Digital Breast Tomosynthesis & the Informatics Infra-structure How Digital Breast Tomosynthesis Kills Your PACS/VNA

Rasu Shrestha MD MBA Vice President, Medical Information Technology Medical Director, Interoperability and Imaging Informatics UPMC Saturday, June 8, 2013

Conflict of Interest Disclosure Rasu Shrestha, MD MBA

VP Medical Information Technology, UPMC

Medical Director, Interoperability & Imaging

Medical Advisory Board, GE Healthcare Medical Advisory Board, Vital Images Inc.

Medical Advisory Board, Nuance Inc. Editorial Board, Applied Radiology Advisory Board, KLAS Research

Growing role of Imaging in HIT

Increased utilization of imaging annotations & feature extractions to support care/research

Inclusion of images in regional, state, and national clinical data exchanges

Increased utilization of OE and DS algorithms to guide provider ordering behavior

Expansion of imaging to support advances in molecular medicine-based research

Integrated approach to managing imaging across the “ologies”

Growing diversity of modalities

• Increases detection of Invasive breast cancers by 40% in comparison to 2D mammography

• False-positive readings reduced by 15%

• Uncertain readings and patient call-backs reduced by 20-30%

Tomosynthesis

• Utilizes low-level X-rays to produce multiple images of the breast, layer by layer, using a swinging camera

• This layering of images makes it simpler to detect normal breast structures (milk ducts, lobules, fatty tissues, etc.) from cancerous ones

• Dense tissue is more easily examined through Tomography than traditional Mammography

Tomosynthesis

Reconstructed Slices {

Mammography vs Tomosynthesis

No lesion detected Lesion detected

Presenter

Presentation Notes

The pursuit of perfection; Nimble;

• Mammography has always been managed separately from the core PACS for a number of reasons

• With tomosynthesis, significant image management challenges

• Digital breast tomosynthesis adopters need to be aware of and plan for issues such as – Large file sizes – Proprietary file formats

“We’re special!”

• Data processing is manufacturer specific

Vendor Data processing

Hologic Back projection/ Shift and Add

Siemens Filtered back projection (like CT)

IMS Iterative reconstruction (like new CTs)

GE Iterative reconstruction algorithm

Dr Tim Wood, Clinical Scientist, Hull and East Yorkshire Hospitals, NHS Trust

• Get ready for a dramatic increase (x20) in the size of each study for which tomosynthesis is used in place of or in addition to conventional FFDM

Challenge: File size

2D Mammography Tomosynthesis

4 view (Full-field Digital Mammography, FFDM)

50- 100 slices/ view (depending on the size of the breast)

8- 54 MB/ single mammography image, uncompressed

450 MB/ single tomosynthesis image, uncompressed

32 – 216 MB (4 views) 1800 MB (4 views), Compressed to approx. 350 MB, not including projection views or an additional FFDM set

• Mammography Quality Standards Act (MQSA) does not permit lossy compression (like for CT studies)

• Will become more problematic as patients return or this becomes more of the standard workflow for screening

Challenge: File size

• Tomosynthesis greatly enhances the traditional challenges associated with FFDM display – hanging of multiple priors, – smoothly scrolling at a rapid frame rate

synchronized with same-size contralateral and prior views

• Challenges: – Computational requirements for efficient display – Network bandwidth for high throughput reading in

screening settings or telemammography

Challenge: Display

• IHE Mammography Image Integration Profile – Additional extension/s to accommodate

tomosynthesis viewing • Tomosynthesis CAD

– New questions on how display systems will interpret and render the CAD marks

Challenge: Viewing Interoperability

• PACS upgrade – DICOM SOP Class for proper support of tomosynthesis – If PACS is upgraded to allow view of standard new tomo data, all

old tomo data must be converted to be viewed in new workflow

• Use of proprietary format – Hides pixel data in private attributes inside a secondary capture

DICOM object – Makes users dependent on proprietary workstation – Archive filled with priors that are unusable by 3rd parties without

tricky conversions • Same challenges too for patient CD/DVDs or Cloud

– Projection images can be saved to PACS, but cannot be viewed

Challenge: Migration

• Be aware of the challenges: size, features, interoperability, migration

• Make bandwidth and underlying infrastructure more robust

• Stay in sync with your PACS vendors on developments related to tomosynthesis

• Push vendors to avoid dependency on proprietary technologies – DICOM Standard Breast Tomosynthesis object,

rather than proprietary formats

So what’s one to do?

T H AN K Y O U

Emai l : sh res tharb@upmc.edu

Tw i t te r : @RasuShres tha