diff --git a/common/reviews/api/tools.api.md b/common/reviews/api/tools.api.md
index b89234a614..db9825d1c9 100644
--- a/common/reviews/api/tools.api.md
+++ b/common/reviews/api/tools.api.md
@@ -2606,9 +2606,23 @@ enum KeyboardBindings {
     // (undocumented)
     Alt = 18,
     // (undocumented)
+    AltMeta = 1891,
+    // (undocumented)
     Ctrl = 17,
     // (undocumented)
-    Shift = 16
+    CtrlAlt = 1718,
+    // (undocumented)
+    CtrlMeta = 1791,
+    // (undocumented)
+    Meta = 91,
+    // (undocumented)
+    Shift = 16,
+    // (undocumented)
+    ShiftAlt = 1618,
+    // (undocumented)
+    ShiftCtrl = 1617,
+    // (undocumented)
+    ShiftMeta = 1691
 }
 
 // @public (undocumented)
diff --git a/packages/streaming-image-volume-loader/src/sharedArrayBufferImageLoader.ts b/packages/streaming-image-volume-loader/src/sharedArrayBufferImageLoader.ts
index e6365286a0..de45a0fe4f 100644
--- a/packages/streaming-image-volume-loader/src/sharedArrayBufferImageLoader.ts
+++ b/packages/streaming-image-volume-loader/src/sharedArrayBufferImageLoader.ts
@@ -129,6 +129,8 @@ function getTransferSyntaxForContentType(contentType: string): string {
     'image/x-jls': '1.2.840.10008.1.2.4.80',
     'image/jp2': '1.2.840.10008.1.2.4.90',
     'image/jpx': '1.2.840.10008.1.2.4.92',
+    'image/jphc': '3.2.840.10008.1.2.4.96',
+    'image/jls': '1.2.840.10008.1.2.4.80',
   };
 
   if (params['transfer-syntax']) {
diff --git a/packages/tools/src/enums/ToolBindings.ts b/packages/tools/src/enums/ToolBindings.ts
index 548f1aecca..21f5424ddd 100644
--- a/packages/tools/src/enums/ToolBindings.ts
+++ b/packages/tools/src/enums/ToolBindings.ts
@@ -25,6 +25,13 @@ enum KeyboardBindings {
   Shift = 16,
   Ctrl = 17,
   Alt = 18,
+  Meta = 91,
+  ShiftCtrl = 1617,
+  ShiftAlt = 1618,
+  ShiftMeta = 1691,
+  CtrlAlt = 1718,
+  CtrlMeta = 1791,
+  AltMeta = 1891,
 }
 
 export { MouseBindings, KeyboardBindings };
diff --git a/packages/tools/src/eventDispatchers/shared/getActiveToolForMouseEvent.ts b/packages/tools/src/eventDispatchers/shared/getActiveToolForMouseEvent.ts
index a670b0ad9c..6fac058a64 100644
--- a/packages/tools/src/eventDispatchers/shared/getActiveToolForMouseEvent.ts
+++ b/packages/tools/src/eventDispatchers/shared/getActiveToolForMouseEvent.ts
@@ -2,6 +2,7 @@ import { ToolGroupManager } from '../../store';
 import { MouseBindings, ToolModes } from '../../enums';
 import { keyEventListener } from '../../eventListeners';
 import { EventTypes } from '../../types';
+import getMouseModifier from './getMouseModifier';
 
 const { Active } = ToolModes;
 
@@ -22,7 +23,9 @@ export default function getActiveToolForMouseEvent(
   const mouseEvent = evt.detail.event;
 
   // If any keyboard modifier key is also pressed
-  const modifierKey = keyEventListener.getModifierKey();
+  // Use the actual key if set, otherwise get the key from the mouse event.
+  const modifierKey =
+    keyEventListener.getModifierKey() || getMouseModifier(mouseEvent);
 
   const toolGroup = ToolGroupManager.getToolGroupForViewport(
     viewportId,
diff --git a/packages/tools/src/eventDispatchers/shared/getMouseModifier.ts b/packages/tools/src/eventDispatchers/shared/getMouseModifier.ts
new file mode 100644
index 0000000000..43259b849c
--- /dev/null
+++ b/packages/tools/src/eventDispatchers/shared/getMouseModifier.ts
@@ -0,0 +1,30 @@
+import { KeyboardBindings as kb } from '../../enums';
+
+/**
+ * Gets the mouse modifier key from a mouse event.
+ * Supports Shift, Ctrl, Alt, in singly and in combinations of 2
+ * Supports Meta singly.
+ */
+const getMouseModifierKey = (evt) => {
+  // The logic is a hard coded key mapping
+  if (evt.shiftKey) {
+    if (evt.ctrlKey) return kb.ShiftCtrl;
+    if (evt.altKey) return kb.ShiftAlt;
+    if (evt.metaKey) return kb.ShiftMeta;
+    return kb.Shift;
+  }
+  if (evt.ctrlKey) {
+    if (evt.altKey) return kb.CtrlAlt;
+    if (evt.metaKey) return kb.CtrlMeta;
+    return kb.Ctrl;
+  }
+  if (evt.altKey) {
+    return (evt.metaKey && kb.AltMeta) || kb.Alt;
+  }
+  if (evt.metaKey) {
+    kb.Meta;
+  }
+  return undefined;
+};
+
+export default getMouseModifierKey;
diff --git a/packages/tools/src/utilities/segmentation/triggerSegmentationRender.ts b/packages/tools/src/utilities/segmentation/triggerSegmentationRender.ts
index 8971e315aa..6dd5b3fc3d 100644
--- a/packages/tools/src/utilities/segmentation/triggerSegmentationRender.ts
+++ b/packages/tools/src/utilities/segmentation/triggerSegmentationRender.ts
@@ -129,6 +129,10 @@ class SegmentationRenderingEngine {
     const segmentationDisplayToolInstance = toolGroup.getToolInstance(
       SegmentationDisplayTool.toolName
     ) as SegmentationDisplayTool;
+    if (!segmentationDisplayToolInstance) {
+      console.warn('No segmentation tool found inside', toolGroupId);
+      return;
+    }
 
     function onSegmentationRender(evt: Types.EventTypes.ImageRenderedEvent) {
       const { element, viewportId, renderingEngineId } = evt.detail;