Linking Whole-Slide Microscope Images with DICOM by Using JPEG2000 Interactive Protocol

The use of digitized histopathologic specimens (also known as whole-slide images (WSIs)) in clinical medicine requires compatibility with the Digital Imaging and Communications in Medicine (DICOM) standard. Unfortunately, WSIs usually exceed DICOM image object size limit, making it impossible to store and exchange them in a straightforward way. Moreover, transmitting the entire DICOM image for viewing is ineffective for WSIs. With the JPEG2000 Interactive Protocol (JPIP), WSIs can be linked with DICOM by transmitting image data over an auxiliary connection, apart from patient data. In this study, we explored the feasibility of using JPIP to link JPEG2000 WSIs with a DICOM-based Picture Archiving and Communications System (PACS). We first modified an open-source DICOM library by adding support for JPIP as described in the existing DICOM Supplement 106. Second, the modified library was used as a basis for a software package (JVSdicom), which provides a proof-of-concept for a DICOM client–server system that can transmit patient data, conventional DICOM imagery (e.g., radiological), and JPIP-linked JPEG2000 WSIs. The software package consists of a compression application (JVSdicom Compressor) for producing DICOM-compatible JPEG2000 WSIs, a DICOM PACS server application (JVSdicom Server), and a DICOM PACS client application (JVSdicom Workstation). JVSdicom is available for free from our Web site (), which also features a public JVSdicom Server, containing example X-ray images and histopathology WSIs of breast cancer cases. The software developed indicates that JPEG2000 and JPIP provide a well-working solution for linking WSIs with DICOM, requiring only minor modifications to current DICOM standard specification.     

OpenRIMS: An Open Architecture Radiology Informatics Management System

The benefits of an integrated picture archiving and communication system/radiology information system (PACS/RIS) archive built with open source tools and methods are 2-fold. Open source permits an inexpensive development model where interfaces can be updated as needed, and the code is peer reviewed by many eyes (analogous to the scientific model). Integration of PACS/RIS functionality reduces the risk of inconsistent data by reducing interfaces among databases that contain largely redundant information. Also, wide adoption would promote standard data mining tools—reducing user needs to learn multiple methods to perform the same task. A model has been constructed capable of accepting HL7 orders, performing examination and resource scheduling, providing digital imaging and communications in medicine (DICOM) worklist information to modalities, archiving studies, and supporting DICOM query/retrieve from third party viewing software. The multitiered architecture uses a single database communicating via an ODBC bridge to a Linux server with HL7, DICOM, and HTTP connections. Human interaction is supported via a web browser, whereas automated informatics services communicate over the HL7 and DICOM links. The system is still under development, but the primary database schema is complete as well as key pieces of the web user interface. Additional work is needed on the DICOM/HL7 interface broker and completion of the base DICOM service classes.     

Concordance between whole-slide imaging and light microscopy for routine surgical pathology

The use of high-resolution digital images of histopathology slides as a routine diagnostic tool for surgical pathology was investigated. The study purpose was to determine the diagnostic concordance between pathologic interpretations using whole-slide imaging and standard light microscopy. Two hundred fifty-one consecutive surgical pathology cases (312 parts, 1085 slides) from a single pathology service were included in the study after cases had been signed out and reports generated. A broad array of diagnostic challenges and tissue sources were represented, including 52 neoplastic cases. All cases were digitized at ×20 and presented to 2 pathologists for diagnosis using whole-slide imaging as the sole diagnostic tool. Diagnoses rendered by the whole-slide imaging pathologists were compared with the original light microscopy diagnoses. Overall concordance between whole-slide imaging and light microscopy as determined by a third pathologist and jury panel was 96.5% (95% confidence interval, 94.8%-98.3%). Concordance between whole-slide imaging pathologists was 97.7% (95% confidence interval, 94.7%-99.2%). Five cases were discordant between the whole-slide imaging diagnosis and the original light microscopy diagnosis, of which 2 were clinically significant. Discordance resulted from interpretive criteria or diagnostic error. The whole-slide imaging modality did not contribute to diagnostic differences. Problems encountered by the whole-slide imaging pathologists primarily involved the inability to clearly visualize nuclear detail or microscopic organisms. Technical difficulties associated with image scanning required at least 1 slide be rescanned in 13% of the cases. Technical and operational issues associated with whole-slide imaging scanning devices used in this study were found to be the most significant obstacle to the use of whole-slide imaging in general surgical pathology.     

Enterprise-scale image distribution with a Web PACS

The integration of images with existing and new health care information systems poses a number of challenges in a multi-facility network: image distribution to clinicians; making DICOM image headers consistent across information systems; and integration of teleradiology into PACS. A novel, Web-based enterprise PACS architecture introduced at Massachusetts General Hospital provides a solution. Four AMICAS Web/Intranet Image Servers were installed as the default DICOM destination of 10 digital modalities. A fifth AMICAS receives teleradiology studies via the Internet. Each AMICAS includes: a Java-based interface to the IDXrad radiology information system (RIS), a DICOM autorouter to tape-library archives and to the Agfa PACS, a wavelet image compressor/decompressor that preserves compatibility with DICOM workstations, a Web server to distribute images throughout the enterprise, and an extensible interface which permits links between other HIS and AMICAS. Using wavelet compression and Internet standards as its native formats, AMICAS creates a bridge to the DICOM networks of remote imaging centers via the Internet. This teleradiology capability is integrated into the DICOM network and the PACS thereby eliminating the need for special teleradiology workstations. AMICAS has been installed at MGH since March of 1997. During that time, it has been a reliable component of the evolving digital image distribution system. As a result, the recently renovated neurosurgical ICU will be filmless and use only AMICAS workstations for mission-critical patient care.     

Research and Implementation of DICOM Format Conversion on Medical Images

INTRODUCTION　　With the developmentof technology of network and communication and the gen-eralization of medical digital imaging facilities,Picture Achieving and CommunicationSystem( PACS) has been developing rapidly recently.By means of computer com-munication network,PACS,instead of traditional film- format imaging,captures,saves,shows and transfers medical imaging and related information of digital way.It s obvious that PACScan help to efficiently diagnose.In order to transfer i…     

一种符合医学数字影像与通讯标准的医学影像管理系统的设计

医学影像的存储与传输在数字化医疗快速发展的今天占据着非常重要的地位。为了实现医学数字影像与通讯（DICOM）医学影像在局域网上的传输和查询,本文设计了一个符合DICOM标准的医学影像管理系统。该系统能对DICOM格式文件进行解析,并在数据库中把DICOM影像文件与对应的病历信息进行关联存储,可以给医院影像科提供完全数字化的影像和数据。此研究工作不仅满足了医院影像中心对大量影像数据存储的需求,同时也促进了PACS系统的发展。     

The Orthanc Ecosystem for Medical Imaging

This paper reviews the components of Orthanc, a free and open-source, highly versatile ecosystem for medical imaging. At the core of the Orthanc ecosystem, the Orthanc server is a lightweight vendor neutral archive that provides PACS managers with a powerful environment to automate and optimize the imaging flows that are very specific to each hospital. The Orthanc server can be extended with plugins that provide solutions for teleradiology, digital pathology, or enterprise-ready databases. It is shown how software developers and research engineers can easily develop external software or Web portals dealing with medical images, with minimal knowledge of the DICOM standard, thanks to the advanced programming interface of the Orthanc server. The paper concludes by introducing the Stone of Orthanc, an innovative toolkit for the cross-platform rendering of medical images.     

DICOM医学图像采集的方法与实践

医学图像采集是PACS的重要环节,也是PACS实用化的关键。本文比较了几种常见的图像采集方法,重点介绍了通过DICOM接口的图像采集,在详细阐明了DICOM网络的概念和DICOM消息交换的规范之后,介绍了我们编写的DICOM医学图像采集软件,本软件是在Windows平台上利用SocketAPI编写而成,提供了DICOM标准定义的验证、存储、查询和检索等服务,测试结果表明,本软件能够顺利地与成像设备连接并采集图像。     

Anatomy of an Extensible Open Source PACS

The conception and deployment of cost effective Picture Archiving and Communication Systems (PACS) is a concern for small to medium medical imaging facilities, research environments, and developing countries’ healthcare institutions. Financial constraints and the specificity of these scenarios contribute to a low adoption rate of PACS in those environments. Furthermore, with the advent of ubiquitous computing and new initiatives to improve healthcare information technologies and data sharing, such as IHE and XDS-i, a PACS must adapt quickly to changes. This paper describes Dicoogle, a software framework that enables developers and researchers to quickly prototype and deploy new functionality taking advantage of the embedded Digital Imaging and Communications in Medicine (DICOM) services. This full-fledged implementation of a PACS archive is very amenable to extension due to its plugin-based architecture and out-of-the-box functionality, which enables the exploration of large DICOM datasets and associated metadata. These characteristics make the proposed solution very interesting for prototyping, experimentation, and bridging functionality with deployed applications. Besides being an advanced mechanism for data discovery and retrieval based on DICOM object indexing, it enables the detection of inconsistencies in an institution’s data and processes. Several use cases have benefited from this approach such as radiation dosage monitoring, Content-Based Image Retrieval (CBIR), and the use of the framework as support for classes targeting software engineering for clinical contexts.     

Applications and implications of whole-slide imaging in breast pathology

Technological advances in whole slide imaging (WSI) technology and artificial intelligence (AI) applications in recent years have resulted in increasing adoption of this paradigm shift technology. This brings with it many advantages, new challenges, and potential adaptations to the microscopic assessment of specimens that pathologists need to be aware of. This article describes the applications and implications of WSI within the context of the reporting of breast pathology specimens. Challenging diagnostic entities in digital breast pathology are presented and the key areas in which AI could be useful in breast pathology are highlighted.     

Dicoogle - an Open Source Peer-to-Peer PACS

Picture Archiving and Communication Systems (PACS) have been widely deployed in healthcare institutions, and they now constitute a normal commodity for practitioners. However, its installation, maintenance, and utilization are still a burden due to their heavy structures, typically supported by centralized computational solutions. In this paper, we present Dicoogle, a PACS archive supported by a document-based indexing system and by peer-to-peer (P2P) protocols. Replacing the traditional database storage (RDBMS) by a documental organization permits gathering and indexing data from file-based repositories, which allows searching the archive through free text queries. As a direct result of this strategy, more information can be extracted from medical imaging repositories, which clearly increases flexibility when compared with current query and retrieval DICOM services. The inclusion of P2P features allows PACS internetworking without the need for a central management framework. Moreover, Dicoogle is easy to install, manage, and use, and it maintains full interoperability with standard DICOM services.     

Reconciliation of diverse telepathology system designs. Historic issues and implications for emerging markets and new applications

Telepathology, the distant service component of digital pathology, is a growth industry. The word "telepathology" was introduced into the English Language in 1986. Initially, two different, competing imaging modalities were used for telepathology. These were dynamic (real time) robotic telepathology and static image (store-and-forward) telepathology. In 1989, a hybrid dynamic robotic/static image telepathology system was developed in Norway. This hybrid imaging system bundled these two primary pathology imaging modalities into a single multi-modality pathology imaging system. Similar hybrid systems were subsequently developed and marketed in other countries as well. It is noteworthy that hybrid dynamic robotic/static image telepathology systems provided the infrastructure for the first truly sustainable telepathology services. Since then, impressive progress has been made in developing another telepathology technology, so-called "virtual microscopy" telepathology (also called "whole slide image" telepathology or "WSI" telepathology). Over the past decade, WSI has appeared to be emerging as the preferred digital telepathology digital imaging modality. However, recently, there has been a re-emergence of interest in dynamic-robotic telepathology driven, in part, by concerns over the lack of a means for up-and-down focusing (i.e., Z-axis focusing) using early WSI processors. In 2010, the initial two U.S. patents for robotic telepathology (issued in 1993 and 1994) expired enabling many digital pathology equipment companies to incorporate dynamic-robotic telepathology modules into their WSI products for the first time. The dynamic-robotic telepathology module provided a solution to the up-and-down focusing issue. WSI and dynamic robotic telepathology are now, rapidly, being bundled into a new class of telepathology/digital pathology imaging system, the "WSI-enhanced dynamic robotic telepathology system". To date, six major WSI processor equipment companies have embraced the approach and developed WSI-enhanced dynamic-robotic digital telepathology systems, marketed under a variety of labels. Successful commercialization of such systems could help overcome the current resistance of some pathologists to incorporate digital pathology, and telepathology, into their routine and esoteric laboratory services. Also, WSI-enhanced dynamic robotic telepathology could be useful for providing general pathology and subspecialty pathology services to many of the world's underserved populations in the decades ahead. This could become an important enabler for the delivery of patient-centered healthcare in the future.     

医学图像DICOM格式转换软件的设计与实现

PACS（图像存档与通讯系统）应遵循DICOM（医学数字图像通讯）标准。目前国内存在大量不符合DICOM标准的影像设备,为了使这些设备也应用于PACS,我们使用面向对象方法设计和实现了一个具有良好扩充性的格式转换工具包,可进行DICOM格式与各种通用图像格式之间的转换,并具有视频输入与格式转换工具包,可进行DICOM格式与各种通用图像格式之间的转换,并具有视频输入与扫描仪输入的接口。该工具包提供一组DICOM API,可供Windows平台的各种编程环境使用。     

Development of a Next-Generation Automated DICOM Processing System in a PACS-Less Research Environment

The use of clinical imaging modalities within the pharmaceutical research space provides value and challenges. Typical clinical settings will utilize a Picture Archive and Communication System (PACS) to transmit and manage Digital Imaging and Communications in Medicine (DICOM) images generated by clinical imaging systems. However, a PACS is complex and provides many features that are not required within a research setting, making it difficult to generate a business case and determine the return on investment. We have developed a next-generation DICOM processing system using open-source software, commodity server hardware such as Apple Xserve®, high-performance network-attached storage (NAS), and in-house-developed preprocessing programs. DICOM-transmitted files are arranged in a flat file folder hierarchy easily accessible via our downstream analysis tools and a standard file browser. This next-generation system had a minimal construction cost due to the reuse of all the components from our first-generation system with the addition of a second server for a few thousand dollars. Performance metrics were gathered and the system was found to be highly scalable, performed significantly better than the first-generation system, is modular, has satisfactory image integrity, and is easier to maintain than the first-generation system. The resulting system is also portable across platforms and utilizes minimal hardware resources, allowing for easier upgrades and migration to smaller form factors at the hardware end-of-life. This system has been in production successfully for 8 months and services five clinical instruments and three pre-clinical instruments. This system has provided us with the necessary DICOM C-Store functionality, eliminating the need for a clinical PACS for day-to-day image processing.     

Leveraging Internet Technologies with DICOM WADO

The digital imaging and communications in medicine (DICOM) 3.0 standard was first officially ratified by the national electrical manufacturers association in 1993. The success of the DICOM open standard cannot be overstated in its ability to enable an explosion of innovation in the best of breed picture archiving and communication systems (PACS) industry. At the heart of the success of allowing interoperability between disparate systems have been three fundamental DICOM operations: C-MOVE, C-FIND, and C-STORE. DICOM C-MOVE oversees the transfer of DICOM Objects between two systems using C-STORE. DICOM C-FIND negotiates the ability to discover DICOM objects on another node. This paper will discuss the efforts within the DICOM standard to adapt this core functionality to Internet standards. These newer DICOM standards look to address the next generation of PACS challenges including highly distributed mobile acquisition systems and viewing platforms.     

Developing a Multi-Institutional PACS Archive and Designing Processes to Manage the Shift from a Film to a Digital-Based Archive

The Quality Assurance Review Center (QARC) works to improve the standards of care in treating cancer by improving the quality of clinical trials medicine. QARC operates as a data management and review center providing quality assurance services for multiple external groups including cooperative groups and pharmaceutical companies. As the medical world migrates from analog film to digital files, QARC has developed an innovative and unique digital imaging management system to accommodate this trend. As QARC acquires electronic data from institutions across six continents, the system is continually developed to accommodate Digital Imaging and Communications in Medicine (DICOM) imaging originating from a wide variety of Picture Archival and Communications System (PACS) manufacturers, thus creating one of the largest and most diverse multi-institutional imaging archives in the cancer research community.     

XML-Based DICOM Data Format

To enhance the readability, improve the structure, and facilitate the sharing of digital imaging and communications in medicine (DICOM) files, this research proposed one kind of XML-based DICOM data format. Because XML Schema offers great flexibility for expressing constraints on the content model of elements, we used it to describe the new format, thus making it consistent with the one originally defined by DICOM. Meanwhile, such schemas can be used in the creation and validation of the XML-encoded DICOM files, acting as a standard for data transmission and sharing on the Web. Upon defining the new data format, we started with representing a single data element and further improved the whole data structure with the method of modularization. In contrast to the original format, the new one possesses better structure without loss of related information. In addition, we demonstrated the application of XSLT and XQuery. All of the advantages mentioned above resulted from this new data format.     

DICOM Modality Worklist: An essential component in a PACS environment

The development and acceptance of the digital communication in medicine (DICOM) standard has become a basic requirement for the implementation of electronic imaging in radiology. DICOM is now evolving to provide a standard for electronic communication between radiology and other parts of the hospital enterprise. In a completely integrated filmless radiology department, there are 3 core computer systems, the picture archiving and communication system (PACS), the hospital or radiology information system (HIS, RIS), and the acquisition modality. Ideally, each would have bidirectional communication with the other 2 systems. At a minimum, a PACS must be able to receive and acknowledge receipt of image and demographic data from the modalities. Similarly, the modalities must be able to send images and demographic data to the PACS. Now that basic DICOM communication protocols for query or retrieval, storage, and print classes have become established through both conformance statements and intervendor testing, there has been an increase in interest in enhancing the functionality of communication between the 3 computers. Historically, demographic data passed to the PACS have been generated manually at the modality despite the existence of the same data on the HIS or RIS. In more current sophisticated implementations, acquisition modalities are able to receive patient and study-related data from the HIS or RIS. DICOM Modality Worklist is the missing electronic link that transfers this critical information between the acquisition modalities and the HIS or RIS. This report describes the concepts, issues, and impact of DICOM Modality Worklist implementation in a PACS environment.     

Cybersecurity in PACS and Medical Imaging: an Overview

This article provides an overview on the literature published on the topic of cybersecurity for PACS (Picture Archiving and Communications Systems) and medical imaging. From a practical perspective, PACS specific security measures must be implemented together with the measures applicable to the IT infrastructure as a whole, in order to prevent incidents such as PACS systems exposed to access from the Internet. Therefore, the article first offers an overview of the physical, technical and organizational mitigation measures that are proposed in literature on cybersecurity in healthcare information technology in general, followed by an overview on publications discussing specific cybersecurity topics that apply to PACS and medical imaging and present the “building blocks” for a secure PACS environment available in the literature. These include image de-identification, transport security, the selective encryption of the DICOM (Digital Imaging and Communications in Medicine) header, encrypted DICOM files, digital signatures and watermarking techniques. The article concludes with a discussion of gaps in the body of published literature and a summary.