Positron emission tomography (PET) is an emerging clinical imaging technique that is facing the challenges of expansion in a period of imminent health care contraction and reform. Although PET began showing utility in clinical medicine in the mid-1980s [1], its proliferation into mainstream medical practice has not matched that of other new imaging technologies such as MR imaging. Many factors have contributed to this, including the changing health care economy, the high cost of PET, the length of time it takes to develop a PET facility, and its inherent complexity. In part because of the proliferation of the use of other technologies and the general explosion of costs, insurance carriers are now holding diagnostic techniques, including PET, to stricter standards of efficacy. New techniques must show improvement in long-term outcome of patients, a difficult task for diagnostic tools. In addition to these issues, PET is an expensive technology that requires highly trained multidisciplinary personnel. Questions have also been raised about the most appropriate mechanism for regulation of PET isotope preparation, leading to speculation about future regulatory requirements. The current pioneers of PET must meet these challenges in order for it to become a routine imaging technique. Because of its clinical value, PET will probably survive despite the challenges. For many reasons, though, not every hospital should necessarily develop PET services. Conversely, many hospitals without this technology should consider acquiring PET. The purpose of this article is to identify the financial, operational, and clinical challenges facing PET centers today, describe potential organizational configurations that may enable PET to survive in an antitechnology environment, and delineate which institutions should consider this new technology.