Radiation Oncology Image Management: Evolution in the Works

Varian's Eclipse treatment planning and ARIA oncology information systemOver the last few years, radiation oncology has evolved at a rapid clip. Radiation oncologists are tapping into multiple new imaging options to more precisely define and target tumors, which may improve patient outcomes and minimize damage to normal tissue. The new vocabulary at radiation oncology sites across the country includes terms such as on-board imaging, cone beam CT, 4D imaging and image-guided adaptive radiation therapy (IGART). One consequence associated with the use of more sophisticated imaging technologies is an exponential increase in image size, and that’s only one part of the challenge.

IGART hinges on frequent imaging. Hansen Chen, PhD, senior medical physicist at Christiana Care in Newark, Del., explains, “In the past, we would take weekly portal images. Each patient would have a maximum of five or six images or the equivalent of a few megabytes of data per week. Patients undergoing IGART might have daily CT images for localization or for adapted treatment planning, and these CT images yield up to 100 to 200 megabytes of data per week.”

The other catch in the brave new world of radiation oncology is the need for physicians to access all relevant, current patient data. Radiation oncologists often need to refer back to images multiple times to target the cancer and design the treatment plan. “In the past, radiation oncologists would walk to the treatment room and approve portal films prior to treatment,” recalls Sharlon Rodgers, radiation oncology manager at Nebraska Methodist Hospital in Omaha. That sneaker net is not feasible with large datasets and more frequent imaging.

Radiation oncology departments are deploying various solutions to handle their burgeoning image management needs. At this point, image management is a work in progress; users rely on various processes and systems to meet or mitigate their radiation oncology image management needs. Nevertheless, sites have realized multiple benefits including:

  • Access to images throughout the department and across satellite sites
  • Improved patient care and safety
  • Less overtime and increased revenue
  • Fewer expenses related to making hard copies of images
  • Less physical storage space

This month, Health Imaging & IT visits with a few sites to learn about current and future radiation oncology image management solutions.

The quest for excellence

Over the last five years, the radiation oncology department at Nebraska Methodist Hospital has undertaken a major renovation and replacement project to become a center of excellence in radiation oncology. The project is centered on advanced technologies and superior patient care.

The department selected IMPAC Medical Systems image-enabled EMR as its radiation oncology management system for several reasons, says Rodgers. The software offers comprehensive record management for radiation oncologists and allied professionals; it stores and manages multiple types of images including cone-beam CT studies acquired on Elekta Synergy XVI and can house other essential radiation oncology data such as treatment plans. The ability to handle radiation oncology-specific data like treatment plans is essential to the success of a radiation oncology management system.

Another key component is the record and verify functionality. Radiation oncology departments must verify accurate treatment delivery and provide a permanent record of treatment. Acquiring a port film image is essential for verification. IMPAC records and stores these initial and ongoing reference images, allowing departments to graduate from film to digital images. “Images are accessible anywhere in the department. A radiation oncologist can approve the images or review a treatment plan without walking back to the linear accelerator. Faster, online approvals allow us to deliver treatment in a timelier manner,” explains Rodgers.

At the same time, radiation oncology departments are producing and consuming more and larger imaging datasets. “We realized storage would be a concern and worked closely with IMPAC and our IT department to build capacity to hold our images,” explains Rodgers. The department deployed IMPAC two years ago and has added more storage capacity, due to increased storage demands stemming associated with cone-beam CT. The radiation oncology department worked closely with the hospital’s IT department; IT was able to proactively alert radiation oncology of its diminishing storage capacity, enabling the department to plan and budget for a timely storage upgrade.

Another essential IT ingredient at Nebraska Methodist Hospital is the integration option between IMPAC and the hospital EMR. “One of our top priorities was finding a vendor that would enable the department to connect into the larger system,” Rodgers says. IMPAC offers multiple interface options such as the capability to pull demographic information for registration and billing from the EMR.

The hospital is looking into future upgrades and upcoming interfaces to further improve dialogue with the hospital. For example, IMPAC Oncology PACS might enable IMPAC users to store, manage and access PET or MRI images from the hospital PACS and reduce the number of steps needed to view these images.

Radiation oncology on the cutting edge

Most sites are working toward image-guided radiation therapy (IGRT), including volume-guided radiation therapy, which uses 3D images to verify treatment. Christiana Care in Wilmington, Del., began moving in this direction last year. Under the new models, patient treatment can entail daily cone-beam CT imaging, which fills a traditional workstation very quickly. In addition, 4DCT simulation for respiratory gating may yield eight image sets for different breathing phases, which yield at least 400 to 500 megabytes of data. “Image management is the major challenge faced by radiation oncology departments today,” sums Chen.

Christiana Care partnered with Siemens Medical Solutions and deployed its RT-Archive to address its radiation oncology image storage issue. “It’s similar to a radiology PACS and handles DICOM and DICOM-RT objects,” says Chen. The department sends images from the acquisition workstation to RT-Archive for storage.

The next level of the challenge is image management, says Chen. Radiation oncologists need a system to browse and review imaging datatsets. Christiana Care plans to deploy Siemens Workflow Manager early in 2007. The new system will allow physicians to access images and DICOM RT objects such as contours, isocenters and beams.

Chen and his colleagues are banking on the Siemens systems to centralize image management for the hospital and its radiation oncology satellite centers. The systems allow physicians to access and manage images and other radiation oncology data from anywhere in the health system. “Work follows the physicians. They don’t need to return to the main center to view patient data,” says Chen.

The site is keeping its eyes on the future and recommending that new solutions store non-DICOM-RT data like treatment plans, archive files and department information systems backups. “The PACS specialized and customized for radiation oncology workflow with seamless integration of patient imaging, treatment records and clinical data is definitely the next step for us and for all emerging radiation oncology centers,” concludes Chen.

Digital imaging’s double-edge sword

Like many sites, Enloe Medical Center in Chico, Calif., is challenged by the advent of digital imaging. “The kilovoltage camera on the treatment machine lets us take more images, and they are practically free. The potential is fabulous. We can make small corrections if necessary or replan the treatment. On the other hand, digital imaging does bring a host of challenges,” says Randall Holt, PhD, chief of physics. The hitch is the images must be pushed around; they need to be moved from the acquisition device to the database to the physician’s desktop. An effective solution combines bandwidth, storage and a user-friendly interface that allows radiation oncologists to glean the essential information from the thousands of images generated weekly.

The center deployed Varian Medical Systems Vision image and treatment plan management system to streamline operations in 2000. Physicians can log onto the worklist-oriented system from anywhere in the building to view images and make any necessary adjustments. Vision reflects the changes to the therapist or dosimetrist for corrective action. In addition, Vision integrates with other Varian software. “The bonus,” says Holt, “is that there are no vendor/vendor incompatibilities.”

This year, Enloe Medical Center transitioned to ARIA oncology information system. “It’s a natural progression of Vision that incorporates changes to accommodate megavoltage and kilovoltage imaging,” explains Holt.

The new system further improves workflow and patient throughput, allowing radiation oncologists to create a record of localized anatomy in the Trilogy treatment system. The patient is automatically moved into position, which is faster than manual methods and removes the potential for human error. Treatment times have plummeted with the new system. For example, daily prostate cancer treatments took 25 minutes before ARIA. Now, treatment is complete in 10 minutes. Head and neck treatment times have dropped from 45 minutes to 17, says Holt. The approach brings other benefits in addition to faster treatments and improved patient care and safety. “Our bottom line is better because therapists are leaving on time, so we don’t have to pay overtime,” states Holt.

RT-PACS: A first look under the hood

Currently, Washington University of St. Louis (Mo.) relies on Philips Medical Systems Pinnacle treatment planning system for streamlined patient treatment plans; however, the academic medical center is looking forward to the development of RT-PACS. “Radiation therapy needs to deal with images in a formal, more cohesive way. We can learn from diagnostic radiology and build an RT-PACS,” says Dan Low, PhD, director of medical physics and professor of radiation oncology and biomedical engineering.

The elusive RT system would handle traditional archiving functions and incorporate the ‘stuff’ of radiation oncology. “We don’t care about the image as much as we care about the patient. We want to know everything about John Smith — why was the image taken, was the patient moved, what is the treatment plan(s) — and we need the story or the logical connection between the multiple pieces of data. This includes patient charts, checklists, electronic communication. RT-PACS is not a trivial extension of PACS,” explains Low. 

Although Low and his colleagues have considered the composition of RT-PACS, the physicist is unsure where it will reside. “It might be new software, record and verify system or in the treatment planning system,” explains Low. The ultimate payoffs, however, are significant and include streamlined workflow and improved patient care.


Radiation oncology has taken a tremendous leap forward in the amount and types of images used to develop and fine-tune treatment plans. The potential patient benefits are significant, but to effectively implement state-of-the-art imaging and treatment, departments must deploy a system for managing images. Vendors offer multiple solutions to address image management needs, allowing departments to handle increased image volume and improve workflow and patient care. New developments should bring the market closer to the radiation oncology version of PACS, which may cover a broader range of radiation oncology-specific needs.


Expert Advice
Most radiation oncology departments are moving in the same direction and exploring more advanced imaging technologies to implement image-guided radiation therapy. Insiders at sites that have tackled the challenges associated with image management offer some tips for their colleagues.
  • The integrated database approach to image management makes the most sense from both the caretaker and patient care point of view, but there must be a commitment from the institution and the department, says Randall Holt, PhD, chief of physics at Enloe Medical Center in Chico, Calif. New systems do have a learning curve, and results don’t happen overnight.
  • Plan for image management in advance with IGRT and 4DCT. Calculate image size and storage needs, and put it into the budget at the beginning.
  • Involve the IT department early in the process, and make sure IT understands the goals of the project, says Sharlon Rodgers, radiation oncology manager at Nebraska Methodist Hospital in Omaha.
  • Assess the network. A 100 megabit or gigabit network should suffice. Don’t overlook satellite facilities; the common T1 link to satellite centers may be too slow for effective image transfer.
  • Try to forecast far enough into the future, and look for a flexible solution that will allow you to accomplish the ultimate goal. Calculate all costs related to the ultimate goal including warranties, service and storage upgrades.