1300 North 17th Street, Suite 1752
Arlington, VA 22209, USA
(Mammography and CAD)
April 17, 2012
Members Present Represented by
Agfa Healthcare Ron Hitzelberger
Fujifilm Medical Systems Paul Morgan
GE Healthcare Jeanne Couder
Hologic, Inc. Janet Keyes
iCAD, Inc. Topher Gedeon
Siemens Medical Solutions Renate Hoecker
Members Absent Voting Representative
American College of Radiology Judith Wolfman
FDA Kish Chakrabarti
*Planmed Oy Mari Varjonen
Philips Medical Systems Bas Revet
* = Does not count toward quorum.
Alternate Representatives, Observers and Others Present:
American College of Radiology Staff Wil Creech
American College of Radiology Staff Anthony Levering
American College of Radiology Staff Dwight Chandler
Hologic, Inc. Julian Marshall
Presiding Officer: Janet Keyes, Industry Co-Chair
Page 1 DICOM Working Group 15 April 17, 2012
1. WELCOME AND REVIEW AGENDA
Janet Keyes called the meeting to order at 10:05 am Eastern Time.
Note: Based on the DICOM Standards Committee Procedures, the following members that
have missed at least four consecutive face-to-face meetings are being converted to observer
(mailer) status. They may be reinstated the next time they attend a face-to-face meeting:
Carestream Health Zhimin Huo
2. REVIEW OF PREVIOUS MINUTES
The meeting minutes for the April 3, 2012 teleconference were presented and approved.
3. REVIEW OF PREVIOUS ACTION ITEMS
Janet: Provide feedback to WG 6 regarding CP-1194 draft letter ballot text (mGy).
Janet: Update and distribute the proposed CP, Stereotactic Information for Breast
Tomosynthesis: Image Type (0008,0008) Value 3 for review and consensus prior to
WG 6 submission. Completed.
Digital Breast Tomosynthesis Projections:
Modality producers: Provide a list of attributes that can be used to distinguish 2D
images from digital breast tomosynthesis projection images stored using Digital
Mammography X-Ray Image. Completed. Siemens provided a list.
Workstation producers: Evaluate impact of detecting and displaying digital breast
tomosynthesis projection images stored using Digital Mammography X-Ray Image.
Discussed during the meeting.
Digital Breast Tomosynthesis CAD Results:
Janet: Redistribute the link to the proposed CP and a file summarizing the e-mail
feedback to date. Completed.
4. CORRECTION PROPOSALS
CP-1077: Add CR report type to Dose SR: Final Text published April 6, 2012.
CP-1194: Clarify dose for breast X-Ray: Janet presented the Letter Ballot version that
incorporated WG 15 feedback. CPack 66 ballot is due May 25, 2012.
Proposed CP: Stereotactic Information for Breast Tomosynthesis: Image Type
(0008,0008) Value 3: Janet presented the updated version. The updates to the Breast
View module (for reconstructed slices) were accepted. The updates to the
Mammography Image module (for projection images) were accepted pending further
discussion of interoperable projection images. A request was made to revisit the
possibility of adding post-clip to the list of stereo identifiers to differentiate it from
post-biopsy for hanging order purposes. Currently post-clip images are labeled as
post-biopsy. The group will seek clinician feedback regarding whether or not this
differentiation is important on a review workstation with respect to hanging order.
Page 2 DICOM Working Group 15 April 17, 2012
5. DIGITAL BREAST TOMOSYNTHESIS PROJECTIONS
Julian had spoken with a few review workstation producers regarding DICOM formats for
exchange of digital breast tomosynthesis projection images, and summarized their feedback:
1) receiving many (11-22) individual Digital Mammography X-Ray Image – For
Presentation objects per laterality+view representing tomosynthesis projection images would
likely result in many thumbnails per study (44-88) rather than the typical 4 thumbnails per
conventional screening mammography study, 2) extra work would be required to add logic to
distinguish 2D from tomosynthesis projection images, not desirable, 3) seemed resistant to a
new multi-frame image SOP Class given current demand versus the long lead-time for
DICOM definition and approval, followed by implementation..
If existing Digital Mammography X-Ray Image is used, would it be possible for workstations
to learn to stack tomosynthesis projection images for display using distinguishing attributes
from the image headers? Janet presented the list of potential distinguishing attributes
provided by Siemens (available in the WG 15 ftp folder under Tomosynthesis).
The question was raised, would it be possible with some changes to use the Breast
Tomosynthesis Image SOP Class to store projection images as well as reconstructed slices?
The group concluded that reconstructed slices and projection images are too different, and
the SOP Class is specifically structured for reconstructed slices, so this is not a viable option.
A point raised in favor of a new SOP Class is the need for archives to be able to distinguish
(typically by SOP Class) which images may be eligible for deletion if they are not used for
diagnostic purposes, such as Digital Mammography X-Ray Image – For Processing (delete)
vs. For Presentation (keep) with conventional digital mammography. If tomosynthesis
projection images (For Presentation) eventually fall into this category of being eligible to
delete, there should be a way for archives to distinguish them easily from 2D For
Presentation images and tomosynthesis reconstructed slices.
The clinical need for interoperable tomosynthesis projection images was reiterated based on
current clinical usage by radiologists along with the reconstructed slices. Some radiologists
who are teaching others how to review digital breast tomosynthesis images specifically
instruct to review the projection images: Eventually with experience there may be a transition
away from radiologists reviewing the projection images, but until then they are needed.
The group agreed to write a DICOM work item proposal for a new SOP Class, with the goal
of presenting at the June 26 DICOM Standards Committee meeting upon reaching consensus.
Given current demand for interoperable projections, the group is concerned that the time line
for defining a new SOP Class will be too long, risking a variety of undesirable interim
solutions. Incorporating similar existing DICOM models may shorten the time line.
A new SOP Class should provide for storing raw projections (e.g. to CAD devices, for later
reconstruction) and processed projections (for review workstation display).
What are the advantages / disadvantages of a single-frame SOP Class versus a multi-frame
SOP Class? Would multi-frame objects be too large? Should mammography-specific
compression be considered, potentially in the form of a new compression transfer syntax?
Page 3 DICOM Working Group 15 April 17, 2012
6. DIGITAL BREAST TOMOSYNTHESIS CAD RESULTS
Other topics took precedence, so Janet quickly presented the collection of December 2011 e-
mail responses that is available on the ftp site. Discussion tabled until the next meeting.
7. BI-RADS® ATLAS
Fifth edition status update: The ACR is awaiting some final narrative. Internal review of
some parts has started.
8. OLD BUSINESS
ACR guidelines for noting in a digital mammography image why a marker (scar, mole, lump,
bbs) was used. Modality producers have received questions from clinicians stating there are
new guidelines, and asking where to record this information in digital mammography images.
Wil Creech reported: The use of markers to indicate skin lesions and, to a lesser extent,
palpable lesions was discussed with the recommendation that different shapes of markers be
used to differentiate between skin lesions and palpable lesions for physicians within the same
facility and noted either on the image or in the report for extramural interpreting physicians
Wil Creech provided the following draft text from the BI-RADS Atlas fifth edition as of
April 12, 2012 (subject to change):
“(Finally, because the clinical significance of a palpable lesion is greater than that of a raised
skin lesion, because the radiopaque devices used to mark both palpable and skin lesions are
available in several different shapes, and because there has been no consensus in establishing
the use of specific-shaped markers to represent palpable versus skin lesions, the following
two practices are recommended.
 To properly inform interpreting physicians within a given mammography facility, the
facility should adopt a policy requiring consistent use of two different shapes of radiopaque
devices for palpable and skin lesions, respectively.
 To properly inform interpreting physicians outside the facility, there should be an
indication of the type of underlying lesion marked by every radiopaque device (palpable
versus skin lesion), either as a permanent annotation on the appropriate mammographic
image(s) or as a description in the mammography report.)”
SIIM roundtable discussion Friday, June 8 in Orlando, FL, 11:30am – 12:15pm Eastern,
David Clunie as moderator. Nothing new to report.
9. NEW ACTION ITEMS
All: Seek clinician input regarding whether or not there is a need to differentiate post-
clip from post-biopsy images on review workstations for hanging order purposes.
All: Review the proposed CP, Stereotactic Information for Breast Tomosynthesis:
Image Type (0008,0008) Value 3 updates to the Mammography Image module for
tomosynthesis projection image identification.
Page 4 DICOM Working Group 15 April 17, 2012
Digital Breast Tomosynthesis Projections:
Janet: Provide DICOM work item proposal template and preliminary text for group to
review and complete.
Julian: Start a first draft Supplement outline for a new multi-frame SOP Class.
Digital Breast Tomosynthesis CAD Results:
All: Review the proposed CP and the file summarizing the e-mail feedback to date.
10. NEXT MEETING
Thursday-Friday, July 12-13, 2012 at the ACR in Reston, VA, pending ACR confirmation.
The meeting was adjourned at 12:10pm Eastern.
Reported by: Janet Keyes (co-Chair)
WG 15 of the DICOM Stds. Comte.
April 18, 2012
Reviewed by Counsel: CRS 2012-04-30
Page 5 DICOM Working Group 15 April 17, 2012