DICOM IN RADIOTHERAPY

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The Impact of DICOM in Radiotherapy
Teaching lecture given by Michael Neumann at the 5th Biennal ESTRO meeting on
Physics for Clinical Radiotherapy in Göttingen, April 8, 1999.
(Download 782kB zip file of Power Point presentation)

First, what is DICOM ?

In the 1980’s, it became clear to radiologists and the manufacturers of medical imaging equipment that the tremendous growth in image acquisition systems, display workstations, archiving systems, and hospital-radiology information systems made vital the connectivity and interoperability of all pieces of equipment. In order to simplify and improve equipment connectivity, medical professionals joined forces with medical equipment manufacturers in an international effort to develop DICOM, the Digital Imaging and Communications in Medicine Standard. When DICOM is built into a medical imaging device, it can be directly connected to another DICOM-compatible device, eliminating the need for a custom interface. DICOM defines the interface.

DICOM was first developed to address connectivity and inter-operability problems in radiology, but today there are sections of the DICOM standard which define objects for many other modalities, including ultrasound, X-ray, and radiotherapy. DICOM provides a variety of capabilities, the most important of which are:

Network Image Transfer : Provides the capability for two devices to communicate by sending objects such as images or RT Plans, querying remote devices, and retrieving these objects. Network transfer is currently the most common connectivity feature supported by DICOM products.
Open Media Interchange : Provides the capability to manually exchange objects (images or RT objects) and related information (such as reports or filming information). DICOM standardizes a common file format, a medical directory, and a physical media. Examples include the exchange of images for a publication and mailing a patient imaging study for remote consultation.
Integration within the Healthcare Environment : Hospital workflow and integration with other hospital information systems have been or are being addressed, with the addition of DICOM supplements such as Modality Worklist, Modality Performed Procedure Step, and Structured Reporting. At RSNA in 1999 there is an important demonstration (IHE – „Integrating the Healthcare Enterprise”) of which the DICOM standard forms a vital part.

How and why were radiotherapy objects developed ?

During the RSNA meeting of 1994, a meeting was held at which a clear need was expressed for standardization of the way radiotherapy data (such as external beam and brachytherapy treatment plans, doses, and images) are transferred from one piece of equipment to another. The importance of such a standard was clear. The cost of developing custom interfaces, especially in radiotherapy departments where multi-vendor installations are common, is high, an expense which must be passed on to the user. Not only are such developments costly, they can be technically difficult, slowing down the progress of integration of the radiotherapy department, and are also safety critical. Although a standard such as DICOM does not eliminate these issues, it can facilitate development of safe, reliable inter-operability.

As a result of the RSNA meeting, an ad-hoc Working Group, later to become Working Group 7 (Radiotherapy Objects) was formed under the auspices of NEMA (National Electrical Manufacturers’ Association). Participating members of this group include many manufacturers of radiotherapy equipment, some academics, and also members involved with the IEC.

In 1997, four radiotherapy-specific DICOM objects were ratified: RT Structure Set, RT Plan, RT Dose, and RT Image. In 1999, three additional objects, RT Beams Treatment Record, RT Brachy Treatment Record, and RT Treatment Summary Record, were added to the DICOM standard, along with CD-R support for the storage of all radiotherapy objects.

Working Group 7 is currently involved in the maintenance of the existing radiotherapy objects, and is examining potential uses of newer DICOM extensions in the radiotherapy context.

What can DICOM provide in radiotherapy ?

In order to understand what DICOM can and cannot provide in radiotherapy, it is important for radiotherapy professionals to distinguish between DICOM connectivity and application interoperability. DICOM connectivity refers to the DICOM message exchange standard responsible for establishing connections and exchanging properly structured messages so that an information object sent from one node will be completely received by the receiving node. In other words, the successful transfer of information: the successful „plug and exchange” between two pieces of equipment.

Beyond connectivity lies application interoperability – the ability to process and manipulate information objects. DICOM radiotherapy objects play a crucial role in enabling such interoperability, but sometimes „plug and play” at this level requires more than the standardized definition and coding of information provided by DICOM. Specification and testing of the clinical application capabilities and data flow needs to be performed by the healthcare facility to ensure effective integration of the various DICOM applications. For example, transfer of IMRT (intensity-modulated) data from an IMRT-capable treatment planning system requires a record and verify or treatment system capable of managing such dynamic treatments. As we will see later, DICOM requires implementers to explicitly specify these application-specific information needs in a DICOM Conformance Statement that will provide the basis for achieving such application interoperability.

What are the radiotherapy objects and what do they do ?

There are four DICOM RT objects that have been implemented today:

RT Structure Set, containing information related to patient anatomy, for example structures, markers, and isocenters. These entities are typically identified on devices such as CT scanners, physical or virtual simulation workstations, or treatment planning systems.
RT Plan, containing geometric and dosimetric data specifying a course of external beam and/or brachytherapy treatment, for example beam angles, collimator openings, beam modifiers, and brachytherapy channel and source specifications. The RT Plan entity may be created by a simulation workstation, and subsequently enriched by a treatment planning system before being passed on to a record and verify system or treatment device. An instance of the RT Plan object usually references a RT Structure Set instance to define a coordinate system and set of patient structures.
RT Image, specifying radiotherapy images which have been obtained on a conical imaging geometry, such as those found on conventional simulators and portal imaging devices. It can also be used for calculated images using the same geometry, such as digitally reconstructed radiographs (DRRs).
RT Dose, containing dose data generated by a treatment planning system in one or more of several formats: three-dimensional dose data, isodose curves, DVHs, or dose points.
RT Beams Treatment Record, RT Brachy Treatment Record, and RT Treatment Summary Record, containing data obtained from actual radiotherapy treatments. These objects are the historical record of treatment, and are linked with the other „planning” objects to form a complete picture of the treatment.

DICOM : A radiotherapy example

To illustrate how DICOM objects can be used during an external beam patient treatment, here is a list of possible treatment steps, and their associated DICOM objects:

The patient is scanned on a CT scanner, producing a DICOM CT image study. Other DICOM image modalities, such as MR, could also be produced.
A virtual simulation application queries the scanner using DICOM, retrieves the images, and performs a virtual simulation. An RT Structure Set object is produced, containing identified structures such as the tumor and critical organs. An associated RT Plan is also created, containing beam geometry information. Digitally-reconstructed radiographs (DRRs) may also be created as RT Image objects.
A treatment planning system (TPS) then reads the CT Images, RT Structure Set, and RT Plan. It adds beam modifiers, modifies the beam geometries where necessary, and also calculates dosimetry data for the plan. A new RT Plan object is created, and RT Image DRRs may also be produced.
A record and verify system then obtains the completed RT Plan object, and uses the data contained within it to initialize a linac treatment. Alternatively, the linac itself could make use of the object directly. An EPID can create RT Image verification images, or compare acquired images with DRRs created by the above steps.
Periodically during the course of treatment, the linac or record and verify system creates Treatment Record objects, generally one for each treatment session.

The above sequence illustrates just one scenario. In reality there is a wide variety of different utilizations possible, and DICOM RT objects have been designed with this flexibility in mind.

The DICOM Conformance Statement

Connectivity between two pieces of equipment can be evaluated ahead of time by the use of the equipment’s DICOM Conformance Statements. However, for RT applications, it is not usually possible to determine inter-operability – this must be done by extensive testing. Nevertheless, conformance statements provide a foundation to determine connectivity and assess the potential inter-operability of two products, and in some cases identify potential problems without ever having physically connected them.

It is not enough for a vendor to simply claim conformance to DICOM, and the statement “This product is DICOM” has even less meaning in the radiotherapy domain, in which inter-operability is a very complex issue. Radiotherapy professionals should insist upon a conformance statement for any device that claims to be DICOM conformant. Many manufacturers make their conformance statements available on the Internet.

How are the manufacturers doing today ? (today = 1999)

DICOM is now a mature standard, and the core radiotherapy objects have been ratified since 1997. After a lot of hard work understanding, developing and testing product inter-operability in the radiotherapy context, a large number of manufacturers now have products available that support one of more of the radiotherapy DICOM objects. Vendors who have such products available, or have demonstrated them as works in progress, include: Elekta, General Electric Medical Systems, IMPAC, MDS Nordion, Merge Technologies, Multidata, NOMOS, Nucletron, Picker International, ROCS, Siemens Medical Systems, SSGI, and Varian Medical Systems.

Further information

For information regarding NEMA, or how to order the DICOM standard (including the RT objects), visit the NEMA web site at medical.nema.org/dicom.html. Alternatively, contact Howard Clark, Industry Manager, NEMA, 1300 North 17th Street, Suite 1847, Rosslyn, VA 22209 USA. Phone: (703) 841-3285; fax (703) 841-3385, mail

This text was a leaflet prepared by the DICOM RT Working Group for the AAPM meeting in August 1998, and updated in 1999. Reproduced with kind permission.