Free PACS clients: what is available?

1. Free PACS clients: what is available? Filipe Ramos Barra Renato Ramos Barra AlaorBarraSobrinho HUB/UnB– University Hospital of Brasília, Brazil IMEB – ImagensMédicas de Brasília, Brazil filipebarra@gmail.com

2. Introduction • Radiology services are changing its structures • Most of radiology equipments are now integrated into a network • Number of exams interpretation on workstations is increasing • Film-less is becoming a reality

3. Introduction • Eventually, radiologist needs to use exams images for case databases, lectures or staff meetings • These images are available in DICOM format, the worldwide standard • Software such as PowerPoint, Word and Paint cannot import these images without specific plugin DICOM: Digital Imaging and Communications in Medicine

4. Introduction • There are software that convert DICOM images in common formats (JPEG, TIFF, BMP), CDs viewers and complex viewers that works as PACS clients • As most modern diagnostic imaging services has at least a small network connecting CT or MR to workstations, the use of viewers that work as PACS clients is much more practical and fast CT: Computer Tomography MR: Magnetic Resonance PACS: Picture Archiving and Communication System

5. Introduction • Technology improves a lot, requiring constantly updating of viewers • Free and open-source software usually are developed and not updated. This is a major problem in using these kind of software • The free program considered the gold standard among the viewers is the OsiriX. It is the program with a lot of functions, but is only available to the operating system MacOS X, reason why we did not include in our study

6. Objective • Our objective is to find free Medical Image Viewers available on the internet capable of work as PACS client and evaluate its main functions, as well as the feasibility of its use in personal computers with Windows

7. Materials and Methods • We searched at Google and specialized sites (Idoimaging, RTstudents e Medfloss) for free software available for Windows • About 70 programs were found, 11 able to work as PACS client. Six were selected for analysis (table 1) • Based on authors needs 16 functions were selected for evaluation

8. Table 1 – Free PACS clients found

9. Materials and Methods • One of our proposal was analyze the feasibility of PACS viewers use in personal computers, so as we tested these software with two computers, a basic and a more powerful one: • Intel Celeron 1.6GHz, 2GB RAM, 40GB storage, on-board video card, with Windows XP SP2 installed • AMD Athlon 64 Dual Core 2.7GHz, 4GB RAM, 1TB storage, ATI Radeon HD 4350 video card, with Windows 7 installed

10. Materials and Methods • MPR • MIP • VR • Image fusion • Series synchronization • Reference lines • Add comments • Cine • Use of multiple monitor • PACS server • Create CDs • Anonymize studies • Export in JPG, BMP e DICOM • Windows 7 compatibility Functions evaluated were: MPR: multiplanar reformation MIP: maximum-intensity projection VR: volume rendering

11. Results

12. ClearCanvas Workstation 2.0 SP1 • Integrates an open-source project that also includes an ImageServer and a RIS • It is the only one that has accreditation for clinical use (Health Canada) • Some functions are: MPR, series synchronization and spatial localization of a point in different series • Can not export images as DICOM or create CDs • Can work as a PACS server • There are various community plugins allowing study tagging and comments, for example RIS: Radiology Information System

13. ClearCanvas Worskstation creen capture. Two series are displayed. Reference line and spatial location are shown (arrow head) and a ROI in thyroid (arrow)

14. KPACS 1.6 • The oldest software of those analyzed • Incompatible with Windows 7 • Buttons are big and inferiorly placed • Can work as a PACS server • Allows multiple monitors use and create CD with a built-in viewer but does not perform MIP, MPR or VR • As PACS client is a little bit slow, sometimes giving the impression of having stopped working

15. K-PACS screen capture. Buttons are big and inferiorly placed

16. Onis 2.1 • Free version of a commercial software • Number of patients in database is limited to 15 • On demand capability (can open DICOM files directly from the server or CD without downloading them) • Performs MPR, oblique MPR and 3D-MIP • Create CDs with built-in viewer • Very fast software

17. Onis screen capture showing MPR function. It is possible to choose plane of view (arrow) and layout (arrow head)

18. Synedra View Personal 1.0.12.3 • Powerful PACS client • Different interface with buttons placed inferiorly • ISO 9001 and ISO 13485 certificates • Performs MPR, MIP and min-MIP with the possibility to increase thickness • Major problem is that does not have a database. Exams need to be saved manually for future view • Very fast software

19. Onis screen capture showing MPR function. Slice thickness were changed to 25mm. Buttons are inferiorly placed (arrow head)

20. Mito (Medical Imaging Toolkit) 1.0 • Open-source software • It is the only one able to perform image fusion • Also performs VR and MIP • Compared to others is a little bit slow

21. Mito screen capture. A PET-CT is shown with a “hot area” on patient neck (arrow)

22. Tudor DicomViewer • Simple software with few functions • Require Java Runtime Environment instalation • Does not perform MPR, MIP or VR • Enable the use of 3 monitors • Can be integrate with ImageJ, increasing its functions

23. Tudor Dicom Viewer screen capture. Two series are shown. Note that there is no reference line.

24. Table 2 – Software functions (a): one image at time (b): need specific plugin

25. Conclusion • Several free software are available, there is not a perfect one • Onis, Synedra and ClearCanvas stand out, each one with its own peculiarity • The user has to analyze and select the software that best fits their needs • The use of free software is entirely feasible for the radiologist

26. Conclusion • PET-CT: Mito • On demand: Onis • Thick MIP: Synedra • Big database and more functions: ClearCanvas • PACS server: ClearCanvas, KPACS • Simple PACS client: Tudor, KPACS • Multiple monitors: Tudor, Syndra, KPACS • CD creation: Onis, KPACS

27. References Software information

28. References • Liao W, Deserno TM, Spitzer K. Evaluation of free non-diagnostic DICOM software tools. vol. 6919. SPIE; 2008. Available from: http://spie.org/x648.html?product_id=770431 • Zeman RK, Lyshkow H, Garra BS et al. Viewing DICOM-compliant CT images on a desktop personal computer: use of an inexpensive DICOM receive agent and freeware image display applications. AJR. 1999:172:305-8. • Escott EJ, Rubinstein D. Free DICOM Image Viewing and Processing Software for Your Desktop Computer: What’s Available and What It Can Do for You. RadioGraphics. 2003:23:1341-57. • Varma DR. Free DICOM browsers. Indian J of Radiol Imaging. 2008;18:12-6 • Rosset A, Spadola L, Ratib O. OsiriX: An Open-Source Software for Navigating in Multidimensional DICOM Images. J Digit Imaging. 2004;17:205-16. • Andrew Crabb. Free DICOM and Medical Image Viewer / Convert Software, Open Source DICOM Conversion [Internet]. Baltimore, USA; c2002-2010; [revised 2009 Nov 19; cited 2010 Apr 10]. Available from: http://www.idoimaging.com/ • RTstudents.com. Radiology for Students and Professionals [Internet]. USA: c2004-2010; [revised 2009 Nov 19; cited 2010 Apr 10]. Available from: http://www.rtstudents.com/pacs/free-dicom-viewers.htm • Holger Schmuhl: Medical Free/Libre and Open Source Software [Internet]. Munich, Germany; [cited 2010 Apr 10]. Available from: http://www.medfloss.org/