Significant improvements have made it possible to add the technology of time-of-flight (TOF) to improve PET, particularly for oncology applications. The goals of this work were to investigate the benefits of TOF in experimental phantoms and to determine how these benefits translate into improved performance for patient imaging. Methods: In this study we used a fully 3-dimensional scanner with the scintillator lutetium-yttrium oxyorthosilicate and a system timing resolution of ;600 ps. The data are acquired in list-mode and reconstructed with a maximum-likelihood expectation maximization algorithm; the system model includes the TOF kernel and corrections for attenuation, detector normalization, randoms, and scatter. The scatter correction is an extension of the model-based singlescatter simulation to include the time domain. Phantom measurements to study the benefit of TOF include 27-cm-and 35-cm-diameter distributions with spheres ranging in size from 10 to 37 mm. To assess the benefit of TOF PET for clinical imaging, patient studies are quantitatively analyzed. Results: The lesion phantom studies demonstrate the improved contrast of the smallest spheres with TOF compared with non-TOF and also confirm the faster convergence of contrast with TOF. These gains are evident from visual inspection of the images as well as a quantitative evaluation of contrast recovery of the spheres and noise in the background. The gains with TOF are higher for larger objects. These results correlate with patient studies in which lesions are seen more clearly and with higher uptake at comparable noise for TOF than with non-TOF. Conclusion: TOF leads to a better contrast-versus-noise trade-off than non-TOF but one that is difficult to quantify in terms of a simple sensitivity gain improvement: A single gain factor for TOF improvement does not include the increased rate of convergence with TOF nor does it consider that TOF may converge to a different contrast than non-TOF. The experimental phantom results agree with those of prior simulations and help explain the improved image quality with TOF for patient oncology studies. There has been considerable advancement of the technology and instrumentation in PET over the last 30 y since the first tomography ring systems were developed. Significant improvements have been made in detectors, hardware, and image processing that impact both image quality and accuracy of quantification. Some of the major achievements include (a) the development and incorporation of new scintillators and detector configurations for higher spatial resolution and sensitivity, (b) the evolution from 2-dimensional (2D) systems with septa to 3-dimensional (3D) systems with larger axial fields of view for improved sensitivity, (c) the transition from analytic filtered-backprojection reconstruction algorithms to fully 3D iterative techniques with data corrections included in the system model for improved image quality and quantification, and (d) the combination of a CT scanner with the PET instrument for both attenuation ...