, and quantitative biomarkers to improve diagnostic accuracy and response 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European Radiology (2026) 36:5414–5428  \n[https://doi.org/10.1007/s00330-025-12307-4](https://doi.org/10.1007/s00330-025-12307-4)  \nINVITED REVIEW Open Access  \nESR Essentials: bone marrow MRI in oncology—practice recommendations by the European Society of Musculoskeletal Radiology  \nFrédéric E. Lecouvet 1* , Lokmane Taihi 1, Thomas Kirchgesner 1, Vassiliki Pasoglou 1, Marin Halut2,3,4, Hatice Tuba Sanal5, Salvatore Gitto6,7, Teodoro Martín-Noguerol8, Violeta Vasilevska-Nikodinovska9,10, Filip Vanhoenacker 11,12,13 and Joan C. Vilanova 14  \nAbstract  \nInvolvement of the bone marrow by metastases from solid tumors or multiple myeloma (MM) is a critical challenge in oncologic imaging. Lesion detection and staging, as well as accurate assessment of treatment response, disease recurrence, and complications, are key to optimal patient management. This article provides recommendations for performing and interpreting bone marrow MRI in cancer patients. MRI should be the primary imaging modality for patients suspected of having skeletal bone metastases or MM, and should replace radiography, bone scintigraphy, and CT for these indications. Protocols must be tailored to the clinical context and to each specific cancer. Whole-body MRI (WB-MRI) is preferred for a comprehensive assessment, while axial skeleton MRI (AS-MRI) is a fast and reliable alternative for targeted or follow-up evaluations. We recommend standardized protocols that incorporate anatomical sequences (preferably fast spin echo T2 Dixon) and diffusion-weighted imaging (DWI) . Quantitative biomarkers, e. g., apparent diffusion coefficient (ADC) and fat fraction (FF), should be implemented to improve diagnostic accuracy and evaluate treatment response. Radiologists must be familiar with the typical patterns of bone marrow replacement by cancer cells, response assessment principles, and common imaging pitfalls. Every medical imaging facility should offer optimal bone marrow MRI and implement these recommendations using available MRI systems and existing diseaseoriented guidelines. This ESR Essentials illustrates when, how, and why to perform bone marrow MRI to improve diagnostic precision and oncologic care across a broad range of indications.  \nKey Points  \n● Prefer MRI of the bone marrow over radiographs, bone scintigraphy, or CT for suspected bone metastases of solid cancersand for myeloma staging.  \n● Use MRI for diagnosis of bone involvement, disease staging, assessment of lesion response to treatment, detection of recurrence, and assessment of osseous complications.  \n● Tailor MRI protocol to cancer type following existing guidelines, targeting either the axial skeleton or the “whole body,”and using a panel of sequences with fat-sensitive, fast spin echo T2 Dixon and diffusion-weighted sequences as the fundamental components.  \nThis article belongs to the ESR Essentials series, guest edited by Marc Dewey (Berlin/Germany) .  \n*Correspondence: Frédéric E. Lecouvet  \n[frederic.lecouvet@saintluc.uclouvain.be](frederic.lecouvet@saintluc.uclouvain.be)  \nFull list of author information is available at the end of the article  \n© The Author(s) 2026 . Open Access This article is licensed under a Creative Commons Attribution 4 . 0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit [http://creativecommon","cbCaifEoBN8hhSDm","https://ap.wps.com/l/cbCaifEoBN8hhSDm","pdf",7665789,15,"English","# Key Recommendations\n## Key Points\n## Introduction","[{\"question\":\"Which patients should receive bone marrow MRI first-line?\",\"answer\":\"MRI should be the primary imaging modality for patients suspected of having skeletal bone metastases from solid tumors or for multiple myeloma (MM) staging.\"},{\"question\":\"What MRI approaches are recommended for different evaluation needs?\",\"answer\":\"Whole-body MRI (WB-MRI) is preferred for comprehensive assessment, while axial skeleton MRI (AS-MRI) is a fast and reliable alternative for targeted or follow-up evaluations.\"},{\"question\":\"Which MRI sequences and quantitative biomarkers are emphasized in the recommendations?\",\"answer\":\"Standardized protocols should include anatomical sequences (preferably fast spin echo T2 Dixon) and diffusion-weighted imaging (DWI), with quantitative biomarkers such as ADC and fat fraction (FF) to improve diagnostic accuracy and evaluate treatment response.\"}]","ESR Essentials - bone marrow MRI in oncology - practice recommendations by the European Society of Musculoskeletal Radiology | PDF",1790103203,38]