1. Integration of digital
mammography on PACS
This paper discusses support for digital mammography on PACS and describes options for
connectivity and workflow. It is provided to help in planning the deployment of digital mammo-
graphy and connectivity to PACS, and to outline the benefits of Philips iSite PACS. Please consult
national or regional regulations for details on requirements for digital mammography.*
With its proven clinical and throughput benefits,
digital mammography has become an appealing option
for imaging centers and radiology departments.
Several studies and publications have shown digital
mammography’s advantages in breast cancer detection,
including increased sensitivity at a lower dose,
improved productivity, and faster patient turnaround
as compared to film-screen mammography. Particularly
for screening patients under 50 years of age, those with
radiographically dense breasts, and premenopausal or
perimenopausal women, digital mammography provides
greater diagnostic accuracy.1
Transitioning to digital mammography presents
challenges that may impact productivity. After an initial
decrease in efficiency, radiologists’ reading speed
improves over time and is expected to approach those
of film, as users become more familiar with the softcopy
Early PACS workstations were not equipped with
reading and workflow tools to support mammography.
Early adopters of digital mammography users were
compelled to adopt separate IT solutions. The resulting
complexity and redundancy led to additional costs
Philips iSite PACS offers workflow advantages and
reading tools to help streamline the transition to digital
mammography. iSite PACS can help enhance productivity
and reduce costs, with the following benefits:
• Enhance workflow by interfacing with ordering
systems, reporting systems, and additional workflow
tools for a best-of-breed solution.
• Improve patient care by providing point-of-care
access to physicians throughout the enterprise.
• Improve productivity with a single workstation
platform and the ability to review multiple modalities
simultaneously: digital mammography, MRI, ultrasound,
• Reduce costs by leveraging existing investments in
PACS (including archives and workstations).
*In the U.S., refer to the Mammography Quality Standards Act of 1992 and subsequent
2. Considerations in deploying digital mammography
There are a number of technical issues to consider in planning the
deployment of digital mammography in your department:
Image size: Because of high contrast and spatial resolution
(matrix size), digital mammography image file sizes are very large,
around 30 MB each (depending on the equipment used). A standard
screening exam consisting of four views could be as large as 120 MB,
uncompressed. This places significant strains on resources such as
network bandwidth, workstation resources, and storage scalability.
Workstation and diagnostic monitors: In addition to processor
and memory requirements, 5 Megapixel (MP) monitors are required
for softcopy reading (monitor requirements may vary between
countries). These tend to be significantly more expensive than the
standard 2 MP or 3 MP monitors that are commonly used for the
interpretation of diagnostic radiology studies.
Monitor resolution: The high image resolution of digital
mammography (~ 50–100 microns/pixel) makes them less efficient
to review by radiologists. For example, the fully displayed digital
mammogram expands beyond the boundaries of a 5 MP monitor,
requiring the physician to pan and zoom in order to view all pixels.
Raw data and image data: Full Field Digital Mammography
systems typically produce two sets of data. “For processing” data
are the raw data produced by the detector, and typically require
extensive proprietary processing to generate “for presentation”
data. “For presentation” data are the final images that the radiologist
views. Although medical device vendors may provide the option
to store both “for processing” and “for presentation” data, this
requires twice the storage space while providing limited additional
Computer Aided Detection (CAD) results: CAD servers can
process digital mammography images before the radiologist reviews
them. CAD results can be sent to the PACS and displayed on the
workstation along with the images to aid interpretation.
Prior exams on film: There are two options for managing prior
exams on film:
• Reading priors on film requires keeping a light box or a Mammolux
unit in the reading room near the workstation. Films would have
to be requested the previous day for all scheduled patients, taking
into account transfer times if films are stored offsite.
• You can digitize priors for scheduled patients before exam dates
and have the data available on the PACS for the reading radiologist.
This option demands an analysis of cost, labor, and space
requirements for the digitization equipment and storage space on
Mammography support on iSite Radiology
Philips iSite PACS offers workflow advantages and reading tools
to help streamline the transition to digital mammography. iSite
can help enhance productivity and reduce costs. Several workflow
enhancements and display features have been designed to support
mammography softcopy reading workflow:
• Advanced hanging protocols options – users have more
options in building hanging protocols (automatic scaling of
priors, flip/rotate, multiple links, mirror links, click and drag,
series matching rules to designate hanging, zoom factor, image
• Sequence of hanging protocols – users can configure multiple
protocols to display in a sequence.
• Mammography CAD – interactive display/hide of
Mammography CAD Structured Reports results from Hologic
(R2) and iCAD.
• Step zoom – step sequentially through images at pixel-to-pixel
• True size – automatically scale images so the selected anatomy
appears on the monitor scaled to actual size.
• Mirrored and non-mirrored panning – users can link any
series and pan them simultaneously in a mirrored or non-mirrored
• Roaming magnification glass – quickly zoom in on a small
portion of the image with configurable magnification settings in
• Keyboard hot keys – Many configurable shortcuts are provided
to improve workflow. These are saved as preferences in the user
profile and are available on workstations across the system.
• Keypad support –all keyboard short cuts can be programmed on
commercially available keypads based on user preferences.
3. Sample workflow
1. Exam is scheduled on RIS/HIS and HL7 order message
is sent to iSite.
2. Acquisition Modality queries Philips iSite PACS
DICOM Modality Worklist (DMWL).
3. Prior imaging studies and physicians’ annotations
for recalls can be viewed on iSite Enterprise inside
mammography procedure room.
4. Acquisition modality acquires images and sends “for
processing” raw data to CAD server.
5. Acquisition modality sends “for presentation” images
Integration of mammography workflow
There are several options to integrate digital mammography
workflow with iSite PACS:
4 “For Processing” images 6 CAD SR
3 Priors OR Recalls
5 “For Presentation” images
1 HL7 order
7 Images +
Priors + CAD
iSite Enterprise workstations iSite Radiology
Figure 1. Workflow using iSite Radiology for mammography SCR
6. CAD server sends CAD results to iSite in the form
of DICOM Mammography CAD Structured Reports
or as DICOM Secondary Capture images.
7. Radiologist reviews images, priors and CAD results
on iSite Radiology.
8. Radiologists can mark key images and annotate
images for mammographers in the case of recall or to
emphasize findings for referring physicians.
9. Images and associated information are available to
referring physicians on any computer through iSite
Using iSite Radiology for softcopy reading (SCR)
4. Sample workflow
1. Exam is scheduled on RIS/HIS and HL7 order message
is sent to iSite (third-party specialty workstation may
provide, if available).
2. Acquisition Modality queries Philips iSite PACS DICOM
Modality Worklist (DMWL) (third-party specialty
workstation may provide, if available).
3. Prior imaging studies may be queried and retrieved from
the specialty workstation (if available) or may be sent
manually from iSite to third-party specialty workstation.
4. Priors and physicians’ annotations for recalls are sent
from third-party specialty workstation to third-party
QA workstation (priors can be sent manually from iSite
to third-party QA workstation–not shown in figure
5. Acquisition modality acquires images and sends “for
processing” raw data to CAD server.
6. Acquisition modality sends “for presentation” images to
third-party specialty workstation and a copy to iSite for
long term archive.
7. CAD server sends CAD results to third-party
workstation (CAD results can be sent to iSite for long-
8. Radiologists review images, priors, and CAD results on
9. Images and reports are available on iSite for enterprise-
wide distribution to referring physicians.
Potential workflow limitations:
1. Third-party specialty workstations may not provide
HL7 integration, thus requiring additional tools to view
prior diagnostic reports.
2. Third-party specialty workstations may not provide
Patient Information Reconciliation capability associated
with HL7 integration, requiring additional work to
3. Third-party specialty workstations may not be able to
write imaging studies to portable media such as CD or
4. Third-party specialty workstations may require
additional workflow steps to retrieve prior imaging
studies, especially non-digital studies.
5. Third-party SCR workstation may not be capable of
displaying multimodality or prior imaging studies such as
ultrasound, MRI, or PET.
6. Annotations, key images and measurements created
on third-party SCR by physicians are typically stored
in proprietary format and may not be viewable on iSite
Enterprise or iSite Radiology for referring physicians.
7. The iSite Radiology Exam Status would need to be
changed to “Mark Read” manually, requiring additional
8. Third-party specialty workstations may not be able to
print hard copy film.
Using a third-party workstation for SCR
The following diagram shows an example configuration with
a third-party workstation and does not cover all possible
3rd party QA
7 CAD SR
4 Recall Images
6 “For Presentation” images
1 HL7 order
5 “For Processing” images
iSite Enterprise workstations
Figure 2. Workflow using third party workstation for mammography SCR
Digital mammography offers opportunities to improve
patient care, but also presents costs, demands on
infrastructure, and potential delays that a department
must weigh against the benefits. Philips iSite PACS offers
one solution for digital mammography workflow to help
overcome these challenges. Together with the diagnostic
and cost-saving benefits of digital mammography, iSite
PACS can help you deliver better, more efficient patient
1. Pisano ED, Gatsonis C, Hendrick E, Yaffe M, Baum JK,
Acharyya S, et al. Diagnostic performance of digital versus
film mammography for breast-cancer screening. N Engl J Med.
2005 Oct 27;353(17):1773-83.