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Foreword

This DICOM Standard was developed according to the procedures of the DICOM Standards Committee.

The DICOM Standard is structured as a multi-part document using the guidelines established in [ISO/IEC Directives, Part 2].

PS3.1 should be used as the base reference for the current parts of this Standard.

1 Scope and Field of Application

This Part of the DICOM Standard contains explanatory information in the form of Normative and Informative Annexes.

2 Normative References

The following standards contain provisions which, through reference in this text, constitute provisions of this Standard. At the time of publication, the editions indicated were valid. All standards are subject to revision, and parties to agreements based on this Standard are encouraged to investigate the possibilities of applying the most recent editions of the standards indicated below.

2.1 International Organization for Standardization (ISO) and International Electrotechnical Commission (IEC)

[ISO/IEC Directives, Part 2] ISO/IEC. 2016/05. 7.0. Rules for the structure and drafting of International Standards. http://www.iec.ch/members_experts/refdocs/iec/isoiecdir-2%7Bed7.0%7Den.pdf .

2.2 Other References

[IHE RAD TF-1] IHE International. 2020. Integrating the Healthcare Enterprise Radiology Technical Framework Volume 1 Integration Profiles. http://www.ihe.net/uploadedFiles/Documents/Radiology/IHE_RAD_TF_Vol1.pdf .

[IHE RAD TF-2] IHE International. 2020. Integrating the Healthcare Enterprise Radiology Technical Framework Volume 2 Transactions. http://www.ihe.net/uploadedFiles/Documents/Radiology/IHE_RAD_TF_Vol2.pdf .

[RFC7233] IETF. June 2014. Hypertext Transfer Protocol (HTTP/1.1): Range Requests. http://tools.ietf.org/html/rfc7233 .

3 Definitions

For the purposes of this Standard the following definitions apply.

3.1 DICOM Introduction and Overview Definitions

This Part of the Standard makes use of the following terms defined in PS3.1:

Attribute: See Attribute in PS3.1 .
Service-Object Pair Class (SOP Class): See Service-Object Pair Class in PS3.1

3.2 DICOM Conformance

This Part of the Standard makes use of the following terms defined in PS3.2:

Standard Attribute: See Standard Attribute in PS3.2
Private Attribute: See Private Attribute in PS3.2

3.3 Information Object Definitions:

This Part of the Standard makes use of the following terms defined in PS3.3:

Attribute Tag: See Attribute Tag in PS3.3 .
Code Sequence Attribute: See Code Sequence Attribute in PS3.3 .
Information Object Definition (IOD): See Information Object Definition in PS3.3 .
Multi-frame Image: See Multi-frame Image in PS3.3 .

3.4 DICOM Service Class Specifications Definitions

This Part of the Standard makes use of the following terms defined in PS3.4:

Service-Object Pair Instance (SOP Instance): See Service-Object Pair Instance in PS3.4

3.5 DICOM Data Structures and Encoding

This Part of the Standard makes use of the following terms defined in PS3.5:

Data Set: See Data Set in PS3.5 .
Value: See Value in PS3.5 .
Value Representation (VR): See Value Representation in PS3.5 .

3.6 Structured Report Definitions

This Part of the Standard makes use of the following terms defined in PS3.3:

Content Item: See Content Item in PS3.3 .
Content Tree: See Content Tree in PS3.3 .

4 Symbols and Abbreviations

The following symbols and abbreviations are used in this Part of the Standard.

FHIR: HL7 Fast Healthcare Interoperability Resources (draft standard)

5 Conventions

Terms listed in Section 3 are capitalized throughout the document.

A Explanation of Patient Orientation (Normative)

This Annex was formerly located in Annex E “Explanation of Patient Orientation (Retired)” in PS3.3 in the 2003 and earlier revisions of the Standard.

This Annex provides an explanation of how to use the patient orientation data elements.

Figure A-1. Standard Anatomic Position Directions - Whole Body

Figure A-2. Standard Anatomic Position Directions - Hand

Figure A-3. Standard Anatomic Position Directions - Foot

As for the hand, the direction labels are based on the foot in the standard anatomic position. For the right foot, for example, RIGHT will be in the direction of the 5th toe. This assignment will remain constant through movement or positioning of the extremity. This is also true of the HEAD and FOOT directions.

Figure A-4. Views - Anterior and Lateral

Figure A-5. Planes - Whole Body - Transverse

Figure A-6. Planes - Whole Body - Sagittal

Figure A-7. Planes - Whole Body - Coronal

Figure A-8. Planes - Hand

Figure A-9. Planes - Double Obliquity

Figure A-10. Standard Anatomic Position Directions - Paired Hands

Figure A-11. Breast - MedioLateral Oblique

Figure A-12. Panoramic Zonogram Directions

B Integration of Modality Worklist and Modality Performed Procedure Step in The Original DICOM Standard (Informative)

This Annex was formerly located in Annex G “Integration of Modality Worklist and Modality Performed Procedure Step in the Original DICOM Standard (Retired)” in PS3.3 in the 2003 and earlier revisions of the Standard.

DICOM was published in 1993 and effectively addresses image communication for a number of modalities and Image Management functions for a significant part of the field of medical imaging. Since then, many additional medical imaging specialties have contributed to the extension of the DICOM Standard and developed additional Image Object Definitions. Furthermore, there have been discussions about the harmonization of the DICOM Real-World domain model with other standardization bodies. This effort has resulted in a number of extensions to the DICOM Standard. The integration of the Modality Worklist and Modality Performed Procedure Step address an important part of the domain area that was not included initially in the DICOM Standard. At the same time, the Modality Worklist and Modality Performed Procedure Step integration make steps in the direction of harmonization with other standardization bodies (CEN TC 251, HL7, etc.).

The purpose of this Annex is to show how the original DICOM Standard relates to the extension for Modality Worklist Management and Modality Performed Procedure Step. The two included figures outline the void filled by the Modality Worklist Management and Modality Performed Procedure Step specification, and the relationship between the original DICOM Data Model and the extended model.

Figure B-1. Functional View - Modality Worklist and Modality Performed Procedure Step Management in the Context of DICOM Service Classes

The management of a patient starts when the patient enters a physical facility (e.g., a hospital, a clinic, an imaging center) or even before that time. The DICOM Patient Management SOP Class provides many of the functions that are of interest to imaging departments. Figure B-1 is an example where one presumes that an order for a procedure has been issued for a patient. The order for an imaging procedure results in the creation of a Study Instance within the DICOM Study Management SOP Class. At the same time (A) the Modality Worklist Management SOP Class enables a modality operator to request the scheduling information for the ordered procedures. A worklist can be constructed based on the scheduling information. The handling of the requested imaging procedure in DICOM Study Management and in DICOM Worklist Management are closely related. The worklist also conveys patient/study demographic information that can be incorporated into the images.

Worklist Management is completed once the imaging procedure has started and the Scheduled Procedure Step has been removed from the Worklist, possibly in response to the Modality Performed Procedure Step (B). However, Study Management continues throughout all stages of the Study, including interpretation. The actual procedure performed (based on the request) and information about the images produced are conveyed by the DICOM Study Component SOP Class or the Modality Performed Procedure Step SOP Classes.

Figure B-2. Relationship of the Original Model and the Extensions for Modality Worklist and Modality Performed Procedure Step Management

Figure B-2 shows the relationship between the original DICOM Real-World model and the extensions of this Real-World model required to support the Modality Worklist and the Modality Performed Procedure Step. The new parts of the model add entities that are needed to request, schedule, and describe the performance of imaging procedures, concepts that were not supported in the original model. The entities required for representing the Worklist form a natural extension of the original DICOM Real-World model.

Common to both the original model and the extended model is the Patient entity. The Service Episode is an administrative concept that has been shown in the extended model in order to pave the way for future adaptation to a common model supported by other standardization groups including HL7, CEN TC 251 WG 3, CAP-IEC, etc. The Visit is in the original model but not shown in the extended model because it is a part of the Service Episode.

There is a 1 to 1 relationship between a Requested Procedure and the DICOM Study (A). A DICOM Study is the result of a single Requested Procedure. A Requested Procedure can result in only one Study.

A n:m relationship exists between a Scheduled Procedure Step and a Modality Performed Procedure Step (B). The concept of a Modality Performed Procedure Step is a superset of the Study Component concept contained in the original DICOM model. The Modality Performed Procedure Step SOP Classes provide a means to relate Modality Performed Procedure Steps to Scheduled Procedure Steps.

C Waveforms (Informative)

This Annex was formerly located in Annex J “Waveforms (Informative)” in PS3.3 in the 2003 and earlier revisions of the Standard.

C.1 Domain of Application

Waveform acquisition is part of both the medical imaging environment and the general clinical environment. Because of its broad use, there has been significant previous and complementary work in waveform standardization of which the following are particularly important:

ASTM E31.16 - E1467: Specification for Transferring Digital Neurophysiological Data Between Independent Computer Systems
CEN TC251 PT5-007 - prENV1064 draft: Standard Communications Protocol for Computer-Assisted Electrocardiography (SCP-ECG).
CEN TC251 PT5-021 - draft: Vital Signs Information Representation Standard (VITAL)
HL7 Automated Data SIG: HL7 Version 2.3, Chapter 7.14-20
IEEE P1073 - draft: Medical Information Bus Standard (MIB)
DICOM Section A.10 in PS3.3: Standalone Curve Information Object Definition

For DICOM, the domain of waveform standardization is waveform acquisition within the imaging context. It is specifically meant to address waveform acquisitions that will be analyzed with other data that is transferred and managed using the DICOM protocol. It allows the addition of waveform data to that context with minimal incremental cost. Further, it leverages the DICOM persistent object capability for maintaining referential relationships to other data collected in a multi-modality environment, including references necessary for multi-modality synchronization.

Waveform interchange in other clinical contexts may use different protocols more appropriate to those domains. In particular, HL7 may be used for transfer of waveform observations to general clinical information systems, and MIB may be used for real-time physiological monitoring and therapy.

The waveform information object definition in DICOM has been specifically harmonized at the semantic level with the HL7 waveform message format. The use of a common object model allows straightforward transcoding and interoperation between systems that use DICOM for waveform interchange and those that use HL7, and may be viewed as an example of common semantics implemented in the differing syntaxes of two messaging systems.

Note

HL7 allows transport of DICOM SOP Instances (information objects) encapsulated within HL7 messages. Since the DICOM and HL7 waveform semantics are harmonized, DICOM Waveform SOP Instances need not be transported as encapsulated data, as they can be transcoded to native HL7 Waveform Observation format.

C.2 Use Cases

The following are specific use case examples for waveforms in the imaging environment.

Case 1: Catheterization Laboratory - During a cardiac catheterization, several independent pieces of data acquisition equipment may be brought together for the exam. An electrocardiographic subsystem records surface ECG waveforms; an X-ray angiographic subsystem records motion images; a hemodynamic subsystem records intracardiac pressures from a sensor on the catheter. These subsystems send their acquired data by network to a repository. These data are assembled at an analytic workstation by retrieving from the repository. For a left ventriculographic procedure, the ECG is used by the physician to determine the time of maximum and minimum ventricular fill, and when coordinated with the angiographic images, an accurate estimate of the ejection fraction can be calculated. For a valvuloplasty procedure, the hemodynamic waveforms are used to calculate the pre-intervention and post-intervention pressure gradients.
Case 2: Electrophysiology Laboratory - An electrophysiological exam will capture waveforms from multiple sensors on a catheter; the placement of the catheter in the heart is captured on an angiographic image. At an analytic workstation, the exact location of the sensors can thus be aligned with a model of the heart, and the relative timing of the arrival of the electrophysiological waves at different cardiac locations can be mapped.
Case 3: Stress Exam - A stress exam may involve the acquisition of both ECG waveforms and echocardiographic ultrasound images from portable equipment at different stages of the test. The waveforms and the echocardiograms are output on an interchange disk, which is then input and read at a review station. The physician analyzes both types of data to make a diagnosis of cardiac health.

C.3 Time Synchronization Frame of Reference

Synchronization of acquisition across multiple modalities in a single study (e.g., angiography and electrocardiography) requires either a shared trigger, or a shared clock. A Synchronization Module within the Frame of Reference Information Entity specifies the synchronization mechanism. A common temporal environment used by multiple equipment is identified by a shared Synchronization Frame of Reference UID. How this UID is determined and distributed to the participating equipment is outside the scope of the Standard.

The method used for time synchronization of equipment clocks is implementation or site specific, and therefore outside the scope of this proposal. If required, standard time distribution protocols are available (e.g., NTP, IRIG, GPS).

An informative description of time distribution methods can be found at: http://web.archive.org/web/20001001065227/http://www.bancomm.com/cntpApp.htm

A second method of synchronizing acquisitions is to utilize a common reference channel (temporal fiducial), which is recorded in the data acquired from the several equipment units participating in a study, and/or that is used to trigger synchronized data acquisitions. For instance, the "X-ray on" pulse train that triggers the acquisition of frames for an X-ray angiographic SOP Instance can be recorded as a waveform channel in a simultaneously acquired hemodynamic waveform SOP Instance, and can be used to align the different object instances. Associated with this Supplement are proposed coded entry channel identifiers to specifically support this synchronization mechanism (DICOM Terminology Mapping Resource Context Group ID 3090).

C.4 Waveform Acquisition Model

Figure C.4-1 shows a canonical model of waveform data acquisition. A patient is the subject of the study. There may be several sensors placed at different locations on or in the patient, and waveforms are measurements of some physical quality (metric) by those sensors (e.g., electrical voltage, pressure, gas concentration, or sound). The sensor is typically connected to an amplifier and filter, and its output is sampled at constant time intervals and digitized. In most cases, several signal channels are acquired synchronously. The measured signal usually originates in the anatomy of the patient, but an important special case is a signal that originates in the equipment, either as a stimulus, such as a cardiac pacing signal, as a therapy, such as a radio frequency signal used for ablation, or as a synchronization signal.

Figure C.4-1. Waveform Acquisition Model

C.5 Waveform Information Model

The part of the composite information object that carries the waveform data is the Waveform Information Entity (IE). The Waveform IE includes the technical parameters of waveform acquisition and the waveform samples.

The information model, or internal organizational structure, of the Waveform IE is shown in Figure C.5-1. A waveform information object includes data from a continuous time period during which signals were acquired. The object may contain several multiplex groups, each defined by digitization with the same clock whose frequency is defined for the group. Within each multiplex group there will be one or more channels, each with a full technical definition. Finally, each channel has its set of digital waveform samples.

Figure C.5-1. DICOM Waveform Information Model

C.6 Harmonization With HL7

This Waveform IE definition is harmonized with the HL7 waveform semantic constructs, including the channel definition Attributes and the use of multiplex groups for synchronously acquired channels. The use of a common object model allows straightforward transcoding and interoperation between systems that use DICOM for waveform interchange and those that use HL7, and may be viewed as an example of common semantics implemented in the differing syntaxes of two messaging systems.

This section describes the congruence between the DICOM Waveform IE and the HL7 version 2.3 waveform message format (see HL7 version 2.3 Chapter 7, sections 7.14 - 7.20).

C.6.1 HL7 Waveform Observation

Waveforms in HL7 messages are sent in a set of OBX (Observation) Segments. Four subtypes of OBX segments are defined:

The CHN subtype defines one channel in a CD (Channel Definition) Data Type
The TIM subtype defines the start time of the waveform data in a TS (Time String) Data Type
The WAV subtype carries the waveform data in an NA (Numeric Array) or MA (Multiplexed Array) Data Type (ASCII encoded samples, character delimited)
The ANO subtype carries an annotation in a CE (Coded Entry) Data Type with a reference to a specific time within the waveform to which the annotation applies

Other segments of the HL7 message definition specify patient and study identification, whose harmonization with DICOM constructs is not defined in this Annex.

C.6.2 Channel Definition

The Waveform Module Channel Definition sequence Attribute (003A,0200) is defined in harmonization with the HL7 Channel Definition (CD) Data Type, in accordance with the following Table. Each Item in the Channel Definition sequence Attribute corresponds to an OBX Segment of subtype CHN.

Table C.6-1. Correspondence Between DICOM and HL7 Channel Definition

DICOM Attribute	DICOM Tag	HL7 CD Data Type Component
Waveform Channel Number	(003A,0202)	Channel Identifier (number&name)
Channel Label	(003A,0203)	Channel Identifier (number&name)
Channel Source Sequence	(003A,0208)	Waveform Source
Channel Source Modifier Sequence	(003A,0209)	Waveform Source
Channel Sensitivity	(003A,0210)	Channel Sensitivity and Units
Channel Sensitivity Units Sequence	(003A,0211)	Channel Sensitivity and Units
Channel Sensitivity Correction Factor	(003A,0212)	Channel Calibration Parameters (correctionfactor&baseline&timeskew)
Channel Baseline	(003A,0213)
Channel Time Skew	(003A,0214)
[Group] Sampling Frequency	(003A,001A)	Channel Sampling Frequency
Channel Minimum Value	(5400,0110)	Minimum and Maximum Data Values (minimum & maximum)
Channel Maximum Value	(5400,0112)	Minimum and Maximum Data Values (minimum & maximum)
Channel Offset	(003A,0218)	not defined in HL7
Channel Status	(003A,0205)
Filter Low Frequency	(003A,0220)
Filter High Frequency	(003A,0221)
Notch Filter Frequency	(003A,0222)
Notch Filter Bandwidth	(003A,0223)

In the DICOM information object definition, the sampling frequency is defined for the multiplex group, while in HL7 it is defined for each channel, but is required to be identical for all multiplexed channels.

Note that in the HL7 syntax, Waveform Source is a string, rather than a coded entry as used in DICOM. This should be considered in any transcoding between the two formats.

C.6.3 Timing

In HL7, the exact start time for waveform data is sent in an OBX Segment of subtype TIM. The corresponding DICOM Attributes, which must be combined to form the equivalent time string, are:

Acquisition DateTime	(0008,002A)
Multiplex Group Time Offset	(0018,1068)

C.6.4 Waveform Data

The DICOM binary encoding of data samples in the Waveform Data (5400,1010) corresponds to the ASCII representation of data samples in the HL7 OBX Segment of subtype WAV. The same channel-interleaved multiplexing used in the HL7 MA (Multiplexed Array) Data Type is used in the DICOM Waveform Data Attribute.

Because of its binary representation, DICOM uses several data elements to specify the precise encoding, as listed in the following Table. There are no corresponding HL7 data elements, since HL7 uses explicit character-delimited ASCII encoding of data samples.

Number of Waveform Channels	(003A,0005)
Number of Waveform Samples	(003A,0010)
Waveform Bits Stored	(003A,021A)
Waveform Bits Allocated	(5400,1004)
Waveform Sample Interpretation	(5400,1006)
Waveform Padding Value	(5400,100A)

C.6.5 Annotation

In HL7, Waveform Annotation is sent in an OBX Segment of subtype ANO, using the CE (Coded Entry) Data Type CE. This corresponds precisely to the DICOM Annotation using Coded Entry Sequences. However, HL7 annotation ROI is to a single point only (time reference), while DICOM allows reference to ranges of samples delimited by time or by explicit sample position.

C.7 Harmonization With SCP-ECG

The SCP-ECG standard is designed for recording routine resting electrocardiograms. Such ECGs are reviewed prior to cardiac imaging procedures, and a typical use case would be for SCP-ECG waveforms to be translated to DICOM for inclusion with the full cardiac imaging patient record.

SCP-ECG provides for either simultaneous or non-simultaneous recording of the channels, but does not provide a multiplexed data format (each channel is separately encoded). When translating to DICOM, each subset of simultaneously recorded channels may be encoded in a Waveform Sequence Item (multiplex group), and the delay to the recording of each multiplex group shall be encoded in the Multiplex Group Time Offset (0018,1068).

The electrode configuration of SCP-ECG Section 1 may be translated to the DICOM Acquisition Context (0040,0555) sequence items using TID 3401 “ECG Acquisition Context” and Context Groups 3263 and 3264.

The lead identification of SCP-ECG Section 3, a term coded as an unsigned integer, may be translated to the DICOM Waveform Channel Source (003A,0208) coded sequence using CID 3001 “ECG Lead”.

Pacemaker spike records of SCP-ECG Section 7 may be translated to items in the Waveform Annotations Sequence (0040,B020) with a code term from CID 3335 “ECG Annotation”. The annotation sequence item may record the spike amplitude in its Numeric Value and Measurement Units Attributes.

D SR Encoding Example (Informative)

This Annex was formerly located in Annex K “SR Encoding Example (Retired)” in PS3.3 in the 2003 and earlier revisions of the Standard.

The following is a simple and non-comprehensive illustration of the encoding of the Informative SR Content Tree Example in PS3.3.

SR Tree Depth	Nesting	Attribute	Tag	VR	VL (hex)	Value
		SOP Class UID	(0008,0016)	UI	001e	1.2.840.10008.5.1.4.1.1.88.33
		SOP Instance UID	(0008,0018)	UI	0012	1.2.3.4.5.6.7.300
		Study Date	(0008,0020)	DA	0008	19991029
		Content Date	(0008,0023)	DA	0008	19991029
		Study Time	(0008,0030)	TM	0006	154500
		Content Time	(0008,0033)	TM	0006	154510
		Accession Number	(0008,0050)	SH	0006	123456
		Modality	(0008,0060)	CS	0002	SR
		Manufacturer	(0008,0070)	LO	0004	WG6
		Referring Physician's Name	(0008,0090)	PN	0014	Luke^Will^^Dr.^M.D.
		Coding Scheme Identification Sequence	(0008,0110)	SQ	ffffffff
	%item
	>	Coding Scheme Designator	(0008,0102)	SH	000e	99STElsewhere
	>	Coding Scheme UID	(0008,010C)	UI	0010	1.2.3.4.6.7.8.91
	>	Responsible Organization	(0008,0116)	ST	0034	Informatics Dept St Elsewhere Hosp Boston, MA 02390
	%enditem
	%endseq
		Referenced Performed Procedure Step Sequence	(0008,1111)	SQ	ffffffff
	%endseq
		Patient's Name	(0010,0010)	PN	000e	Homer^Jane^^^
		Patient's ID	(0010,0020)	LO	0006	234567
		Patient's Birth Date	(0010,0030)	DA	0008	19991109
		Patient's Sex	(0010,0040)	CS	0002	F
		Study Instance UID	(0020,000D)	UI	0012	1.2.3.4.5.6.7.100
		Series Instance UID	(0020,000E)	UI	0012	1.2.3.4.5.6.7.200
		Study ID	(0020,0010)	SH	0006	345678
		Series Number	(0020,0011)	IS	0002	1
		Instance (formerly Image) Number	(0020,0013)	IS	0002	1
1		Value Type	(0040,a040)	CS	000a	CONTAINER
1		Concept Name Code Sequence	(0040,a043)	SQ	ffffffff
1	%item
1	>	Code Value	(0008,0100)	SH	0006	43468-8
1	>	Coding Scheme Designator	(0008,0102)	SH	0002	LN
1	>	Code Meaning	(0008,0104)	LO	000c	X-Ray Report
1	%enditem
	%endseq
1		Continuity Of Content	(0040,a050)	CS	0008	SEPARATE
		Verifying Observer Sequence	(0040,a073)	SQ	ffffffff
	%item
	>	Verifying Organization	(0040,a027)	LO	0004	WG6
	>	Verification DateTime	(0040,a030)	DT	000e	19991029154510
	>	Verifying Observer Name	(0040,a075)	PN	000e	Jones^Joe^^Dr^
	>	Verifying Observer Identification Code Sequence	(0040,a088)	SQ	ffffffff
	%item
	>>	Code Value	(0008,0100)	SH	0006	369842
	>>	Coding Scheme Designator	(0008,0102)	SH	000e	99STElsewhere
	>>	Code Meaning	(0008,0104)	LO	0006	369842
	%enditem
	%endseq
	%enditem
	%endseq
		Referenced Request Sequence	(0040,a370)	SQ	ffffffff
	%item
	>	Accession Number	(0008,0050)	SH	0006	123456
	>	Referenced Study Sequence	(0008,1110)	SQ	ffffffff
	%endseq
	>	Study Instance UID	(0020,000D)	UI	0012	1.2.3.4.5.6.7.100
	>	Requested Procedure Description	(0032,1060)	LO	000a	Chest Xray
	>	Requested Procedure Code Sequence	(0032,1064)	SQ	ffffffff
	%item
	>>	Code Value	(0008,0100)	SH	0006	42272-5
	>>	Coding Scheme Designator	(0008,0102)	SH	0002	LN
	>>	Code Meaning	(0008,0104)	LO	001a	Chest X-Ray PA and lateral
	%enditem
	%endseq
	>	Requested Procedure ID	(0040,1001)	SH	0006	012340
	>	Placer Order Number/Imaging Service Request	(0040,2016)	LO	0
	>	Filler Order Number/Imaging Service Request	(0040,2017)	LO	0
	%enditem
	%endseq
		Performed Procedure Code Sequence	(0040,a372)	SQ	ffffffff
	%item
	>	Code Value	(0008,0100)	SH	0006	42272-5
	>	Coding Scheme Designator	(0008,0102)	SH	0002	LN
	>	Code Meaning	(0008,0104)	LO	001a	Chest X-Ray PA and lateral
	%enditem
	%endseq
		Current Requested Procedure Evidence Sequence	(0040,a375)	SQ	ffffffff
	%item
	>	Referenced Series Sequence	(0008,1115)	SQ	ffffffff
	%item
	>>	Referenced SOP Sequence	(0008,1199)	SQ	ffffffff
	%item
	>>>	Referenced SOP Class UID	(0008,1150)	UI	0008	1.2.3.4
	>>>	Referenced SOP Instance UID	(0008,1155)	UI	000a	1.2.3.4.5
	%enditem
	%endseq
	>>	Series Instance UID	(0020,000E)	UI	0012	1.2.3.4.5.6.7.200
	%enditem
	%endseq
	>	Study Instance UID	(0020,000D)	UI	0012	1.2.3.4.5.6.7.100
	%enditem
	%endseq
		Completion Flag	(0040,a491)	CS	0008	COMPLETE
		Verification Flag	(0040,a493)	CS	0008	VERIFIED
1		Content Sequence	(0040,a730)	SQ	ffffffff
1.1	%item
1.1	>	Relationship Type	(0040,a010)	CS	0010	HAS OBS CONTEXT
1.1	>	Value Type	(0040,a040)	CS	0006	PNAME
1.1	>	Concept Name Code Sequence	(0040,a043)	SQ	ffffffff
1.1	%item
1.1	>>	Code Value	(0008,0100)	SH	0006	121008
1.1	>>	Coding Scheme Designator	(0008,0102)	SH	0004	DCM
1.1	>>	Code Meaning	(0008,0104)	LO	0014	Person Observer Name
1.1	%enditem
1.1	%endseq
1.1	>	Person Name	(0040,a123)	PN	0010	Smith^John^^Dr^
1.1	%enditem
1.2	%item
1.2	>	Relationship Type	(0040,a010)	CS	0010	HAS OBS CONTEXT
1.2	>	Value Type	(0040,a040)	CS	0006	UIDREF
1.2	>	Concept Name Code Sequence	(0040,a043)	SQ	ffffffff
1.2	%item
1.2	>>	Code Value	(0008,0100)	SH	0006	121018
1.2	>>	Coding Scheme Designator	(0008,0102)	SH	0004	DCM
1.2	>>	Code Meaning	(0008,0104)	LO	001c	Procedure Study Instance UID
1.2	%enditem
1.2	%endseq
1.2	>	UID	(0040,a124)	UI	0012	1.2.3.4.5.6.7.100
1.2	%enditem
1.3	%item
1.3	>	Relationship Type	(0040,a010)	CS	0010	HAS OBS CONTEXT
1.3	>	Value Type	(0040,a040)	CS	0006	PNAME
1.3	>	Concept Name Code Sequence	(0040,a043)	SQ	ffffffff
1.3	%item
1.3	>>	Code Value	(0008,0100)	SH	0006	121029
1.3	>>	Coding Scheme Designator	(0008,0102)	SH	0004	DCM
1.3	>>	Code Meaning	(0008,0104)	LO	000c	Subject Name
1.3	%enditem
1.3	%endseq
1.3	>	Person Name	(0040,a123)	PN	000e	Homer^Jane^^^
1.3	%enditem
1.4	%item
1.4	>	Relationship Type	(0040,a010)	CS	0008	CONTAINS
1.4	>	Value Type	(0040,a040)	CS	0004	CODE
1.4	>	Concept Name Code Sequence	(0040,a043)	SQ	ffffffff
1.4	%item
1.4	>>	Code Value	(0008,0100)	SH	0006	121071
1.4	>>	Coding Scheme Designator	(0008,0102)	SH	0004	DCM
1.4	>>	Code Meaning	(0008,0104)	LO	0008	Finding
1.4	%enditem
1.4	%endseq
1.4	>	Concept Code Sequence	(0040,a168)	SQ	ffffffff
1.4	%item
1.4	>>	Code Value	(0008,0100)	SH	000A	118538004
1.4	>>	Coding Scheme Designator	(0008,0102)	SH	0004	SCT
1.4	>>	Code Meaning	(0008,0104)	LO	0004	Mass
1.4	%enditem
1.4	%endseq
1.4	>	Content Sequence	(0040,a730)	SQ	ffffffff
1.4.1	%item
1.4.1	>>	Relationship Type	(0040,a010)	CS	000e	HAS PROPERTIES
1.4.1	>>	Value Type	(0040,a040)	CS	0004	NUM
1.4.1	>>	Concept Name Code Sequence	(0040,a043)	SQ	ffffffff
1.4.1	%item
1.4.1	>>>	Code Value	(0008,0100)	SH	0008	81827009
1.4.1	>>>	Coding Scheme Designator	(0008,0102)	SH	0004	SCT
1.4.1	>>>	Code Meaning	(0008,0104)	LO	0008	Diameter
1.4.1	%enditem
1.4.1	%endseq
1.4.1	>>	Measured Value Sequence	(0040,a300)	SQ	ffffffff
1.4.1	%item
1.4.1	>>>	Measurement Units Code Sequence	(0040,08ea)	SQ	ffffffff
1.4.1	%item
1.4.1	>>>>	Code Value	(0008,0100)	SH	0002	cm
1.4.1	>>>>	Coding Scheme Designator	(0008,0102)	SH	0004	UCUM
1.4.1	>>>>	Code Meaning	(0008,0104)	LO	0002	cm
1.4.1	%enditem
1.4.1	%endseq
1.4.1	>>>	Numeric Value	(0040,a30a)	DS	0004	1.3
1.4.1	%enditem
1.4.1	%endseq
1.4.1	%enditem
1.4.2	%item
1.4.2	>>	Relationship Type	(0040,a010)	CS	000e	HAS PROPERTIES
1.4.2	>>	Value Type	(0040,a040)	CS	0004	CODE
1.4.2	>>	Concept Name Code Sequence	(0040,a043)	SQ	ffffffff
1.4.2	%item
1.4.2	>>>	Code Value	(0008,0100)	SH	000A	112233002
1.4.2	>>>	Coding Scheme Designator	(0008,0102)	SH	0004	SCT
1.4.2	>>>	Code Meaning	(0008,0104)	LO	0006	Margin
1.4.2	%enditem
1.4.2	%endseq
1.4.2	>>	Concept Code Sequence	(0040,a168)	SQ	ffffffff
1.4.2	%item
1.4.2	>>>	Code Value	(0008,0100)	SH	0006	112136
1.4.2	>>>	Coding Scheme Designator	(0008,0102)	SH	0004	DCM
1.4.2	>>>	Code Meaning	(0008,0104)	LO	000a	Spiculated
1.4.2	%enditem
1.4.2	%endseq
1.4.2	%enditem
1.4	%endseq
1.4	%enditem
1.5	%item
1.5	>	Referenced SOP Sequence	(0008,1199)	SQ	ffffffff
1.5	%item
1.5	>>	Referenced SOP Class UID	(0008,1150)	UI	0008	1.2.3.4
1.5	>>	Referenced SOP Instance UID	(0008,1155)	UI	000a	1.2.3.4.5
1.5	%enditem
1.5	%endseq
1.5	>	Relationship Type	(0040,a010)	CS	0008	CONTAINS
1.5	>	Value Type	(0040,a040)	CS	0006	IMAGE
1.5	>	Concept Name Code Sequence	(0040,a043)	SQ	ffffffff
1.5	%item
1.5	>>	Code Value	(0008,0100)	SH	0006	121079
1.5	>>	Coding Scheme Designator	(0008,0102)	SH	0004	DCM
1.5	>>	Code Meaning	(0008,0104)	LO	0008	Baseline
1.5	%enditem
1.5	%endseq
1.5	%enditem
1.6	%item
1.6	>	Relationship Type	(0040,a010)	CS	0008	CONTAINS
1.6	>	Value Type	(0040,a040)	CS	000a	CONTAINER
1.6	>	Concept Name Code Sequence	(0040,a043)	SQ	ffffffff
1.6	%item
1.6	>>	Code Value	(0008,0100)	SH	0006	55110-1
1.6	>>	Coding Scheme Designator	(0008,0102)	SH	0002	LN
1.6	>>	Code Meaning	(0008,0104)	LO	000c	Conclusions
1.6	%enditem
1.6	%endseq
1.6		Continuity Of Content	(0040,a050)	CS	0008	SEPARATE
1.6	>	Content Sequence	(0040,a730)	SQ	ffffffff
1.6.1	%item
1.6.1	>>	Relationship Type	(0040,a010)	CS	0008	CONTAINS
1.6.1	>>	Value Type	(0040,a040)	CS	0004	CODE
1.6.1	>>	Concept Name Code Sequence	(0040,a043)	SQ	ffffffff
1.6.1	%item
1.6.1	>>>	Code Value	(0008,0100)	SH	0006	121077
1.6.1	>>>	Coding Scheme Designator	(0008,0102)	SH	0004	DCM
1.6.1	>>>	Code Meaning	(0008,0104)	LO	000a	Conclusion
1.6.1	%enditem
1.6.1	%endseq
1.6.1	>>	Concept Code Sequence	(0040,a168)	SQ	ffffffff
1.6.1	%item
1.6.1	>>>	Code Value	(0008,0100)	SH	0006	888000
1.6.1	>>>	Coding Scheme Designator	(0008,0102)	SH	000e	99STElsewhere
1.6.1	>>>	Code Meaning	(0008,0104)	LO	0014	Probable malignancy
1.6.1	%enditem
1.6.1	%endseq
1.6.1	>>	Content Sequence	(0040,a730)	SQ	ffffffff
1.6.1.1	%item
1.6.1.1	>>>	Relationship Type	(0040,a010)	CS	000e	INFERRED FROM
1.6.1.1	>>>	Referenced Content Item Identifier	(0040,db73)	UL	000c	0001,0004,0002
1.6.1.1	%enditem
1.6.1.2	%item
1.6.1.2	>>>	Relationship Type	(0040,a010)	CS	000e	INFERRED FROM
1.6.1.2	>>>	Referenced Content Item Identifier	(0040,db73)	UL	000c	0001,0007,0001
1.6.1.2	%enditem
1.6.1	%endseq
1.6.1	%enditem
1.6	%endseq
1.6	%enditem
1.7	%item
1.7	>	Relationship Type	(0040,a010)	CS	0008	CONTAINS
1.7	>	Value Type	(0040,a040)	CS	000a	CONTAINER
1.7	>	Concept Name Code Sequence	(0040,a043)	SQ	ffffffff
1.7	%item
1.7	>>	Code Value	(0008,0100)	SH	0006	59776-5
1.7	>>	Coding Scheme Designator	(0008,0102)	SH	0006	LN
1.7	>>	Code Meaning	(0008,0104)	LO	0008	Findings
1.7	%enditem
1.7	%endseq
1.7		Continuity Of Content	(0040,a050)	CS	0008	SEPARATE
1.7	>	Content Sequence	(0040,a730)	SQ	ffffffff
1.7.1	%item
1.7.1	>>	Relationship Type	(0040,a010)	CS	0008	CONTAINS
1.7.1	>>	Value Type	(0040,a040)	CS	0006	SCOORD
1.7.1	>>	Concept Name Code Sequence	(0040,a043)	SQ	ffffffff
1.7.1	%item
1.7.1	>>>	Code Value	(0008,0100)	SH	0006	121080
1.7.1	>>>	Coding Scheme Designator	(0008,0102)	SH	0004	DCM
1.7.1	>>>	Code Meaning	(0008,0104)	LO	001c	Best illustration of finding
1.7.1	%enditem
1.7.1	%endseq
1.7.1	>>	Content Sequence	(0040,a730)	SQ	ffffffff
1.7.1.1	%item
1.7.1.1	>>>	Referenced SOP Sequence	(0008,1199)	SQ	ffffffff
1.7.1.1	%item
1.7.1.1	>>>>	Referenced SOP Class UID	(0008,1150)	UI	0008	1.2.3.4
1.7.1.1	>>>>	Referenced SOP Instance UID	(0008,1155)	UI	000a	1.2.3.4.6
1.7.1.1	%enditem
1.7.1.1	%endseq
1.7.1.1	>>>	Relationship Type	(0040,a010)	CS	000e	SELECTED FROM
1.7.1.1	>>>	Value Type	(0040,a040)	CS	0006	IMAGE
1.7.1.1	%enditem
1.7.1	%endseq
1.7.1	>>	Graphic Data	(0070,0022)	FL	0020	0,0,0,0,0,0,0,0
1.7.1	>>	Graphic Type	(0070,0023)	CS	0008	POLYLINE
1.7.1	%enditem
1.7	%endseq
1.7	%enditem
1.8	%item
1.8	>	Relationship Type	(0040,a010)	CS	0010	HAS CONCEPT MOD
1.8	>	Value Type	(0040,a040)	CS	0004	CODE
1.8	>	Concept Name Code Sequence	(0040,a043)	SQ	ffffffff
1.8	%item
1.8	>>	Code Value	(0008,0100)	SH	000a	LP28726-5
1.8	>>	Coding Scheme Designator	(0008,0102)	SH	0002	LN
1.8	>>	Code Meaning	(0008,0104)	LO	0006	Views
1.8	%enditem
1.8	%endseq
1.8	>	Concept Code Sequence	(0040,a168)	SQ	ffffffff
1.8	%item
1.8	>>	Code Value	(0008,0100)	SH	000a	LP33431-5
1.8	>>	Coding Scheme Designator	(0008,0102)	SH	0002	LN
1.8	>>	Code Meaning	(0008,0104)	LO	000e	PA and Lateral
1.8	%enditem
1.8	%endseq
1.8	%enditem
1	%endseq

E Mammography CAD (Informative)

This Annex was formerly located in Annex L “Mammography CAD (Retired)” in PS3.3 in the 2003 and earlier revisions of the Standard.

E.1 Mammography CAD SR Content Tree Structure

The templates for the Mammography CAD SR IOD are defined in Mammography CAD SR IOD Templates in PS3.16 . Relationships defined in the Mammography CAD SR IOD templates are by-value, unless otherwise stated. Content Items referenced from another SR object instance, such as a prior Mammography CAD SR, are inserted by-value in the new SR object instance, with appropriate original source observation context. It is necessary to update Rendering Intent, and referenced Content Item identifiers for by-reference relationships, within Content Items paraphrased from another source.

Figure E.1-1. Top Levels of Mammography CAD SR Content Tree

The Document Root, Image Library, Summaries of Detections and Analyses, and CAD Processing and Findings Summary sub-trees together form the Content Tree of the Mammography CAD SR IOD. There are no constraints regarding the 1-n multiplicity of the Individual Impression/Recommendation or its underlying structure, other than the TID 4001 “Mammography CAD Overall Impression/Recommendation” and TID 4003 “Mammography CAD Individual Impression/Recommendation” requirements in PS3.16. Individual Impression/Recommendation containers may be organized, for example per image, per finding or composite feature, or some combination thereof.

Figure E.1-2. Summary of Detections and Analyses Levels of Mammography CAD SR Content Tree

The Summary of Detections and Summary of Analyses sub-trees identify the algorithms used and the work done by the CAD device, and whether or not each process was performed on one or more entire images or selected regions of images. The findings of the detections and analyses are not encoded in the summary sub-trees, but rather in the CAD Processing and Findings Summary sub-tree. CAD processing may produce no findings, in which case the sub-trees of the CAD Processing and Findings Summary sub-tree are incompletely populated. This occurs in the following situations:

All algorithms succeeded, but no findings resulted
Some algorithms succeeded, some failed, but no findings resulted
All algorithms failed

Note

If the tree contains no Individual Impression/Recommendation nodes and all attempted detections and analyses succeeded then the mammography CAD device made no findings.
Detections and Analyses that are not attempted are not listed in the Summary of Detections and Summary of Analyses trees.
If the code value of the Summary of Detections or Summary of Analyses codes in TID 4000 “Mammography CAD Document Root” is "Not Attempted" then no detail is provided as to which algorithms were not attempted.

Figure E.1-3. Example of Individual Impression/Recommendation Levels of Mammography CAD SR Content Tree

The shaded area in Figure E.1-3 demarcates information resulting from Detection, whereas the unshaded area is information resulting from Analysis. This distinction is used in determining whether to place algorithm identification information in the Summary of Detections or Summary of Analyses sub-trees.

The clustering of calcifications within a single image is considered to be a Detection process that results in a Single Image Finding. The spatial correlation of a calcification cluster in two views, resulting in a Composite Feature, is considered Analysis. The clustering of calcifications in a single image is the only circumstance in which a Single Image Finding can result from the combination of other Single Image Findings, which must be Individual Calcifications.

Once a Single Image Finding or Composite Feature has been instantiated, it may be referenced by any number of Composite Features higher in the tree.

E.2 Mammography CAD SR Observation Context Encoding

Any Content Item in the Content Tree that has been inserted (i.e., duplicated) from another SR object instance has a HAS OBS CONTEXT relationship to one or more Content Items that describe the context of the SR object instance from which it originated. This mechanism may be used to combine reports (e.g., Mammography CAD 1, Mammography CAD 2, Human).
By-reference relationships within Single Image Findings and Composite Features paraphrased from prior Mammography CAD SR objects need to be updated to properly reference Image Library Entries carried from the prior object to their new positions in the present object.

The Impression/Recommendation section of the SR Document Content Tree of a Mammography CAD SR IOD may contain a mixture of current and prior single image findings and composite features. The Content Items from current and prior contexts are target Content Items that have a by-value INFERRED FROM relationship to a Composite Feature Content Item. Content Items that come from a context other than the Initial Observation Context have a HAS OBS CONTEXT relationship to target Content Items that describe the context of the source document.

In Figure E.2-1, Composite Feature and Single Image Finding are current, and Single Image Finding (from Prior) is duplicated from a prior document.

Figure E.2-1. Example of Use of Observation Context

E.3 Mammography CAD SR Examples

The following is a simple and non-comprehensive illustration of an encoding of the Mammography CAD SR IOD for Mammography computer aided detection results. For brevity, some Mandatory Content Items are not included, such as several acquisition context Content Items for the images in the Image Library.

E.3.1 Example 1: Calcification and Mass Detection With No Findings

A mammography CAD device processes a typical screening mammography case, i.e., there are four films and no cancer. Mammography CAD runs both density and calcification detection successfully and finds nothing. The mammograms resemble:

Figure E.3-1. Mammograms as Described in Example 1

The Content Tree structure would resemble:

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	Mammography CAD Report		TID 4000
1.1	Image Library		TID 4000
1.1.1		IMAGE 1	TID 4020
1.1.1.1	Image Laterality	Right	TID 4020
1.1.1.2	Image View	Cranio-caudal	TID 4020
1.1.1.3	Study Date	19980101	TID 4020
1.1.2		IMAGE 2	TID 4020
1.1.2.1	Image Laterality	Left	TID 4020
1.1.2.2	Image View	Cranio-caudal	TID 4020
1.1.2.3	Study Date	19980101	TID 4020
1.1.3		IMAGE 3	TID 4020
1.1.3.1	Image Laterality	Right	TID 4020
1.1.3.2	Image View	Medio-lateral oblique	TID 4020
1.1.3.3	Study Date	19980101	TID 4020
1.1.4		IMAGE 4	TID 4020
1.1.4.1	Image Laterality	Left	TID 4020
1.1.4.2	Image View	Medio-lateral oblique	TID 4020
1.1.4.3	Study Date	19980101	TID 4020
1.2	CAD Processing and Findings Summary	All algorithms succeeded; without findings	TID 4001
1.3	Summary of Detections	Succeeded	TID 4000
1.3.1	Successful Detections		TID 4015
1.3.1.1	Detection Performed	Mammography breast density	TID 4017
1.3.1.1.1	Algorithm Name	"Density Detector"	TID 4019
1.3.1.1.2	Algorithm Version	"V3.7"	TID 4019
1.3.1.1.3		Reference to node 1.1.1	TID 4017
1.3.1.1.4		Reference to node 1.1.2	TID 4017
1.3.1.1.5		Reference to node 1.1.3	TID 4017
1.3.1.1.6		Reference to node 1.1.4	TID 4017
1.3.1.2	Detection Performed	Individual Calcification	TID 4017
1.3.1.2.1	Algorithm Name	"Calc Detector"	TID 4019
1.3.1.2.2	Algorithm Version	"V2.4"	TID 4019
1.3.1.2.3		Reference to node 1.1.1	TID 4017
1.3.1.2.4		Reference to node 1.1.2	TID 4017
1.3.1.2.5		Reference to node 1.1.3	TID 4017
1.3.1.2.6		Reference to node 1.1.4	TID 4017
1.4	Summary of Analyses	Not Attempted	TID 4000

E.3.2 Example 2: Calcification and Mass Detection With Findings

A mammography CAD device processes a screening mammography case with four films and a mass in the left breast. Mammography CAD runs both density and calcification detection successfully. It finds two densities in the LCC, one density in the LMLO, a cluster of two calcifications in the RCC and a cluster of 20 calcifications in the RMLO. It performs two clustering algorithms. One identifies individual calcifications and then clusters them, and the second simply detects calcification clusters. It performs mass correlation and combines one of the LCC densities and the LMLO density into a mass; the other LCC density is flagged Not for Presentation, therefore not intended for display to the end-user. The mammograms resemble:

Figure E.3-2. Mammograms as Described in Example 2

The Content Tree structure in this example is complex. Structural illustrations of portions of the Content Tree are placed within the Content Tree table to show the relationships of data within the tree. Some Content Items are duplicated (and shown in boldface) to facilitate use of the diagrams.

Figure E.3-3. Content Tree Root of Example 2 Content Tree

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	Mammography CAD Report		TID 4000
1.1	Image Library		TID 4000
1.2	CAD Processing and Findings Summary	All algorithms succeeded; with findings	TID 4001
1.3	Summary of Detections	Succeeded	TID 4000
1.4	Summary of Analyses	Succeeded	TID 4000

Figure E.3-4. Image Library Branch of Example 2 Content Tree

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.1	Image Library		TID 4000
1.1.1		IMAGE 1	TID 4020
1.1.1.1	Image Laterality	Right	TID 4020
1.1.1.2	Image View	Cranio-caudal	TID 4020
1.1.1.3	Study Date	19990101	TID 4020
1.1.2		IMAGE 2	TID 4020
1.1.2.1	Image Laterality	Left	TID 4020
1.1.2.2	Image View	Cranio-caudal	TID 4020
1.1.2.3	Study Date	19990101	TID 4020
1.1.3		IMAGE 3	TID 4020
1.1.3.1	Image Laterality	Right	TID 4020
1.1.3.2	Image View	Medio-lateral oblique	TID 4020
1.1.3.3	Study Date	19990101	TID 4020
1.1.4		IMAGE 4	TID 4020
1.1.4.1	Image Laterality	Left	TID 4020
1.1.4.2	Image View	Medio-lateral oblique	TID 4020
1.1.4.3	Study Date	19990101	TID 4020

Figure E.3-5. CAD Processing and Findings Summary Bifurcation of Example 2 Content Tree

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.2	CAD Processing and Findings Summary	All algorithms succeeded; with findings	TID 4001
1.2.1	Individual Impression/Recommendation		TID 4003
1.2.2	Individual Impression/Recommendation		TID 4003
1.2.3	Individual Impression/Recommendation		TID 4003
1.2.4	Individual Impression/Recommendation		TID 4003

Figure E.3-6. Individual Impression/Recommendation 1.2.1 from Example 2 Content Tree

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.2.1	Individual Impression/Recommendation		TID 4003
1.2.1.1	Rendering Intent	Presentation Required	TID 4003
1.2.1.2	Composite Feature	Mass	TID 4004
1.2.1.2.1	Rendering Intent	Presentation Required	TID 4004
1.2.1.2.2	Composite type	Target Content Items are related spatially	TID 4005
1.2.1.2.3	Scope of Feature	Feature was detected on multiple images	TID 4005
1.2.1.2.4	Algorithm Name	"Mass Maker"	TID 4019
1.2.1.2.5	Algorithm Version	"V1.9"	TID 4019
1.2.1.2.6	Single Image Finding	Mammography breast density	TID 4006
1.2.1.2.7	Single Image Finding	Mammography breast density	TID 4006

Figure E.3-7. Single Image Finding Density 1.2.1.2.6 from Example 2 Content Tree

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.2.1.2.6	Single Image Finding	Mammography breast density	TID 4006
1.2.1.2.6.1	Rendering Intent	Presentation Required	TID 4006
1.2.1.2.6.2	Algorithm Name	"Density Detector"	TID 4019
1.2.1.2.6.3	Algorithm Version	"V3.7"	TID 4019
1.2.1.2.6.4	Center	POINT	TID 4021
1.2.1.2.6.4.1		Reference to node 1.1.2	TID 4021
1.2.1.2.6.5	Outline	SCOORD	TID 4021
1.2.1.2.6.5.1		Reference to node 1.1.2	TID 4021

Figure E.3-8. Single Image Finding Density 1.2.1.2.7 from Example 2 Content Tree

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.2.1.2.7	Single Image Finding	Mammography breast density	TID 4006
1.2.1.2.7.1	Rendering Intent	Presentation Required	TID 4006
1.2.1.2.7.2	Algorithm Name	"Density Detector"	TID 4019
1.2.1.2.7.3	Algorithm Version	"V3.7"	TID 4019
1.2.1.2.7.4	Center	POINT	TID 4021
1.2.1.2.7.4.1		Reference to node 1.1.4	TID 4021
1.2.1.2.7.5	Outline	SCOORD	TID 4021
1.2.1.2.7.5.1		Reference to node 1.1.4	TID 4021
1.2.1.2.7.6	Area of Defined Region	1 cm²	TID 1401
1.2.1.2.7.6.1	Area Outline	SCOORD	TID 1401
1.2.1.2.7.6.1.1		Reference to node 1.1.4	TID 1401

Figure E.3-9. Individual Impression/Recommendation 1.2.2 from Example 2 Content Tree

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.2.2	Individual Impression/Recommendation		TID 4003
1.2.2.1	Rendering Intent	Not for Presentation	TID 4003
1.2.2.2	Single Image Finding	Mammography breast density	TID 4006
1.2.2.2.1	Rendering Intent	Not for Presentation	TID 4006
1.2.2.2.2	Algorithm Name	"Density Detector"	TID 4019
1.2.2.2.3	Algorithm Version	"V3.7"	TID 4019
1.2.2.2.4	Center	POINT	TID 4021
1.2.2.2.4.1		Reference to node 1.1.2	TID 4021
1.2.2.2.5	Outline	SCOORD	TID 4021
1.2.2.2.5.1		Reference to node 1.1.2	TID 4021

Figure E.3-10. Individual Impression/Recommendation 1.2.3 from Example 2 Content Tree

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.2.3	Individual Impression/Recommendation		TID 4003
1.2.3.1	Rendering Intent	Presentation Required	TID 4003
1.2.3.2	Single Image Finding	Calcification Cluster	TID 4006
1.2.3.2.1	Rendering Intent	Presentation Required	TID 4006
1.2.3.2.2	Algorithm Name	"Calc Cluster Detector"	TID 4019
1.2.3.2.3	Algorithm Version	"V2.4"	TID 4019
1.2.3.2.4	Center	POINT	TID 4021
1.2.3.2.4.1		Reference to node 1.1.3	TID 4021
1.2.3.2.5	Outline	SCOORD	TID 4021
1.2.3.2.5.1		Reference to node 1.1.3	TID 4021
1.2.3.2.6	Number of Calcifications	20	TID 4010

Figure E.3-11. Individual Impression/Recommendation 1.2.4 from Example 2 Content Tree

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.2.4	Individual Impression/Recommendation		TID 4003
1.2.4.1	Rendering Intent	Presentation Required	TID 4003
1.2.4.2	Single Image Finding	Calcification Cluster	TID 4006
1.2.4.2.1	Rendering Intent	Presentation Required	TID 4006
1.2.4.2.2	Algorithm Name	"Calc Clustering"	TID 4019
1.2.4.2.3	Algorithm Version	"V2.4"	TID 4019
1.2.4.2.4	Center	POINT	TID 4021
1.2.4.2.4.1		Reference to node 1.1.1	TID 4021
1.2.4.2.5	Outline	SCOORD	TID 4021
1.2.4.2.5.1		Reference to node 1.1.1	TID 4021
1.2.4.2.6	Number of Calcifications	2	TID 4010

Figure E.3-12. Single Image Finding 1.2.4.2.7 from Example 2 Content Tree

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.2.4.2.7	Single Image Finding	Individual Calcification	TID 4006
1.2.4.2.7.1	Rendering Intent	Presentation Optional	TID 4006
1.2.4.2.7.2	Algorithm Name	"Calc Detector"	TID 4019
1.2.4.2.7.3	Algorithm Version	"V2.4"	TID 4019
1.2.4.2.7.4	Center	POINT	TID 4021
1.2.4.2.7.4.1		Reference to node 1.1.1	TID 4021
1.2.4.2.7.5	Outline	SCOORD	TID 4021
1.2.4.2.7.5.1		Reference to node 1.1.1	TID 4021

Figure E.3-13. Single Image Finding 1.2.4.2.8 from Example 2 Content Tree

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.2.4.2.8	Single Image Finding	Individual Calcification	TID 4006
1.2.4.2.8.1	Rendering Intent	Presentation Optional	TID 4006
1.2.4.2.8.2	Algorithm Name	"Calc Detector"	TID 4019
1.2.4.2.8.3	Algorithm Version	"V2.4"	TID 4019
1.2.4.2.8.4	Center	POINT	TID 4021
1.2.4.2.8.4.1		Reference to node 1.1.1	TID 4021
1.2.4.2.8.5	Outline	SCOORD	TID 4021
1.2.4.2.8.5.1		Reference to node 1.1.1	TID 4021

Figure E.3-14. Summary of Detections Branch of Example 2 Content Tree

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.3	Summary of Detections	Succeeded	TID 4000
1.3.1	Successful Detections		TID 4015
1.3.1.1	Detection Performed	Mammography breast density	TID 4017
1.3.1.1.1	Algorithm Name	"Density Detector"	TID 4019
1.3.1.1.2	Algorithm Version	"V3.7"	TID 4019
1.3.1.1.3		Reference to node 1.1.1	TID 4017
1.3.1.1.4		Reference to node 1.1.2	TID 4017
1.3.1.1.5		Reference to node 1.1.3	TID 4017
1.3.1.1.6		Reference to node 1.1.4	TID 4017
1.3.1.2	Detection Performed	Individual Calcification	TID 4017
1.3.1.2.1	Algorithm Name	"Calc Detector"	TID 4019
1.3.1.2.2	Algorithm Version	"V2.4"	TID 4019
1.3.1.2.3		Reference to node 1.1.1	TID 4017
1.3.1.2.4		Reference to node 1.1.2	TID 4017
1.3.1.2.5		Reference to node 1.1.3	TID 4017
1.3.1.2.6		Reference to node 1.1.4	TID 4017
1.3.1.3	Detection Performed	Calcification Cluster	TID 4017
1.3.1.3.1	Algorithm Name	"Calc Clustering"	TID 4019
1.3.1.3.2	Algorithm Version	"V2.4"	TID 4019
1.3.1.3.3		Reference to node 1.1.1	TID 4017
1.3.1.4	Detection Performed	Calcification Cluster	TID 4017
1.3.1.4.1	Algorithm Name	"Calc Cluster Detector"	TID 4019
1.3.1.4.2	Algorithm Version	"V2.4"	TID 4019
1.3.1.4.3		Reference to node 1.1.1	TID 4017
1.3.1.4.4		Reference to node 1.1.2	TID 4017
1.3.1.4.5		Reference to node 1.1.3	TID 4017
1.3.1.4.6		Reference to node 1.1.4	TID 4017

Figure E.3-15. Summary of Analyses Branch of Example 2 Content Tree

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.4	Summary of Analyses	Succeeded	TID 4000
1.4.1	Successful Analyses		TID 4016
1.4.1.1	Analysis Performed	Mass Correlation	TID 4018
1.4.1.1.1	Algorithm Name	"Mass Maker"	TID 4019
1.4.1.1.2	Algorithm Version	"V1.9"	TID 4019
1.4.1.1.3		Reference to node 1.1.2	TID 4018
1.4.1.1.4		Reference to node 1.1.4	TID 4018

E.3.3 Example 3: Calcification and Mass Detection, Temporal Differencing With Findings

The patient in Example 2 returns for another mammogram. A more comprehensive mammography CAD device processes the current mammogram; analyses are performed that determine some Content Items for Overall and Individual Impression/Recommendations. Portions of the prior mammography CAD report (Example 2) are incorporated into this report. In the current mammogram the number of calcifications in the RCC has increased, and the size of the mass in the left breast has increased from 1 to 4 cm².

Figure E.3-16. Mammograms as Described in Example 3

Italicized entries (xxx) in the following table denote references to or by-value inclusion of Content Tree items reused from the prior Mammography CAD SR instance (Example 2).

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	Mammography CAD Report		TID 4000

While the Image Library contains references to Content Tree items reused from the prior Mammography CAD SR instance, the images are actually used in the mammography CAD analysis and are therefore not italicized as indicated above.

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.1	Image Library		TID 4000
1.1.1		IMAGE 1	TID 4020
1.1.1.1	Image Laterality	Right	TID 4020
1.1.1.2	Image View	Cranio-caudal	TID 4020
1.1.1.3	Study Date	20000101	TID 4020
1.1.2		IMAGE 2	TID 4020
1.1.2.1	Image Laterality	Left	TID 4020
1.1.2.2	Image View	Cranio-caudal	TID 4020
1.1.2.3	Study Date	20000101	TID 4020
1.1.3		IMAGE 3	TID 4020
1.1.3.1	Image Laterality	Right	TID 4020
1.1.3.2	Image View	Medio-lateral oblique	TID 4020
1.1.3.3	Study Date	20000101	TID 4020
1.1.4		IMAGE 4	TID 4020
1.1.4.1	Image Laterality	Left	TID 4020
1.1.4.2	Image View	Medio-lateral oblique	TID 4020
1.1.4.3	Study Date	20000101	TID 4020
1.1.5		IMAGE 5	TID 4020
1.1.5.1	Image Laterality	Right	TID 4020
1.1.5.2	Image View	Cranio-caudal	TID 4020
1.1.5.3	Study Date	19990101	TID 4020
1.1.6		IMAGE 6	TID 4020
1.1.6.1	Image Laterality	Left	TID 4020
1.1.6.2	Image View	Cranio-caudal	TID 4020
1.1.6.3	Study Date	19990101	TID 4020
1.1.7		IMAGE 7	TID 4020
1.1.7.1	Image Laterality	Right	TID 4020
1.1.7.2	Image View	Medio-lateral oblique	TID 4020
1.1.7.3	Study Date	19990101	TID 4020
1.1.8		IMAGE 8	TID 4020
1.1.8.1	Image Laterality	Left	TID 4020
1.1.8.2	Image View	Medio-lateral oblique	TID 4020
1.1.8.3	Study Date	19990101	TID 4020

Current year content:

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.2	CAD Processing and Findings Summary	All algorithms succeeded; with findings	TID 4001
1.2.1	Assessment Category	4 - Suspicious abnormality, biopsy should be considered	TID 4002
1.2.2	Recommend Follow-up Interval	0 days	TID 4002
1.2.3	Algorithm Name	"Mammogram Analyzer"	TID 4019
1.2.4	Algorithm Version	"V1.0"	TID 4019
1.2.5	Individual Impression/Recommendation		TID 4003
1.2.5.1	Rendering Intent	Presentation Required	TID 4003
1.2.5.2	Differential Diagnosis/Impression	Increase in size	TID 4002
1.2.5.3	Impression Description	"Worrisome increase in size"	TID 4002
1.2.5.4	Recommended Follow-up	Needle localization and biopsy	TID 4002
1.2.5.5	Certainty of impression	84%	TID 4002
1.2.5.6	Algorithm Name	"Lesion Analyzer"	TID 4019
1.2.5.7	Algorithm Version	"V1.0"	TID 4019
1.2.5.8	Composite Feature	Mass	TID 4004
1.2.5.8.1	Rendering Intent	Presentation Required	TID 4004
1.2.5.8.2	Composite type	Target Content Items are related temporally	TID 4005
1.2.5.8.3	Scope of Feature	Feature was detected on multiple images	TID 4005
1.2.5.8.4	Algorithm Name	"Temporal Change"	TID 4019
1.2.5.8.5	Algorithm Version	"V0.1"	TID 4019
1.2.5.8.6	Certainty of Feature	91%	TID 4005
1.2.5.8.7	Probability of Cancer	84%	TID 4005
1.2.5.8.8	Pathology	Invasive lobular carcinoma	TID 4005
1.2.5.8.9	Difference in Size	3 cm²	TID 4005
1.2.5.8.9.1		Reference to node 1.2.5.8.13.7.6	TID 4005
1.2.5.8.9.2		Reference to node 1.2.5.8.14.8.6	TID 4005
1.2.5.8.10	Lesion Density	High density	TID 4005
1.2.5.8.11	Shape	Lobular	TID 4005
1.2.5.8.12	Margins	Microlobulated	TID 4005
1.2.5.8.13	Composite Feature	Mass	TID 4004
1.2.5.8.13.1	Rendering Intent	Presentation Required	TID 4004
1.2.5.8.13.2	Composite type	Target Content Items are related spatially	TID 4005
1.2.5.8.13.3	Scope of Feature	Feature was detected on multiple images	TID 4005
1.2.5.8.13.4	Algorithm Name	"Mass Maker"	TID 4019
1.2.5.8.13.5	Algorithm Version	"V1.9"	TID 4019
1.2.5.8.13.6	Single Image Finding	Mammography breast density	TID 4006
1.2.5.8.13.6.1	Rendering Intent	Presentation Required	TID 4006
1.2.5.8.13.6.2	Algorithm Name	"Density Detector"	TID 4019
1.2.5.8.13.6.3	Algorithm Version	"V3.7"	TID 4019
1.2.5.8.13.6.4	Center	POINT	TID 4021
1.2.5.8.13.6.4.1		Reference to node 1.1.2	TID 4021
1.2.5.8.13.6.5	Outline	SCOORD	TID 4021
1.2.5.8.13.6.5.1		Reference to node 1.1.2	TID 4021
1.2.5.8.13.7	Single Image Finding	Mammography breast density	TID 4006
1.2.5.8.13.7.1	Rendering Intent	Presentation Required	TID 4006
1.2.5.8.13.7.2	Algorithm Name	"Density Detector"	TID 4019
1.2.5.8.13.7.3	Algorithm Version	"V3.7"	TID 4019
1.2.5.8.13.7.4	Center	POINT	TID 4021
1.2.5.8.13.7.4.1		Reference to node 1.1.4	TID 4021
1.2.5.8.13.7.5	Outline	SCOORD	TID 4021
1.2.5.8.13.7.5.1		Reference to node 1.1.4	TID 4021
1.2.5.8.13.7.6	Area of Defined Region	4 cm²	TID 1401
1.2.5.8.13.7.6.1	Area Outline	SCOORD	TID 1401
1.2.5.8.13.7.6. 1.1		Reference to node 1.1.4	TID 1401

Included content from prior mammography CAD report (see Example 2, starting with node 1.2.1.2)

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.2.5.8.14	Composite Feature	Mass	TID 4004
1.2.5.8.14.1	Rendering Intent	Presentation Required	TID 4004
1.2.5.8.14.2	Composite type	Target Content Items are related spatially	TID 4005
1.2.5.8.14.3	Scope of Feature	Feature was detected on multiple images	TID 4005
1.2.5.8.14.4	Algorithm Name	"Mass Maker"	TID 4019
1.2.5.8.14.5	Algorithm Version	"V1.9"	TID 4019
1.2.5.8.14.6	[Observation Context Content Items]		TID 4022
1.2.5.8.14.7	Single Image Finding	Mammography breast density	TID 4006
1.2.5.8.14.7.1	Rendering Intent	Presentation Required	TID 4006
1.2.5.8.14.7.2	Algorithm Name	"Density Detector"	TID 4019
1.2.5.8.14.7.3	Algorithm Version	"V3.7"	TID 4019
1.2.5.8.14.7.4	Center	POINT	TID 4021
1.2.5.8.14.7.4.1		Reference to node 1.1.6	TID 4021
1.2.5.8.14.7.5	Outline	SCOORD	TID 4021
1.2.5.8.14.7.5.1		Reference to node 1.1.6	TID 4021
1.2.5.8.14.8	Single Image Finding	Mammography breast density	TID 4006
1.2.5.8.14.8.1	Rendering Intent	Presentation Required	TID 4006
1.2.5.8.14.8.2	Algorithm Name	"Density Detector"	TID 4019
1.2.5.8.14.8.3	Algorithm Version	"V3.7"	TID 4019
1.2.5.8.14.8.4	Center	POINT	TID 4021
1.2.5.8.14.8.4.1		Reference to node 1.1.8	TID 4021
1.2.5.8.14.8.5	Outline	SCOORD	TID 4021
1.2.5.8.14.8.5.1		Reference to node 1.1.8	TID 4021
1.2.5.8.14.8.6	Area of Defined Region	1 cm²	TID 1401
1.2.5.8.14.8.6.1	Area Outline	SCOORD	TID 1401
1.2.5.8.14.8.6.1.1		Reference to node 1.1.8	TID 1401

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.2.6	Individual Impression/Recommendation		TID 4003
1.2.6.1	Rendering Intent	Not for Presentation	TID 4003
1.2.6.2	Single Image Finding	Mammography breast density	TID 4006
1.2.6.2.1	Rendering Intent	Not for Presentation	TID 4006
1.2.6.2.2	Algorithm Name	"Density Detector"	TID 4019
1.2.6.2.3	Algorithm Version	"V3.7"	TID 4019
1.2.6.2.4	Center	POINT	TID 4021
1.2.6.2.4.1		Reference to node 1.1.2	TID 4021
1.2.6.2.5	Outline	SCOORD	TID 4021
1.2.6.2.5.1		Reference to node 1.1.2	TID 4021
1.2.7	Individual Impression/Recommendation	INDIVIDUAL	TID 4003
1.2.7.1	Rendering Intent	Presentation Required	TID 4003
1.2.7.2	Single Image Finding	Calcification Cluster	TID 4006
1.2.7.2.1	Rendering Intent	Presentation Required	TID 4006
1.2.7.2.2	Algorithm Name	"Calc Cluster Detector"	TID 4019
1.2.7.2.3	Algorithm Version	"V2.4"	TID 4019
1.2.7.2.4	Center	POINT	TID 4021
1.2.7.2.4.1		Reference to node 1.1.3	TID 4021
1.2.7.2.5	Outline	SCOORD	TID 4021
1.2.7.2.5.1		Reference to node 1.1.3	TID 4021
1.2.7.2.6	Number of Calcifications	20	TID 4010
1.2.8	Individual Impression/Recommendation		TID 4003
1.2.8.1	Rendering Intent	Presentation Required	TID 4003
1.2.8.2	Differential Diagnosis/Impression	Increase in number of calcifications	TID 4002
1.2.8.3	Impression Description	"Calcification cluster has increased in size"	TID 4002
1.2.8.4	Recommended Follow-up	Magnification views	TID 4002
1.2.8.5	Certainty of impression	100%	TID 4002
1.2.8.6	Algorithm Name	"Lesion Analyzer"	TID 4019
1.2.8.7	Algorithm Version	"V1.0"	TID 4019
1.2.8.8	Composite Feature	Calcification Cluster	TID 4004
1.2.8.8.1	Rendering Intent	Presentation Required	TID 4004
1.2.8.8.2	Composite type	Target Content Items are related temporally	TID 4005
1.2.8.8.3	Scope of Feature	Feature was detected on multiple images	TID 4005
1.2.8.8.4	Algorithm Name	"Lesion Analyzer"	TID 4019
1.2.8.8.5	Algorithm Version	"V1.0"	TID 4019
1.2.8.8.6	Certainty of Feature	99%	TID 4005
1.2.8.8.7	Probability of Cancer	54%	TID 4005
1.2.8.8.8	Pathology	Intraductal carcinoma, low grade	TID 4005
1.2.8.8.9	Difference in Number of calcifications	4	TID 4005
1.2.8.8.9.1		Reference to node 1.2.8.8.12.6	TID 4005
1.2.8.8.9.2		Reference to node 1.2.8.8.13.6	TID 4005
1.2.8.8.10	Calcification type	Fine, linear, branching (casting)	TID 4005
1.2.8.8.11	Calcification distribution	Grouped or clustered	TID 4005
1.2.8.8.12	Single Image Finding	Calcification Cluster	TID 4006
1.2.8.8.12.1	Rendering Intent	Presentation Required	TID 4006
1.2.8.8.12.2	Algorithm Name	"Calc Clustering"	TID 4019
1.2.8.8.12.3	Algorithm Version	"V2.4"	TID 4019
1.2.8.8.12.4	Center	POINT	TID 4021
1.2.8.8.12.4.1		Reference to node 1.1.1	TID 4021
1.2.8.8.12.5	Outline	SCOORD	TID 4021
1.2.8.8.12.5.1		Reference to node 1.1.1	TID 4021
1.2.8.8.12.6	Number of Calcifications	6	TID 4010
1.2.8.8.12.7	Single Image Finding	Individual Calcification	TID 4006
1.2.8.8.12.7.1	Rendering Intent	Presentation Optional	TID 4006
1.2.8.8.12.7.2	Algorithm Name	"Calc Detector"	TID 4019
1.2.8.8.12.7.3	Algorithm Version	"V2.4"	TID 4019
1.2.8.8.12.7.4	Center	POINT	TID 4021
1.2.8.8.12.7.4.1		Reference to node 1.1.1	TID 4021
1.2.8.8.12.7.5	Outline	SCOORD	TID 4021
1.2.8.8.12.7.5.1		Reference to node 1.1.1	TID 4021
1.2.8.8.12.8	Single Image Finding	Individual Calcification	TID 4006
1.2.8.8.12.8.1	Rendering Intent	Presentation Optional	TID 4006
1.2.8.8.12.8.2	Algorithm Name	"Calc Detector"	TID 4019
1.2.8.8.12.8.3	Algorithm Version	"V2.4"	TID 4019
1.2.8.8.12.8.4	Center	POINT	TID 4021
1.2.8.8.12.8.4.1		Reference to node 1.1.1	TID 4021
1.2.8.8.12.8.5	Outline	SCOORD	TID 4021
1.2.8.8.12.8.5.1		Reference to node 1.1.1	TID 4021
1.2.8.8.12.9	Single Image Finding	Individual Calcification	TID 4006
1.2.8.8.12.9.1	Rendering Intent	Presentation Optional	TID 4006
1.2.8.8.12.9.2	Algorithm Name	"Calc Detector"	TID 4019
1.2.8.8.12.9.3	Algorithm Version	"V2.4"	TID 4019
1.2.8.8.12.9.4	Center	POINT	TID 4021
1.2.8.8.12.9.4.1		Reference to node 1.1.1	TID 4021
1.2.8.8.12.9.5	Outline	SCOORD	TID 4021
1.2.8.8.12.9.5.1		Reference to node 1.1.1	TID 4021
1.2.8.8.12.10	Single Image Finding	Individual Calcification	TID 4006
1.2.8.8.12.10.1	Rendering Intent	Presentation Optional	TID 4006
1.2.8.8.12.10.2	Algorithm Name	"Calc Detector"	TID 4019
1.2.8.8.12.10.3	Algorithm Version	"V2.4"	TID 4019
1.2.8.8.12.10.4	Center	POINT	TID 4021
1.2.8.8.12.10.4.1		Reference to node 1.1.1	TID 4021
1.2.8.8.12.10.5	Outline	SCOORD	TID 4021
1.2.8.8.12.10.5.1		Reference to node 1.1.1	TID 4021
1.2.8.8.12.11	Single Image Finding	Individual Calcification	TID 4006
1.2.8.8.12.11.1	Rendering Intent	Presentation Optional	TID 4006
1.2.8.8.12.11.2	Algorithm Name	"Calc Detector"	TID 4019
1.2.8.8.12.11.3	Algorithm Version	"V2.4"	TID 4019
1.2.8.8.12.11.4	Center	POINT	TID 4021
1.2.8.8.12.11.4.1		Reference to node 1.1.1	TID 4021
1.2.8.8.12.11.5	Outline	SCOORD	TID 4021
1.2.8.8.12.11.5.1		Reference to node 1.1.1	TID 4021
1.2.8.8.12.12	Single Image Finding	Individual Calcification	TID 4006
1.2.8.8.12.12.1	Rendering Intent	Presentation Optional	TID 4006
1.2.8.8.12.12.2	Algorithm Name	"Calc Detector"	TID 4019
1.2.8.8.12.12.3	Algorithm Version	"V2.4"	TID 4019
1.2.8.8.12.12.4	Center	POINT	TID 4021
1.2.8.8.12.12.4.1		Reference to node 1.1.1	TID 4021
1.2.8.8.12.12.5	Outline	SCOORD	TID 4021
1.2.8.8.12.12.5.1		Reference to node 1.1.1	TID 4021

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.2.8.8.13	Single Image Finding	Calcification Cluster	TID 4006
1.2.8.8.13.1	Rendering Intent	Presentation Required	TID 4006
1.2.8.8.13.2	Algorithm Name	"Calc Clustering"	TID 4019
1.2.8.8.13.3	Algorithm Version	"V2.4"	TID 4019
1.2.8.8.13.4	Center	POINT	TID 4021
1.2.8.8.13.4.1		Reference to node 1.1.5	TID 4021
1.2.8.8.13.5	Outline	SCOORD	TID 4021
1.2.8.8.13.5.1		Reference to node 1.1.5	TID 4021
1.2.8.8.13.6	Number of Calcifications	2	TID 4010
1.2.8.8.13.7	[Observation Context Content Items]		TID 4022
1.2.8.8.13.8	Single Image Finding	Individual Calcification	TID 4006
1.2.8.8.13.8.1	Rendering Intent	Presentation Optional	TID 4006
1.2.8.8.13.8.2	Algorithm Name	"Calc Detector"	TID 4019
1.2.8.8.13.8.3	Algorithm Version	"V2.4"	TID 4019
1.2.8.8.13.8.4	Center	POINT	TID 4021
1.2.8.8.13.8.4.1		Reference to node 1.1.5	TID 4021
1.2.8.8.13.8.5	Outline	SCOORD	TID 4021
1.2.8.8.13.8.5.1		Reference to node 1.1.5	TID 4021
1.2.8.8.13.9	Single Image Finding	Individual Calcification	TID 4006
1.2.8.8.13.9.1	Rendering Intent	Presentation Optional	TID 4006
1.2.8.8.13.9.2	Algorithm Name	"Calc Detector"	TID 4019
1.2.8.8.13.9.3	Algorithm Version	"V2.4"	TID 4019
1.2.8.8.13.9.4	Center	POINT	TID 4021
1.2.8.8.13.9.4.1		Reference to node 1.1.5	TID 4021
1.2.8.8.13.9.4	Outline	SCOORD	TID 4021
1.2.8.8.13.9.4.1		Reference to node 1.1.5	TID 4021

E.4 CAD Operating Point

Computer-aided detection algorithms often compute an internal "CAD score" for each Single Image Finding detected by the algorithm. In some implementations the algorithms then group the findings into "bins" as a function of their CAD score. The number of bins is a function of the algorithm and the manufacturer's implementation, and must be one or more. The bins allow an application that is displaying CAD marks to provide a number of operating points on the Free-response Receiver-Operating Characteristic (FROC) curve for the algorithm, as illustrated in Figure E.4-1.

Figure E.4-1. Free-response Receiver-Operating Characteristic (FROC) curve

This is accomplished by displaying all CAD marks of Rendering Intent "Presentation Required" or "Presentation Optional" according to the following rules:

if the display application's Operating Point is 0, only marks with a Rendering Intent = "Presentation Required" are displayed
if the display application's Operating Point is 1, then marks with a Rendering Intent = "Presentation Required" and marks with a Rendering Intent = "Presentation Optional" with a CAD Operating Point = 1 are displayed
if the display application's Operating Point is n, then marks with a Rendering Intent = "Presentation Required" and marks with a Rendering Intent = "Presentation Optional" with a CAD Operating Point <= n are displayed

E.5 Mammography CAD SR and For Processing / For Presentation Images

If a Mammography CAD SR Instance references Digital Mammography X-ray Image Storage - For Processing Instances, but a review workstation has access only to Digital Mammography X-Ray Image Storage - For Presentation Instances, the following steps are recommended in order to display such Mammography CAD SR content with Digital Mammography X-Ray Image - For Presentation Instances.

In most scenarios, the Mammography CAD SR Instance is assigned to the same DICOM Patient and Study as the corresponding Digital Mammography "For Processing" and "For Presentation" image Instances.
If a workstation has a Mammography CAD SR Instance, but does not have images for the same DICOM Patient and Study, the workstation may use the Patient and Study Attributes of the Mammography CAD SR Instance in order to Query/Retrieve the Digital Mammography "For Presentation" images for that Patient and Study.
Once a workstation has the Mammography CAD SR Instance and Digital Mammography "For Presentation" image Instances for the Patient and Study, the Source Image Sequence (0008,2112) Attribute of each Digital Mammography "For Presentation" Instance will reference the corresponding Digital Mammography "For Processing" Instance. The workstation can match the referenced Digital Mammography "For Processing" Instance to a Digital Mammography "For Processing" Instance referenced in the Mammography CAD SR.
The workstation should check for Spatial Locations Preserved (0028,135A) in the Source Image Sequence of each Digital Mammography "For Presentation" image Instance, to determine whether it is spatially equivalent to the corresponding Digital Mammography "For Processing" image Instance.
If the value of Spatial Locations Preserved (0028,135A) is YES, then the CAD results should be displayed.
If the value of Spatial Locations Preserved (0028,135A) is NO, then the CAD results should not be displayed.
If Spatial Locations Preserved (0028,135A) is not present, whether or not the images are spatially equivalent is not known. If the workstation chooses to proceed with attempting to display CAD results, then compare the Image Library (see TID 4020 “CAD Image Library Entry”) Content Item values of the Mammography CAD SR Instance to the associated Attribute values in the corresponding Digital Mammography "For Presentation" image Instance. The Content Items (111044, DCM, "Patient Orientation Row"), (111043, DCM, "Patient Orientation Column"), (111026, DCM, "Horizontal Pixel Spacing"), and (111066, DCM, "Vertical Pixel Spacing") may be used for this purpose. If the values do not match, the workstation needs to adjust the coordinates of the findings in the Mammography CAD SR content to match the spatial characteristics of the Digital Mammography "For Presentation" image Instance.

F Chest CAD (Informative)

This Annex was formerly located in Annex M “Chest CAD (Retired)” in PS3.3 in the 2003 and earlier revisions of the Standard.

F.1 Chest CAD SR Content Tree Structure

The templates for the Chest CAD SR IOD are defined in Annex A “Structured Reporting Templates (Normative)” in PS3.16. Relationships defined in the Chest CAD SR IOD templates are by-value, unless otherwise stated. Content Items referenced from another SR object instance, such as a prior Chest CAD SR, are inserted by-value in the new SR object instance, with appropriate original source observation context. It is necessary to update Rendering Intent, and referenced Content Item identifiers for by-reference relationships, within Content Items paraphrased from another source.

Figure F.1-1. Top Levels of Chest CAD SR Content Tree

The Document Root, Image Library, CAD Processing and Findings Summary, and Summaries of Detections and Analyses sub-trees together form the Content Tree of the Chest CAD SR IOD. See Annex E for additional explanation of the Summaries of Detections and Analyses sub-trees.

Figure F.1-2. Example of CAD Processing and Findings Summary Sub-Tree of Chest CAD SR Content Tree

The shaded area in Figure F.1-2 demarcates information resulting from Detection, whereas the unshaded area is information resulting from Analysis. This distinction is used in determining whether to place algorithm identification information in the Summary of Detections or Summary of Analyses sub-trees.

The identification of a lung nodule within a single image is considered to be a Detection, which results in a Single Image Finding. The temporal correlation of a lung nodule in two instances of the same view taken at different times, resulting in a Composite Feature, is considered Analysis.

Once a Single Image Finding or Composite Feature has been instantiated, it may be referenced by any number of Composite Features higher in the CAD Processing and Findings Summary sub-tree.

F.2 Chest CAD SR Observation Context Encoding

Any Content Item in the Content Tree that has been inserted (i.e., duplicated) from another SR object instance has a HAS OBS CONTEXT relationship to one or more Content Items that describe the context of the SR object instance from which it originated. This mechanism may be used to combine reports (e.g., Chest CAD SR 1, Chest CAD SR 2, Human).
By-reference relationships within Single Image Findings and Composite Features paraphrased from prior Chest CAD SR objects need to be updated to properly reference Image Library Entries carried from the prior object to their new positions in the present object.

The CAD Processing and Findings Summary section of the SR Document Content Tree of a Chest CAD SR IOD may contain a mixture of current and prior single image findings and composite features. The Content Items from current and prior contexts are target Content Items that have a by-value INFERRED FROM relationship to a Composite Feature Content Item. Content Items that come from a context other than the Initial Observation Context have a HAS OBS CONTEXT relationship to target Content Items that describe the context of the source document.

In Figure F.2-1, Composite Feature and Single Image Finding are current, and Single Image Finding (from Prior) is duplicated from a prior document.

Figure F.2-1. Example of Use of Observation Context

F.3 Chest CAD SR Examples

The following is a simple and non-comprehensive illustration of an encoding of the Chest CAD SR IOD for chest computer aided detection results. For brevity, some mandatory Content Items are not included, such as several acquisition context Content Items for the images in the Image Library.

F.3.1 Example 1: Lung Nodule Detection With No Findings

A chest CAD device processes a typical screening chest case, i.e., there is one image and no nodule findings. Chest CAD runs lung nodule detection successfully and finds nothing.

The chest radiograph resembles:

Figure F.3-1. Chest Radiograph as Described in Example 1

The Content Tree structure would resemble:

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	Chest CAD Report		TID 4100
1.1	Image Library		TID 4100
1.1.1		IMAGE 1	TID 4020
1.1.1.1	Image View	Postero-anterior	TID 4020
1.1.1.2	Study Date	19980101	TID 4020
1.2	CAD Processing and Findings Summary	All algorithms succeeded; without findings	TID 4101
1.3	Summary of Detections	Succeeded	TID 4100
1.3.1	Successful Detections		TID 4015
1.3.1.1	Detection Performed	Nodule	TID 4017
1.3.1.1.1	Algorithm Name	"Lung Nodule Detector"	TID 4019
1.3.1.1.2	Algorithm Version	"V1.3"	TID 4019
1.3.1.1.3		Reference to node 1.1.1	TID 4017
1.4	Summary of Analyses	Not Attempted	TID 4100

F.3.2 Example 2: Lung Nodule Detection With Findings and Anatomy/pathology Interpretation

A chest CAD device processes a screening chest case with one image, and a lung nodule detected. The chest radiograph resembles:

Figure F.3-2. Chest Radiograph as Described in Example 2

Figure F.3-3. Content Tree Root of Example 2 Content Tree

The Content Tree structure would resemble:

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	Chest CAD Report		TID 4100
1.1	Image Library		TID 4100
1.2	CAD Processing and Findings Summary	All algorithms succeeded; with findings	TID 4101
1.3	Summary of Detections	Succeeded	TID 4100
1.4	Summary of Analyses	Not Attempted	TID 4100

Figure F.3-4. Image Library Branch of Example 2 Content Tree

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.1	Image Library		TID 4100
1.1.1		IMAGE 1	TID 4020
1.1.1.1	Image View	Postero-anterior	TID 4020
1.1.1.2	Study Date	19990101	TID 4020

Figure F.3-5. CAD Processing and Findings Summary Portion of Example 2 Content Tree

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.2	CAD Processing and Findings Summary	All algorithms succeeded; with findings	TID 4101
1.2.1	Single Image Finding	Abnormal Opacity	TID 4104
1.2.1.1	Single Image Finding Modifier	Nodule	TID 4104
1.2.1.2	Rendering Intent	Presentation Required:…	TID 4104
1.2.1.3	Algorithm Name	"Lung Nodule Detector"	TID 4019
1.2.1.4	Algorithm Version	"V1.3"	TID 4019
1.2.1.5	Center	POINT	TID 4107
1.2.1.5.1		Reference to Node 1.1.1	TID 4107
1.2.1.6	Outline	POLYLINE	TID 4107
1.2.1.6.1		Reference to Node 1.1.1	TID 4107
1.2.1.7	Diameter	2 cm	TID 1400
1.2.1.7.1	Path	POLYLINE	TID 1400
1.2.1.7.1.1		Reference to Node 1.1.1	TID 1400

Figure F.3-6. Summary of Detections Portion of Example 2 Content Tree

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.3	Summary of Detections	Succeeded	TID 4100
1.3.1	Successful Detections		TID 4015
1.3.1.1	Detection Performed	Nodule	TID 4017
1.3.1.1.1	Algorithm Name	"Lung Nodule Detector"	TID 4019
1.3.1.1.2	Algorithm Version	"V1.3"	TID 4019
1.3.1.1.3		Reference to node 1.1.1	TID 4017

F.3.3 Example 3: Lung Nodule Detection, Temporal Differencing With Findings

The patient in Example 2 returns for another chest radiograph. A more comprehensive chest CAD device processes the current chest radiograph, and analyses are performed that determine some temporally related Content Items for Composite Features. Portions of the prior chest CAD report (Example 2) are incorporated into this report. In the current chest radiograph the lung nodule has increased in size.

Figure F.3-8. Chest radiographs as Described in Example 3

Italicized entries (xxx) in the following table denote references to or by-value inclusion of Content Tree items reused from the prior Chest CAD SR instance (Example 2).

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	Chest CAD Report		TID 4100

While the Image Library contains references to Content Tree items reused from the prior Chest CAD SR instance, the images are actually used in the chest CAD analysis and are therefore not italicized as indicated above.

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.1	Image Library		TID 4100
1.1.1		IMAGE 1	TID 4020
1.1.1.1	Image View	Postero-anterior	TID 4020
1.1.1.2	Study Date	20000101	TID 4020
1.1.2		IMAGE 2	TID 4020
1.1.2.1	Image View	Postero-anterior	TID 4020
1.1.2.2	Study Date	19990101	TID 4020

The CAD processing and findings consist of one composite feature, comprised of single image findings, one from each year. The temporal relationship allows a quantitative temporal difference to be calculated:

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1.2	CAD Processing and Findings Summary	All algorithms succeeded; with findings	TID 4101
1.2.1	Composite Feature	Abnormal Opacity	TID 4102
1.2.1.1	Composite Feature Modifier	Nodule	TID 4102
1.2.1.2	Rendering Intent	Presentation Required: …	TID 4102
1.2.1.3	Algorithm Name	"Nodule Change"	TID 4019
1.2.1.4	Algorithm Version	"V2.3"	TID 4019
1.2.1.5	Composite Type	Target Content Items are related temporally	TID 4103
1.2.1.6	Scope of Feature	Feature detected on multiple images	TID 4103
1.2.1.7	Certainty of Feature	85%	TID 4103
1.2.1.8	Difference in size	2 cm	TID 4103
1.2.1.8.1		Reference to Node 1.2.1.9.8	TID 4103
1.2.1.8.2		Reference to Node 1.2.1.10.8	TID 4103
1.2.1.9	Single Image Finding	Abnormal Opacity	TID 4104
1.2.1.9.1	Single Image Finding Modifier	Nodule	TID 4104
1.2.1.9.2	Rendering Intent	Presentation Required: …	TID 4104
1.2.1.9.3	Tracking Identifier	"Watchlist #1"	TID 4108
1.2.1.9.4	Algorithm Name	"Lung Nodule Detector"	TID 4019
1.2.1.9.5	Algorithm Version	"V1.3"	TID 4019
1.2.1.9.6	Center	POINT	TID 4107
1.2.1.9.6.1		Reference to Node 1.1.1	TID 4107
1.2.1.9.7	Outline	POLYLINE	TID 4107
1.2.1.9.7.1		Reference to Node 1.1.1	TID 4107
1.2.1.9.8	Diameter	4 cm	TID 1400
1.2.1.9.8.1	Path	POLYLINE	TID 1400
1.2.1.9.8.1.1		Reference to Node 1.1.1	TID 1400
1.2.1.10	Single Image Finding	Abnormal Opacity	TID 4104
1.2.1.10.1	Single Image Finding Modifier	Nodule	TID 4104
1.2.1.10.2	Rendering Intent	Presentation Required: …	TID 4104
1.2.1.10.3	[Observation Context Content Items]		TID 4022
1.2.1.10.4	Algorithm Name	"Lung Nodule Detector"	TID 4019
1.2.1.10.5	Algorithm Version	"V1.3"	TID 4019
1.2.1.10.6	Center	POINT	TID 4107
1.2.1.10.6.1		Reference to Node 1.1.2	TID 4107
1.2.1.10.7	Outline	POLYLINE	TID 4107
1.2.1.10.7.1		Reference to Node 1.1.2	TID 4107
1.2.1.10.8	Diameter	2 cm	TID 1400
1.2.1.10.8.1	Path	POLYLINE	TID 1400
1.2.1.10.8.1.1		Reference to Node 1.1.2	TID 1400
1.3	Summary of Detections	Succeeded	TID 4100
1.3.1	Successful Detections		TID 4015
1.3.1.1	Detection Performed	Nodule	TID 4017
1.3.1.1.1	Algorithm Name	"Lung Nodule Detector"	TID 4019
1.3.1.1.2	Algorithm Version	"V1.3"	TID 4019
1.3.1.1.3		Reference to node 1.1.1	TID 4017
1.4	Summary of Analyses	Succeeded	TID 4100
1.4.1	Successful Analyses		TID 4016
1.4.1.1	Analysis Performed	"Temporal correlation"	TID 4018
1.4.1.1.1	Algorithm Name	"Nodule Change"	TID 4019
1.4.1.1.2	Algorithm Version	"V2.3"	TID 4019
1.4.1.1.3		Reference to node 1.1.1	TID 4018
1.4.1.1.4		Reference to node 1.1.2	TID 4018

F.3.4 Example 4: Lung Nodule Detection in Chest Radiograph, Spatially Correlated With CT

The patient in Example 3 is called back for CT to confirm the Lung Nodule found in Example 3. The patient undergoes CT of the Thorax and the initial chest radiograph and CT slices are sent to a more comprehensive CAD device for processing. Findings are detected and analyses are performed that correlate findings from the two collections of data. Portions of the prior CAD report (Example 3) are incorporated into this report.

Figure F.3-9. Chest Radiograph and CT slice as described in Example 4

Italicized entries (xxx) in the following table denote references to or by-value inclusion of Content Tree items reused from the prior Chest CAD SR instance (Example 3).

Node	Code Meaning of Concept Name	Code Meaning of Example Value	TID
1	Chest CAD Report		TID 4100
1.1	Language of Content Item and Descendants	English	TID 1204
1.2	Image Library		TID 4100
1.3	CAD Processing and Findings Summary	All algorithms succeeded; with findings	TID 4101
1.4	Summary of Detections	Succeeded	TID 4100
1.5	Summary of Analyses	Succeeded	TID 4100

While the Image Library contains references to Content Tree items reused from the prior Chest CAD SR instance, the images are actually used in the CAD analysis and are therefore not italicized as indicated above.

Node	Code Meaning of Concept Name	Code Meaning of Example Value	TID
1.2	Image Library		TID 4100
1.2.1		IMAGE 1	TID 4020
1.2.1.1	Image View	Postero-anterior	TID 4020
1.2.1.2	Study Date	20000101	TID 4020

Most recent examination content:

Node	Code Meaning of Concept Name	Code Meaning of Example Value	TID
1.3	CAD Processing and Findings Summary	All algorithms succeeded; with findings	TID 4101
1.3.1	Composite Feature	Abnormal opacity	TID 4102

Node	Code Meaning of Concept Name	Code Meaning of Example Value	TID
1.3.1	Composite Feature	Abnormal opacity	TID 4102
1.3.1.1	Composite Feature Modifier	Nodule	TID 4102
1.3.1.2	Rendering Intent	Presentation Required: …	TID 4102
1.3.1.3	Tracking Identifier	"Watchlist #1"	TID 4108
1.3.1.4	Algorithm Name	"Chest/CT Correlator"	TID 4019
1.3.1.5	Algorithm Version	"V2.1"	TID 4019
1.3.1.6	Composite type	Target Content Items are related spatially	TID 4103
1.3.1.7	Scope of Feature	Feature detected on images from multiple modalities	TID 4103
1.3.1.8	Diameter	4 cm	TID 1400
1.3.1.8.1	Path		TID 1400
1.3.1.8.1.1		IMAGE 3 [CT slice 104]	TID 1400
1.3.1.9	Volume estimated from single 2D region	3.2 cm3	TID 1402
1.3.1.9.1	Perimeter Outline		TID 1402
1.3.1.9.1.1		IMAGE 3 [CT slice 104]	TID 1402
1.3.1.10	Size Descriptor	Small	TID 4105
1.3.1.11	Border Shape	Lobulated	TID 4105
1.3.1.12	Location in Chest	Mid lobe	TID 4105
1.3.1.13	Laterality	Right	TID 4105
1.3.1.14	Composite Feature	Abnormal opacity	TID 4102
1.3.1.15	Single Image Finding	Abnormal opacity	TID 4104

Node	Code Meaning of Concept Name	Code Meaning of Example Value	TID
1.3.1.14	Composite Feature	Abnormal opacity	TID 4102
1.3.1.14.1	Composite Feature Modifier	Nodule	TID 4102
1.3.1.14.2	Rendering Intent	Presentation Required: …	TID 4102
1.3.1.14.3	Tracking Identifier	"Nodule #1"	TID 4108
1.3.1.14.4	Algorithm Name	"Nodule Builder"	TID 4019
1.3.1.14.5	Algorithm Version	"V1.4"	TID 4019
1.3.1.14.6	Composite type	Target Content Items are related spatially	TID 4103
1.3.1.14.7	Scope of Feature	Feature detected on multiple images	TID 4103
1.3.1.14.8	Diameter	4 cm	TID 1400
1.3.1.14.9	Volume estimated from single 2D region	3.2 cm3	TID 1402
1.3.1.14.10	Single Image Finding	Abnormal opacity	TID 4104
1.3.1.14.11	Single Image Finding	Abnormal opacity	TID 4104
1.3.1.14.12	Single Image Finding	Abnormal opacity	TID 4104

Node	Code Meaning of Concept Name	Code Meaning of Example Value	TID
1.3.1.14.10	Single Image Finding	Abnormal opacity	TID 4104
1.3.1.14.10.1	Single Image Finding Modifier	Nodule	TID 4104
1.3.1.14.10.2	Rendering Intent	Presentation Required: …	TID 4104
1.3.1.14.10.3	Tracking Identifier	"Detection #1"	TID 4108
1.3.1.14.10.4	Algorithm Name	"CT Nodule Detector"	TID 4019
1.3.1.14.10.5	Algorithm Version	"V2.5"	TID 4019
1.3.1.14.10.6	Center	POINT	TID 4107
1.3.1.14.10.6.1		IMAGE 2 [CT slice 103]	TID 4107
1.3.1.14.10.7	Outline	POLYLINE	TID 4107
1.3.1.14.10.7.1		IMAGE 2 [CT slice 103]	TID 4107

Node	Code Meaning of Concept Name	Code Meaning of Example Value	TID
1.3.1.14.11	Single Image Finding	Abnormal opacity	TID 4104
1.3.1.14.11.1	Single Image Finding Modifier	Nodule	TID 4104
1.3.1.14.11.2	Rendering Intent	Presentation Required: …	TID 4104
1.3.1.14.11.3	Tracking Identifier	"Detection #2"	TID 4108
1.3.1.14.11.4	Algorithm Name	"CT Nodule Detector"	TID 4019
1.3.1.14.11.5	Algorithm Version	"V2.5"	TID 4019
1.3.1.14.11.6	Center	POINT	TID 4107
1.3.1.14.11.6.1		IMAGE 3 [CT slice 104]	TID 4107
1.3.1.14.11.7	Outline	POLYLINE	TID 4107
1.3.1.14.11.7.1		IMAGE 3 [CT slice 104]	TID 4107

Node	Code Meaning of Concept Name	Code Meaning of Example Value	TID
1.3.1.14.12	Single Image Finding	Abnormal opacity	TID 4104
1.3.1.14.12.1	Single Image Finding Modifier	Nodule	TID 4104
1.3.1.14.12.2	Rendering Intent	Presentation Required: …	TID 4104
1.3.1.14.12.3	Tracking Identifier	"Detection #3"	TID 4108
1.3.1.14.12.4	Algorithm Name	"CT Nodule Detector"	TID 4019
1.3.1.14.12.5	Algorithm Version	"V2.5"	TID 4019
1.3.1.14.12.6	Center	POINT	TID 4107
1.3.1.14.12.6.1		IMAGE 4 [CT slice 105]	TID 4107
1.3.1.14.12.7	Outline	POLYLINE	TID 4107
1.3.1.14.12.7.1		IMAGE 4 [CT slice 105]	TID 4107

Node	Code Meaning of Concept Name	Code Meaning of Example Value	TID
1.3.1.15	Single Image Finding	Abnormal opacity	TID 4104
1.3.1.15.1	Single Image Finding Modifier	Nodule	TID 4104
1.3.1.15.2	Rendering Intent	Presentation Required: …	TID 4104
1.3.1.15.3	Tracking Identifier	"Watchlist #1"	TID 4108
1.3.1.15.4	[Observation Context Content Items]		TID 4022
1.3.1.15.5	Algorithm Name	"Lung Nodule Detector"	TID 4019
1.3.1.15.6	Algorithm Version	"V1.3"	TID 4019
1.3.1.15.7	Center	POINT	TID 4107
1.3.1.15.7.1		Reference to node 1.2.1	TID 4107
1.3.1.15.8	Outline	POLYLINE	TID 4107
1.3.1.15.8.1		Reference to node 1.2.1	TID 4107
1.3.1.15.9	Diameter	4 cm	TID 1400
1.3.1.15.9.1	Path	POLYLINE	TID 1400
1.3.1.15.9.1.1		Reference to Node 1.2.1	TID 1400

Node	Code Meaning of Concept Name	Code Meaning of Example Value	TID
1.4	Summary of Detections	Succeeded	TID 4100
1.4.1	Successful Detections		TID 4015
1.4.1.1	Detection Performed	Nodule	TID 4017
1.4.1.1.1	Algorithm Name	"CT Nodule Detector"	TID 4019
1.4.1.1.2	Algorithm Version	"V2.5"	TID 4019
1.4.1.1.3		IMAGE 2 [CT slice 103]	TID 4017
1.4.1.1.4		IMAGE 3 [CT slice 104]	TID 4017
1.4.1.1.5		IMAGE 4 [CT slice 105]	TID 4017
1.5	Summary of Analyses	Succeeded	TID 4100
1.5.1	Successful Analyses		TID 4016
1.5.1.1	Analysis Performed	"Spatial colocation analysis"	TID 4018
1.5.1.1.1	Algorithm Name	"Chest/CT Correlator"	TID 4019
1.5.1.1.2	Algorithm Version	"V2.1"	TID 4019
1.5.1.1.3		Reference to node 1.2.1	TID 4018
1.5.1.1.4		IMAGE 2 [CT slice 103]	TID 4018
1.5.1.1.5		IMAGE 3 [CT slice 104]	TID 4018
1.5.1.1.6		IMAGE 4 [CT slice 105]	TID 4018
1.5.1.2	Analysis Performed	"Spatial colocation analysis"	TID 4018
1.5.1.2.1	Algorithm Name	"Nodule Builder"	TID 4019
1.5.1.2.2	Algorithm Version	"V1.4"	TID 4019
1.5.1.2.3		IMAGE 2 [CT slice 103]	TID 4018
1.5.1.2.4		IMAGE 3 [CT slice 104]	TID 4018
1.5.1.2.5		IMAGE 4 [CT slice 105]	TID 4018

G Explanation of Grouping Criteria For Multi-frame Functional Group IODs (Informative)

This Annex was formerly located in Annex N “Explanation of Grouping Criteria for Multi-frame Functional Group IODs (Retired)” in PS3.3 in the 2003 and earlier revisions of the Standard.

When considering how to group an Attribute, one needs to consider first of all whether or not the values of an Attribute are different per frame. The reasons to consider whether to allow an Attribute to change include:

The more Attributes that change, the more parsing a receiving application has to do in order to determine if the multi-frame object has frames the application should deal with. The more choices, the more complex the application becomes, potentially resulting in interoperability problems.
The frequency of change of an Attribute must also be considered. If an Attribute could be changed every frame then obviously it is not a very good candidate for making it fixed, since this would result in a multi-frame size of 1.
The number of applications that depend on frame level Attribute grouping is another consideration. For example, one might imagine a pulse sequence being changed in a real-time acquisition, but the vast majority of acquisitions would leave this constant. Therefore, it was judged not too large a burden to force an acquisition device to start a new object when this happens. Obviously, this is a somewhat subjective decision, and one should take a close look at the Attributes that are required to be fixed in this document.
The Attributes from the image pixel module must not change in a multi-frame object due to legacy tool kits and implementations.
The potential frequency of change is dependent on the applications both now and likely during the life of this Standard. The penalty for failure to allow an Attribute to change is rather high since it will be hard/impossible to change later. Making an Attribute variable that is static is more complex and could result in more header space usage depending on how it is grouped. Thus there is a trade-off of complexity and potentially header size with not being able to take advantage of the multi-frame organization for an application that requires changes per frame.

Once it is decided which Attributes should be changed within a multi-frame object then one needs to consider the criteria for grouping Attributes together:

Groupings should be designed so those Attributes that are likely to vary together should be in the same sequence. The goal is to avoid the case where Attributes that are mostly static have to be included in a sequence that is repeated for every frame.
Care should be taken so that we define a manageable number of grouping sequences. Too few sequences could result in many static Attributes being repeated for each frame, when some other element in their sequence was varying, and too many sequences becomes unwieldy.
The groupings should be designed such that modality independent Attributes are kept separate from those that are MR specific. This will presumably allow future working groups to reuse the more general groupings. It also should allow software that operates on multi-frame objects from multiple objects maximize code reuse.
Grouping related Attributes together could convey some semantics of the overall contents of the multi-frame object to receiving applications. For instance, if a volumetric application finds the Plane Orientation Macro present in the Per-Frame Functional Groups Sequence, it may decide to reject the object as inappropriate for volumetric calculations.

Specific notes on Attribute grouping:

Attributes not allowed to change: Image Pixel Module (due to legacy toolkit concerns); and Pulse Sequence Module Attributes (normally do not change except in real-time - it is expected real time applications can handle the complexity and speed of starting new IODs when pulse sequence changes).
Sequences not starting with the word "MR" could be applied to more modalities than just MR.
All Attributes that must be in a frame header were placed in the Frame Content Macro.
Position and orientation are in separate sequences since they are changed independently.
For real-time sequences there are contrast mechanisms that can be applied to base pulse sequences and are turned on and off by the operator depending on the anatomy being imaged and the time/contrast trade-off associated with these. Such modifiers include: IR, flow compensation, spoiled, MT, and T2 preparation… These probably are not changed in non-real-time scans. These are all kept in the MR Modifier Macro.

"Number of Averages" Attributes is in its own sequence because real-time applications may start a new averaging process every time a slice position/orientation changes. Each subsequent frame will average with the preceding N frames where N is chosen based on motion and time. Each frame collected at a particular position/orientation will have a different number of averages, but all other Attributes are likely to remain the same. This particular application drives this Attribute being in its own group.

H Clinical Trial Identification Workflow Examples (Informative)

This Annex was formerly located in Annex O “Clinical Trial Identification Workflow Examples (Retired)” in PS3.3 in the 2003 and earlier revisions of the Standard.

The Clinical Trial Identification modules are optional. As such, there are several points in the workflow of clinical trial or research data at which the Clinical Trial Identification Attributes may be added to the data. At the Clinical Trial Site, the Attributes may be added at the scanner, a PACS system, a site workstation, or a workstation provided to the site by a Clinical Trial Coordinating Center. If not added at the site, the Clinical Trial Identification Attributes may be added to the data after receipt by the Clinical Trial Coordinating Center. The addition of clinical trial Attributes does not itself require changes to the SOP Instance UID. However, the clinical trial or research protocol or the process of de-identification may require such a change.

Figure H-1. Workflow Diagram for Clinical Trials

H.1 Example Use-case

Images are obtained for the purpose of comparing patients treated with placebo or the drug under test, then evaluated in a blinded manner by a team of radiologists at the Clinical Trial Coordinating Center (CTCC). The images are obtained at the clinical sites, collected by the CTCC, at which time their identifying Attributes are removed and the Clinical Trial Identification (CTI) module is added. The de-identified images with the CTI information are then presented to the radiologists who make quantitative and/or qualitative assessments. The assessments, and in some cases the images, are returned to the sponsor for analysis, and later are contributed to the submission to the regulating authority.

I Ultrasound Templates (Informative)

I.1 SR Content Tree Structure

Figure I.1-1. Top Level Structure of Content Tree

The templates for ultrasound reports are defined in Annex A “Structured Reporting Templates (Normative)” in PS3.16. Figure I.1-1 is an outline of the common elements of ultrasound structured reports.

The Patient Characteristics Section is for medical data of immediate relevance to administering the procedure and interpreting the results. This information may originate outside the procedure.

The Procedure Summary Section contains exam observations of immediate or primary significance. This is key information a physician typically expects to see first in the report.

Measurements typically reside in a measurement group container within a Section. Measurement groups share context such as anatomical location, protocol or type of analysis. The grouping may be specific to a product implementation or even to a user configuration. OB-GYN measurement groups have related measurements, averages and other derived results.

If present, the Image Library contains a list of images from which observations were derived. These are referenced from the observations with by-reference relationships.

I.2 Procedure Summary

The Procedure Summary Section contains the observations of most immediate interest. Observations in the procedure summary may have by-reference relationships to other Content Items.

I.3 Multiple Fetuses

Where multiple fetuses exist, the observations specific to each fetus must reside under separate section headings. The section heading must specify the fetus observation context and designate so using Subject ID (121030, DCM, "Subject ID") and/or numerical designation (121037, DCM, "Fetus Number") as shown below. See TID 1008 “Subject Context, Fetus”.

Figure I.3-1. Multiple Fetuses

I.4 Explicitly Specifying Calculation Dependencies

Reports may specify dependencies of a calculation on its dependent observations using by-reference relationships. This relationship must be present for the report reader to know the inputs of the derived value.

Figure I.4-1. Explicit Dependencies

I.5 Linking Measurements to Images, Coordinates

Optionally, the relationship of an observation to its image and image coordinates can be encoded with by-reference Content Items as Figure I.5-1 shows. For conciseness, the by-reference relationship points to the Content Item in the Image Library, rather than directly to the image.

Figure I.5-1. Relationships to Images and Coordinates

R-INFERRED FROM relationships to IMAGE Content Items specify that the image supports the observation. A purpose of reference in an SCOORD Content Item may specify an analytic operation (performed on that image) that supports or produces the observation.

I.6 Ob Patterns

A common OB-GYN pattern is that of several instances of one measurement type (e.g., BPD), the calculated average of those values, and derived values such as a gestational age calculated according to an equation or table. The measurements and calculations are all siblings in the measurement group. A child Content Item specifies the equation or table used to calculate the gestational age. All measurement types must relate to the same biometric type. For example, it is not allowed to mix a BPD and a Nuchal Fold Thickness measurement in the same biometry group.

Figure I.6-1. OB Numeric Biometry Measurement group Example

The example above is a gestational age calculated from the measured value. The relationship is to an equation or table. The inferred from relationship identifies equation or table in the Concept Name. Codes from CID 12013 “Gestational Age Equation/Table” identify the specific equation or table.

Another use case is the calculation of a growth parameter's relationship to that of a referenced distribution and a known or assumed gestational age. CID 12015 “Fetal Growth Equation/Table” identify the growth table. Figure I.6-2 shows the assignment of a percentile for the measured BPD, against the growth of a referenced population. The dependency relationship to the gestational age is a by-reference relationship to the established gestational age. Though the percentile rank is derived from the BPD measurement, a by-reference relationship is not essential if one BPD has a concept modifier indicating that it is the mean or has selection status (see TID 300 “Measurement”). A variation of this pattern is the use of Z-score instead of percentile rank. Not shown is the expression of the normal distribution mean, standard deviation, or confidence limits.

Figure I.6-2. Percentile Rank or Z-score Example

Estimated fetal weight (EFW) is a fetus summary item as shown below. It is calculated from one or more growth parameters (the inferred from relationships are not shown). TID 315 “Equation or Table” allows specifying how the value was derived. Terms from CID 12014 “OB Fetal Body Weight Equation/Table” specify the table or equation that yields the EFW from growth parameters.

"EFW percentile rank" is another summary term. By definition, this term depends upon the EFW and the population distribution of the ranking. A Reference Authority Content Item identifies the distribution. CID 12016 “Estimated Fetal Weight Percentile Equation/Table” is list of established reference authorities.

Figure I.6-3. Estimated Fetal Weight

I.7 Selected Value

When multiple observations of the same type exist, one of these may be the selected value. Typically, this value is the average of the others, or it may be the last entered, or user chosen. TID 310 “Measurement Properties” provides a Content Item with concept name of (121404, DCM, "Selection Status") and a value set specified by DCID 224 “Selection Method”.

Figure I.7-1. Selected Value Example

There are multiple ways that a measurement may originate. The measurement value may result as an output of an image interactive, system tool. Alternatively, the user may directly enter the value, or the system may create a value automatically as the mean of multiple measurement instances. TID 300 “Measurement” provides that a concept modifier of the numeric Content Item specify the derivation of the measurement. The concept name of the modifier is (121401, DCM, "Derivation"). CID 3627 “Measurement Type” provides concepts of appropriate measurement modifiers. Figure I.7-2 illustrates such a case.

Figure I.7-2. Selected Value with Mean Example

I.8 OB-GYN Examples

The following are simple, non-comprehensive illustrations of report sections.

I.8.1 Example 1: OB-GYN Root with Observation Context

The following example shows the highest level of Content Items for a second or third trimester OB exam. Subsequent examples show details of section content,

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	OB-GYN Ultrasound Procedure Report		TID 5000
1.1	Language of Content Item and Descendants	English	TID 1204
1.2	Subject Name	Jane Doe	TID 1007
1.3	Subject ID	123-45-6789	TID 1007
1.4	Procedure Study Instance UID	1.2.842.111724.7678.32.34	TID 1005
1.5	Procedure Study Component UID	1.2.842.111724.7678.55.34	TID 1005
1.6	Procedure Accession Number	20011007-21	TID 1005
1.7	Image Library		TID 5000
1.7.1		IMAGE 1	TID 5000
1.7.2		IMAGE 2	TID 5000
1.7.n		IMAGE N	TID 5000
1.8	Patient Characteristics		TID 5001
1.8.n			TID 5001
1.9	Summary		TID 5002
1.9.n			TID 5002
1.10	Fetal Biometry Ratios		TID 5004
1.10.n			TID 5004
1.11	Long Bones		TID 5006
1.11.n			TID 5006
1.12	Fetal Cranium		TID 5007
1.12.n			TID 5007
1.13	Biophysical Profile		TID 5009
1.13.n			TID 5009
1.14	Amniotic Sac		TID 5010
1.14.n			TID 5010

The following example shows the highest level of Content Items for a GYN exam. Subsequent examples show details of section content.

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	OB-GYN Ultrasound Procedure Report		TID 5000
1.1	Subject Name	Jane Doe	TID 1007
1.2	Subject ID	123-45-6789	TID 1007
1.3	Image Library		TID 5000
1.3.1		IMAGE 1	TID 5000
1.3.2		IMAGE 2	TID 5000
1.3.n		IMAGE N	TID 5000
1.4	Patient Characteristics		TID 5001
1.4.n			TID 5001
1.5	Findings		TID 5012
1.5.1	Findings Site	Ovary	TID 5012
1.5.n			TID 5012
1.6	Findings		TID 5013
1.6.1	Findings Site	Ovarian Follicle	TID 5013
1.6.2	Laterality	Left	TID 5013
1.6.n			TID 5013
1.7	Findings		TID 5013
1.7.1	Findings Site	Ovarian Follicle	TID 5013
1.7.2	Laterality	Right	TID 5013
1.7.n			TID 5013
1.8	Pelvis and Uterus		TID 5015
1.8.n			TID 5015

I.8.2 Example 2: OB-GYN Patient Characteristics and Procedure Summary

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	OB-GYN Ultrasound Procedure Report		TID 5000
	….		TID 5000
1.8	Patient Characteristics		TID 5001
1.8.1	Gravida	5	TID 5001
1.8.2	Para	3	TID 5001
1.8.3	Aborta	2	TID 5001
1.8.4	Ectopic Pregnancies	1	TID 5001
1.9	Summary		TID 5002
1.9.1	LMP	20010101	TID 5002
1.9.2	EDD	20010914	TID 5002
1.9.3	EDD from LMP	20010914	TID 5002
1.9.4	EDD from average ultrasound age	20010907	TID 5002
1.9.5	Gestational age by ovulation date	185 d	TID 5002
1.9.6	Fetus Summary		TID 5003
1.9.6.1	EFW	2222 g	TID 300
1.9.6.1.1	+/-, range of measurement uncertainty	200 g	TID 310
1.9.6.1.2	Equation	EFW by AC, BPD, Hadlock 1984	TID 315
1.9.6.2	Comment	Enlarged cisterna magna	TID 5003
1.9.6.3	Comment	Choroid plexus cyst	TID 5003

I.8.3 Example 3: OB-GYN Multiple Fetus

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	OB-GYN Ultrasound Procedure Report		TID 5000
1.n	….		TID 5000
1.5	Summary		TID 5002
1.5.1	EDD from LMP	20020325	TID 5002
1.5.2	Fetus Summary		TID 5003
1.5.2.1	Fetus ID	A	TID 1008
1.5.2.2	EFW	1.6 Kg	TID 300
1.5.2.2.1	Equation	EFW by AC, BPD, Hadlock 1984	TID 315
1.5.2.2.2	+/-, range of measurement uncertainty	160g	TID 310
1.5.2.3	Fetal Heart Rate	120 {H.B.}/min	TID 300
1.5.3	Fetus Summary		TID 5003
1.5.3.1	Fetus ID	B	TID 1008
1.5.3.2	Comment	Choroid plexus cyst	TID 5003
1.5.3.3	EFW	1.4 kg	TID 300
1.5.3.3.1	Equation	EFW by AC, BPD, Hadlock 1984	TID 315
1.5.3.3.2	+/-, range of measurement uncertainty	140 g	TID 310
1.5.3.4	Fetal Heart Rate	135 {H.B.}/min	TID 300
1.6	Biophysical Profile		TID 5009
1.6.1	Fetus ID	A	TID 1008
1.6.n	…
1.7	Biophysical Profile		TID 5009
1.7.1	Fetus ID	B	TID 1008
1.7.n	…

I.8.4 Example 4: Biophysical Profile

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	OB-GYN Ultrasound Procedure Report		TID 5000
1.n	….		TID 5000
1.9	Biophysical Profile		TID 5009
1.9.1	Gross Body Movement	2 {0:2}	TID 5009
1.9.2	Fetal Breathing	2 {0:2}	TID 5009
1.9.3	Fetal Tone	2 {0:2}	TID 5009
1.9.4	Fetal Heart Reactivity	2 {0:2}	TID 5009
1.9.5	Amniotic Fluid Volume	2 {0:2}	TID 5009
1.9.6	Biophysical Profile Sum Score	10 {0:10}	TID 5009

I.8.5 Example 5: Biometry Ratios

Optionally, but not shown, the ratios may have by-reference, inferred-from relationships to the Content Items holding the numerator and denominator values.

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	OB-GYN Ultrasound Procedure Report		TID 5000
1.n	….		TID 5000
1.9	Fetal Biometry Ratios		TID 5004
1.9.1	HC/AC	77%	TID 5004
1.9.2	FL/AC	22 %	TID 5004
1.9.2.1	Normal Range Lower Limit	20 %	TID 312
1.9.2.2	Normal Range Upper Limit	24 %	TID 312
1.9.2.3	Normal Range Authority	Hadlock, AJR 1983	TID 312
1.9.3	FL/BPD	79 %	TID 5004
1.9.3.1	Normal Range Lower Limit	71 %	TID 312
1.9.3.2	Normal Range Upper Limit	81 %	TID 312
1.9.3.3	Normal Range Authority	Hohler, Am J of Ob and Gyn 1981	TID 312
1.9.4	Cephalic Index	82 %	TID 5004
1.9.4.1	Normal Range Lower Limit	70 %	TID 312
1.9.4.2	Normal Range Upper Limit	86 %	TID 312
1.9.4.3	Normal Range Authority	Hadlock, AJR 1981	TID 312

I.8.6 Example 6: Biometry

This example shows measurements and estimated gestational age.

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	OB-GYN Ultrasound Procedure Report		TID 5000
1.n	….		TID 5000
1.8	Fetal Biometry		TID 5005
1.8.1	Biometry Group		TID 5008
1.8.1.1	Biparietal Diameter	5.5 cm	TID 300
1.8.1.2	Biparietal Diameter	5.3 cm	TID 300
1.8.1.3	Biparietal Diameter	5.4 cm	TID 300
1.8.1.3.1	Derivation	Mean	TID 300
1.8.1.4	Gestational Age	190 d	TID 5008
1.8.1.4.1	Equation	Jeanty, 1982	TID 5008
1.8.1.4.2	5^th Percentile Value of population	131 d	TID 5008
1.8.1.4.3	95^th Percentile Value of population	173 d	TID 5008
1.8.2	Biometry Group		TID 5008
1.8.2.1	Occipital-Frontal Diameter	18.1 cm	TID 300
1.8.3	Biometry Group		TID 5008
1.8.3.1	Head Circumference	34.3 cm	TID 300
1.8.3.1.1	Derivation	Estimated	TID 300
1.8.4	Biometry Group		TID 5008
1.8.4.1	Abdominal Circumference	34.9 cm	TID 300
1.8.4.2	Abdominal Circumference	34.3 cm	TID 300
1.8.4.3	Abdominal Circumference	34.3 cm	TID 300
1.8.4.4	Abdominal Circumference	34.5 cm	TID 300
1.8.4.4.1	Derivation	Mean	TID 300
1.8.4.5	Gestational Age	190 d	TID 5008
1.8.4.5.1	Equation	Hadlock, 1984	TID 5008
1.8.4.5.2	2 Sigma Lower Value of population	184 d	TID 5008
1.8.4.5.3	2 Sigma Upper Value of population	196 d	TID 5008
1.8.5	Biometry Group		TID 5008
1.8.5.1	Femur Length	4.5 cm	TID 300
1.8.5.n	…		TID 300

This example shows measurements and with percentile ranking.

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	OB-GYN Ultrasound Procedure Report		TID 5000
1.n	….		TID 5000
1.8	Fetal Biometry		TID 5005
1.8.1	Biometry Group		TID 5008
1.8.1.1	Biparietal Diameter	5.5 cm	TID 300
1.8.1.2	Biparietal Diameter	5.3 cm	TID 300
1.8.1.3	Biparietal Diameter	5.4 cm	TID 300
1.8.1.3.1	Derivation	Mean	TID 300
1.8.1.4	Growth Percentile Rank	63 %	TID 5008
1.8.1.4.1	Equation	BPD, Jeanty 1982	TID 5008
1.8.2	Biometry Group		TID 5008
1.8.2.n	…		TID 300

I.8.7 Example 7: Amniotic Sac

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	OB-GYN Ultrasound Procedure Report		TID 5000
1.n	….		TID 5000
1.6	Findings		TID 5010
1.6.1	Finding Site	Amniotic Sac	TID 5010
1.6.2	Amniotic Fluid Index	11 cm	TID 300
1.6.3	First Quadrant Diameter	10 cm	TID 300
1.6.4	Second Quadrant Diameter	12 cm	TID 300
1.6.5	Third Quadrant Diameter	11 cm	TID 300
1.6.6	Fourth Quadrant Diameter	12 cm	TID 300

I.8.8 Example 8: OB-GYN Ovaries

The content structure in the example below conforms to TID 5012 “Ovaries Section”. The example shows the volume derived from three perpendicular diameters.

Figure I.8-1. Ovaries Example

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	OB-GYN Ultrasound Procedure Report		TID 5000
1.n	….		TID 5000
1.9	Findings		TID 5012
1.9.1	Finding Site	Ovary	TID 5012
1.9.2	Ovary		TID 5016
1.9.2.1	Left Ovary Volume	6 cm3	TID 300
1.9.2.2	Left Ovary Length	3 cm	TID 300
1.9.2.3	Left Ovary Length	3 cm	TID 300
1.9.2.4	Left Ovary Length	3 cm	TID 300
1.9.2.4.1	Derivation	Mean	TID 300
1.9.2.5	Left Ovary Width	2 cm	TID 300
1.9.2.5.1	Derivation	Mean	TID 300
1.9.2.6	Left Ovary Height	2 cm	TID 300
1.9.2.6.1	Derivation	Mean	TID 300
1.9.3	Ovary		TID 5016
1.9.3.1	Right Ovary Volume	7 cm3	TID 300
1.9.3.2	…		TID 300

I.8.9 Example 9: OB-GYN Follicles

The content structure in the example below conforms to TID 5013 “Follicles Section”. It uses multiple measurements and derived averages for each of the perpendicular diameters.

Figure I.8-2. Follicles Example

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	OB-GYN Ultrasound Procedure Report		TID 5000
1.n	….		TID 5000
1.8	Findings		TID 5013
1.8.1	Finding Site	Ovarian Follicle	TID 5013
1.8.2	Laterality	Right	TID 5013
1.8.3	Number of follicles in right ovary	2	TID 5013
1.8.4	Measurement Group		TID 5014
1.8.4.1	Identifier	#1	TID 5014
1.8.4.2	Volume	3 cm3	TID 300
1.8.4.3	Follicle Diameter	15 mm	TID 300
1.8.4.4	Follicle Diameter	13 mm	TID 300
1.8.4.5	Follicle Diameter	14 mm	TID 300
1.8.4.5.1	Derivation	Mean	TID 300
1.8.5	Measurement Group		TID 5014
1.8.5.1	Identifier	#2	TID 5014
1.8.5.2	Volume	4 cm3	TID 300
1.8.5.3	Follicle Diameter	18 mm	TID 300
1.9	Findings		TID 5013
1.9.1	Finding Site	Ovarian Follicle	TID 5013
1.9.2	Laterality	Left	TID 5013
1.9.3	Number of follicles in left ovary	1	TID 5013
1.9.4	Follicle Measurement Group		TID 5014
1.9.4.1	Identifier	#1	TID 5014
1.9.4.2	Volume	3 cm3	TID 300
1.9.4.3	Follicle Diameter	15 mm	TID 300

I.8.10 Example 10: Pelvis and Uterus

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	OB-GYN Ultrasound Procedure Report		TID 5000
1.n	….
1.9	Pelvis and Uterus		TID 5015
1.9.1	Uterus		TID 5016
1.9.1.1	Uterus Volume	136 cm3	TID 300
1.9.1.2	Uterus Length	9.5 cm	TID 300
1.9.1.3	Uterus Width	5.9 cm	TID 300
1.9.1.4	Uterus Height	4.2 cm	TID 300
1.9.2	Endometrium Thickness	4 mm	TID 5015
1.9.3	Cervix Length	5.3 cm	TID 5015

J Handling of Identifying Parameters (Informative)

This Annex was formerly located in Annex M “Handling of Identifying Parameters (Informative)” in PS3.4 in the 2003 and earlier revisions of the Standard.

J.1 Purpose of This Annex

The DICOM Standard was published in 1993 and addresses medical images communication between medical modalities, workstations and other medical devices as well as data exchange between medical devices and the Information System (IS). DICOM defines SOP Instances with Patient, Visit and Study information managed by the Information System and allows to communicate the Attribute values of these objects.

Since the publication of the DICOM Standard great effort has been made to harmonize the Information Model of the DICOM Standard with the models of other relevant standards, especially with the HL7 model and the CEN TC 251 WG3 PT 022 model. The result of these effort is a better understanding of the various practical situations in hospitals and an adaptation of the model to these situations. In the discussion of models, the definition of Information Entities and their Identifying Parameters play a very important role.

The purpose of this Informative Annex is to show which identifying parameters may be included in Image SOP Instances and their related Modality Performed Procedure Step (MPPS) SOP Instance. Different scenarios are elucidated to describe varying levels of integration of the Modality with the Information System, as well as situations in which a connection is temporarily unavailable.

Note

In this Annex, "Image SOP Instance" is used as a collective term for all Composite Image Storage SOP Instances.

The scenarios described here are informative and do not constitute a normative section of the DICOM Standard.

J.2 Integrated Environment

"Integrated" means in this context that the Acquisition Modality is connected to an Information System or Systems that may be an SCP of the Modality Worklist SOP Class or an SCP of the Modality Performed Procedure Step SOP Class or both. In the following description only the behavior of "Modalities" is mentioned, it goes without saying that the IS must conform to the same SOP Classes.

The Modality receives identifying parameters by querying the Modality Worklist SCP and generates other Attribute values during image generation. It is desirable that these identifying parameters be included in the Image SOP Instances as well as in the MPPS object in a consistent manner. In the case of a Modality that is integrated but unable to receive or send identifying parameters, e.g., link down, emergency case, the Modality may behave as if it were not integrated.

The Study Instance UID is a crucial Attribute that is used to relate Image SOP Instances (whose Study is identified by their Study Instance UID), the Modality PPS SOP Instance that contains it as a reference, and the actual or conceptual Requested Procedure (i.e., Study) and related Imaging Service Request in the IS. An IS that manages an actual or conceptual Detached Study Management entity is expected to be able to relate this Study Instance UID to the SOP Instance UID of the Detached Study Management SOP Instance, whether or not the Study Instance UID is provided by the IS or generated by the modality.

For a detailed description of an integrated environment see the IHE Radiology Technical Framework. This document can be obtained at http://www.ihe.net/

J.2.1 Modality Conforms to Modality Worklist and MPPS SOP Classes

The modality may:

N-CREATE a MPPS SOP Instance and include its SOP Instance UID in the Image SOP Instances within the Referenced Performed Procedure Step Sequence Attribute.
Copy the following Attribute values from the Modality Worklist information into the Image SOP Instances and into the related MPPS SOP Instance:
- Study Instance UID
- Referenced Study Sequence
- Accession Number
- Requested Procedure ID
- Scheduled Procedure Step ID
- Scheduled Procedure Step Description
- Scheduled Protocol Code Sequence
Create the following Attribute value and include it into the Image SOP Instances and the related MPPS SOP Instance:
- Performed Procedure Step ID
Include the following Attribute values that may be generated during image acquisition, if supported, into the Image SOP Instances and the related MPPS SOP Instance:
- Performed Procedure Step Start Date
- Performed Procedure Step Start Time
- Performed Procedure Step Description
- Study ID

J.2.2 Modality Conforms Only to The Modality Worklist SOP Class

The modality may:

In the absence of the ability to N-CREATE a MPPS SOP Instance, generate a MPPS SOP Instance UID and include it into the Referenced Performed Procedure Step Sequence Attribute of the Image SOP Instances. A system that later N-CREATEs a MPPS SOP Instance may use this UID extracted from the related Image SOP Instances.
Copy the following Attribute values from the Modality Worklist information into the Image SOP Instances:
- Study Instance UID
- Referenced Study Sequence
- Accession Number
- Requested Procedure ID
- Scheduled Procedure Step ID
- Scheduled Procedure Step Description
- Scheduled Protocol Code Sequence
Create the following Attribute value and include it into the Image SOP Instances:
- Performed Procedure Step ID

A system that later N-CREATEs a MPPS SOP Instance may use this Attribute value extracted from the related Image SOP Instances.

Include the following Attribute values that may be generated during image acquisition, if supported, into the Image SOP Instances:
- Performed Procedure Step Start Date
- Performed Procedure Step Start Time
- Performed Procedure Step Description
- Study ID

A system that later N-CREATEs a MPPS SOP Instance may use these Attribute values extracted from the related Image SOP Instances.

J.2.3 Modality Conforms Only to The MPPS SOP Class

The modality may:

N-CREATE a MPPS SOP Instance and include its SOP Instance UID in the Image SOP Instances within the Referenced Performed Procedure Step Sequence Attribute.
Create the following Attribute values and include them in the Image SOP Instances and the related MPPS SOP Instance:
- Study Instance UID
- Performed Procedure Step ID
Copy the following Attribute values, if available to the Modality, into the Image SOP Instances and into the related MPPS SOP Instance:
- Accession Number
- Patient ID
- Patient's Name
- Patient's Birth Date
- Patient's Sex

If sufficient identifying information is included, it will allow the Image SOP Instances and the MPPS SOP Instance to be later related to the Requested Procedure and the actual or conceptual Detached Study Management entity.

Include the following Attribute values that may be generated during image acquisition, if supported, into the Image SOP Instances and the related MPPS SOP Instance:
- Performed Procedure Step Start Date
- Performed Procedure Step Start Time
- Performed Procedure Step Description
- Study ID

J.3 Non-integrated Environment

"Non-Integrated" means in this context that the Acquisition Modality is not connected to an Information System Systems, does not receive Attribute values from an SCP of the Modality Worklist SOP Class, and cannot create a Performed Procedure Step SOP Instance.

The modality may:

In the absence of the ability to N-CREATE a MPPS SOP Instance, generate a MPPS SOP Instance UID and include it into the Referenced Performed Procedure Step Sequence Attribute of the Image SOP Instances. A system that later N-CREATEs a MPPS SOP Instance may use this UID extracted from the related Image SOP Instances.
Create the following Attribute values and include them in the Image SOP Instances:
- Study Instance UID
- Performed Procedure Step ID

A system that later N-CREATEs a MPPS SOP Instance may use these Attribute values extracted from the related Image SOP Instances.

Copy the following Attribute values, if available to the Modality, into the Image SOP Instances:
- Accession Number
- Patient ID
- Patient's Name
- Patient's Birth Date
- Patient's Sex

If sufficient identifying information is be included, it will allow the Image SOP Instances to be later related to the Requested Procedure and the actual or conceptual Detached Study Management entity.

Include the following Attribute values that may be generated during image acquisition, if supported, into the Image SOP Instances:
- Performed Procedure Step Start Date
- Performed Procedure Step Start Time
- Performed Procedure Step Description
- Study ID

A system that later N-CREATEs a MPPS SOP Instance may use these Attribute values extracted from the related Image SOP Instances.

J.4 One MPPS Is Created in Response to Two Or More Requested Procedures

In the MPPS SOP Instance, all the specific Attributes of a Scheduled Procedure Step or Steps are included in the Scheduled Step Attributes Sequence. In the Image SOP Instances, these Attributes may be included in the Request Attributes Sequence. This is an optional Sequence in order not to change the definition of existing SOP Classes by adding new required Attributes or changing the meaning of existing Attributes.

Both Sequences may have more than one Item if more than one Requested Procedure results in a single Performed Procedure Step.

Because of the definitions of existing Attributes in existing Image SOP Classes, the following solutions are a compromise. The first one chooses or creates a value for the single valued Attributes Study Instance UID and Accession Number. The second one completely replicates the Image data with different values for the Attributes Study Instance UID and Accession Number.

J.4.1 Choose Or Create A Value For Study Instance UID and Accession Number

The modality may:

In the Image SOP Instances:
- create a Request Attributes Sequence containing two or more Items each containing the following Attributes:
  - Requested Procedure ID
  - Scheduled Procedure Step ID
  - Scheduled Procedure Step Description
  - Scheduled Protocol Code Sequence
- create a Referenced Study Sequence containing two or more Items sufficient to contain the Study SOP Instance UID values from the Modality Worklist for both Requested Procedures
- select one value from the Modality Worklist or generate a new value for:
  - Study Instance UID
- select one value from the Modality Worklist or generate a new value or assign an empty value for:
  - Accession Number
In the MPPS SOP Instance:
- create a Scheduled Step Attributes Sequence containing two or more Items each containing the following Attributes:
  - Study Instance UID
  - Referenced Study Sequence
  - Accession Number
  - Requested Procedure ID
  - Scheduled Procedure Step ID
  - Scheduled Procedure Step Description
  - Scheduled Protocol Code Sequence
- include the following Attribute value that may be generated during image acquisition, if supported:
  - Procedure Code Sequence
In both the Image SOP Instances and the MPPS SOP Instance
- create a Performed Procedure Step ID
- include the following Attribute values that may be generated during image acquisition, if supported:
  - Performed Procedure Step Start Date
  - Performed Procedure Step Start Time
  - Performed Procedure Step Description
  - Study ID

J.4.2 Replicate The Image IOD

An alternative method is to replicate the entire Image SOP Instance with a new SOP Instance UID, and assign each Image IOD it's own identifying Attributes. In this case, each of the Study Instance UID and the Accession Number values can be used in their own Image SOP Instance.

Both Image SOP Instances may reference a single MPPS SOP Instance (via the MPPS SOP Instance UID in the Referenced Performed Procedure Step Sequence).

Each individual Image SOP Instance may reference it's own related Study SOP Instance, if it exists (via the Referenced Study Sequence). This Study SOP Instance has a one to one relationship with the corresponding Requested Procedure.

If an MPPS SOP Instance is created, it may reference both related Study SOP Instances.

The modality may:

For all Series in the MPPS, replicate the entire Series of Images using new Series Instance UIDs
Create replicated Image SOP Instances with different SOP Instance UIDs that use the new Series Instance UIDs, for each of the two or more Requested Procedures
In each of the Image SOP Instances, using values from the corresponding Requested Procedure:
- create a Request Attributes Sequence containing an Item containing the following Attributes:
  - Requested Procedure ID
  - Scheduled Procedure Step ID
  - Scheduled Procedure Step Description
  - Scheduled Protocol Code Sequence
- copy from the Modality Worklist:
  - Study Instance UID
  - Accession Number
- create a Referenced Study Sequence containing an Item containing the following Attribute:
  - Study SOP Instance in the Referenced Study Sequence from the Worklist
In the MPPS SOP Instance (if supported):
- create a Scheduled Step Attributes Sequence containing two or more Items each containing the following Attributes:
  - Study Instance UID
  - Referenced Study Sequence
  - Accession Number
  - Requested Procedure ID
  - Scheduled Procedure Step ID
  - Scheduled Procedure Step Description
  - Scheduled Protocol Code Sequence
- include the following Attribute value that may be generated during image acquisition, if supported:
  - Procedure Code Sequence
In both the Image SOP Instances and the MPPS SOP Instance (if supported):
- create a Performed Procedure Step ID
  - include the following Attribute values that may be generated during image acquisition, if supported:
    
    Performed Procedure Step Start Date
    
    Performed Procedure Step Start Time
    
    Performed Procedure Step Description
    
    Study ID

J.5 MPPS SOP Instance Created by Another System (not the Modality)

If for some reason the Modality was unable to create the MPPS SOP Instance, another system may wish to perform this service. This system must make sure that the created PPS SOP Instance is consistent with the related Image SOP Instances.

Depending on the availability and correctness of values for the Attributes in the Image SOP Instances, these values may be copied into the MPPS SOP Instance, or they may have to be coerced, e.g., if they are not consistent with corresponding values available from the IS.

For example, if the MPPS SOP Instance UID is already available in the Image SOP Instance (in the Referenced Performed Procedure Step Sequence), it may be utilized to N-CREATE the MPPS SOP Instance. If not available, a new MPPS SOP Instance UID may be generated and used to N-CREATE the MPPS SOP Instance. In this case there may be no MPPS SOP Instance UID in the Referenced Performed Procedure Step Sequence in the corresponding Image SOP Instances. An update of the Image SOP Instances will restore the consistency, but this is not required.

J.6 Mapping of Study Instance UIDs to the Study SOP Instance UID

Retired. See PS3.17-2004.

K Ultrasound Staged Protocol Data Management (Informative)

K.1 Purpose of this Annex

The purpose of this annex is to enhance consistency and interoperability among creators and consumers of Ultrasound images within Staged Protocol Exams. An ultrasound "Staged Protocol Exam" is an exam that acquires a set of images under specified conditions during time intervals called "Stages". An example of such an exam is a cardiac stress-echo Staged Protocol.

This informative annex describes the use of ultrasound Staged Protocol Attributes within the following DICOM Services: Ultrasound Image, Ultrasound Multi-frame Image, and Key Object Selection Document Storage, Modality Worklist, and Modality Performed Procedure Step Services.

K.2 Prerequisites For Support

The support of ultrasound Staged Protocol Data Management requires support for the Ultrasound Image SOP Class or Ultrasound Multi-frame Image SOP Class as appropriate for the nature of the Protocol. By supporting some optional Elements of these SOP Classes, Staged-Protocols can be managed. Support of Key Object Selection allows control of the order of View and Stage presentation. Support of Modality Worklist Management and Modality Performed Procedure Step allow control over specific workflow use cases as described in this Annex.

K.3 Definition of a Staged Protocol Exam

A "Staged Protocol Exam" acquires images in two or more distinct time intervals called "Stages" with a consistent set of images called "Views" acquired during each Stage of the exam. A View is of a particular cross section of the anatomy acquired with a specific ultrasound transducer position and orientation. During the acquisition of a Staged Protocol Exam, the modality may also acquire non-Protocol images at one or more Protocol Stages.

A common real-world example of an ultrasound Staged Protocol exam is a cardiac stress-echo ultrasound exam. Images are acquired in distinct time intervals (Stages) of different levels of stress and Views as shown in Figure K.3-1. Typically, stress is induced by means of patient exercise or medication. Typical Stages for such an exam are baseline, mid-stress, peak-stress, and recovery. During the baseline Stage the patient is at rest, prior to inducing stress through medication or exercise. At mid-stress Stage the heart is under a moderate level of stress. During peak-stress Stage the patient's heart experiences maximum stress appropriate for the patient's condition. Finally, during the recovery Stage, the heart recovers because the source of stress is absent.

At each Stage an equivalent set of Views is acquired. Examples of typical Views are parasternal long axis and parasternal short axis. Examination of wall motion between the corresponding Views of different Stages may reveal ischemia of one or more regions ("segments") of the myocardium. Figure K.3-1 illustrates the typical results of a cardiac stress-echo ultrasound exam.

Figure K.3-1. Cardiac Stress-Echo Staged Protocol US Exam

K.4 Attributes Used in Staged Protocol Exams

The DICOM Standard includes a number of Attributes of significance to Staged Protocol Exams. This Annex explains how scheduling and acquisition systems may use these Attributes to convey Staged Protocol related information.

Table K.4-1 lists all the Attributes relevant to convey Staged Protocol related information (see PS3.3 for details about these Attributes).

Table K.4-1. Attributes That Convey Staged Protocol Related Information

Modality Worklist (Tag) [Return Key Type]	US Image and US Multi-frame IOD (TAG) [Type]	MPPS IOD (Tag) [SCU/SCP Type]
----	----	Scheduled Step Attributes Sequence (0040,0270) [1/1] (b)
Study Instance UID (0020,000D) [1]	Study Instance UID (0020,000D) [1]	>Study Instance UID (0020,000D) [1/1]
Scheduled Procedure Step Sequence (0040,0100)	Request Attributes Sequence (0040,0275) [3] (a,b)	----
>Scheduled Procedure Step Description (0040,0007) [1C]	>Scheduled Procedure Step Description (0040,0007) [3]	>Scheduled Procedure Step Description (0040,0007) [2/2]
>Scheduled Protocol Code Sequence (0040,0008) [1C]	>Scheduled Protocol Code Sequence (0040,0008) [3]	>Scheduled Protocol Code Sequence (0040,0008) [2/2]
----	Performed Procedure Step Description (0040,0254) [3]	Performed Procedure Step Description (0040,0254) [2/2]
----	Protocol Name (0018,1030) [3]	Performed Series Sequence (0040,0340)>Protocol Name (0018,1030) [1/1]
----	Performed Protocol Code Sequence (0040,0260) [3]	Performed Protocol Code Sequence (0040,0260) [1/1]
----	Number of Stages (0008,2124) [2C]	----
----	Number of Views In Stage (0008,212A) [2C]	----
----	Stage Name (0008,2120) [3]	----
----	Stage Number (0008,2122) [3]	----
----	Stage Code Sequence (0040,000A) [3]	----
----	View Name (0008,2127) [3]	----
----	View Number (0008,2128) [3]	----
----	Number of Event Timers (0008,2129) [3]	----
----	Event Elapsed Time(s) (0008,2130) [3]	----
----	Event Timer Name(s) (0008,2132) [3]	----
----	View Code Sequence (0054,0220) [3]	----
----	>View Modifier Code Sequence (0054,0222) [3]	----

Recommended if the Modality conforms as an SCU to the Modality Worklist SOP Class and Modality Performed Procedure Step
Sequence may have one or more Items

K.5 Guidelines

This annex provides guidelines for implementation of the following aspects of Staged Protocol exams:

Identification of a Staged Protocol exam.
Identification of Stages and Views within a Staged Protocol exam.
Identification of extra-Protocol images within a Staged Protocol exam.
Acquisition of multiple images of a View during a Stage, and identification of the preferred image for that Stage.
Workflow management of Staged Protocol images.

K.5.1 Staged Protocol Exam Identification

The Attributes Number of Stages (0008,2124) and Number of Views in Stage (0008,212A) are each Type 2C with the condition "Required if this image was acquired in a Staged Protocol." These two Attributes will be present with values in image SOP Instances if the exam meets the definition of a Staged Protocol Exam stated in Section K.3. This includes both the Protocol View images as well as any extra-Protocol images acquired during the Protocol Stages.

The Attributes Protocol Name (0018,1030) and Performed Protocol Code Sequence (0040,0260) identify the Protocol of a Staged Protocol Exam, but the mere presence of one or both of these Attributes does not in itself identify the acquisition as a Staged Protocol Exam. If both Protocol Name and Performed Protocol Code Sequence Attributes are present, the Protocol Name value takes precedence over the Performed Protocol Code Sequence Code Meaning value as a display label for the Protocol, since the Protocol Name would convey the institutional preference better than the standardized code meaning.

K.5.2 Stage and View Identification

Display devices usually include capabilities that aid in the organization and presentation of images acquired as part of the Staged Protocol. These capabilities allow a clinician to display images of a given View acquired during different Stages of the Protocol side by side for comparison. A View is a particular combination of the transducer position and orientation at the time of image acquisition. Images are acquired at the same View in different Protocol Stages for the purpose of comparison. For these features to work properly, the display device must be able to determine the Stage and View of each image in an unambiguous fashion.

There are three possible mechanisms for conveying Stage and View identification in the image SOP Instances:

"Numbers" (Stage Number (0008,2122) and View Number (0008,2128) ), which number Stages and Views, starting with one.
"Names" (Stage Name (0008,2120) and View Name (0008,2127) ), which specify textual names for each Stage and View, respectively.
"Code sequences" (Stage Code Sequence (0040,000A) for Stage identification, and View Code Sequence (0054,0220) for View identification), which give identification "codes" to the Stage and View respectively.

The use of code sequences to identify Stage and View, using Context Group values specified in PS3.16 (e.g., CID 12002 “Ultrasound Protocol Stage Type” and CID 12226 “Echocardiography Image View”), allows a display application with knowledge of the code semantics to render a display in accordance with clinical domain uses and user preferences (e.g., populating each quadrant of an echocardiographic display with the user desired stage and view). The IHE Echocardiography Workflow Profile requires such use of code sequences for stress-echo studies.

Table K.5-1 provides an example of the Staged Protocol relevant Attributes in images acquired during a typical cardiac stress-echo ultrasound exam.

Table K.5-1. Staged Protocol Image Attributes Example

Baseline Stage - View 1	Mid-Stress Stage - View 1	Mid-Stress Stage - View 2
Study Instance UID: "1.2.840….123.1"	Study Instance UID: "1.2.840….123.1"	Study Instance UID: "1.2.840….123.1"
Request Attributes Sequence:	Request Attributes Sequence:	Request Attributes Sequence:
>Scheduled Procedure Step Description: "Exercise stress echocardiography"	>Scheduled Procedure Step Description: "Exercise stress echocardiography"	>Scheduled Procedure Step Description: "Exercise stress echocardiography"
>Scheduled Protocol Code Sequence:	>Scheduled Protocol Code Sequence:	>Scheduled Protocol Code Sequence:
>>Code Value: "433233004"	>>Code Value: "433233004"	>>Code Value: "433233004"
>>Coding Scheme Designator: "SCT"	>>Coding Scheme Designator: "SCT"	>>Coding Scheme Designator: "SCT"
>>Code Meaning: "Exercise stress echocardiography"	>>Code Meaning: "Exercise stress echocardiography"	>>Code Meaning: "Exercise stress echocardiography"
Performed Procedure Step Description: "Exercise stress echocardiography"	Performed Procedure Step Description: "Exercise stress echocardiography"	Performed Procedure Step Description: "Exercise stress echocardiography"
Protocol Name: "EXERCISE STRESS-ECHO"	Protocol Name: "EXERCISE STRESS-ECHO"	Protocol Name: "EXERCISE STRESS-ECHO"
Performed Protocol Code Sequence:	Performed Protocol Code Sequence:	Performed Protocol Code Sequence:
>Code Value: "433233004"	>Code Value: "433233004"	>Code Value: "433233004"
>Coding Scheme Designator: "SCT"	>Coding Scheme Designator: "SCT"	>Coding Scheme Designator: "SCT"
>Code Meaning: "Exercise stress echocardiography"	>Code Meaning: "Exercise stress echocardiography"	>Code Meaning: "Exercise stress echocardiography"
Number of Stages: "4"	Number of Stages: "4"	Number of Stages: "4"
Number of Views In Stage: "2"	Number of Views In Stage: "2"	Number of Views In Stage: "2"
Stage Name: "BASELINE"	Stage Name: "MID-STRESS"	Stage Name: "MID-STRESS"
Stage Number: "1"	Stage Number: "2"	Stage Number: "2"
Stage Code Sequence:	Stage Code Sequence:	Stage Code Sequence:
>Code Value:"128974000"	>Code Value: "109091"	>Code Value: "109091"
>Coding Scheme Designator: "SCT"	>Coding Scheme Designator: "DCM"	>Coding Scheme Designator: "DCM"
>Code Meaning: "Baseline state"	>Code Meaning: "Cardiac Stress State"	>Code Meaning: "Cardiac Stress State"
View Name: "Para-sternal long axis"	View Name: "Para-sternal long axis"	View Name: "Para-sternal short axis"
View Number: "1"	View Number: "1"	View Number: "2"
----	Number of Event Timers: "1"	Number of Event Timers: "1"
----	Event Elapsed Time(s): "10000" (ms)	Event Elapsed Time(s): "25000" (ms)
----	Event Elapsed Timer Name(s): "Time Since Exercise Halted"	Event Elapsed Timer Name(s): "Time Since Exercise Halted"
View Code Sequence:	View Code Sequence:	View Code Sequence:
>Code Value: "399139001"	>Code Value: "399139001"	>Code Value: "399306005"
>Coding Scheme Designator: "SCT"	>Coding Scheme Designator: "SCT"	>Coding Scheme Designator: "SCT"
>Code Meaning: "Parasternal long axis"	>Code Meaning: "Parasternal long axis"	>Code Meaning: "Parasternal short axis"

K.5.3 Extra-protocol Image Identification

At any Stage of a Staged Protocol exam, the operator may acquire images that are not part of the Protocol. These images are so-called "extra-Protocol images". Information regarding the performed Protocol is still included because such images are acquired in the same Procedure Step as the Protocol images. The Stage number and optionally other Stage identification Attributes (Stage Name and/or Stage Code Sequence) should still be conveyed in extra-Protocol images. However, the View number should be omitted to signify that the image is not one of the standard Views in the Protocol. Other View identifying information, such as name or code sequences, may indicate the image location.

Table K.5-2. Comparison Of Protocol And Extra-Protocol Image Attributes Example

Mid-Stress Stage - View 1 Protocol Image	Mid-Stress Stage Extra-Protocol Image
Study Instance UID: "1.2.840….123.1"	Study Instance UID: "1.2.840….123.1"
Request Attributes Sequence:	Request Attributes Sequence:
>Scheduled Procedure Step Description: " Exercise stress echocardiography protocol"	>Scheduled Procedure Step Description: " Exercise stress echocardiography protocol"
>Scheduled Protocol Code Sequence:	>Scheduled Protocol Code Sequence:
>>Code Value: " 433233004"	>>Code Value: " 433233004"
>>Coding Scheme Designator: "SCT"	>>Coding Scheme Designator: "SCT"
>>Code Meaning:" Exercise stress echocardiography"	>>Code Meaning:" Exercise stress echocardiography"
Performed Procedure Step Description: "Exercise stress echocardiography"	Performed Procedure Step Description: "Exercise stress echocardiography"
Protocol Name: "EXERCISE STRESS-ECHO"	Protocol Name: "EXERCISE STRESS-ECHO"
Performed Protocol Code Sequence:	Performed Protocol Code Sequence:
>Code Value: "433233004"	>Code Value: "433233004"
>Coding Scheme Designator: "SCT"	>Coding Scheme Designator: "SCT"
>Code Meaning:" Exercise stress echocardiography"	>Code Meaning:" Exercise stress echocardiography"
Number of Stages: "4"	Number of Stages: "4"
Number of Views In Stage: "2"	Number of Views In Stage: "2"
Stage Name: "MID-STRESS"	Stage Name: "MID-STRESS"
Stage Number: "2"	Stage Number: "2"
Stage Code Sequence:	Stage Code Sequence:
>Code Value: "109091"	>Code Value: "109091"
>Coding Scheme Designator: "DCM"	>Coding Scheme Designator: "DCM"
>Code Meaning: "Cardiac Stress state"	>Code Meaning: "Cardiac Stress state"
View Name: "Para-sternal long axis"	----
View Number: "1"	----
View Code Sequence:	----
>Code Value: "399139001"	----
>Coding Scheme Designator: "SCT"	----
>Code Meaning: "Parasternal long axis"	----

K.5.4 Multiple Images of A Stage-view

Ultrasound systems often acquire multiple images at a particular stage and view. If one image is difficult to interpret or does not fully portray the ventricle wall, the physician may choose to view an alternate. In some cases, the user may identify the preferred image. The Key Object Selection Document can identify the preferred image for any or all of the Stage-Views. This specific usage of the Key Object Selection Document has a Document Title of (113013, DCM, "Best In Set") and Document Title Modifier of (113017, DCM, "Stage-View").

K.5.5 Workflow Management of Staged Protocol Images

K.5.5.1 Uninterrupted Exams - Single MPPS

Modality Performed Procedure Step (MPPS) is the basic organizational unit of Staged Protocol Exams. It is recommended that a single MPPS instance encompass the entire acquisition of an ultrasound Staged Protocol Exam if possible.

There are no semantics assigned to the use of Series within a Staged Protocol Exam other than the DICOM requirements as to the relationship between Series and Modality Performed Procedure Steps. In particular, all of the following scenarios are possible:

one Series for all images in the MPPS.
separate Series for Protocol View images and extra-Protocol images in the MPPS.
separate Series for images of each Stage within the MPPS.
more than one Series for the images acquired in a single Protocol Stage.

There is no recommendation on the organization of images into Series because clinical events make such recommendations impractical. Figure K.5.5-1 shows a possible sequence of interactions for a protocol performed as a single MPPS.

Figure K.5.5-1. Example of Uninterrupted Staged-Protocol Exam WORKFLOW

K.5.5.2 Interrupted Exams - Multiple MPPS

A special case arises when the acquisition during a Protocol Stage is halted for some reason. For example, such a situation can occur if signs of patient distress are observed, such as angina in a cardiac stress exam. These criteria are part of the normal exam Protocol, and as long as the conditions defined for the Protocol are met the MPPS status is set to COMPLETED. Only if the exam terminates before meeting the minimum acquisition requirements of the selected Protocol would MPPS status be set to DISCONTINUED. It is recommended that the reason for discontinuation should be conveyed in the Modality Procedure Step Discontinuation Reason Code Sequence (0040,0281). Staged Protocols generally include criteria for ending the exam, such as when a target time duration is reached or if signs of patient distress are observed.

If a Protocol Stage is to be acquired at a later time with the intention of using an earlier completed Protocol Stage of a halted Staged Protocol then a new Scheduled Procedure Step may or may not be created for this additional acquisition. Workflow management recommendations vary depending on whether the care institution decides to create a new Scheduled Procedure Step or not.

Follow-up Stages must use View Numbers, Names, and Code Sequences identical to those in the prior Stages to enable automatically correlating images of the original and follow-up Stages.

K.5.5.2.1 Unscheduled Follow-up Stages

Follow-up Stages require a separate MPPS. Since follow-up stages are part of the same Requested Procedure and Scheduled Procedure Step, all acquired image SOP Instances and generated MPPS instances specify the same Study Instance UID. If the Study Instance UID is different, systems will have difficulty associating related images. This creates a significant problem if Modality Worklist is not supported. Therefore systems should assign the same Study Instance UID for follow-up Stages even if Modality Worklist is not supported. Figure K.5.5-2 shows a possible interaction sequence for this scenario.

Figure K.5.5-2. Example Staged-Protocol Exam with Unscheduled Follow-up Stages

K.5.5.2.2 Scheduled Follow-up Stages

In some cases a new Scheduled Procedure Step is created to acquire follow-up Stages. For example, a drug induced stress-echo exam may be scheduled because an earlier exercise induced stress-echo exam had to be halted due to patient discomfort. In such cases it would be redundant to reacquire earlier Stages such as the rest Stage of a cardiac stress-echo ultrasound exam. One MPPS contains the Image instances of the original Stage and a separate MPSS contains the follow-up instances.

If Scheduled and Performed Procedure Steps for Staged Protocol Exam data use the same Study Instance UID, workstations can associate images from the original and follow-up Stages. Figure K.5.5-3 shows a possible interaction sequence for this scenario.

Figure K.5.5-3. Example Staged-Protocol Exam with Scheduled Follow-up Stages

L Hemodynamics Report Structure (Informative)

The Hemodynamics Report is based on TID 3500 “Hemodynamics Report”. The report contains one or more measurement containers, each corresponding to a phase of the cath procedure. Within each container may be one or more sub-containers, each associated with a single measurement set. A measurement set consists of measurements from a single anatomic location. The resulting hierarchical structure is depicted in Figure L-1.

Figure L-1. Hemodynamics Report Structure

The container for each phase has an optional subsidiary container for Clinical Context with a parent-child relationship of has-acquisition-context. This Clinical Context container allows the recording of pertinent patient state information that may be essential to understanding the measurements made during that procedure phase. It should be noted that any such patient state information is necessarily only a summary; a more complete clinical picture may be obtained by review of the cath procedure log.

The lowest level containers for the measurement sets are specialized by the class of anatomic location - arterial, venous, atrial, ventricular - for the particular measurements appropriate to that type of location. These containers explicitly identify the anatomic location with a has-acquisition-context relationship. Since such measurement sets are typically measured on the same source (e.g., pressure waveform), the container may also have a has-acquisition-context relationship with a source DICOM waveform SOP Instance.

The "atomic" level of measurements within the measurement set containers includes three types of data. First is the specific measurement data acquired from waveforms related to the site. Second is general measurement data that may include any hemodynamic, patient vital sign, or blood chemistry data. Third, derived data are produced from a combination of other data using a mathematical formula or table, and may provide reference to the equation.

M Vascular Ultrasound Reports (Informative)

M.1 Vascular Report Structure

Figure M.2-1. Vascular Numeric Measurement Example

The vascular procedure report partitions numeric measurements into section headings by anatomic region and by laterality. A laterality concept modifier of the section heading concept name specifies whether laterality is left or right. Therefore, laterally paired anatomy sections may appear two times, once for each laterality. Findings of unpaired anatomy, are separately contained in a separate "unilateral" section container. Therefore, in vascular ultrasound, laterality is always expressed at the section heading level with one of three states: left, right, or unilateral (unpaired). There is no provision for anatomy of unknown laterality other than as a TEXT Content Item in the summary.

Note that expressing laterality at the heading level differs from OB-GYN Pelvic and fetal vasculature, which expresses laterality as concept modifiers of the anatomic containers.

Section Heading Concept Name	Section Heading Laterality
Cerebral Vessels	Left, Right or Unilateral
Artery of Neck	Left, Right
Artery of Lower Extremity	Left, Right
Vein of Lower Extremity	Left, Right
Artery of Upper Extremity	Left, Right
Vein of Upper Extremity	Left, Right
Vascular Structure of Kidney	Left, Right
Artery of Abdomen	Left, Right or Unilateral
Vein of Abdomen	Left, Right or Unilateral

The common vascular pattern is a battery of measurements and calculations repeatedly applied to various anatomic locations. The anatomic location is the acquisition context of the measurement group. For example, a measurement group may have a measurement source of Common Iliac Artery with several measurement instances and measurement types such as mean velocity, peak systolic velocity, acceleration time, etc.

There are distinct anatomic concepts to modify the base anatomy concept. The modification expression is a Content Item with a modifier concept name and value selected from a Context Group as the table shows below.

Anatomic Modifier Concept Name	Context Group	Usage
(272741003, SCT, "Laterality")	CID 244 “Laterality”	Distinguishes laterality
(106233006, SCT, "Topographical Modifier")	CID 12116 “Vessel Segment Modifier”	Distinguishes the location along a segment: prox, mid, distal, …
(125101, DCM, "Vessel Branch")	CID 12117 “Vessel Branch Modifier”	Distinguishes between one of multiple branches: inferior, middle

M.2 Vascular Examples

The following are simple, non-comprehensive illustrations of significant report sections.

M.2.1 Example 1: Renal Vessels

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	Vascular Ultrasound Procedure Report		TID 5100
1.1	Language of Content Item and Descendants	English	TID 1204
1.2	Subject Name	John Doe	TID 1007
1.3	Subject ID	123-45-9876	TID 1007
1.4	Procedure Study Instance UID	1.2.842.111724.7678.12.33	TID 1005
1.5	Procedure Study Component UID	1.2.842.111724.7678.55.33	TID 1005
1.6	Procedure Accession Number	20011007-21	TID 1005
1.7	Patient Characteristics		TID 5101
1.7.n	…		TID 5101
1.8	Summary		TID 5102
1.8.n	…		TID 5102
1.9	Findings		TID 5103
1.9.1	Finding Site	Vascular Structure Of Kidney	TID 5103
1.9.2	Laterality	Right	TID 5103
1.9.3	Renal Artery		TID 5104
1.9.3.1	Topographical Modifier	Origin	TID 5104
1.9.3.2	Peak Systolic Velocity	420 cm/s	TID 300
1.9.3.3	End Diastolic Velocity	120 cm/s	TID 300
1.9.3.4	Resistive Index	3.7	TID 300
1.9.3.5	Pulsatility Index	0.7	TID 300
1.9.3.6	Systolic to Diastolic Velocity Ratio	3.5	TID 300
1.9.4	Renal Artery		TID 5104
1.9.4.1	Topographical Modifier	Proximal	TID 5104
1.9.4.n	. . . other measurements		TID 300
1.9.5	Renal Artery		TID 5104
1.9.5.1	Topographical Modifier	Middle	TID 5104
1.9.5.n	. . . other measurements		TID 300
1.9.6	Renal Artery		TID 5104
1.9.6.1	Topographical Modifier	Distal	TID 5104
1.9.6.n	. . . other measurements		TID 300
1.9.7	Renal Vein		TID 5104
1.9.7.1	Topographical Modifier	Middle	TID 5104
1.9.7.2	Peak Systolic Velocity	120 cm/s	TID 300
1.9.7.n	. . . other measurements		TID 300
1.9.8	Renal Artery/Aorta Velocity Ratio	2.9	TID 5103
1.9.n	other renal vessels		TID 5104
1.10	Findings		TID 5103
1.10.1	Finding Site	Vascular Structure of Kidney	TID 5103
1.10.2	Laterality	Left	TID 5103
	…		TID 5104

M.2.2 Example 2: Carotids Extracranial

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
1	Vascular Ultrasound Procedure Report		TID 5100
1.n	….		TID 5100
1.10	Findings		TID 5103
1.10.1	Findings Site	Artery of neck	TID 5103
1.10.2	Laterality	Right	TID 5103
1.10.3	Common Carotid Artery		TID 5104
1.10.3.1	Topographical Modifier	Proximal	TID 5104
1.10.3.2	Peak Systolic Velocity	80 cm/s	TID 300
1.10.3.3	Peak Systolic Velocity	88 cm/s	TID 300
1.10.3.4	Peak Systolic Velocity	84 cm/s	TID 300
1.10.3.4.1	Derivation	Mean	TID 300
1.10.4	Common Carotid Artery		TID 5104
1.10.4.1	Topographical Modifier	Middle	TID 5104
1.10.4.2	Peak Systolic Velocity	180 cm/s	TID 300
1.10.5	Common Carotid Artery		TID 5104
1.10.5.1	Topographical Modifier	Distal	TID 5104
1.10.5.2	Peak Systolic Velocity	180 cm/s	TID 300
1.10.6	Carotid bulb		TID 5104
1.10.6.1	Peak Systolic Velocity	190 cm/s	TID 300
1.10.7	Internal Carotid Artery		TID 5104
1.10.7.1	Topographical Modifier	Proximal	TID 5104
1.10.7.2	Peak Systolic Velocity	180 cm/s	TID 300
1.10.8	Internal Carotid Artery		TID 5104
1.10.8.1	Topographical Modifier	Distal	TID 5104
1.10.8.2	Peak Systolic Velocity	180 cm/s	TID 300
1.10.9	ICA/CCA velocity ratio	1.5	TID 5103
1.10.n	….		TID 300
1.11	Findings		TID 5103
1.11.1	Finding Site	Artery of neck	TID 5103
1.11.2	Laterality	Left	TID 5103
	….

N Echocardiography Procedure Reports (Informative)

The templates for ultrasound reports are defined in PS3.16. Figure N.1-1 is an outline of the echocardiography report.

Figure N.1-1. Top Level Structure of Content

N.1 Echo Patterns

The common echocardiography measurement pattern is a group of measurements obtained in the context of a protocol. Figure N.1-2 shows the pattern.

Figure N.1-2. Echocardiography Measurement Group Example

N.2 Measurement Terminology Composition

DICOM identifies echocardiography observations with various degrees of pre- and post-coordination. The concept name of the base Content Item typically specifies both anatomy and property for commonly used terms, or purely a property. Pure property concepts require an anatomic site concept modifier. Pure property concepts such as those in CID 12222 “Orifice Flow Property” and CID 12239 “Cardiac Output Property” use concept modifiers shown below.

Concept Name of Modifier	Value Set
(370129005, SCT, "Measurement Method")	CID 12227 “Echocardiography Measurement Method”
(363698007, SCT, "Finding Site")	CID 12236 “Echocardiography Anatomic Site”
(106233006, SCT, "Topographical Modifier")	CID 12237 “Echocardiography Anatomic Site Modifier”
(260674002, SCT, "Flow Direction")	CID 12221 “Flow Direction”
(272517003, SCT, "Respiratory Cycle Point")	CID 12234 “Respiration State”
(272518008, SCT, "Cardiac Cycle Point")	CID 12233 “Cardiac Phase”
(121401, DCM, "Derivation")	CID 3627 “Measurement Type”

Further qualification specifies the image mode and the image plane using HAS ACQ CONTEXT with the value sets shown below.

Concept Name	Value Set
(399264008, SCT, "Image Mode")	CID 12224 “Ultrasound Image Mode”
(111031, DCM, "Image View")	CID 12226 “Echocardiography Image View”

N.3 Illustrative Mapping to ASE Concepts

The content of this section provides recommendations on how to express the concepts from draft ASE guidelines with measurement type concept names and concept name modifiers.

The leftmost column is the name of the ASE concept. The Base Measurement Concept Name is the concept name of the numeric measurement Content Item. The modifiers column specifies a set of modifiers for the base measurement concept name. Each modifier consists of a modifier concept name (e.g., method or mode) and its value (e.g., Continuity). Where no Concept Modifier appears, the base concept matches the ASE concept.

N.3.1 Aorta

Name of ASE Concept	Base Measurement Concept Name	Concept or Acquisition Context Modifiers
Aortic Root Diameter	(18015-8, LN, "Aortic Root Diameter")
Ascending Aortic Diameter	(18012-5, LN, "Ascending Aortic Diameter")
Aortic Arch Diameter	(18011-7, LN, "Aortic Arch Diameter")
Descending Aortic Diameter	(18013-3, LN, "Descending Aortic Diameter")

N.3.2 Aortic Valve

Name of ASE Concept	Base Measurement Concept Name	Concept or Acquisition Context Modifiers
Aortic Valve Cusp Separation	(17996-0, LN, "Aortic Valve Cusp Separation")
Aortic Valve Systolic Peak Velocity	(11726-7, LN, "Peak Velocity")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Aortic Valve Systolic Velocity Time Integral	(20354-7, LN, "Velocity Time Integral")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Aortic Valve Systolic Area	(399367004, SCT, "Cardiovascular Orifice Area")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Aortic Valve Planimetered Systolic Area	(399367004, SCT, "Cardiovascular Orifice Area")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow") (370129005, SCT, "Measurement Method") = (125220, DCM, "Planimetry")
Aortic Valve Systolic Area by Continuity	(399367004, SCT, "Cardiovascular Orifice Area")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow") (370129005, SCT, "Measurement Method") = (125212, DCM, "Continuity Equation")
Aortic Valve Systolic Area by Continuity of Peak Velocity	(399367004, SCT, "Cardiovascular Orifice Area")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow") (370129005, SCT, "Measurement Method") = (125214. DCM, "Continuity Equation Peak Velocity")
Aortic Valve Systolic Area by Continuity of Mean Velocity	(399367004, SCT, "Cardiovascular Orifice Area")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow") (370129005, SCT, "Measurement Method") = (125213. DCM, "Continuity Equation by Mean Velocity")
Aortic Valve Systolic Area by Continuity of VTI	(399367004, SCT, "Cardiovascular Orifice Area")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow") (370129005, SCT, "Measurement Method") = (125215, DCM, "Continuity Equation by Velocity Time Integral")
Aortic Valve Systolic Peak Instantaneous Gradient	(20247-3 LN, "Peak Gradient")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Aortic Valve Systolic Mean Gradient	(20256-4, LN, "Mean Gradient")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Aortic Annulus Systolic Diameter	(399027007, SCT, "Cardiovascular Orifice Diameter")	(363698007, SCT, "Finding Site") = (77583004, SCT, "Aortic Valve Ring") (260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Aortic Valve Regurgitant Diastolic Deceleration Slope	(20216-8, LN, "Deceleration Slope")	(260674002, SCT, "Direction of Flow") = (312004007, SCT, "Regurgitant Flow")
Aortic Valve Regurgitant Diastolic Deceleration Time	(20217-6, LN, "Deceleration Time")	(260674002, SCT, "Direction of Flow") = (312004007, SCT, "Regurgitant Flow")
Aortic Valve Regurgitant Diastolic Pressure Half-time	(20280-4, LN, "Pressure Half-Time")	(260674002, SCT, "Direction of Flow") = (312004007, SCT, "Regurgitant Flow")
Aortic Insufficiency, End-Diastolic Pressure Gradient	(20247-3, LN, "Peak Gradient")	(260674002, SCT, "Direction of Flow") = (312004007, SCT, "Regurgitant Flow")
Aortic Insufficiency, End Diastolic Velocity	(11653-3, LN, "End Diastolic Velocity")	(260674002, SCT, "Direction of Flow") = (312004007, SCT, "Regurgitant Flow")

Note

Aortic Valve measurements appear in TID 5202 “Echo Section”, which specifies the Finding Site to be Aortic Valve with the concept modifier (363698007, SCT, "Finding Site") = (34202007, SCT, "Aortic Valve").Therefore, the Finding Site modifier does not appear in the right column.

N.3.3 Left Ventricle - Linear

N.3.4 Left Ventricle Volumes and Ejection Fraction

Name of ASE Concept	Base Measurement Concept Name	Concept or Acquisition Context Modifiers
Left Ventricular End Diastolic Volume	(18026-5, LN, "Left Ventricular End Diastolic Volume")
Left Ventricular End Diastolic Volume by Teichholz Method	(18026-5, LN, "Left Ventricular End Diastolic Volume")	(370129005, SCT, "Measurement Method") = (125209, DCM, "Teichholz")
Left Ventricular End Diastolic Volume by 2-D Single Plane by Method of Disks (4-Chamber)	(18026-5, LN, "Left Ventricular End Diastolic Volume")	(111031, DCM, "Image View") = (399214001, SCT, "Apical Four Chamber") (370129005, SCT, "Measurement Method") = (125208, DCM, "Method of Disks, Single Plane")
Left Ventricular End Diastolic Volume by 2-D Biplane by Method of Disks	(18026-5, LN, "Left Ventricular End Diastolic Volume")	(370129005, SCT, "Measurement Method") = (125207, DCM, "Method of Disks, Biplane")
Left Ventricular End Systolic Volume	(18148-7, LN, "Left Ventricular End Systolic Volume")
Left Ventricular End Systolic Volume by Teichholz Method	(18148-7, LN, "Left Ventricular End Systolic Volume")	(370129005, SCT, "Measurement Method") = (125209, DCM, "Teichholz")
Left Ventricular End Systolic Volume by 2D Single Plane by Method of Disks (4-Chamber)	(18148-7, LN, "Left Ventricular End Systolic Volume")	(111031, DCM, "Image View") = (399214001, SCT, "Apical Four Chamber") (370129005, SCT, "Measurement Method") = (125208, DCM, "Method of Disks, Single Plane")
Left Ventricular End Systolic Volume by 2-D Biplane by Method of Disks	(18148-7, LN, "Left Ventricular End Systolic Volume")	(370129005, SCT, "Measurement Method") = (125207, DCM, "Method of Disks, Biplane")
Left Ventricular EF	(18043-0, LN, "Left Ventricular Ejection Fraction")
Left Ventricular EF by Teichholz Method	(18043-0, LN, "Left Ventricular Ejection Fraction")	(370129005, SCT, "Measurement Method") = (125209, DCM, "Teichholz")
Left Ventricular EF by 2D Single Plane by Method of Disks (4-Chamber)	(18043-0, LN, "Left Ventricular Ejection Fraction")	(111031, DCM, "Image View") = (399214001, SCT, "Apical Four Chamber ") (370129005, SCT, "Measurement Method") = (125208, DCM, "Method Of Disks, Single Plane")
Left Ventricular EF by 2-D Biplane by Method of Disks	(18043-0, LN, "Left Ventricular Ejection Fraction")	(370129005, SCT, "Measurement Method") = (125207, DCM, "Method of Disks, Biplane")

N.3.5 Left Ventricle Output

Name of ASE Concept	Base Measurement Concept Name	Concept or Acquisition Context Modifiers
Left Ventricular Stroke Volume	(90096001, SCT, "Stroke Volume")
Left Ventricular Stroke Volume by Doppler Volume Flow	(90096001, SCT, "Stroke Volume")	(370129005, SCT, "Measurement Method") = (125219, DCM, "Doppler Volume Flow") (363698007, SCT, "Finding Site") = (13418002, SCT, "Left Ventricle Outflow Tract")
Left Ventricular Stroke Volume by Teichholz Method	(90096001, SCT, "Stroke Volume")	(370129005, SCT, "Measurement Method") = (125209, DCM, "Teichholz")
Left Ventricular Stroke Volume by 2-D Single Plane by Method of Disks (4-Chamber)	(90096001, SCT, "Stroke Volume")	(1110321 DCM, "Image View")= (399214001, SCT, "Apical Four Chamber") (370129005, SCT, "Measurement Method") = (125208, DCM, "Method of Disks, Single Plane")
Left Ventricular Stroke Volume by 2-D Biplane by Method of Disks	(90096001, SCT, "Stroke Volume")	(370129005, SCT, "Measurement Method") = (125207, DCM, "Method of Disks, Biplane")
Left Ventricular Cardiac Output	(82799009, SCT, "Cardiac Output")
Left Ventricular Cardiac Output by Doppler Volume Outflow	(82799009, SCT, "Cardiac Output")	(370129005, SCT, "Measurement Method") = (125219, DCM, "Doppler Volume Flow") (363698007, SCT, "Finding Site") = (13418002, SCT, "Left Ventricle Outflow Tract")
Left Ventricular Cardiac Output by Teichholz Method	(82799009, SCT, "Cardiac Output")	(370129005, SCT, "Measurement Method") = (125209, DCM, "Teichholz")
Left Ventricular Cardiac Output by 2-D Single Plane by Method of Disks (4-Chamber)	(82799009, SCT, "Cardiac Output")	(111031, DCM, "Image View") = (399214001, SCT, "Apical Four Chamber") (370129005, SCT, "Measurement Method") = (125208, DCM, "Method of Disks, Single Plane")
Left Ventricular Cardiac Output by 2-D Biplane by Method of Disks	(82799009, SCT, "Cardiac Output")	(370129005, SCT, "Measurement Method") = (125207, DCM, "Method of Disks, Biplane")
Left Ventricular Cardiac Index	(54993008, SCT, "Cardiac Index")
Left Ventricular Cardiac Index by Doppler Volume Flow	(54993008, SCT, "Cardiac Index")	(370129005, SCT, "Measurement Method") = (125219, DCM, "Doppler Volume Flow")
Left Ventricular Cardiac Index by Teichholz Method	(54993008, SCT, "Cardiac Index")	(370129005, SCT, "Measurement Method") = (125209, DCM, "Teichholz")
Left Ventricular Cardiac Index by 2-D Single Plane by Method of Disks (4-Chamber)	(54993008, SCT, "Cardiac Index")	(111031, DCM, "Image View") = (399214001, SCT, "Apical Four Chamber") (370129005, SCT, "Measurement Method") = (125208, DCM, "Method Of Disks, Single Plane")
Left Ventricular Cardiac Index by 2-D Biplane by Method of Disks	(54993008, SCT, "Cardiac Index")	(370129005, SCT, "Measurement Method") = (125207, DCM, "Method of Disks, Biplane")

Note

Measurements in the Left Ventricle section have context of Left Ventricle and do not require a Finding Site modifier (363698007, SCT, "Finding Site") = (87878005, SCT, "Left Ventricle") to specify the site. The Finding Site modifier appears for more specificity.

N.3.6 Left Ventricular Outflow Tract

Name of ASE Concept	Base Measurement Concept Name	Concept or Acquisition Context Modifiers
Left Ventricular Outflow Tract Systolic Diameter	(399027007, SCT, "Cardiovascular Orifice Diameter")	(363698007, SCT, "Finding Site") = (13418002, SCT, "Left Ventricular Outflow Tract")
Left Ventricular Outflow Tract Systolic Cross Sectional Area	(399367004, SCT, "Cardiovascular Orifice Area")	(363698007, SCT, "Finding Site") = (13418002, SCT, "Left Ventricular Outflow Tract")
Left Ventricular Outflow Tract Systolic Peak Velocity	(11726-7, LN, "Peak Velocity")	(363698007, SCT, "Finding Site") = (13418002, SCT, "Left Ventricular Outflow Tract")
Left Ventricular Outflow Tract Systolic Peak Instantaneous Gradient	(20247-3, LN, "Peak Gradient")	(363698007, SCT, "Finding Site") = (13418002, SCT, "Left Ventricular Outflow Tract")
Left Ventricular Outflow Tract Systolic Mean Velocity	(20352-1, LN, "Mean Velocity")	(363698007, SCT, "Finding Site") = (13418002, SCT, "Left Ventricular Outflow Tract")
Left Ventricular Outflow Tract Systolic Mean Gradient	(20256-4, LN, "Mean Gradient")	(363698007, SCT, "Finding Site") = (13418002, SCT, "Left Ventricular Outflow Tract")
Left Ventricular Outflow Tract Systolic Velocity Time Integral	(20354-7, LN, "Velocity Time Integral")	(363698007, SCT, "Finding Site") = (13418002, SCT, "Left Ventricular Outflow Tract")

N.3.7 Left Ventricle Mass

Name of ASE Concept	Base Measurement Concept Name	Concept or Acquisition Context Modifiers
Left Ventricle Mass	(18087-7, LN, "Left Ventricle Mass")
Left Ventricular Mass by 2-D Method of Disks, Single Plane (4-Chamber)	(18087-7, LN, "Left Ventricle Mass")	(399264008, SCT, "Image Mode") = (399064001, SCT, "2D mode") (370129005, SCT, "Measurement Method") = (125208, DCM, "Method Of Disks, single plane")
Left Ventricular Mass by 2-D Biplane by Method of Disks	(18087-7, LN, "Left Ventricle Mass")	(399264008, SCT, "Image Mode") = (399064001, SCT, "2D mode") (370129005, SCT, "Measurement Method") = (125207, DCM, "Method of disks, biplane")
Left Ventricular Mass by M-Mode	(18087-7, LN, "Left Ventricle Mass")	(399264008, SCT, "Image Mode") = (399155008, SCT, "M mode")

N.3.8 Left Ventricle Miscellaneous

Name of ASE Concept	Base Measurement Concept Name	Concept or Acquisition Context Modifiers
Left Ventricular Isovolumic Relaxation Time	(18071-1, LN, "Left Ventricular Isovolumic Relaxation Time")
Left Ventricular Isovolumic Contraction Time	(399051002, SCT, "Left Ventricular Isovolumic Contraction Time")
Left Ventricular Peak Early Diastolic Tissue Velocity at the Medial Mitral Annulus	(399133000, SCT, "Left Ventricular Peak Early Diastolic Tissue Velocity")	(363698007, SCT, "Finding Site") = (399093001, SCT, "Medial Mitral Annulus")
Left Ventricular Peak Early Diastolic Tissue Velocity at the Lateral Mitral Annulus	(399133000, SCT, "Left Ventricular Peak Early Diastolic Tissue Velocity")	(363698007, SCT, "Finding Site") = (399086000, SCT, "Lateral Mitral Annulus")
Ratio of Mitral Valve E-Wave Peak Velocity to Left Ventricular Peak Early Diastolic Tissue Velocity at the Medial Mitral Annulus	(399140004, SCT, "Ratio of MV Peak Velocity to LV Peak Tissue Velocity E-Wave")	(363698007, SCT, "Finding Site") = (399093001, SCT, "Medial Mitral Annulus")
Ratio of Mitral Valve E-Wave Peak Velocity to Left Ventricular Peak Early Diastolic Tissue Velocity at the Lateral Mitral Annulus	(399140004, SCT, "Ratio of MV Peak Velocity to LV Peak Tissue Velocity E-Wave")	(363698007, SCT, "Finding Site") = (399086000, SCT, "Lateral Mitral Annulus")
Left Ventricular Peak Diastolic Tissue Velocity at the Medial Mitral Annulus During Atrial Systole	(399007006, SCT, "LV Peak Diastolic Tissue Velocity During Atrial Systole")	(363698007, SCT, "Finding Site") = (399093001, SCT, "Medial Mitral Annulus")
Left Ventricular Peak Diastolic Tissue Velocity at the Lateral Mitral Annulus During Atrial Systole	(399007006, SCT, "LV Peak Diastolic Tissue Velocity During Atrial Systole")	(363698007, SCT, "Finding Site") = (399086000, SCT, "Lateral Mitral Annulus")
Left Ventricular Peak Systolic Tissue Velocity at the Medial Mitral Annulus	(399167005, SCT, "Left Ventricular Peak Systolic Tissue Velocity")	(363698007, SCT, "Finding Site") = (399093001, SCT, "Medial Mitral Annulus")
Left Ventricular Peak Systolic Tissue Velocity at the Lateral Mitral Annulus	(399167005, SCT, "Left Ventricular Peak Systolic Tissue Velocity")	(363698007, SCT, "Finding Site") = (399086000, SCT, "Lateral Mitral Annulus")

N.3.9 Mitral Valve

Name of ASE Concept	Base Measurement Concept Name	Concept or Acquisition Context Modifiers
Mitral Valve Area	(399367004, SCT, "Cardiovascular Orifice Area")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Mitral Valve Area by Continuity	(399367004, SCT, "Cardiovascular Orifice Area")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow") (370129005, SCT, "Measurement Method") = (125212. DCM, "Continuity Equation")
Mitral Valve Area by Planimetry	(399367004, SCT, "Cardiovascular Orifice Area")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow") (370129005, SCT, "Measurement Method") = (125220, DCM, "Planimetry")
Mitral Valve Area by Pressure Half-time	(399367004, SCT, "Cardiovascular Orifice Area")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow") (370129005, SCT, "Measurement Method") = (125210, DCM, "Area by PHT")
Mitral Valve Area by Proximal Isovelocity Surface Area	(399367004, SCT, "Cardiovascular Orifice Area")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow") (370129005, SCT, "Measurement Method") = (125216, DCM, "Proximal Isovelocity Surface Area")
Mitral Valve Pressure Half-time	(20280-4, LN, "Pressure Half-Time")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Mitral Valve A-Wave Peak Velocity	(17978-8, LN, "Mitral Valve A-Wave Peak Velocity")
Mitral Valve E-Wave Peak Velocity	(18037-2, LN, "Mitral Valve E-Wave Peak Velocity")
Mitral Valve E to A Ratio	(18038-0, LN, "Mitral Valve E to A Ratio")
Mitral Valve E-Wave Deceleration Time	(399354002, SCT, "Mitral Valve E-Wave Deceleration Time")
Mitral Valve E-F Slope by M-Mode	(18040-6, LN, "Mitral Valve E-F Slope by M-Mode")
Mitral Valve Velocity Time Integral	(20354-7, LN, "Velocity Time Integral")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Mitral Valve Diastolic Peak Instantaneous Gradient	(20247-3, LN, "Peak Gradient")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Mitral Valve Diastolic Mean Gradient	(20256-4, LN, "Mean Gradient")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Mitral Valve Annulus Diastolic Velocity Time Integral	(20354-7, LN, "Velocity Time Integral")	(363698007, SCT, "Finding Site") = (279174006, SCT, "Mitral Annulus") (260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Mitral Valve Annulus Diastolic Diameter	(399027007, SCT, "Cardiovascular Orifice Diameter")	(363698007, SCT, "Finding Site") = (279174006, SCT, "Mitral Annulus") (260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Mitral Regurgitant Peak Velocity	(11726-7, LN, "Peak Velocity")	(260674002, SCT, "Direction of Flow") = (312004007, SCT, "Regurgitant Flow")
Mitral Valve Effective Regurgitant Orifice by Proximal Isovelocity Surface Area Method	(399367004, SCT, "Cardiovascular Orifice Area")	(260674002, SCT, "Direction of Flow") = (312004007, SCT, "Regurgitant Flow") (370129005, SCT, "Measurement Method") = (125216, DCM, "Proximal Isovelocity Surface Area")
Mitral Valve Regurgitant Volume by Proximal Isovelocity Surface Area Method	(33878-0, LN, "Volume Flow")	(363698007, SCT, "Finding Site") = (279174006, SCT, "Mitral Annulus") (260674002, SCT, "Direction of Flow") = (312004007, SCT, "Regurgitant Flow") (370129005, SCT, "Measurement Method") = (125216, DCM, "Proximal Isovelocity Surface Area")
Mitral Valve Regurgitant Fraction	(399301000, SCT, "Regurgitant Fraction")
Mitral Valve Regurgitant Fraction by PISA	(399301000, SCT, "Regurgitant Fraction")	(370129005, SCT, "Measurement Method") = (125216, DCM, "Proximal Isovelocity Surface Area")
Mitral Valve Regurgitant Fraction by Mitral Annular Flow	(399301000, SCT, "Regurgitant Fraction")	(363698007, SCT, "Finding Site") = (279174006, SCT, "Mitral Annulus") (370129005, SCT, "Measurement Method") = (125219, DCM, "Doppler Volume Flow")
Mitral Regurgitation Peak Gradient	(20247-3, LN, "Peak Gradient")	(260674002, SCT, "Direction of Flow") = (312004007, SCT, "Regurgitant Flow")
Left Ventricular dP/dt derived from Mitral Regurgitation velocity	(18035-6, LN, "Mitral Regurgitation dP/dt derived from Mitral Regurgitation velocity")

Note

Mitral Valve measurements appear in TID 5202 “Echo Section”, which specifies the Finding Site to be Mitral Valve with the concept modifier (363698007, SCT, "Finding Site") = (91134007, SCT, "Mitral Valve").Therefore, the Finding Site modifier does not appear in the right column.

N.3.10 Pulmonary Vein

Name of ASE Concept	Base Measurement Concept Name	Concept or Acquisition Context Modifiers
Pulmonary Vein Systolic Peak Velocity	(29450-4, LN, "Pulmonary Vein Systolic Peak Velocity")
Pulmonary Vein Diastolic Peak Velocity	(29451-2, LN, "Pulmonary Vein Diastolic Peak Velocity")
Pulmonary Vein Systolic to Diastolic Ratio	(29452-0, LN, "Pulmonary Vein Systolic to Diastolic Ratio")
Pulmonary Vein Atrial Contraction Reversal Peak Velocity	(29453-8, LN, "Pulmonary Vein Atrial Contraction Reversal Peak Velocity")
Right Upper Pulmonary Vein Peak Systolic Velocity	(29450-4, LN, "Pulmonary Vein Systolic Peak Velocity")	(106233006, SCT, "Topographical Modifier") = (255499006, SCT, "Right Upper Segment")
Right Upper Pulmonary Vein Diastolic Peak Velocity	(29451-2, LN, "Pulmonary Vein Diastolic Peak Velocity")	(106233006, SCT, "Topographical Modifier") = (255499006, SCT, "Right Upper Segment")
Right Upper Pulmonary Vein Systolic to Diastolic Velocity Ratio	(29452-0, LN, "Pulmonary Vein Systolic to Diastolic Ratio")	(106233006, SCT, "Anatomic Site Modifier") = (255499006, SCT, "Right Upper Segment")
Right Lower Pulmonary Vein Peak Systolic Velocity	(29450-4, LN, "Pulmonary Vein Systolic Peak Velocity")	(106233006, SCT, "Topographical Modifier") = (255496004, SCT, "Right Lower Segment")
Right Lower Pulmonary Vein Diastolic Peak Velocity	(29451-2, LN, "Pulmonary Vein Diastolic Peak Velocity")	(106233006, SCT, "Topographical Modifier") = (255496004, SCT, "Right Lower Segment")
Right Lower Pulmonary Vein Systolic to Diastolic Velocity Ratio	(29452-0, LN, "Pulmonary Vein Systolic to Diastolic Ratio")	(106233006, SCT, "Topographical Modifier") = (255496004, SCT, "Right Lower Segment")
Left Upper Pulmonary Vein Peak Systolic Velocity	(29450-4, LN, "Pulmonary Vein Systolic Peak Velocity")	(106233006, SCT, "Topographical Modifier") = (255482005, SCT, "Left Upper Segment")
Left Upper Pulmonary Vein Velocity Peak Diastolic	(29451-2, LN, "Pulmonary Vein Diastolic Peak Velocity")	(106233006, SCT, "Topographical Modifier") = (255482005, SCT, "Left Upper Segment")
Left Upper Pulmonary Vein Systolic to Diastolic Velocity Ratio	(29452-0, LN, "Pulmonary Vein Systolic to Diastolic Ratio")	(106233006, SCT, "Topographical Modifier") = (255482005, SCT, "Left Upper Segment")
Left Lower Pulmonary Vein Peak Systolic Velocity	(29450-4, LN, "Pulmonary Vein Systolic Peak Velocity")	(106233006, SCT, "Topographical Modifier") = (264068005, SCT, "Left Lower Segment")
Left Lower Pulmonary Vein Diastolic Peak Velocity	(29451-2, LN, "Pulmonary Vein Diastolic Peak Velocity")	(106233006, SCT, "Topographical Modifier") = (264068005, SCT, "Left Lower Segment")
Left Lower Pulmonary Vein Systolic to Diastolic Velocity Ratio	(29452-0, LN, "Pulmonary Vein Systolic to Diastolic Ratio")	(106233006, SCT, "Topographical Modifier") = (264068005, SCT, "Left Lower Segment")

N.3.11 Left Atrium / Appendage

Name of ASE Concept	Base Measurement Concept Name	Concept or Acquisition Context Modifiers
Left Atrium Antero-posterior Systolic Dimension	(29469-4, LN, "Left Atrium Antero-posterior Systolic Dimension")
Left Atrial Antero-posterior Systolic Dimension by M-Mode	(29469-4, LN, "Left Atrium Antero-posterior Systolic Dimension")	(399264008, SCT, "Image Mode") = (399155008, SCT, "M mode")
Left Atrial Antero-posterior Systolic Dimension by 2-D	(29469-4, LN, "Left Atrium Antero-posterior Systolic Dimension")	(399264008, SCT, "Image Mode") = (399064001, SCT, "2D mode")
Left Atrium to Aortic Root Ratio	(17985-3, LN, "Left Atrium to Aortic Root Ratio")
Left Atrial Appendage Peak Velocity	(29486-8, LN, "Left Atrial Appendage Peak Velocity")
Left Atrium Systolic Area	(17977-0, LN, "Left Atrium Area A4C view")	(272518008, SCT, "Cardiac Cycle Point") = (111973004, SCT, "Systole")
Left Atrium Systolic Volume	(399235004, SCT, "Left Atrium Systolic Volume")

N.3.12 Right Ventricle

Name of ASE Concept	Base Measurement Concept Name	Concept or Acquisition Context Modifiers
Right Ventricular Internal Diastolic Dimension by M-Mode	(20304-2, LN, "Right Ventricular Internal Diastolic Dimension")	(399264008, SCT, "Image Mode") = (399155008, SCT, "M mode")
Right Ventricular Internal Diastolic Dimension by 2-D	(20304-2, LN, "Right Ventricular Internal Diastolic Dimension")	(399264008, SCT, "Image Mode") = (399064001, SCT, "2D mode")
Right Ventricular Outflow Tract Systolic Peak Velocity	(11726-7, LN, "Peak Velocity")	(363698007, SCT, "Finding Site") = (44627009, SCT, "Right Ventricular Outflow Tract")
Right Ventricular Outflow Tract Systolic Velocity Time Integral	(20354-7, LN, "Velocity Time Integral")	(363698007, SCT, "Finding Site") = (44627009, SCT, "Right Ventricular Outflow Tract")
Right Ventricular Outflow Systolic Diameter by 2-D	(399027007, SCT, "Cardiovascular Orifice Diameter")	(363698007, SCT, "Finding Site") = (44627009, SCT, "Right Ventricular Outflow Tract") (399264008, SCT, "Image Mode") = (399064001, SCT, "2D mode")
Right Ventricular Outflow Tract Systolic Peak Instantaneous Gradient	(20247-3, LN, "Peak Gradient")	(363698007, SCT, "Finding Site") = (44627009, SCT, "Right Ventricular Outflow Tract")
Right Ventricular Outflow Tract Systolic Mean Gradient	(20256-4, LN, "Mean Gradient")	(363698007, SCT, "Finding Site") = (44627009, SCT, "Right Ventricular Outflow Tract")
Right Ventricular Stroke Volume by Doppler Volume Outflow	(90096001, SCT, "Stroke Volume")	(370129005, SCT, "Measurement Method") = (125219, DCM, "Doppler Volume Flow") (363698007, SCT, "Finding Site") = (44627009, SCT, "Right Ventricular Outflow Tract")
Right Ventricular Outflow Tract Area	(399367004, SCT, "Cardiovascular Orifice Area")	(363698007, SCT, "Finding Site") = (44627009, SCT, "Right Ventricular Outflow Tract")
Right Ventricular Outflow Tract Mean Velocity	(20352-1, LN, "Mean Velocity")	(363698007, SCT, "Finding Site") = (44627009, SCT, "Right Ventricular Outflow Tract")
Right Ventricle Anterior Wall Diastolic Thickness	(18153-7, LN, "Right Ventricle Anterior Wall Diastolic Thickness")
Right Ventricular Anterior Wall Systolic Thickness	(18157-8, LN, "Right Ventricular Anterior Wall Systolic Thickness")
Right Ventricular Peak Systolic Pressure	(399023006, SCT, "Right Ventricular Peak Systolic Pressure")

N.3.13 Pulmonic Valve / Pulmonic Artery

Name of ASE Concept	Base Measurement Concept Name	Concept or Acquisition Context Modifiers
Main Pulmonary Artery Diameter	(18020-8, LN, "Main Pulmonary Artery Diameter")
Main Pulmonary Artery Velocity	(399048009, SCT, "Main Pulmonary Artery Velocity")
Right Pulmonary Artery Diameter	(18021-6, LN, "Right Pulmonary Artery Diameter")
Left Pulmonary Artery Diameter	(18019-0, LN, "Left Pulmonary Artery Diameter")
Pulmonic Valve Systolic Peak Instantaneous Gradient	(20247-3, LN, "Peak Gradient")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Pulmonic Valve Systolic Mean Gradient	(20256-4, LN, "Mean Gradient")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Pulmonic Valve Systolic Peak Velocity	(20354-7, LN, 11726-7, LN, "Peak Velocity")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Pulmonic Valve Systolic Velocity Time Integral	(20354-7, LN, "Velocity Time Integral")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Pulmonic Valve Area by Continuity	(18096-8, LN, "Pulmonic valve Area by Continuity")
Pulmonic Valve Acceleration Time	(20168-1, LN, "Acceleration Time")	(260674002, SCT, "Direction of Flow") = (312004007, SCT, "Regurgitant Flow")
Pulmonic Valve Regurgitant End Diastolic Velocity	(11653-3, LN, "End Diastolic Velocity")	(260674002, SCT, "Direction of Flow") = (312004007, SCT, "Regurgitant Flow")
Pulmonic Valve Regurgitant Diastolic Peak Velocity	(11726-7, LN, "Peak Velocity")	(260674002, SCT, "Direction of Flow") = (312004007, SCT, "Regurgitant Flow")

Note

Pulmonic Valve measurements appear in TID 5202 “Echo Section”, which specifies the Finding Site to be Pulmonic Valve with the concept modifier (363698007, SCT, "Finding Site") = (46030003, SCT, "Pulmonic Valve"). Therefore, this Finding Site concept modifier does not appear in the right column.

N.3.14 Tricuspid Valve

Name of ASE Concept	Base Measurement Concept Name	Concept or Acquisition Context Modifiers
Tricuspid Valve Mean Diastolic Velocity	(20352-1, LN, "Mean Velocity")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Tricuspid Valve E Wave Peak Velocity	(18031-5, LN, "Tricuspid Valve E Wave Peak Velocity")
Tricuspid Valve A Wave Peak Velocity	(18030-7, LN, "Tricuspid Valve A Wave Peak Velocity")
Tricuspid Valve Diastolic Velocity Time Integral	(20354-7, LN, "Velocity Time Integral")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Tricuspid Valve Peak Diastolic Gradient	(20247-3, LN, Peak Gradient")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Tricuspid Valve Mean Diastolic Gradient	(20256-4, LN, Mean Gradient")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Tricuspid Valve Annulus Diastolic Diameter	(399027007, SCT, Cardiovascular Orifice Diameter")	(363698007, SCT, "Finding Site") = (279170002, SCT, "Tricuspid Annulus") (260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")
Tricuspid Valve Regurgitant Peak Velocity	(11726-7, LN, "Peak Velocity")	(260674002, SCT, "Direction of Flow") = (312004007, SCT, "Regurgitant Flow")
Tricuspid Regurgitation Peak Pressure Gradient	(20247-3, LN, "Peak Gradient")	(260674002, SCT, "Direction of Flow") = (312004007, SCT, "Regurgitant Flow")
Tricuspid Regurgitation Velocity Time Integral	(20354-7, LN, "Velocity Time Integral")	(260674002, SCT, "Direction of Flow") = (312004007, SCT, "Regurgitant Flow")
Tricuspid Valve Deceleration Time	(20217-6, LN, "Deceleration Time")	(260674002, SCT, "Direction of Flow") = (263677008, SCT, "Antegrade Flow")

Note

TRICUSPID Valve measurements appear in TID 5202 “Echo Section”, which specifies the Finding Site to be Tricuspid Valve with the concept modifier (363698007, SCT, "Finding Site") = (46030003, SCT, "Tricuspid Valve"). Therefore, the Finding Site modifier does not appear in the right column.

N.3.15 Right Atrium / Inferior Vena Cava

Name of ASE Concept	Base Measurement Concept Name	Concept or Acquisition Context Modifiers
Right Atrium Systolic Pressure	(18070-3, LN, "Right Atrium Systolic Pressure")
Right Atrium Systolic Area	(17988-7, LN, "Right Atrium Area A4C view")	(272518008, SCT, "Cardiac Cycle Point") = (111973004, SCT, "Systole")
Inferior Vena Cava Diameter	(18006-7, LN, "Inferior Vena Cava Diameter")
Inferior Vena Cava Diameter at Inspiration	(18006-7, LN, "Inferior Vena Cava Diameter")	(272517003, SCT, "Respiratory Cycle Point") = (14910006, SCT, "During Inspiration")
Inferior Vena Cava Diameter at Expiration	(18006-7, LN, "Inferior Vena Cava Diameter")	(272517003, SCT, "Respiratory Cycle Point") = (58322009, SCT, "During Expiration")
Inferior Vena Cava % Collapse	(18050-5, LN, "Inferior Vena Cava % Collapse")
Hepatic Vein Systolic Peak Velocity	(29471-0, LN, "Hepatic Vein Systolic Peak Velocity")
Hepatic Vein Diastolic Peak Velocity	(29472-8, LN, "Hepatic Vein Diastolic Peak Velocity")
Hepatic Vein Systolic to Diastolic Ratio	(29473-6, LN, "Hepatic Vein Systolic to Diastolic Ratio")
Hepatic Vein Atrial Contraction Reversal Peak Velocity	(29474-4, LN, "Hepatic Vein Atrial Contraction Reversal Peak Velocity")
Hepatic Vein Peak Systolic Velocity at Inspiration	(29471-0, LN, "Hepatic Vein Systolic Peak Velocity")	(272517003, SCT, "Respiratory Cycle Point") = (14910006, SCT, "During Inspiration")
Hepatic Vein Peak Diastolic Velocity at Inspiration	(29472-8, LN, "Hepatic Vein Diastolic Peak Velocity")	(272517003, SCT, "Respiratory Cycle Point") = (14910006, SCT, "During Inspiration")
Hepatic Vein Systolic to Diastolic Ratio at Inspiration	(29473-6, LN, "Hepatic Vein Systolic to Diastolic Ratio")	(272517003, SCT, "Respiratory Cycle Point") = (14910006, SCT, "During Inspiration")
Hepatic Vein Peak Atrial Contraction Reversal Velocity at Inspiration	(29474-4, LN, "Hepatic Vein Atrial Contraction Reversal Peak Velocity")	(272517003, SCT, "Respiratory Cycle Point") = (14910006, SCT, "During Inspiration")
Hepatic Vein Peak Systolic Velocity at Expiration	(29471-0, LN, "Hepatic Vein Systolic Peak Velocity")	(272517003, SCT, "Respiratory Cycle Point") = (58322009, SCT, "During Expiration")
Hepatic Vein Peak Diastolic Velocity at Expiration	(29472-8, LN, "Hepatic Vein Diastolic Peak Velocity")	(272517003, SCT, "Respiratory Cycle Point") = (58322009, SCT, "During Expiration")
Hepatic Vein Systolic to Diastolic Ratio at Expiration	(29473-6, LN, "Hepatic Vein Systolic to Diastolic Ratio")	(272517003, SCT, "Respiratory Cycle Point") = (58322009, SCT, "During Expiration")
Hepatic Vein Peak Atrial Contraction Reversal Velocity at Expiration	(29474-4, LN, "Hepatic Vein Atrial Contraction Reversal Peak Velocity")	(272517003, SCT, "Respiratory Cycle Point") = (58322009, SCT, "During Expiration")

N.3.16 Congenital/Pediatric

Name of ASE Concept	Base Measurement Concept Name	Concept or Acquisition Context Modifiers
Thoracic Aorta Coarctation Systolic Peak Velocity	(29460-3, LN, "Thoracic Aorta Coarctation Systolic Peak Velocity")
Thoracic Aorta Coarctation Systolic Peak Instantaneous Gradient	(20256-4, LN, "Mean Gradient")	(363698007, SCT, "Finding Site") = (253678000, SCT, "Thoracic Aortic Coarctation")
Thoracic Aorta Coarctation Systolic Mean Gradient	(17995-2, LN, "Thoracic Aorta Coarctation Systolic Peak Instantaneous Gradient")
Ventricular Septal Defect Diameter	(399027007, SCT, "Cardiovascular Orifice Diameter")	(363698007, SCT, "Finding Site") = (30288003, SCT, "Ventricular Septal Defect")
Ventricular Septal Defect Systolic Peak Instantaneous Gradient	(20247-3, LN, "Peak Gradient")	(363698007, SCT, "Finding Site") = (30288003, SCT, "Ventricular Septal Defect")
Ventricular Septal Defect Systolic Mean Gradient	(20256-4, LN, "Mean Gradient")	(363698007, SCT, "Finding Site") = (30288003, SCT, "Ventricular Septal Defect")
Ventricular Septum Defect Systolic Peak Velocity	(11726-7, LN, "Peak Velocity")	(363698007, SCT, "Finding Site") = (30288003, SCT, "Ventricular Septal Defect")
Atrial Septal Defect Diameter	(399027007, SCT, "Cardiovascular Orifice Diameter")	(363698007, SCT, "Finding Site") = (70142008, SCT, "Atrial Septal Defect")
Pulmonary-to-Systemic Shunt Flow Ratio	(29462-9, LN, "Pulmonary-to-Systemic Shunt Flow Ratio")
Pulmonary-to-Systemic Shunt Flow Ratio by Doppler Volume Flow	(29462-9, LN, "Pulmonary-to-Systemic Shunt Flow Ratio")	(370129005, SCT, "Measurement Method") = (125219, DCM, "Doppler Volume Flow")

N.4 Encoding Examples

N.4.1 Example 1: Patient Characteristics

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
	Adult Echocardiography Procedure Report		TID 5200
>	….		…
>	Patient Characteristics		TID 5201
>>	Subject Age	39 years	TID 5201
>>	Subject Sex	M	TID 5201
>>	Patient Height	167 cm	TID 300
>>	Patient Weight	72.6 kg	TID 300
>>	Body Surface Area	1.82 m2	TID 300
>>>	Body Surface Area Formula	Code: 122240	TID 5201

N.4.2 Example 2: LV Dimensions and Fractional Shortening

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
	Adult Echocardiography Procedure Report		TID 5200
>	….		…
>	Findings		TID 5202
>>	Finding Site	Left Ventricle	TID 5202
>>	Measurement Group		TID 5202
>>	Acquisition Protocol	2D Dimensions	TID 5202
>>>	Heart Rate	45 bpm	TID 300
>>>	Left Ventricle Internal End Diastolic Dimension	5.09 cm	TID 300
>>>>	Image Mode	2d	TID 5203
>>>	Left Ventricle Internal End Diastolic Dimension	5.34 cm	TID 300
>>>>	Image Mode	2d	TID 5203
>>>	Left Ventricle Internal End Diastolic Dimension	5.22 cm	TID 300
>>>>	Image Mode	2d	TID 5203
>>>>	Derivation	Mean	TID 300
>>>	Left Ventricle Internal Systolic Dimension	5.09 cm	TID 300
>>>>	Image Mode	2d	TID 5203
>>>	Left Ventricle Internal Systolic Dimension	5.34 cm	TID 300
>>>>	Image Mode	2d	TID 5203
>>>	Left Ventricle Internal Systolic Dimension	5.22 cm	TID 300
>>>>	Image Mode	2d	TID 5203
>>>>	Derivation	Mean	TID 300
>>>	Interventricular Septum Diastolic Thickness	1.20 cm	TID 300
>>>	Interventricular Septum Diastolic Thickness	1.20 cm	TID 300
>>>>	Derivation	Mean	TID 300
>>>	Left Ventricle Internal Systolic Dimension	5.09 cm	TID 300
>>>	Left Ventricle Internal Systolic Dimension	5.30 cm	TID 300
>>>>	Derivation	Mean	TID 300
>>>	Left Ventricular Fractional Shortening	54.8%	TID 300
>>>	…		…

N.4.3 Example 3: Left Atrium / Aortic Root Ratio

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
	Adult Echocardiography Procedure Report		TID 5200
>	….		…
>	Findings		TID 5202
>>	Finding Site	Left Atrium	TID 5202
>>	Measurement Group		TID 5202
>>>	Acquisition Protocol	2D Dimensions	TID 5202
>>>	Left Atrium Antero-posterior Systolic Dimension	3.45 cm	TID 5202
>>>	Left Atrium Antero-posterior Systolic Dimension	3.45 cm	TID 5202
>>>>	Derivation	Mean	TID 5202
>>>	Left Atrium to Aortic Root Ratio	1.35	TID 5202
>	Findings		TID 5202
>>	Finding Site	Aorta	TID 5202
>>	Measurement Group		TID 5202
>>	Acquisition Protocol	2D Dimensions	TID 5202
>>>	Aortic Root Diameter	2.55 cm	TID 5202
>>>	…		…

N.4.4 Example 4: Pressures

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
	Adult Echocardiography Procedure Report		TID 5200
>	….		…
>	Findings		TID 5202
>>	Finding Site	Right Atrium	TID 5202
>>	Measurement Group		TID 5202
>>>	Acquisition Protocol	Pressure Predictions	TID 5202
>>>	Right Atrium Systolic Pressure	10 mmHg	TID 5202
>>>>	Derivation	User estimate	TID 5202
>>	Finding Site	Right Ventricle	TID 5202
>>	Measurement Group		TID 5202
>>>	Acquisition Protocol	Pressure Predictions	TID 5202
>>>	Right Ventricular Peak Systolic Pressure	49.3 mmHg	TID 5202

N.4.5 Example 5: Cardiac Output

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
	Adult Echocardiography Procedure Report		TID 5200
>	….		…
>	Findings		TID 5202
>>	Finding Site	Left Ventricle	TID 5202
>>	Measurement Group		TID 5202
>>	Image Mode	2D	TID 5202
>>>	Heart Rate	89 bpm	TID 5202
>>>	Left Ventricular End Diastolic Volume	38.914 ml	TID 5202
>>>>	Measurement Method	Teichholz	TID 5202
>>>	Left Ventricular End Systolic Volume	12.304 ml	TID 5202
>>>>	Measurement Method	Teichholz	TID 5202
…	…	…	…
>>>	Stroke Volume	26.6 ml	TID 5202
>>>>	Anatomic Site	Left Ventricle	TID 5202
>>>	Stroke Index	13.49 ml/m2	TID 5202
>>>>	Anatomic Site	Left Ventricle	TID 5202
>>>	Cardiac Output	2.37 l/min	TID 5202
>>>>	Anatomic Site	Left Ventricle	TID 5202
>>>	Cardiac Index	1.20 l/min/m2	TID 5202
>>>>	Anatomic Site	Left Ventricle	TID 5202
>>>>	Index	BSA	TID 5202
>>>	Left Ventricular Ejection Fraction	68.4 %	TID 5202
>>>	…		…

N.4.6 Example 6: Wall Scoring

Nest	Code Meaning of Concept Name	Code Meaning or Example Value	TID
	Adult Echocardiography Procedure Report		TID 5200
>	….		…
>	Findings		TID 5204
>>	Procedure Reported	Echocardiography for Determining Ventricular Contraction	TID 5204
>>	Stage	Pre-stress image acquisition	TID 5204
>>	LV Wall Motion Score Index	1.0	TID 5204
>>>	Assessment Scale	5 Point Segment Finding Scale	TID 5204
>>	Findings		TID 5204
>>>	Wall Segment	Basal anterior	TID 5204
>>>>	Wall motion finding	Normal	TID 5204
>>>	Wall Segment	Basal anteroseptal	TID 5204
>>>>	Wall motion finding	Normal	TID 5204
>>>	Wall Segment	Basal inferoseptal	TID 5204
>>>>	Wall motion finding	Akinetic	TID 5204
…	… remaining segments …		TID 5204
>	Wall Motion Analysis		TID 5204
>>	Stage	Peak-stress image acquisition	TID 5204
>>	LV Wall Motion Score Index	1.23	TID 5204
>>>	Assessment Scale	5 Point Segment Finding Scale	TID 5204
>>	Findings		TID 5204
>>>	Wall Segment	Basal anterior	TID 5204
>>>>	Score	Hypokinesis	TID 5204
>>>	Wall Segment	Basal anteroseptal	TID 5204
>>>>	Score	Akinetic	TID 5204
>>>>	Morphology	Scar / Thinning	TID 5204
>>>	Wall Segment	Basal inferoseptal	TID 5204
>>>>	Score	Normal	TID 5204
…	… remaining segments …		TID 5204

N.5 IVUS Report

The IVUS Report contains one or more vessel containers, each corresponding to the vessel (arterial location) being imaged. Each vessel is associated with one or more IVUS image pullbacks (Ultrasound Multi-frame Images), acquired during a phase of a catheterization procedure. Each vessel may contain one or more sub-containers, each associated with a single lesion. Each lesion container includes a set of IVUS measurements and qualitative assessments. The resulting hierarchical structure is depicted in Figure N.5-1.

Figure N.5-1. IVUS Report Structure

O Registration (Informative)

O.1 Spatial Registration and Spatial Fiducials SOP Classes

These SOP Classes allow describing spatial relationships between sets of images. Each instance can describe any number of registrations as shown in Figure O.1-1. It may also reference prior registration instances that contribute to the creation of the registrations in the instance.

A Reference Coordinate System (RCS) is a spatial Frame of Reference described by the DICOM Frame of Reference Module. The chosen Frame of Reference of the Registration SOP Instance may be the same as one or more of the Referenced SOP Instances. In this case, the Frame of Reference UID (0020,0052) is the same, as shown by the Registered RCS in the figure. The registration information is a sequence of spatial transformations, potentially including deformation information. The composite of the specified spatial transformations defines the complete transformation from one RCS to the other.

Image instances may have no DICOM Frame of Reference, in which case the registration is to that single image (or frame, in the case of a Multi-frame Image). The Spatial Registration IOD may also be used to establish a coordinate system for an image that has no defined Frame of Reference. To do this, the center of the top left pixel of the source image is treated as being located at (0, 0, 0). Offsets from the first pixel are computed using the resolution specified in the Source IOD. Multiplying that coordinate by the Transformation matrix gives the patient coordinate in the new Frame of Reference.

A special case is an atlas. DICOM has defined Well-Known Frame of Reference UIDs for several common atlases. There is not necessarily image data associated with an atlas.

When using the Spatial Registration or Deformable Registration SOP Classes there are two types of coordinate systems. The coordinate system of the referenced data is the Source RCS. The coordinate system established by the SOP instance is the Registered RCS.

The sense of the direction of transformation differs between the Spatial Registration SOP Class and the Deformable Spatial Registration SOP Class. The Spatial Registration SOP Class specifies a transformation that maps Source coordinates, in the Source RCS, to Registered coordinates, in the Registered RCS. The Deformable Spatial Registration SOP Class specifies transformations that map Registered coordinates, in the Registered RCS, to coordinates in the Source RCS.

The Spatial Fiducials SOP Class stores spatial fiducials as implicit registration information.

Figure O.1-1. Registration of Image SOP Instances

O.2 Functional Use Cases

Multi-Modality Fusion: A workstation or modality performs a registration of images from independent acquisition modalities-PET, CT, MR, NM, and US-from multiple series. The workstation stores the registration data for subsequent visualization and image processing. Such visualization may include side-by-side synchronized display, or overlay (fusion) of one modality image on the display of another. The processes for such fusion are beyond the scope of the Standard. The workstation may also create and store a ready-for-display fused image, which references both the source image instances and the registration instance that describes their alignment.

Prior Study Fusion: Using post processing or a manual process, a workstation creates a spatial object registration of the current Study's Series from prior Studies for comparative evaluation.

Atlas Mapping: A workstation or a CAD device specifies fiducials of anatomical features in the brain such as the anterior commissure, posterior commissure, and points that define the hemispheric fissure plane. The system stores this information in the Spatial Fiducials SOP Instance. Subsequent retrieval of the fiducials enables a device or workstation to register the patient images to a functional or anatomical atlas, presenting the atlas information as overlays.

CAD: A CAD device creates fiducials of features during the course of the analysis. It stores the locations of the fiducials for future analysis in another imaging procedure. In the subsequent CAD procedure, the CAD device performs a new analysis on the new data. As before, it creates comparable fiducials, which it may store in a Spatial Fiducials SOP Instance. The CAD device then performs additional analysis by registering the images of the current exam to the prior exam. It does so by correlating the fiducials of the prior and current exam. The CAD device may store the registration in Registration SOP Instance.

Adaptive Radiotherapy: A CT Scan is taken to account for variations in patient position prior to radiation therapy. A workstation performs the registration of the most recent image data to the prior data, corrects the plan, and stores the registration and revised plan.

Image Stitching: An acquisition device captures multiple images, e.g., DX images down a limb. A user identifies fiducials on each of the images. The system stores these in one or more Fiducial SOP Instances. Then the images are "stitched" together algorithmically by means that utilize the Fiducial SOP Instances as input. The result is a single image and optionally a Registration SOP Instance that indicates how the original images can be transformed to a location on the final image.

O.3 System Interaction

Figure O.3-1 shows the system interaction of storage operations for a registration of MR and CT using the Spatial Registration SOP Class. The Image Plane Module Attributes of the CT Series specify the spatial mapping to the RCS of its DICOM Frame of Reference.

Figure O.3-1. Stored Registration System Interaction

The receiver of the Registration SOP Instance may use the spatial transformation to display or process the referenced image data in a common coordinate system. This enables interactive display in 3D during interpretation or planning, tissue classification, quantification, or Computer Aided Detection. Figure O.3-2 shows a typical interaction scenario.

Figure O.3-2. Interaction Scenario

In the case of coupled acquisition modalities, one acquisition device may know the spatial relationship of its image data relative to the other. The acquisition device may use the Registration SOP Class to specify the relationship of modality B images to modality A images as shown below in Figure O.3-3. In the most direct case, the data of both modalities are in the same DICOM Frame of Reference for each SOP Class Instance.

Figure O.3-3. Coupled Modalities

A Spatial Registration instance consists of one or more instances of a Registration. Each Registration specifies a transformation from the RCS of the Referenced Image Set, to the RCS of this Spatial Registration instance (see PS3.3) identified by the Frame of Reference UID (0020,0052).

O.4 Overview of Encoding

Figure O.4-1 shows an information model of a Spatial Registration to illustrate the relationship of the Attributes to the objects of the model. The DICOM Attributes that describe each object are adjacent to the object.

Figure O.4-1. Spatial Registration Encoding

Figure O.4-2 shows an information model of a Deformable Spatial Registration to illustrate the relationship of the Attributes to the objects of the model. The DICOM Attributes that describe each object are adjacent to the object.

Figure O.4-2. Deformable Spatial Registration Encoding

Figure O.4-3 shows a Spatial Fiducials information model to illustrate the relationship of the Attributes to the objects of the model. The DICOM Attributes that describe each object are adjacent to the object.

Figure O.4-3. Spatial Fiducials Encoding

O.5 Matrix Registration

A 4x4 affine transformation matrix describes spatial rotation, translation, scale changes and affine transformations that register referenced images to the Registration IE's homogeneous RCS. These steps are expressible in a single matrix, or as a sequence of multiple independent rotations, translations, or scaling, each expressed in a separate matrix. Normally, registrations are rigid body, involving only rotation and translation. Changes in scale or affine transformations occur in atlas registration or to correct minor mismatches.

O.6 Spatial Fiducials

Fiducials are image-derived reference markers of location, orientation, or scale. These may be labeled points or collections of points in a data volume that specify a shape. Most commonly, fiducials are individual points.

Correlated fiducials of separate image sets may serve as inputs to a registration process to estimate the spatial registration between similar objects in the images. The correlation may, or may not, be expressed in the fiducial identifiers. A fiducial identifier may be an arbitrary number or text string to uniquely identify each fiducial from others in the set. In this case, fiducial correlation relies on operator recognition and control.

Alternatively, coded concepts may identify the acquired fiducials so that systems can automatically correlate them. Examples of such coded concepts are points of a stereotactic frame, prosthesis points, or well-resolved anatomical landmarks such as bicuspid tips. Such codes could be established and used locally by a department, over a wider area by a society or research study coordinator, or from a standardized set.

The table below shows each case of identifier encoding. A and B represent two independent registrations: one to some image set A, and the other to image set B.

Fiducial Identifier (0070,0310)

Fiducial Identifier Code Sequence (0070,0311)

Uncorrelated

A: 1, 2, 3

B: 4, 5, 6

A: (1, 99_A_CSD, label A1) …

B: (4, 99_B_CSD, label B4) …

Correlated

A: 1, 2, 3 …

B: 1, 2, 3 …

A: (1, 99_MY_CSD, label 1) …

B: (1, 99_MY_CSD, label 1) …

Fiducials may be a point or some other shape. For example, three or more arbitrarily chosen points might designate the inter-hemispheric plane for the registration of head images. Many arbitrarily chosen points may identify a surface such as the inside of the skull.

A fiducial also has a Fiducial UID. This UID identifies the creation of the fiducial and allows other SOP Instances to reference the fiducial assignment.

P Transforms and Mappings (Informative)

The Affine Transform Matrix is of the following form.

Equation P-1.

This matrix requires the bottom row to be [0 0 0 1] to preserve the homogeneous coordinates.

The matrix can be of type: RIGID, RIGID_SCALE and AFFINE. These different types represent different conditions on the allowable values for the matrix elements.

RIGID:

This transform requires the matrix obey orthonormal transformation properties:

Equation P-2.

for all combinations of j = 1,2,3 and k = 1,2,3 where δ = 1 for i = j and zero otherwise.

The expansion into non-matrix equations is:
- M₁₁ M₁₁ + M₂₁ M₂₁ + M₃₁ M₃₁ = 1 where j = 1, k = 1
- M₁₁ M₁₂ + M₂₁ M₂₂ + M₃₁ M₃₂ = 0 where j = 1, k = 2
- M₁₁ M₁₃ + M₂₁ M₂₃ + M₃₁ M₃₃ = 0 where j = 1, k = 3
- M₁₂ M₁₁ + M₂₂ M₂₁ + M₃₂ M₃₁ = 0 where j = 2, k = 1
- M₁₂ M₁₂ + M₂₂ M₂₂ + M₃₂ M₃₂ = 1 where j = 2, k = 2
- M₁₂ M₁₃ + M₂₂ M₂₃ + M₃₂ M₃₃ = 0 where j = 2, k = 3
- M₁₃ M₁₁ + M₂₃ M₂₁ + M₃₃ M₃₁ = 0 where j = 3, k = 1
- M₁₃ M₁₂ + M₂₃ M₂₂ + M₃₃ M₃₂ = 0 where j = 3, k = 2
- M₁₃ M₁₃ + M₂₃ M₂₃ + M₃₃ M₃₃ = 1 where j = 3, k = 3
The Frame of Reference Transformation Matrix ^AM_B describes how to transform a point (B_x,B_y,B_z) with respect to RCS_B into (A_x,A_y,A_z) with respect to RCS_A.

Equation P-3.

The matrix above consists of two parts: a rotation and translation as shown below;

Rotation:

Equation P-4.

Translation:

Equation P-5.

The first column [M₁₁,M₂₁,M₃₁ ] are the direction cosines (projection) of the X-axis of RCS_B with respect to RCS_A . The second column [M₁₂,M₂₂,M₃₂] are the direction cosines (projection) of the Y-axis of RCS_B with respect to RCS_A. The third column [M₁₃,M₂₃,M₃₃] are the direction cosines (projection) of the Z-axis of RCS_B with respect to RCS_A. The fourth column [T₁,T₂,T₃] is the origin of RCS_B with respect to RCS_A.

There are three degrees of freedom representing rotation, and three degrees of freedom representing translation, giving a total of six degrees of freedom.
RIGID_SCALE

The following constraint applies:

Equation P-6.

for all combinations of j = 1,2,3 and k = 1,2,3 where δ = 1 for i=j and zero otherwise.

The expansion into non-matrix equations is:
- M₁₁ M₁₁ + M₂₁ M₂₁ + M₃₁ M₃₁ = S₁ ² where j = 1, k = 1
- M₁₁ M₁₂ + M₂₁ M₂₂ + M₃₁ M₃₂ = 0 where j = 1, k = 2
- M₁₁ M₁₃ + M₂₁ M₂₃ + M₃₁ M₃₃ = 0 where j = 1, k = 3
- M₁₂ M₁₁ + M₂₂ M₂₁ + M₃₂ M₃₁ = 0 where j = 2, k = 1
- M₁₂ M₁₂ + M₂₂ M₂₂ + M₃₂ M₃₂ = S₂ ² where j = 2, k = 2
- M₁₂ M₁₃ + M₂₂ M₂₃ + M₃₂ M₃₃ = 0 where j = 2, k = 3
- M₁₃ M₁₁ + M₂₃ M₂₁ + M₃₃ M₃₁ = 0 where j = 3, k = 1
- M₁₃ M₁₂ + M₂₃ M₂₂ + M₃₃ M₃₂ = 0 where j = 3, k = 2
- M₁₃ M₁₃ + M₂₃ M₂₃ + M₃₃ M₃₃ = S₃ ² where j = 3, k = 3
The above equations show a simple way of extracting the spatial scaling parameters Sj from a given matrix. The units of S_j ² is the RCS unit dimension of one millimeter.

This type can be considered a simple extension of the type RIGID. The RIGID_SCALE is easily created by pre-multiplying a RIGID matrix by a diagonal scaling matrix as follows:

Equation P-7.

where M_RBWS is a matrix of type RIGID_SCALE and M_RB is a matrix of type RIGID.
AFFINE:

No constraints apply to this matrix, so it contains twelve degrees of freedom. This type of Frame of Reference Transformation Matrix allows shearing in addition to rotation, translation and scaling.

For a RIGID type of Frame of Reference Transformation Matrix, the inverse is easily computed using the following formula (inverse of an orthonormal matrix):

Equation P-8.

For RIGID_SCALE and AFFINE types of Registration Matrices, the inverse cannot be calculated using the above equation, and must be calculated using a conventional matrix inverse operation.

Q Breast Imaging Report (Informative)

Q.1 Breast Imaging Report Content Tree Structure

The templates for the Breast Imaging Report are defined in PS3.16. Relationships defined in the Breast Imaging Report templates are by-value. This template structure may be conveyed using the Enhanced SR SOP Class or the Basic Text SR SOP Class.

Figure Q.1-1. Top Level of Breast Imaging Report Content Tree

As shown in Figure Q.1-1, the Breast Imaging Report Narrative and Breast Imaging Report Supplementary Data sub-trees together form the Content Tree of the Breast Imaging Report.

Figure Q.1-2. Breast Imaging Procedure Reported Content Tree

The Breast Imaging Procedure Reported sub-tree is a mandatory child of the Supplementary Data Content Item, to describe all of the procedures to which the report applies using coded terminology. It may also be used as a sub-tree of sections within the Supplementary Data sub-tree, for the instance in which a report covers more than one procedure, but different sections of the Supplementary Data record the evidence of a subset of the procedures.

Figure Q.1-3. Breast Imaging Report Narrative Content Tree

An instance of the Breast Imaging Report Narrative sub-tree contains one or more text-based report sections, with a name chosen from CID 6052 “Breast Imaging Report Section Title”. Within a report section, one or more observers may be identified. This sub-tree is intended to contain the report text as it was created, presented to, and signed off by the verifying observer. It is not intended to convey the exact rendering of the report, such as formatting or visual organization. Report text may reference one or more image or other composite objects on which the interpretation was based.

Figure Q.1-4. Breast Imaging Report Supplementary Data Content Tree

An instance of the Breast Imaging Report Supplementary Data sub-tree contains one or more of: Breast Imaging Procedure Reported, Breast Composition Section, Breast Imaging Report Finding Section, Breast Imaging Report Intervention Section, Overall Assessment. This sub-tree is intended to contain the supporting evidence for the Breast Imaging Report Narrative sub-tree, using coded terminology and numeric data.

Figure Q.1-5. Breast Imaging Assessment Content Tree

The Breast Imaging Assessment sub-tree may be instantiated as the content of an Overall Assessment section of a report (see Figure Q.1-4), or as part of a Findings section of a report (see TID 4206 “Breast Imaging Report Finding Section”). Reports may provide an individual assessment for each Finding, and then an overall assessment based on an aggregate of the individual assessments.

Q.2 Breast Imaging Report Examples

The following are simple illustrations of encoding Mammography procedure based Breast Imaging Reports.

Q.2.1 Example 1: Screening Mammogram With Negative Findings

A screening mammography case, i.e., there are typically four films and no suspicious abnormalities. The result is a negative mammogram with basic reporting. This example illustrates a report encoded as narrative text only:

Example Q.2-1. Report Sample: Narrative Text Only

Procedure reported

Film screen mammography, both breasts.

Reason for procedure

Screening

Findings

Comparison was made to exam from 11/14/2001. The breasts are heterogeneously dense. This may lower the sensitivity of mammography. No significant masses, calcifications, or other abnormalities are present. There is no significant change from the prior exam.

Impressions

BI-RADS® Category 1: Negative. Recommend normal interval follow-up in 12 months

Table Q.2-1. Breast Image Report Content for Example 1

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID/CID
1	Breast Imaging Report		TID 4200
1.1	Language of Content Item and Descendants	English	TID 1204
1.2	Narrative Summary		TID 4202
1.2.1	Procedure reported		TID 4202 CID 6052
1.2.1.1	Procedure reported	Film screen mammography, both breasts.	TID 4202 CID 6053
1.2.2	Reason for procedure		TID 4202 CID 6052
1.2.2.1	Reason for procedure	Screening	TID 4202 CID 6053
1.2.3	Findings		TID 4202 CID 6052
1.2.3.1	Finding	Comparison was made to exam from 11/14/2001. The breasts are heterogeneously dense. This may lower the sensitivity of mammography. No significant masses, calcifications, or other abnormalities are present. There is no significant change from the prior exam.	TID 4202 CID 6053
1.2.4	Impressions		TID 4202 CID 6052
1.2.4.1	Impression	BI-RADS® Category 1: Negative. Recommend normal interval follow-up in 12 months.	TID 4202 CID 6053

Q.2.2 Example 2: Screening Mammogram With Negative Findings

Example Q.2-2. Report Sample: Narrative Text with Minimal Supplementary Data

Procedure reported

Film screen mammography, both breasts.

Reason for procedure

Screening

Comparison to previous exams

Comparison was made to exam from 11/14/2001.

Breast composition

The breasts are heterogeneously dense. This may lower the sensitivity of mammography.

Findings

No significant masses, calcifications, or other abnormalities are present. There is no significant change from the prior exam.

Impressions

BI-RADS® Category 1: Negative. Recommend normal interval follow-up in 12 months.

Overall Assessment

Negative

Table Q.2-2. Breast Imaging Report Content for Example 2

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID/CID
1	Breast Imaging Report		TID 4200
1.1	Language of Content Item and Descendants	English	TID 1204
1.2	Narrative Summary		TID 4202
1.2.1	Procedure reported		TID 4202 CID 6052
1.2.1.1	Procedure reported	Film screen mammography, both breasts.	TID 4202 CID 6053
1.2.2	Reason for procedure		TID 4202 CID 6052
1.2.2.1	Reason for procedure	Screening	TID 4202 CID 6053
1.2.3	Comparison to previous exams		TID 4202 CID 6052
1.2.3.1	Comparison to previous exams	Comparison was made to exam from 11/14/2001.	TID 4202 CID 6053
1.2.4	Breast composition		TID 4202 CID 6052
1.2.4.1	Breast composition	The breasts are heterogeneously dense. This may lower the sensitivity of mammography.	TID 4202 CID 6053
1.2.5	Findings		TID 4202 CID 6052
1.2.5.1	Finding	No significant masses, calcifications, or other abnormalities are present. There is no significant change from the prior exam.	TID 4202 CID 6053
1.2.6	Impressions		TID 4202 CID 6052
1.2.6.1	Impression	BI-RADS® Category 1: Negative. Recommend normal interval follow-up in 12 months.	TID 4202 CID 6053
1.2.7	Overall Assessment		TID 4202 CID 6052
1.2.7.1	Overall Assessment	Negative	TID 4202 CID 6053
1.3	Supplementary Data		TID 4208
1.3.1	Procedure reported	Film Screen Mammography	TID 4201 CID 6050
1.3.1.1	Laterality	Both breasts	TID 4201 CID 6022
1.3.1.2	Reason for procedure	Screening	TID 4201 CID 6051
1.3.2	Breast composition		TID 4205
1.3.2.1	Breast composition	Heterogeneously dense	TID 4205 CID 6000
1.3.2.1.1	Laterality	Both breasts	TID 4205 CID 6022
1.3.3	Overall Assessment		TID 4208
1.3.3.1	Assessment Category	1 - Negative	TID 4203 CID 6026
1.3.3.2	Recommended Follow-up	Normal interval follow-up	TID 4203 CID 6028

Q.2.3 Example 3: Diagnostic Mammogram - Unilateral

A diagnostic mammogram was prompted by a clinical finding. The result is a probably benign finding with a short interval follow-up of the left breast. This report provides the narrative text with more extensive supplementary data.

Example Q.2-3. Report Sample: Narrative Text with More Extensive Supplementary Data

Procedure reported

Film screen mammography, left breast.

Reason for procedure

Non-bloody discharge left breast.

Breast composition

The breast is almost entirely fat.

Findings

Film screen mammograms were performed. There are heterogeneous calcifications regionally distributed in the 1 o'clock upper outer quadrant, anterior region of the left breast. There is an increase in the number of calcifications from the prior exam.

Impressions

BI-RADS® Category 3: Probably Benign Finding. Short interval follow-up of the left breast is recommended in 6 months.

Table Q.2-3. Breast Imaging Report Content for Example 3

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID/CID
1	Breast Imaging Report		TID 4200
1.1	Language of Content Item and Descendants	English	TID 1204
1.2	Narrative Summary		TID 4202
1.2.1	Procedure reported		TID 4202 CID 6052
1.2.1.1	Procedure reported	Film screen mammography, left breast.	TID 4202 CID 6053
1.2.2	Reason for procedure		TID 4202 CID 6052
1.2.2.1	Reason for procedure	Non-bloody discharge left breast.	TID 4202 CID 6053
1.2.3	Breast composition		TID 4202 CID 6052
1.2.3.1	Breast composition	The breast is almost entirely fat.	TID 4202 CID 6053
1.2.4	Findings		TID 4202 CID 6052
1.2.4.1	Finding	Film screen mammograms were performed. There are heterogeneous calcifications regionally distributed in the 1 o'clock upper outer quadrant, anterior region of the left breast. There is an increase in the number of calcifications from the prior exam.	TID 4202 CID 6053
1.2.5	Impressions		TID 4202 CID 6052
1.2.5.1	Impression	BI-RADS® Category 3: Probably Benign Finding. Short interval follow-up of the left breast is recommended in 6 months.	TID 4202 CID 6053
1.3	Supplementary Data		TID 4208
1.3.1	Procedure reported	Film Screen Mammography	TID 4201 CID 6050
1.3.1.1	Laterality	Left breast	TID 4201 CID 6022
1.3.1.2	Reason for procedure	Clinical Finding	TID 4201 CID 6051
1.3.1.2.1	Clinical Finding	Non-bloody discharge	TID 4201 CID 6055
1.3.1.2.1.1	Laterality	Left breast	TID 4201 CID 6022
1.3.2	Breast composition		TID 4205
1.3.2.1	Breast composition	Almost entirely fat	TID 4205 CID 6000
1.3.2.1.1	Laterality	Left breast	TID 4205 CID 6022
1.3.3	Findings		TID 4206
1.3.3.1	Finding	Calcification of breast	TID 4206 CID 6054
1.3.3.1.1	Assessment Category	3 - Probably Benign Finding - short interval follow-up	TID 4203 CID 6026
1.3.3.1.2	Recommended Follow-up	Follow-up at short interval (1-11 months)	TID 4203 CID 6028
1.3.3.1.2.1	Laterality	Left breast	TID 4203 CID 6022
1.3.3.1.2.2	Recommended Follow-up Interval	6 months	TID 4203 CID 6046
1.3.3.1.3	Clockface or region	1 o'clock position	TID 4206 CID 6018
1.3.3.1.4	Quadrant location	Upper outer quadrant of breast	TID 4206 CID 6020
1.3.3.1.5	Depth	Anterior	TID 4206 CID 6024
1.3.3.1.6	Calcification Type	Heterogeneous calcification	TID 4206 CID 6010
1.3.3.1.7	Calcification Distribution	Regional calcification distribution	TID 4206 CID 6012
1.3.3.1.8	Change since last mammogram	Increase in number of calcifications	TID 4206 CID 6002

Q.2.4 Example 4: Diagnostic Mammogram and Ultrasound - Unilateral

Following a screening mammogram, the patient was asked to return for additional imaging and an ultrasound on the breast, for further evaluation of a mammographic mass. This example demonstrates a report on multiple breast imaging procedures. This report provides the narrative text with some supplementary data.

Example Q.2-4. Report Sample: Multiple Procedures, Narrative Text with Some Supplementary Data

Procedure reported

Film screen mammography, left breast; Ultrasound procedure, left breast.

Reason for procedure

Additional evaluation requested at current screening.

Comparison to previous exams

Comparison was made to exam from 11/14/2001.

Findings

Film Screen Mammography: A lobular mass with obscured margins is present measuring 7mm in the upper outer quadrant.

Findings

Ultrasound demonstrates a simple cyst.

Impressions

BI-RADS® Category 2: Benign, no evidence of malignancy. Normal interval follow-up of both breasts is recommended in 12 months.

Overall Assessment

Benign

Table Q.2-4. Breast Imaging Report Content for Example 4

Node	Code Meaning of Concept Name	Code Meaning or Example Value	TID/CID
1	Breast Imaging Report		TID 4200
1.1	Language of Content Item and Descendants	English	TID 1204
1.2	Narrative Summary		TID 4202
1.2.1	Procedure reported		TID 4202 CID 6052
1.2.1.1	Procedure reported	Film screen mammography, left breast; Ultrasound procedure, left breast.	TID 4202 CID 6053
1.2.2	Reason for procedure		TID 4202 CID 6052
1.2.2.1	Reason for procedure	Additional evaluation requested at current screening.	TID 4202 CID 6053
1.2.3	Comparison to previous exams		TID 4202 CID 6052
1.2.3.1	Comparison to previous exams	Comparison was made to exam from 11/14/2001.	TID 4202 CID 6053
1.2.4	Findings		TID 4202 CID 6052
1.2.4.1	Finding	Film Screen Mammography: A lobular mass with obscured margins is present measuring 7mm in the upper outer quadrant.	TID 4202 CID 6053
1.2.5	Findings		TID 4202 CID 6052
1.2.5.1	Finding	Ultrasound demonstrates a simple cyst.	TID 4202 CID 6053
1.2.6	Impressions		TID 4202 CID 6052
1.2.6.1	Impression	BI-RADS® Category 2: Benign, no evidence of malignancy. Normal interval follow-up of both breasts is recommended in 12 months.	TID 4202 CID 6053
1.2.7	Overall Assessment		TID 4202 CID 6052
1.2.7.1	Overall Assessment	Benign	TID 4202 CID 6053
1.3	Supplementary Data		TID 4208
1.3.1	Procedure reported	Film Screen Mammography	TID 4201 CID 6050
1.3.1.1	Laterality	Left breast	TID 4201 CID 6022
1.3.1.2	Reason for procedure	Additional evaluation requested at current screening	TID 4201 CID 6051
1.3.2	Procedure reported	Ultrasound procedure	TID 4201 CID 6050
1.3.2.1	Laterality	Left breast	TID 4201 CID 6022
1.3.2.2	Reason for procedure	Additional evaluation requested at current screening	TID 4201 CID 6051
1.3.3	Findings		TID 4206
1.3.3.1	Procedure reported	Film Screen Mammography	TID 4201 CID 6050
1.3.3.1.1	Laterality	Left breast	TID 4201 CID 6022
1.3.3.1.2	Reason for procedure	Additional evaluation requested at current screening	TID 4201 CID 6051
1.3.3.2	Finding	Mammographic breast mass	TID 4206 CID 6054
1.3.3.2.1	Quadrant location	Upper outer quadrant of breast	TID 4206 CID 6020
1.3.3.2.2	Diameter	7 mm	TID 1400 CID 7470
1.3.3.2.3	Shape	Lobular	TID 4206 CID 6004
1.3.3.2.4	Margins	Obscured lesion	TID 4206 CID 6006
1.3.4	Findings		TID 4206
1.3.4.1	Procedure reported	Ultrasound procedure	TID 4201 CID 6050
1.3.4.1.1	Laterality	Left breast	TID 4201 CID 6022
1.3.4.1.2	Reason for procedure	Additional evaluation requested at current screening	TID 4201 CID 6051
1.3.4.2	Finding	Simple cyst of breast	TID 4206 CID 6054
1.3.5	Overall Assessment		TID 4208
1.3.5.1	Assessment Category	2 - Benign Finding	TID 4203 CID 6026

R Configuration Use Cases (Informative)

The following use cases are the basis for the decisions made in defining the Configuration Management Profiles specified in PS3.15. Where possible specific protocols that are commonly used in IT system management are specifically identified.

R.1 Install A New Machine

When a new machine is added there need to be new entries made for:

TCP/IP parameters
DICOM Application Entity Related Parameters

The service staff effort needed for either of these should be minimal. To the extent feasible these parameters should be generated and installed automatically.

The need for some sort of ID is common to most of the use cases, so it is assumed that each machine has sufficient non-volatile storage to at least remember its own name for later use.

Updates may be made directly to the configuration databases or made via the machine being configured. A common procedure for large networks is for the initial network design to assign these parameters and create the initial databases during the complete initial network design. Updates can be made later as new devices are installed.

One step that specifically needs automation is the allocation of AE Titles. These must be unique. Their assignment has been a problem with manual procedures. Possibilities include:

Fully automatic allocation of AE Titles as requested. This interacts with the need for AE title stability in some use cases. The automatic process should permit AE Titles to be persistently associated with particular devices and application entities. The automatic process should permit the assignment of AE titles that comply with particular internal structuring rules.
Assisted manual allocation, where the service staff proposes AE Titles (perhaps based on examining the list of present AE Titles) and the system accepts them as unique or rejects them when non-unique.

These AE Titles can then be associated with the other application entity related information. This complete set of information needs to be provided for later uses.

The local setup may also involve searches for other AEs on the network. For example, it is likely that a search will be made for archives and printers. These searches might be by SOP class or device type. This is related to vendor specific application setup procedures, which are outside the scope of DICOM.

R.1.1 Configure DHCP

The network may have been designed in advance and the configuration specified in advance. It should be possible to pre-configure the configuration servers prior to other hardware installation. This should not preclude later updates or later configuration at specific devices.

The DHCP servers have a database that is manually maintained defining the relationship between machine parameters and IP parameters. This defines:

Hardware MAC addresses that are to be allocated specific fixed IP information.
Client machine names that are to be allocated specific fixed IP information.
Hardware MAC addresses and address ranges that are to be allocated dynamically assigned IP addresses and IP information.
Client machine name patterns that are to be allocated dynamically assigned IP addresses and IP information.

The IP information that is provided will be a specific IP address together with other information. The present recommendation is to provide all of the following information when available.

The manual configuration of DHCP is often assisted by automated user interface tools that are outside the scope of DICOM. Some people utilize the DHCP database as a documentation tool for documenting the assignment of IP addresses that are preset on equipment. This does not interfere with DHCP operation and can make a gradual transition from equipment presets to DHCP assignments easier. It also helps avoid accidental re-use of IP addresses that are already manually assigned. However, DHCP does not verify that these entries are in fact correct.

R.1.2 Configure LDAP

There are several ways that the LDAP configuration information can be obtained.

A complete installation may be pre-designed and the full configuration loaded into the LDAP server, with the installation Attribute set to false. Then as systems are installed, they acquire their own configurations from the LDAP server. The site administration can set the installation Attribute to true when appropriate.
When the LDAP server permits network clients to update the configuration, they can be individually installed and configured. Then after each device is configured, that device uploads its own configuration to the LDAP server.
When the LDAP server does not permit network clients to update configurations, they can be individually installed and configured. Then, instead of uploading their own configuration, they create a standard format file with their configuration objects. This file is then manually added to the LDAP server (complying with local security procedures) and any conflicts resolved manually.

R.1.2.1 Pre-configure

LDAP defines a standard file exchange format for transmitting LDAP database subsets in an ASCII format. This file exchange format can be created by a variety of network configuration tools. There are also systems that use XML tools to create database subsets that can be loaded into LDAP servers. It is out of scope to specify these tools in any detail. The use case simply requires that such tools be available.

When the LDAP database is pre-configured using these tools, it is the responsibility of the tools to ensure that the resulting database entries have unique names. The unique name requirement is common to any LDAP database and not just to DICOM AE Titles. Consequently, most tools have mechanisms to ensure that the database updates that they create do have unique names.

Figure R.1-1. System Installation with Pre-configured Configuration

At an appropriate time, the installed Attribute is set on the device objects in the LDAP configuration.

R.1.2.2 Updating Configuration During Installation

The "unconfigured" device start up begins with use of the pre-configured services from DHCP, DNS, and NTP. It then performs device configuration and updates the LDAP database. This description assumes that the device has been given permission to update the LDAP database directly.

DHCP is used to obtain IP related parameters. The DHCP request can indicate a desired machine name that DHCP can associate with a configuration saved at the DHCP server. DHCP does not guarantee that the desired machine name will be granted because it might already be in use, but this mechanism is often used to maintain specific machine configurations. The DHCP will also update the DNS server (using the DDNS mechanisms) with the assigned IP address and hostname information. Legacy note: A machine with pre-configured IP addresses, DNS servers, and NTP servers may skip this step. As an operational and documentation convenience, the DHCP server database may contain the description of this pre-configured machine.
The list of NTP servers is used to initiate the NTP process for obtaining and maintaining the correct time. This is an ongoing process that continues for the duration of device activity. See Time Synchronization below.
The list of DNS servers is used to obtain the address of the DNS servers at this site. Then the DNS servers are queried to get the list of LDAP servers. This utilizes a relatively new addition to the DNS capabilities that permit querying DNS to obtain servers within a domain that provide a particular service.
The LDAP servers are queried to find the server that provides DICOM configuration services, and then obtain a description for the device matching the assigned machine name. This description includes device specific configuration information and a list of Network AEs. For the unconfigured device there will be no configuration found.

Note

These first four steps are the same as a normal start up (described below).
Through a device specific process it determines its internal AE structure. During initial device installation it is likely that the LDAP database lacks information regarding the device. Using some vendor specific mechanism, e.g., service procedures, the device configuration is obtained. This device configuration includes all the information that will be stored in the LDAP database. The fields for "device name" and "AE Title" are tentative at this point.
Each of the Network AE objects is created by means of the LDAP object creation process. It is at this point that LDAP determines whether the AE Title is in fact unique among all AE Titles. If the title is unique, the creation succeeds. If there is a conflict, the creation fails and "name already in use" is given as a reasonless uses propose/create as an atomic operation for creating unique items. The LDAP approach permits unique titles that comply with algorithms for structured names, check digits, etc. DICOM does not require structured names, but they are a commonplace requirement for other LDAP users. It may take multiple attempts to find an unused name. This multiple probe behavior can be a problem if "unconfigured device" is a common occurrence and name collisions are common. Name collisions can be minimized at the expense of name structure by selecting names such as "AExxxxxxxxxxxxxx" where "xxxxxxxxxxxxxx" is a truly randomly selected number. The odds of collision are then exceedingly small, and a unique name will be found within one or two probes.
The device object is created. The device information is updated to reflect the actual AE titles of the AE objects. As with AE objects, there is the potential for device name collisions.
The network connection objects are created as subordinates to the device object.
The AE objects are updated to reflect the names of the network connection objects.

The "unconfigured device" now has a saved configuration. The LDAP database reflects its present configuration.

In the following example, the new system needs two AE Titles. During its installation another machine is also being installed and takes one of the two AE Titles that the first machine expected to use. The new system then claims another different EYE-title that does not conflict.

Figure R.1-2. Configuring a System when network LDAP updates are permitted

R.1.2.3 Configure Client Then Update Server

Much of the initial start up is the same for restarting a configured device and for configuring a client first and then updating the server. The difference is two-fold.

The AE Title uniqueness must be established manually, and the configuration information saved at the client onto a file that can then be provided to the LDAP server. There is a risk that the manually assigned AE Title is not unique, but this can be managed and is easier than the present entirely manual process for assigning AE Titles.

Figure R.1-3. Configuring a system when LDAP network updates are not permitted

R.1.3 Distributed Update Propagation

The larger enterprise networks require prompt database responses and reliable responses during network disruptions. This implies the use of a distributed or federated database. These have update propagation issues. There is not a requirement for a complete and accurate view of the DICOM network at all times. There is a requirement that local subsets of the network maintain an accurate local view. E.g., each hospital in a large hospital chain may tolerate occasional disconnections or problems in viewing the network information in other hospitals in that chain, but they require that their own internal network be reliably and accurately described.

LDAP supports a variety of federation and distribution schemes. It specifically states that it is designed and appropriate for federated situations where distribution of updates between federated servers may be slow. It is specifically designed for situations where database updates are infrequent and database queries dominate.

R.2 Legacy Compatibility

Legacy devices utilize some internal method for obtaining the IP addresses, port numbers, and AE Titles of the other devices. For legacy compatibility, a managed node must be controlled so that the IP addresses, port numbers, and AE Titles do not change. This affects DHCP because it is DHCP that assigns IP addresses. The LDAP database design must preserve port number and AE Title so that once the device is configured these do not change.

DHCP was designed to deal with some common legacy issues:

Documenting legacy devices that do not utilize DHCP. Most DHCP servers can document a legacy device with a DHCP entry that describes the device. This avoids IP address conflicts. Since this is a manual process, there still remains the potential for errors. The DHCP server configuration is used to reserve the addresses and document how they are used. This documented entry approach is also used for complex multi-homed servers. These are often manually configured and kept with fixed configurations.
Specifying fixed IP addresses for DHCP clients. Many servers have clients that are not able to use DNS to obtain server IP addresses. These servers may also utilize DHCP for start up configuration. The DHCP servers must support the use of fixed IP allocations so that the servers are always assigned the same IP address. This avoids disrupting access by the server's legacy clients. This usage is quite common because it gives the IT administrators the centralized control that they need without disrupting operations. It is a frequent transitional stage for machines on networks that are transitioning to full DHCP operation.

There are two legacy-related issues with time configuration:

The NTP system operates in UTC. The device users probably want to operate in local time. This introduces additional internal software requirements to configure local time. DHCP will provide this information if that option is configured into the DHCP server.
Device clock setting must be documented correctly. Some systems set the battery-powered clock to local time; others use UTC. Incorrect settings will introduce very large time transient problems during start up. Eventually NTP clients do resolve the huge mismatch between battery clock and NTP clock, but the device may already be in medical use by the time this problem is resolved. The resulting time discontinuity can then pose problems. The magnitude of this problem depends on the particular NTP client implementation.

R.3 Obtain Configuration of Other Devices

Managed devices can utilize the LDAP database during their own installation to establish configuration parameters such as the AE Title of destination devices. They may also utilize the LDAP database to obtain this information at run time prior to association negotiation.

R.3.1 Find AE When Given Device Type

The LDAP server supports simple relational queries. This query can be phrased:

Return devices where

DeviceType == <device type>

Then, for each of those devices, query

Return Network AE where

[ApplicationCluster == name]

The result will be the Network AE entries that match those two criteria. The first criteria selects the device type match. There are LDAP scoping controls that determine whether the queries search the entire enterprise or just this server. LDAP does not support complex queries, transactions, constraints, nesting, etc. LDAP cannot provide the hostnames for these Network AEs as part of a single query. Instead, the returned Network AEs will include the names of the network connections for each Network AE. Then the application would need to issue LDAP reads using the DN of the NetworkConnection objects to obtain the hostnames.

R.4 Device Start up

Normal start up of an already configured device will obtain IP information and DICOM information from the servers.

Figure R.4-1. Configured Device Start up (Normal Start up)

The device start up sequence is:

DHCP is used to obtain IP related parameters. The DHCP request can indicate a desired machine name that DHCP can associate with a configuration saved at the DHCP server. DHCP does not guarantee that the desired machine name will be granted because it might already be in use, but this mechanism is often used to maintain specific machine configurations. The DHCP will also update the DNS server (using the DDNS mechanisms) with the assigned IP address and hostname information. Legacy note: A machine with pre-configured IP addresses, DNS servers, and NTP servers may skip this step. As an operational and documentation convenience, the DHCP server database may contain the description of this pre-configured machine.
The list of NTP servers is used to initiate the NTP process for obtaining and maintaining the correct time. This is an ongoing process that continues for the duration of device activity. See Time Synchronization below.
The list of DNS servers is used to obtain the list of LDAP servers. This utilizes a relatively new addition to the DNS capabilities that permit querying DNS to obtain servers within a domain that provide a particular service.
The "nearest" LDAP server is queried to obtain a description for the device matching the assigned machine name. This description includes device specific configuration information and a list of Network AEs.

Note

A partially managed node may reach this point and discover that there is no description for that device in the LDAP database. During installation (as described above) this may then proceed into device configuration. Partially managed devices may utilize an internal configuration mechanism.
The AE descriptions are obtained from the LDAP server. Key information in the AE description is the assigned AE Title. The AE descriptions probably include vendor unique information in either the vendor text field or vendor extensions to the AE object. The details of this information are vendor unique. DICOM is defining a mandatory minimum capability because this will be a common need for vendors that offer dynamically configurable devices. The AE description may be present even for devices that do not support dynamic configuration. If the device has been configured with an AE Title and description that is intended to be fixed, then a description should be present in the LDAP database. The device can confirm that the description matches its stored configuration. The presence of the AE Title in the description will prevent later network activities from inadvertently re-using the same AE Title for another purpose. The degree of configurability may also vary. Many simple devices may only permit dynamic configuration of the IP address and AE Title, with all other configuration requiring local service modifications.
The device performs whatever internal operations are involved to configure itself to match the device description and AE descriptions.

At this point, the device is ready for regular operation, the DNS servers will correctly report its IP address when requested, and the LDAP server has a correct description of the device, Network AEs, and network connections.

R.5 Shutdown

R.5.1 Shutdown

The lease timeouts eventually release the IP address at DHCP, which can then update DNS to indicate that the host is down. Clients that utilize the hostname information in the LDAP database will initially experience reports of connection failure; and then after DNS is updated, they will get errors indicating the device is down when they attempt to use it. Clients that use the IP entry directly will experience reports of connection failure.

R.5.2 Online/offline

A device may be deliberately placed offline in the LDAP database to indicate that it is unavailable and will remain unavailable for an extended period of time. This may be utilized during system installation so that pre-configured systems can be marked as offline until the system installation is complete. It can also be used for systems that are down for extended maintenance or upgrades. It may be useful for equipment that is on mobile vans and only present for certain days.

For this purpose a separate Installed Attribute has been given to devices, Network AEs, and Network Connections so that it can be manually managed.

R.6 Time Synchronization

Medical device time requirements primarily deal with synchronization of machines on a local network or campus. There are very few requirements for accurate time (synchronized with an international reference clock). DICOM time users are usually concerned with:

local time synchronization between machines
local time base stability. This means controlling the discontinuities in the local time and its first derivative. There is also an upper bound on time base stability errors that results from the synchronization error limits.
international time synchronization with the UTC master clocks

Other master clocks and time references (e.g., sidereal time) are not relevant to medical users.

R.6.1 High Accuracy Time Synchronization

High accuracy time synchronization is needed for devices like cardiology equipment. The measurements taken on various different machines are recorded with synchronization modules specifying the precise time base for measurements such as waveforms and Multi-frame Images. These are later used to synchronize data for analysis and display.

Typical requirements are:

Local synchronization

Synchronized to within approximately 10 millisecond. This corresponds to a few percent of a typical heartbeat. Under some circumstances, the requirements may be stricter than this.

Time base stability

During the measurement period there should be no discontinuities greater than a few milliseconds. The time base rate should be within 0.01% of standard time rate.

International Time Synchronization

There are no special extra requirements. Note however that time base stability conflicts with time synchronization when UTC time jumps (e.g., leap seconds).

R.6.2 Ordinary Time Synchronization

Ordinary medical equipment uses time synchronization to perform functions that were previously performed manually, e.g., record-keeping and scheduling. These were typically done using watches and clocks, with resultant stability and synchronization errors measured in seconds or longer. The most stringent time synchronization requirements for networked medical equipment derive from some of the security protocols and their record keeping.

Ordinary requirements are:

Local synchronization

Synchronized to within approximately 500 milliseconds. Some security systems have problems when the synchronization error exceeds 1 second.

Time base stability

Large drift errors may cause problems. Typical clock drift errors approximately 1 second/day are unlikely to cause problems. Large discontinuities are permissible if rare or during start up. Time may run backwards, but only during rare large discontinuities.

International Time Synchronization

Some sites require synchronization to within a few seconds of UTC. Others have no requirement.

R.6.3 Background

R.6.3.1 Unsynchronized Time

The local system time of a computer is usually provided by two distinct components.

There is a battery-powered clock that is used to establish an initial time estimate when the machine is turned on. These clocks are typically very inaccurate. Local and international synchronization errors are often 5-10 minutes. In some cases, the battery clock is incorrect by hours or days.
The ongoing system time is provided by a software function and a pulse source. The pulse source "ticks" at some rate between 1-1000Hz. It has a nominal tick rate that is used by the system software. For every tick the system software increments the current time estimate appropriately. E.g., for a system with a 100Hz tick, the system time increments 10ms each tick.

This lacks any external synchronization and is subject to substantial initial error in the time estimate and to errors due to systematic and random drift in the tick source. The tick sources are typically low cost quartz crystal based, with a systematic error up to approximately 10^-5 in the actual versus nominal tick rate and with a variation due to temperature, pressure, etc. up to approximately 10^-5. This corresponds to drifts on the order of 10 seconds per day.

R.6.3.2 Network Synchronized Time

There is a well established Internet protocol (NTP) for maintaining time synchronization that should be used by DICOM. It operates in several ways.

The most common is for the computer to become an NTP client of one or more NTP servers. As a client it uses occasional ping-pong NTP messages to:

Estimate the network delays. These estimates are updated during each NTP update cycle.
Obtain a time estimate from the server. Each estimate includes the server's own statistical characteristics and accuracy assessment of the estimate.
Use the time estimates from the servers, the network delay estimates, and the time estimates from the local system clock, to obtain a new NTP time estimate. This typically uses modern statistical methods and filtering to perform optimal estimation.
Use the resulting time estimate to
1. Adjust the system time, and
2. Update drift and statistical characteristics of the local clock.

The local applications do not normally communicate with the NTP client software. They normally continue to use the system clock services. The NTP client software adjusts the system clock. The NTP standard defines a nominal system clock service as having two adjustable parameters:

The clock frequency. In the example above, the nominal clock was 100Hz, with a nominal increment of 10 milliseconds. Long term measurement may indicate that the actual clock is slightly faster and the NTP client can adjust the clock increment to be 9.98 milliseconds.
The clock phase. This adjustment permits jump adjustments, and is the fixed time offset between the internal clock and the estimated UTC.

The experience with NTP in the field is that NTP clients on the same LAN as their NTP server will maintain synchronization to within approximately 100 microseconds. NTP clients on the North American Internet and utilizing multiple NTP servers will maintain synchronization to within approximately 10 milliseconds.

There are low cost devices with only limited time synchronization needs. NTP has been updated to include SNTP for these devices. SNTP eliminates the estimation of network delays and eliminates the statistical methods for optimal time estimation. It assumes that the network delays are nil and that each NTP server time estimate received is completely accurate. This reduces the development and hardware costs for these devices. The computer processing costs for NTP are insignificant for a PC, but may be burdensome for very small devices. The SNTP synchronization errors are only a few milliseconds in a LAN environment. They are very topology sensitive and errors may become huge in a WAN environment.

Most NTP servers are in turn NTP clients to multiple superior servers and peers. NTP is designed to accommodate a hierarchy of server/clients that distributes time information from a few international standard clocks out through layers of servers.

R.6.3.3 External Clocks

The NTP implementations anticipate the use of three major kinds of external clock sources:

External NTP servers

Many ISPs and government agencies offer access to NTP servers that are in turn synchronized with the international standard clocks. This access is usually offered on a restricted basis.

External clock broadcasts

The US, Canada, Germany, and others offer radio broadcasts of time signals that may be used by local receivers attached to an NTP server. The US and Russia broadcast time signals from satellites, e.g., GPS. Some mobile telephone services broadcast time signals. These signals are synchronized with the international standard clocks. GPS time signals are popular worldwide time sources. Their primary problem is difficulties with proper antenna location and receiver cost. Most of the popular low cost consumer GPS systems save money by sacrificing the clock accuracy.

External pulse sources

For extremely high accuracy synchronization, atomic clocks can be attached to NTP servers. These clocks do not provide a time estimate, but they provide a pulse signal that is known to be extremely accurate. The optimal estimation logic can use this in combination with other external sources to achieve sub microsecond synchronization to a reference clock even when the devices are separated by the earth's diameter.

The details regarding selecting an external clock source and appropriate use of the clock source are outside the scope of the NTP protocol. They are often discussed and documented in conjunction with the NTP protocol and many such interfaces are included in the reference implementation of NTP.

R.6.4 SNTP Restrictions

In theory, servers can be SNTP servers and NTP servers can be SNTP clients of other servers. This is very strongly discouraged. The SNTP errors can be substantial, and the clients of a server using SNTP will not have the statistical information needed to assess the magnitude of these errors. It is feasible for SNTP clients to use NTP servers. The SNTP protocol packets are identical to the NTP protocol packets. SNTP differs in that some of the statistical information fields are filled with nominal SNTP values instead of having actual measured values.

R.6.5 Implementation Considerations

There are several public reference implementations of NTP server and client software available. These are in widespread use and have been ported to many platforms (including Unix, Windows, and Macintosh). There are also proprietary and built-in NTP services for some platforms (e.g., Windows 2000). The public reference implementations include sample interfaces to many kinds of external clock sources.

There are significant performance considerations in the selection of locations for servers and clients. Devices that need high accuracy synchronization should probably be all on the same LAN together with an NTP server on that LAN.

Real time operating system (RTOS) implementations may have greater difficulties. The reference NTP implementations have been ported to several RTOSs. There were difficulties with the implementations of the internal system clock on the RTOS. The dual frequency/phase adjustment requirements may require the clock functions to be rewritten. The reference implementations also require access to a separate high resolution interval timer (with sub microsecond accuracy and precision). This is a standard CPU feature for modern workstation processors, but may be missing on low end processors.

An RTOS implementation with only ordinary synchronization requirements might choose to write their own SNTP only implementation rather than use the reference NTP implementation. The SNTP client is very simple. It may be based on the reference implementation or written from scratch. The operating system support needed for accurate adjustment is optional for SNTP clients. The only requirement is the time base stability requirement, which usually implies the ability to specify fractional seconds when setting the time.

The conflict between the user desire to use local time and the NTP use of UTC must be resolved in the device. DHCP offers the ability to obtain the offset between local time and UTC dynamically, provided the DHCP server supports this option. There remain issues such as service procedures, start up in the absence of DHCP, etc.

The differences between local time, UTC, summer time, etc. are a common source of confusion and errors setting the battery clock. The NTP algorithms will eventually resolve these errors, but the final convergence on correct time may be significantly delayed. The device might be ready for medical use before these errors are resolved.

S Legacy Transition For Configuration Management (Informative)

There will usually be a period of time where a network will have some applications that utilize the configuration management protocols coexisting with applications that are only manually configured. The transition issues arise when a legacy Association Requester interacts with a managed Association Acceptor or when a managed Association Requester interacts with a legacy Association Acceptor. Some of these issues also arise when the Association Requester and Association Acceptor support different configuration management profiles. These are discussed below and some general recommendations made for techniques that simplify the transition to a fully configuration managed network.

S.1 Legacy Association Requester, Configuration Managed Association Acceptor

The legacy Association Requester requires that the IP address of the Association Acceptor not change dynamically because it lacks the ability to utilize DNS to obtain the current IP address of the Association Acceptor. The legacy Association Requester also requires that the AE Title of the Association Acceptor be provided manually.

S.1.1 DHCP Server

The DHCP server should be configurable with a database of hostname, IP, and MAC address relationships. The DHCP server can be configured to provide the same IP address every time that a particular machine requests an IP address. This is a common requirement for Association Acceptors that obtain IP addresses from DHCP. The Association Acceptor may be identified by either the hardware MAC address or the hostname requested by the Association Acceptor.

The IP address can be permanently assigned as a static IP address so that legacy Association Requester can be configured to use that IP address while managed Association Requester can utilize the DNS services to obtain its IP address.

S.1.2 DNS Server

No specific actions are needed, although see below for the potential that the DHCP server does not perform DDNS updates.

S.1.3 LDAP Server

Although the managed Association Acceptor may obtain information from the LDAP server, the legacy Association Requester will not. This means that the legacy mechanisms for establishing EYE-Titles and related information on the Association Requester will need to be coordinated manually. Most LDAP products have suitable GUI mechanisms for examining and updating the LDAP database. These are not specified by this Standard.

An LDAP entry for the Association Requester should be manually created, although this may be a very abbreviated entry. It is needed so that the EYE-Title mechanisms can maintain unique AE Titles. There must be entries created for each of the AEs on the legacy Association Requester.

The legacy Association Requester will need to be configured based on manual examination of the LDAP information for the server and using the legacy procedures for that Association Requester.

S.2 Managed Association Requester, Legacy Association Acceptor

S.2.1 DHCP Server

The DHCP server may need to be configured with a pre-assigned IP address for the Association Requester if the legacy Association Acceptor restricts access by IP addresses. Otherwise no special actions are needed.

S.2.2 DNS Server

The legacy Association Acceptor hostname and IP address should be manually placed into the DNS database.

S.2.3 LDAP Server

The LDAP server should be configured with a full description of the legacy Association Acceptor, even though the Association Acceptor itself cannot provide this information. This will need to be done manually, most likely using GUI tools. The legacy Association Acceptor will need to be manually configured to match the EYE-Titles and other configuration information.

S.3 No DDNS Support

In the event that the DHCP server or DNS server do not support or permit DDNS updates, then the DNS server database will need to be manually configured. Also, because these updates are not occurring, all of the machines should have fixed pre-assigned IP addresses. This is not strictly necessary for clients, since they will not have incoming DICOM connections, but may be needed for other reasons. In practice maintaining this file is very similar to the maintenance of the older hostname files. There is still a significant administrative gain because only the DNS and DHCP configuration files need to be maintained, instead of maintaining files on each of the servers and clients

S.4 Partially Managed Devices

It is likely that some devices will support only some of the system management profiles. A typical example of such partial support is a node that supports:

DHCP Client,
DNS Client, and
NTP Client

Configurations like this are common because many operating system platforms provide complete tools for implementing these clients. The support for LDAP Client requires application support and is often released on a different cycle than the operating system support. These devices will still have their DICOM application manually configured, but will utilize the DHCP, DNS, and NTP services.

S.5 Adding The First Managed Device to A Legacy Network

The addition of the first fully managed device to a legacy network requires both server setup and device setup.

S.5.1 New Servers Required

The managed node requires that servers be installed or assigned to provide the following actors:

DHCP Server
DNS Server
NTP Server
LDAP Server

These may be existing servers that need only administrative additions, they may be existing hardware that has new software

Name of ASE Concept	Base Measurement Concept Name	Concept or Acquisition Context Modifiers
Left Ventricle Internal End Diastolic Dimension	(29436-3, LN "Left Ventricle Internal End Diastolic Dimension")
Left Ventricle Internal Systolic Dimension	(29438-9, LN, "Left Ventricle Internal Systolic Dimension")
Left Ventricle Diastolic Major Axis	(18077-8, LN, "Left Ventricle Diastolic Major Axis")
Left Ventricle Systolic Major Axis	(18076-0, LN, "Left Ventricle Systolic Major Axis")
Left Ventricular Fractional Shortening	(18051-3, LN, "Left Ventricular Fractional Shortening")
Interventricular Septum Diastolic Thickness	(18154-5, LN, "Interventricular Septum Diastolic Thickness")
Interventricular Septum Systolic Thickness	(18158-6, LN, "Interventricular Septum Systolic Thickness")
Interventricular Septum % Thickening	(18054-7, LN, "Interventricular Septum % Thickening")
Left Ventricle Posterior Wall Diastolic Thickness	(18152-9, LN, "Left Ventricle Posterior Wall Diastolic Thickness")
Left Ventricle Posterior Wall Systolic Thickness	(18156-0, LN, "Left Ventricle Posterior Wall Systolic Thickness")
Left Ventricle Posterior Wall % Thickening	(18053-9, LN, "Left Ventricle Posterior Wall % Thickening")
Interventricular Septum to Posterior Wall Thickness ratio	(18155-2, LN, "Interventricular Septum to Posterior Wall Thickness Ratio")
Left Ventricular Internal End Diastolic Dimension by 2-D	(29436-3, LN, "Left Ventricle Internal End Diastolic Dimension")	(399264008, SCT, "Image Mode") = (399064001, SCT, "2D mode")
Left Ventricular Internal Systolic Dimension by 2-D	(29438-9, LN, "Left Ventricle Internal Systolic Dimension")	(399264008, SCT, "Image Mode") = (399064001, SCT, "2D mode")
Left Ventricular Fractional Shortening by 2-D	(18051-3, LN, "Left Ventricular Fractional Shortening")	(399264008, SCT, "Image Mode") = (399064001, SCT, "2D mode")
Interventricular Septum Diastolic Thickness by 2-D	(18154-5, LN, "Interventricular Septum Diastolic Thickness")	(399264008, SCT, "Image Mode") = (399064001, SCT, "2D mode")
Interventricular Septum Systolic Thickness by 2-D	(18158-6, LN, "Interventricular Septum Systolic Thickness")	(399264008, SCT, "Image Mode") = (399064001, SCT, "2D mode")
Interventricular Septum % Thickening by 2-D	(18054-7, LN, "Interventricular Septum % Thickening")	(399264008, SCT, "Image Mode") = (399064001, SCT, "2D mode")
Left Ventricular Posterior Wall Diastolic Thickness by 2-D	(18152-9, LN, "Left Ventricle Posterior Wall Diastolic Thickness")	(399264008, SCT, "Image Mode") = (399064001, SCT, "2D mode")
Left Ventricle Posterior Wall Systolic Thickness by 2-D	(18156-0, LN, "Left Ventricle Posterior Wall Systolic Thickness")	(399264008, SCT, "Image Mode") = (399064001, SCT, "2D mode")
Left Ventricle Posterior Wall % Thickening by 2-D	(18053-9, LN, "Left Ventricle Posterior Wall % Thickening")	(399264008, SCT, "Image Mode") = (399064001, SCT, "2D mode")
Interventricular Septum/ Left Ventricular Posterior Wall Diastolic Thickness Ratio by 2-D	(18155-2, LN, "Interventricular Septum to Posterior Wall Thickness Ratio")	(399264008, SCT, "Image Mode") = (399064001, SCT, "2D mode")
Left Ventricular Internal End Diastolic Dimension by M-Mode	(29436-3, LN, "Left Ventricle Internal End Diastolic Dimension")	(399264008, SCT, "Image Mode") = (399155008, SCT, "M mode")
Left Ventricular Internal Systolic Dimension by M-Mode	(29438-9, LN, "Left Ventricle Internal Systolic Dimension")	(399264008, SCT, "Image Mode") = (399155008, SCT, "M mode")
Left Ventricular Systolic Fractional Shortening by M-Mode	(18051-3, LN, "Left Ventricular Fractional Shortening")	(399264008, SCT, "Image Mode") = (399155008, SCT, "M mode")
Interventricular Septum Diastolic Thickness by M-Mode	(18154-5, LN, "Interventricular Septum Diastolic Thickness")	(399264008, SCT, "Image Mode") = (399155008, SCT, "M mode")
Interventricular Septum Systolic Thickness by M-Mode	(18158-6, LN, "Interventricular Septum Systolic Thickness")	(399264008, SCT, "Image Mode") = (399155008, SCT, "M mode")
Interventricular Septum % Thickening by M-Mode	(18054-7, LN, "Interventricular Septum % Thickening")	(399264008, SCT, "Image Mode") = (399155008, SCT, "M mode")
Left Ventricular Posterior Wall Diastolic Thickness by M-Mode	(18152-9, LN, "Left Ventricle Posterior Wall Diastolic Thickness")	(399264008, SCT, "Image Mode") = (399155008, SCT, "M mode")
Left Ventricle Posterior Wall Systolic Thickness by M-Mode	(18156-0, LN, "Left Ventricle Posterior Wall Systolic Thickness")	(399264008, SCT, "Image Mode") = (399155008, SCT, "M mode")
Left Ventricle Posterior Wall % Thickening by M-Mode	(18053-9, LN, "Left Ventricle Posterior Wall % Thickening")	(399264008, SCT, "Image Mode") = (399155008, SCT, "M mode")
Interventricular Septum to Left Ventricular Posterior Wall Ratio by M-Mode	(18155-2, LN, "Interventricular Septum to Posterior Wall Thickness Ratio")	(399264008, SCT, "Image Mode") = (399155008, SCT, "M mode")

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Categories

Explanatory Information

PS3.17

DICOM PS3.17 2024c - Explanatory Information

DICOM Standards Committee

Notice and Disclaimer

Foreword

1 Scope and Field of Application

2 Normative References

2.1 International Organization for Standardization (ISO) and International Electrotechnical Commission (IEC)

2.2 Other References

3 Definitions

3.1 DICOM Introduction and Overview Definitions

3.2 DICOM Conformance

3.3 Information Object Definitions:

3.4 DICOM Service Class Specifications Definitions

3.5 DICOM Data Structures and Encoding

3.6 Structured Report Definitions

4 Symbols and Abbreviations

5 Conventions

A Explanation of Patient Orientation (Normative)

B Integration of Modality Worklist and Modality Performed Procedure Step in The Original DICOM Standard (Informative)

C Waveforms (Informative)

C.1 Domain of Application

Note

C.2 Use Cases

C.3 Time Synchronization Frame of Reference

C.4 Waveform Acquisition Model

C.5 Waveform Information Model

C.6 Harmonization With HL7

C.6.1 HL7 Waveform Observation

C.6.2 Channel Definition

C.6.3 Timing

C.6.4 Waveform Data

C.6.5 Annotation

C.7 Harmonization With SCP-ECG

D SR Encoding Example (Informative)

E Mammography CAD (Informative)

E.1 Mammography CAD SR Content Tree Structure

Note

E.2 Mammography CAD SR Observation Context Encoding

E.3 Mammography CAD SR Examples

E.3.1 Example 1: Calcification and Mass Detection With No Findings

E.3.2 Example 2: Calcification and Mass Detection With Findings

E.3.3 Example 3: Calcification and Mass Detection, Temporal Differencing With Findings

E.4 CAD Operating Point

E.5 Mammography CAD SR and For Processing / For Presentation Images

F Chest CAD (Informative)

F.1 Chest CAD SR Content Tree Structure

F.2 Chest CAD SR Observation Context Encoding

F.3 Chest CAD SR Examples

F.3.1 Example 1: Lung Nodule Detection With No Findings

F.3.2 Example 2: Lung Nodule Detection With Findings and Anatomy/pathology Interpretation

F.3.3 Example 3: Lung Nodule Detection, Temporal Differencing With Findings

F.3.4 Example 4: Lung Nodule Detection in Chest Radiograph, Spatially Correlated With CT

G Explanation of Grouping Criteria For Multi-frame Functional Group IODs (Informative)

H Clinical Trial Identification Workflow Examples (Informative)

H.1 Example Use-case

I Ultrasound Templates (Informative)

I.1 SR Content Tree Structure

I.2 Procedure Summary

I.3 Multiple Fetuses

I.4 Explicitly Specifying Calculation Dependencies

I.5 Linking Measurements to Images, Coordinates

I.6 Ob Patterns

I.7 Selected Value

I.8 OB-GYN Examples

I.8.1 Example 1: OB-GYN Root with Observation Context

I.8.2 Example 2: OB-GYN Patient Characteristics and Procedure Summary

I.8.3 Example 3: OB-GYN Multiple Fetus

I.8.4 Example 4: Biophysical Profile

I.8.5 Example 5: Biometry Ratios

I.8.6 Example 6: Biometry

I.8.7 Example 7: Amniotic Sac

I.8.8 Example 8: OB-GYN Ovaries

I.8.9 Example 9: OB-GYN Follicles

I.8.10 Example 10: Pelvis and Uterus

J Handling of Identifying Parameters (Informative)