基于DICOM RT的放疗信息系统研究开发
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摘要
放射治疗作为治疗恶性肿瘤的重要手段之一，它比外科手术治疗、内科化疗等方法更依赖于医学影像及其它医学信息。各种高科技技术及计算机的应用，使得放射治疗设备不断更新，功能更加完善。以放射治疗计划为中心的现代放射治疗体系更是通过计算机及相关软件综合利用了各种高新技术来达到满意的治疗效果。该体系已经成为现代放射治疗中不可缺少的极其重要的环节。
但是在该体系中一个突出的问题就是，随着各种成像设备的应用，异源设备之间传递数据的标准性及可靠性成为一个限制其发展的因素。在放疗体系中，如何对不同成像、模拟、治疗设备的数据进行统一的管理和有效的使用成为一个新的课题。此外，由于放射治疗的特殊性，和普通的治疗相比，可以定量控制的过程比较多，定量控制带来的对治疗效果的影像也很大。世界卫生组织(World Health Organization，WHO)二十年的调查结果表明，制定标准、进行质控是放疗中不可缺少的部分。而目前放疗质控使用的还是传统的方法(如手工校对等)，误差较大且效率低，不适应现代多治疗中心的远程实时交流需求。
数字化医学影像的发展，DICOM(Digital Imaging and Communications in Medicine)标准的制定为放射治疗的数字化以及进行有效管理和质量控制提供了先决条件。DICOM根据放射治疗领域的实际需求所度身定制的DICOMRT更是使建立一个规范、统一的放射治疗信息系统成为可能。在放射治疗信息系统的基础可以上对放射治疗中的各种数据进行有效管理，同时加强各放射治疗中心间的交流以进行质控、提高疗效。在该领域，国外已有研究机构及生产厂商进行研究、实现，并且已经商品化。但根据文献检索，目前国内仅有简单的针对放疗基本信息数据库进行管理的系统，还没有对DICOM RT(Radiation Therapy)进行研究和开发，更不要说完整的放疗信息管理系统了，这与医学信息化的需求极不相符。而且，随着我国医疗事业的进步，全国已有上千台放射治疗设备在投入运行，这是一个庞大的市场。因此，适合国情的放射治疗信息系统的开发具有重要的战略发展意义。
本课题首先对DICOM和RT扩展的内容、原理及最新进展进行了详尽分析。从面向对象方法的角度来理解标准的内涵，尤其是DICOM RT的对象定义、相互联系，为具体实现打下坚实的基础。在此基础上，着重研究了DICOM的两大服务类—Worklist和Q/R(Query and Retrieve)。这两大服务类在放射治疗信息系统的实现中起到了关键作用。
接下来的工作是针对具体的放射治疗应用来实现整体系统。在整个系统的设计中，一切以“管理”为核心。Worklist和Q/R都是基于放疗管理对象来实现。整个系统设计分为信息管理、Q/R实现、图像处理、治疗记录管理、DICOM打
圃 浙江大学硕士学位论文 摘要
印等模块。当然重点是在于Qo实现、治疗记录管理上。Qo主要是为了解决异
源设备之间的数据传递问题，而治疗记录管理、Worklist的实现目的在于加强放
射治疗的管理，以便实现质控网络。课题还介绍了数据库的设计方法及实现。
最后，课题尝试采用分布式结构体系建立一个通用的放疗计划评估管理平
台。分布式体系结构是软件应用、开发体系的一个趋势。在当今迅猛发展的网络
时代，以分布式来设计放疗质控网络具有一定的前瞻牲。通过应用Web服务等
’最新技术，无论对传统还是现代的放疗计划系统、适形放射治疗等都能起到促进
作用。同时还可以加强管理（从数据流上执行治疗效果及质量的评价等），做到
资源共享，符合信息化社会的发展需求。
信息社会发展的趋势是不可阻挡的。PACS（PictUre Archiving and
Communication Systems）的应用发展和数字化医院的建立势在必行。现代医疗体
系要体现“以病人为中心”的指导思想必须从加强管理、提高医疗质量着手。因
此，放疗信息管理系统日益会受到关注和重视。信息化技术在医疗卫生领域也将
发挥更大的作用。课题把握了DICOM及相关标准的发展方向，在一个能够充分
显示DICOM的应用价值的领域一放射治疗领域做了一些有益的尝试，获得了宝
贵的经验和第一手的实验材料。在本文的最后，对课题中的问题及解决方式做了
讨论，同时展望了DICOM及相关医学信息技术的发展，以期能够抛砖引玉，更
多地发挥这些技术的作用。
Radiation therapy (RT), more than any other oncology treatment methods (such as surgery and chemical therapy) ,relies heavily and often exclusively on medical imaging and other medical information. There are some disadvantages in radiation therapy , such as limited data transfer between applications , limited linking between applications , lack of information management , and closed environment. How to use information in the process of radiotherapy effectively is a new issue.
The state of the art in radiation therapy take advantage of the development of DICOM (Digital Imaging and Communications in Medicine) . DICOM came out with a separate supplement DICOM RT . It provides the capability for different devices to communicate by sending objects such as images or RT plans, querying remote devices, and retrieving these objects, interchange information with open media and integrate with the healthcare environment.
DICOM is now a mature standard, and the core RT objects have been ratified since 1997. After a lot of hard work understanding, developing and testing product interoperability in the radiotherapy context, many foreign institutes and manufacturers now have products available that support one or more of the DICOM RT objects. By searching articles in the fields of radiation therapy, there is no study and development in China so far. In order to make full use of radiotherapy and imaging devices, and improve the effects of radiation therapy, it is necessary to develop a radiation therapy information system (or oncology information system).
With a deep research in DICOM and DICOM RT, DICOM RT objects were created by using object oriented(OO) method . The main part of this thesis emphasis on the concept and implementation of two DICOM services : worklist and Q/R(Query and Retrieve) . These two services play a crucial role in radiation therapy information system.
The system consists of information management module, Q/R module , image processing module , treatment record module , printing module . All these modules focus on the implements of Q/R and Worklist. A common platform with the frame of distributed database system was established. Such tools and their coupling with emerging technologies (such as web services) can help to develop, assess, and efficient utilize new treatment modalities in radiation oncology.
Quality assurance (QA) and quality control (QC) is important in radiation therapy .How to implement an effective QA (or QC) program at the level of dataflow remains an important issue in radiation therapy . It can take advantages of DICOM
RT to perform QA/QC between different institutes
There is no doubt that the trend not only in radiation therapy , but also in medical information has increasingly moved toward digital and distributed architecture. Full integration of medical imaging information technologies (IT) and patient information in the hospital environment will be achieved. PACS (Picture Archiving and Communication Systems) and any other information technologies will bring us a filmless hospital ( or digital hospital).
All what we done just realized a small part of medical information. As long as vendors, clinicians and hospital administration, engineering and IT departments continue to work together towards the common goal of optimizing work flow, diagnostic quality and patient healthcare, it will happen.
但是在该体系中一个突出的问题就是，随着各种成像设备的应用，异源设备之间传递数据的标准性及可靠性成为一个限制其发展的因素。在放疗体系中，如何对不同成像、模拟、治疗设备的数据进行统一的管理和有效的使用成为一个新的课题。此外，由于放射治疗的特殊性，和普通的治疗相比，可以定量控制的过程比较多，定量控制带来的对治疗效果的影像也很大。世界卫生组织(World Health Organization，WHO)二十年的调查结果表明，制定标准、进行质控是放疗中不可缺少的部分。而目前放疗质控使用的还是传统的方法(如手工校对等)，误差较大且效率低，不适应现代多治疗中心的远程实时交流需求。
数字化医学影像的发展，DICOM(Digital Imaging and Communications in Medicine)标准的制定为放射治疗的数字化以及进行有效管理和质量控制提供了先决条件。DICOM根据放射治疗领域的实际需求所度身定制的DICOMRT更是使建立一个规范、统一的放射治疗信息系统成为可能。在放射治疗信息系统的基础可以上对放射治疗中的各种数据进行有效管理，同时加强各放射治疗中心间的交流以进行质控、提高疗效。在该领域，国外已有研究机构及生产厂商进行研究、实现，并且已经商品化。但根据文献检索，目前国内仅有简单的针对放疗基本信息数据库进行管理的系统，还没有对DICOM RT(Radiation Therapy)进行研究和开发，更不要说完整的放疗信息管理系统了，这与医学信息化的需求极不相符。而且，随着我国医疗事业的进步，全国已有上千台放射治疗设备在投入运行，这是一个庞大的市场。因此，适合国情的放射治疗信息系统的开发具有重要的战略发展意义。
本课题首先对DICOM和RT扩展的内容、原理及最新进展进行了详尽分析。从面向对象方法的角度来理解标准的内涵，尤其是DICOM RT的对象定义、相互联系，为具体实现打下坚实的基础。在此基础上，着重研究了DICOM的两大服务类—Worklist和Q/R(Query and Retrieve)。这两大服务类在放射治疗信息系统的实现中起到了关键作用。
接下来的工作是针对具体的放射治疗应用来实现整体系统。在整个系统的设计中，一切以“管理”为核心。Worklist和Q/R都是基于放疗管理对象来实现。整个系统设计分为信息管理、Q/R实现、图像处理、治疗记录管理、DICOM打
圃 浙江大学硕士学位论文 摘要
印等模块。当然重点是在于Qo实现、治疗记录管理上。Qo主要是为了解决异
源设备之间的数据传递问题，而治疗记录管理、Worklist的实现目的在于加强放
射治疗的管理，以便实现质控网络。课题还介绍了数据库的设计方法及实现。
最后，课题尝试采用分布式结构体系建立一个通用的放疗计划评估管理平
台。分布式体系结构是软件应用、开发体系的一个趋势。在当今迅猛发展的网络
时代，以分布式来设计放疗质控网络具有一定的前瞻牲。通过应用Web服务等
’最新技术，无论对传统还是现代的放疗计划系统、适形放射治疗等都能起到促进
作用。同时还可以加强管理（从数据流上执行治疗效果及质量的评价等），做到
资源共享，符合信息化社会的发展需求。
信息社会发展的趋势是不可阻挡的。PACS（PictUre Archiving and
Communication Systems）的应用发展和数字化医院的建立势在必行。现代医疗体
系要体现“以病人为中心”的指导思想必须从加强管理、提高医疗质量着手。因
此，放疗信息管理系统日益会受到关注和重视。信息化技术在医疗卫生领域也将
发挥更大的作用。课题把握了DICOM及相关标准的发展方向，在一个能够充分
显示DICOM的应用价值的领域一放射治疗领域做了一些有益的尝试，获得了宝
贵的经验和第一手的实验材料。在本文的最后，对课题中的问题及解决方式做了
讨论，同时展望了DICOM及相关医学信息技术的发展，以期能够抛砖引玉，更
多地发挥这些技术的作用。
Radiation therapy (RT), more than any other oncology treatment methods (such as surgery and chemical therapy) ,relies heavily and often exclusively on medical imaging and other medical information. There are some disadvantages in radiation therapy , such as limited data transfer between applications , limited linking between applications , lack of information management , and closed environment. How to use information in the process of radiotherapy effectively is a new issue.
The state of the art in radiation therapy take advantage of the development of DICOM (Digital Imaging and Communications in Medicine) . DICOM came out with a separate supplement DICOM RT . It provides the capability for different devices to communicate by sending objects such as images or RT plans, querying remote devices, and retrieving these objects, interchange information with open media and integrate with the healthcare environment.
DICOM is now a mature standard, and the core RT objects have been ratified since 1997. After a lot of hard work understanding, developing and testing product interoperability in the radiotherapy context, many foreign institutes and manufacturers now have products available that support one or more of the DICOM RT objects. By searching articles in the fields of radiation therapy, there is no study and development in China so far. In order to make full use of radiotherapy and imaging devices, and improve the effects of radiation therapy, it is necessary to develop a radiation therapy information system (or oncology information system).
With a deep research in DICOM and DICOM RT, DICOM RT objects were created by using object oriented(OO) method . The main part of this thesis emphasis on the concept and implementation of two DICOM services : worklist and Q/R(Query and Retrieve) . These two services play a crucial role in radiation therapy information system.
The system consists of information management module, Q/R module , image processing module , treatment record module , printing module . All these modules focus on the implements of Q/R and Worklist. A common platform with the frame of distributed database system was established. Such tools and their coupling with emerging technologies (such as web services) can help to develop, assess, and efficient utilize new treatment modalities in radiation oncology.
Quality assurance (QA) and quality control (QC) is important in radiation therapy .How to implement an effective QA (or QC) program at the level of dataflow remains an important issue in radiation therapy . It can take advantages of DICOM
RT to perform QA/QC between different institutes
There is no doubt that the trend not only in radiation therapy , but also in medical information has increasingly moved toward digital and distributed architecture. Full integration of medical imaging information technologies (IT) and patient information in the hospital environment will be achieved. PACS (Picture Archiving and Communication Systems) and any other information technologies will bring us a filmless hospital ( or digital hospital).
All what we done just realized a small part of medical information. As long as vendors, clinicians and hospital administration, engineering and IT departments continue to work together towards the common goal of optimizing work flow, diagnostic quality and patient healthcare, it will happen.
引文
1．胡逸民，杨定宇主编。肿瘤放射治疗技术。北京医科大学、中国协和医科大学联合出版社，1999。
2. National Electrical Manufacturers' Association. Digital Imaging and Communication in Medicine (DICOM). Virginia, 2001
3. Smith CL, Chu WK, Enke C. A review of digital image networking technologies for radiation oncology treatment planning. Medcal Dosimetry. 1998; 23: 271-277.
4. Olsen, DR, Bruland, (?)S, Davis, BJ. Telemedicine in radiotherapy treatment planning: requirements and applications. Radiotherapy and Oncology. 2000; 54: 255-259
5. Seung JH, Hiroki Shiratob, Seiko Hashimotob, et al. An integrated service digital network (ISDN)-based international telecommunication between Samsung Medical Center and Hokkaido University using telecommunication helped radiotherapy planning and information system (THERAPIS). Radiotherapy and Oncology 2000; 56:121-123
6. Michael Herman. Information Systems and Networks in Radiation Oncology. Medical Physics 1999; 26(6): 1096
7. Foord, Keith. PACS: the second time around. European Journal of Radiology. 1999;32(2) :96-100
8. M. Ferraris, P. Frixionea, S. Squarci. Network oriented radiological and medical archive. Computer Physics Communications. 2001 ;(140): 226-232
9. N.J.G. Brown, K.E. Britton, D.L. Plummer. Standardisation in medical image management. International Journal of Medical Informatics. 1998;(48): 227-238
10．庄天戈 编著。计算机在生物医学中的应用。科学出版社，2000。
11．童明杰 浙江大学硕士学位论文，2000。
12. HIMSS and RSNA . Integrating the Healthcare Enterprise: IHE Technical Framework Year 3, Revision 4.6,2001
13. Purdy, James A. Future directions in 3-d treatment planning and delivery: a physicist's perspective. Int. J. Radiation Oncology Biol. Phys 2000; 46(1) : 3-6
14. K.S. Clifford, Chao Carlos, A.Perez, et al. Radiation Oncology Management Decisions. 天津科技翻译出版公司， 2001。
15．郑小康 陈龙华 主编。三维适形放疗临床实践——CT模拟与三维计划。人民卫生出版社，2001。
16．刘泰福 主编。现代放射肿瘤学。复旦大学出版社 上海医科大学出版社，2001。
17. Lomax Antony, Grossmann Martin, Cozzi Luca, et al. The exchange of radiotherapy data as part of an electronic patient-referral system. Int. J. Radiation Oncology Biol. Phys 2000; 47(5): 1449-1456
18. National Electrical Manufacturers' Association. Digital imaging and communication system in medicine(DICOM), NEMA Standard Publications. 1999, Suppl. 11,29
19. http://www. iec.ch
20. ICRU report No.29: dose specification for reporting external beam therapy with photons and electrons. Washington .DC: ICRU, 1987
21. Panitsa E, Rosenwald JC, Kappas C. Developing a dose-volume histogram program for brachytherapy. Phys. Med. Bio. 1998; 43(8):2109-2121
22. Theodorou K , Platoni K , Ldfkopoulos D, et. al. Dose volume analysis of different sterotacitc radiotherapy mono-isocentric techniques. Acta Oncol. 2000; 39(2):157-163
23．张海藩 编著。软件工程导论。清华大学出版社，1998。
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36． E Panitsa, J C Rosenwald , C Kappas. Quality control of dose volume histogram computation characteristic of 3D treatment planning systems. Phys. Med. Biol, 1998; 43:2807-2816．
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38． General Electronic Co. Advantage SIM 5． 0 Conformance Statement .2000
39． Philips Medical System Co. Pinnacle Conformance Statement for DICOM v3． 0 . 2001
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2. National Electrical Manufacturers' Association. Digital Imaging and Communication in Medicine (DICOM). Virginia, 2001
3. Smith CL, Chu WK, Enke C. A review of digital image networking technologies for radiation oncology treatment planning. Medcal Dosimetry. 1998; 23: 271-277.
4. Olsen, DR, Bruland, (?)S, Davis, BJ. Telemedicine in radiotherapy treatment planning: requirements and applications. Radiotherapy and Oncology. 2000; 54: 255-259
5. Seung JH, Hiroki Shiratob, Seiko Hashimotob, et al. An integrated service digital network (ISDN)-based international telecommunication between Samsung Medical Center and Hokkaido University using telecommunication helped radiotherapy planning and information system (THERAPIS). Radiotherapy and Oncology 2000; 56:121-123
6. Michael Herman. Information Systems and Networks in Radiation Oncology. Medical Physics 1999; 26(6): 1096
7. Foord, Keith. PACS: the second time around. European Journal of Radiology. 1999;32(2) :96-100
8. M. Ferraris, P. Frixionea, S. Squarci. Network oriented radiological and medical archive. Computer Physics Communications. 2001 ;(140): 226-232
9. N.J.G. Brown, K.E. Britton, D.L. Plummer. Standardisation in medical image management. International Journal of Medical Informatics. 1998;(48): 227-238
10．庄天戈 编著。计算机在生物医学中的应用。科学出版社，2000。
11．童明杰 浙江大学硕士学位论文，2000。
12. HIMSS and RSNA . Integrating the Healthcare Enterprise: IHE Technical Framework Year 3, Revision 4.6,2001
13. Purdy, James A. Future directions in 3-d treatment planning and delivery: a physicist's perspective. Int. J. Radiation Oncology Biol. Phys 2000; 46(1) : 3-6
14. K.S. Clifford, Chao Carlos, A.Perez, et al. Radiation Oncology Management Decisions. 天津科技翻译出版公司， 2001。
15．郑小康 陈龙华 主编。三维适形放疗临床实践——CT模拟与三维计划。人民卫生出版社，2001。
16．刘泰福 主编。现代放射肿瘤学。复旦大学出版社 上海医科大学出版社，2001。
17. Lomax Antony, Grossmann Martin, Cozzi Luca, et al. The exchange of radiotherapy data as part of an electronic patient-referral system. Int. J. Radiation Oncology Biol. Phys 2000; 47(5): 1449-1456
18. National Electrical Manufacturers' Association. Digital imaging and communication system in medicine(DICOM), NEMA Standard Publications. 1999, Suppl. 11,29
19. http://www. iec.ch
20. ICRU report No.29: dose specification for reporting external beam therapy with photons and electrons. Washington .DC: ICRU, 1987
21. Panitsa E, Rosenwald JC, Kappas C. Developing a dose-volume histogram program for brachytherapy. Phys. Med. Bio. 1998; 43(8):2109-2121
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