ADVANCED SERVER-BASED DIAGNOSTIC IMAGING AND POST-PROCESSING WORKFLOW AT EUROPEAN CENTRE OF HEALTH OTWOCK , POLAND

We present state of the art diagnostic imaging modalities and the latest trends in post-processing of clinical images implemented atthe European Centre of Health Otwock, Poland. Clinical images are presented as well as chosen application examples of the IntelliSpace Portal thin client/server solution. Radiologists can access any post-processing applications virtually anywhere instead of waiting for a particular workstation to become available. The Centre specializes in oncology, urology and cardioangiology and welcomes medical staff for advanced training courses as well as patients seeking high-end diagnostic and therapeutic procedures. The patients are kept at the center of what we do, as behind every image there is a patient.


INTRODUCTION
The hospital is equipped with a state o f the art diagnostic im aging m odalities that include: 3-Tesla M agnetic Resonance (MR) Philips Achieva 3T TX (first in Poland 3TMultiTransmit system with 32 RF channels), 128-slices Philips Brilliance iCT SP Com puted Tomography (CT), Hologic Selenia Dimensions 3D M ammography with breast tom osynthesis and m any m ore ulta-m odern systems.
As the D iagnostic Im aging D epartm ent provides imaging capabilities at the highest academic level, the image data load is extensive.
For example injust one o f the modalities -MRI, about 3000 scans are performed, m ainly for oncology and cardiology inpatients, as w ell as a w ide variety o f outpatient scans.Examples o f technically advanced 3T MRI images are presented on Fig. 1   Referring physicians are relying on radiologists to provide a confident diagnosis.Their treatm ent plan d epends on th e analysis and report.T he clin ical information can be quickly and easily shared among doctors taking care o f the patient.
Extensive clinical coverage plays a key role, but there are also other dimensions to delivering the confident diagnosis: special tools and efficient workflows allow to concentrate quickly on relevant images.
The radiology IT systems and applications m ust keep evolving to help radiologists adopt the latest clinical advances.
Growing numbers o f images per patient and multi modality cases overall mean the need for an enormous amount o f data to review.Automatic image enhancement tools, allow to focus on what is needed and visualizations, such as graphs and color-coded m aps, presen t the quantified data that are easy to interpret.
By taking steps to achieve definitive diagnoses, the new radiology post-processing systems lay the foundation for developing tailored treatments and improving patient care.Arm ed with clinically relevant information, the doctors can provide patients with the input to treatment planning they need.
IntelliSpace Portal is an advanced visualization and analysis solution to open these dimensions -virtually an y tim e a n d a n y w h e re .I t 's d e sig n e d to g iv e a comprehensive clinical view while helping to work fast and with increased diagnostic confidence.
IntelliSpace Portal is built on client-server architecture (Fig. 3).It securely streams CT, MR, molecular imaging (MI), and ultrasonography (US) images directly to a client o f the choice (such as a PC, laptop, or picture archiving and communication system (PACS)) over a broadband connection through the hospital's virtual private network.
Radiologists can access, review, analyze, diagnose, and present images quickly, efficiently, and collaboratively with the latest technology with a single advanced visualization and analysis tool.It works across clinical specialties, across modalities, and across the enterprise o f the European Centre o f Health.IntelliSpace Portal can transform the way radiologists work and care for patients.This single multi-modality and multi-vendor advanced visualization and analysis system gives the m easurem ent and quan tificatio n capabilities to support efforts in diagnostic objectiveness and consistency like never seen before.
R ich and grow ing portfolio o f IntelliSpace Portal applications with automated image optimization as well as image selection make it easy to focus on what matters m ost in particular cases (Fig. 4).
As the IntelliSpace Portal is a tool w hich evolves continuously, the radiologists are well-equipped for the future diagnoses.The built-in access automatic software updates, IntelliSpace Portal always offers superb means for image posprocessing.The installed thin-client software automatically upgrades itself whenever the main server is upgraded.This takes usually ju st a few minutes and requires no interactions from the user.Thus all the workspots using Portal don't have to be taken care o f when maj or upgrade is performed as it only "physically" affects the main server.A ll o f this can be accom plished right from any networked computer or directly from the PACS -thanks to a single solution that connects to the radiology department network via a powerful, all-in-one applications server.
For example, Portal clients are installed at the operating rooms o f ECH, providing an instant access to any image posprocessing capabilities even during the operation.
The Web Collaboration solution enables viewing and sharing with tablets and smartphone devices -however not intended for diagnosis, only for reference purposes.
Radiologists aren't tied to modality workstations, and are free to access images from virtually anywhere -office ISSN 1996-1960.Медична інформатика та інженерія.2014.№ З PC, home laptop, and even a tablet device.This enables to share images and results with peers, specialists, and referring physicians in real time.
The Portal creates one, unified view, linking multi modality data from multiple vendors with ease.As a result, we can leverage the anatomical, functional, spatial, and temporal dimensions provided by CT, MR, M I and US on a single platform.
R ecently the new applications w ere added to the continuously expanding portfolio to offer a comprehensive suite ofM R applications in cardiology and neurology.New CT applications, for example, also reflect developments in transcatheter aortic heart valve (TAVI) procedure p lan n in g , m y o card ial p e rfu sio n asse ssm e n t, and emergency care.
It is possible to explore more o f every case thanks to a variety o f enhanced applications in several clinical specialties.With M ulti Modality Viewing we can read different neurology application results in one view.We МЕДИЧНА ІНФ ОРМ АТИКА ТА ІНЖЕНЕРІЯ look forward to additional portfolio enhancements in future releases.The expanded view in cardiology benefits from a rich suite o f cardiology applications on IntelliSpace Portal.New M R advanced analysis capabilities join other rich tools for C T and M I to give a comprehensive view.Models, m aps, and o ther v isualization tools turn data into quantitative information (Fig. 6,7).

CARDIOLOGY
With "CT TAVI Planning" application, radiologists and cardiologist can quickly assess the aortic root anatomy for pre-TAVI planning and obtain crucial information about eligibility, proper device size, and a recommendation for C-arm angle for device deployment.
The "CT Comprehensive Cardiac Analysis" (Fig. 5) advanced application provides automatic, model-based, whole heart segmentation and zero-click coronary artery segm entation, en a b lin g au to m atic e x tra ctio n and visualization o f the entire coronary tree.
"M R QFlow" application allows to review flow in large vessels in detail (Fig. 7).The application includes overlays "M R Cardiac" (Fig. 6) application enables easy visual scoring in various exam contexts.It allows to perform a functional volum etric analysis for the ventricles and segmentations to generate global functional parameters.Identification o f spatial enhancement is based on intensity signal changes.
Several applications, such as CT C om prehensive Cardiac Analysis, also offer fused capabilities to offer a deeper view o f each case.

NEUROLOGY IntelliSpace Portal neurology applications include: CT Advanced Vessel Analysis (AVA) Stenosis CT Advanced Brain Perfusion CT Brain Perfusion Time Insensitive Maps CT Body Perfusion
Comprehensive neurology M Rapplicationsjoin existing CT and M I capabilities on IntelliSpace Portal to help assess recoverable tissue quickly and easily.This rich suite o f tools also helps to evaluate n eurolo g ical degenerative diseases by, for example, analyzing FDG and amyloid uptake.

M R Т І Perfusion
The multi-modality suite o f oncology applications on Philips IntelliSpace Portal supports radiologists with tools through the entire oncology patient cycle, from screening to treatment response evaluation.
The "M ulti-modality Tumor Tracking" application (M M TT) ofPhilips IntelliSpace Portal provides the tools to simplify the review and analysis o f multi-modality oncology datasets for tum or detection and monitoring.
The application has semi-automatic segmentation tools to facilitate 2D and 3D segmentation o f tumors and lymph nodes.For instance, it allows the user to make quick bi dimensional measurements using 2D measurements tools.The application also enables graphical tracking o f the size o f the tum or across the different time points.
After the measurements are completed, it automatically performs the RECIST and W HO onco-radiology scale calculations.
The M M TT application can also be used to analyze M R data.A diffusion dataset can be used to assess the size and activity o f a lesion.The Apparent Diffusion Coefficient (ADC) values can be tracked as well as the size changes o f the lesion. Background: The Post-processing o f oncology (CT, PET/CT, and M R) image datasets can pose a m ajor challenge for radiology and oncology staff.It often requires the maneuvering and analysis o f a significant amount o f data due to multiple follow-up studies.The user -radiologist has to: a) load multiple patient examinations for side-by-side comparisons to the baseline scan and nadir scan (smallest criteria recorded since the treatment started) in case o f new progression.These datasets often include exams from multiple imaging modalities, b) scroll through the numerous images oflarge datasets to identify and locate the tumors and lymph nodes for follow-up analysis, c) measure the size o f the tumors and lymph nodes including long axis and short axis diameters, as well as other quantitative parameters such as H U values, d) calculate tum or burden m easurem ents based on R EC IST and W H O criteria and assess response to treatment.

МЕДИЧНА ІНФ ОРМ АТИКА ТА ІНЖЕНЕРІЯ
Response Evaluation Criteria in SolidTumors (RECfST) is a published guideline used to assess the change in size (maximum diameter in 2D plane) o f solid tumors and lymph nodes in response to therapy.The response is categorized into: C om plete R esponse (CR), Partial R esponse (PR ), Stable D isease (SD ), P rogressive Disease (PD).
The World Health Organization (W HO) criteria define shrinkage o f a tum or as the decrease in the product o f the largest perpendicular diameters in the largest "slice" o f the tum or on a scan.
"M ulti Modality Tumor Tracking" assigns labels to the lesions to distinguish target from non-target, tum or or lymph node, or marks new lesions, disappeared lesions, and m ajor growth.
A ll the above actions can be sem i-autom atically perform ed by m eans o f the "M ulti-m odality Tumor Tracking" application.

ORTHOPEDICS
IntelliSpace Portal orthopedics applications include: Due to an aging population and increases in obesity and sports activity,joint surgeries are on the rise.Thanks to IntelliSpace Portal tools radiologists can perform a wide variety o f tasks, such as assessment and reconstruction, quickly and easily thanks to the rich orthop ed ics applications.
The tools are designed for even the m ost challenging m u s c u lo s k e le ta l c a ses su ch as M R C a rtila g e Assessm ent.
Users can perform a complete review o f the source data, verify registration and time intensity changes, and generates all types o f output with or without the use o f an Arterial Input Function (AIF).

CT Acute MultiFunctional Review
R ad io lo g ists can re a d trau m a cases w ith in one comprehensive post-processing application to diagnose traum a patients scanned with CT.It includes four stages o f assessment, such as an M SK and surgical lanning stage as well as an auto-spine stage, which automatically generates multi-planar reformatting along the spinal cord and disk spaces.
Key enhancements in this orthopedics applications suite allow to take a closer look at cases involving bone and cartilage."C T A cute M ultiFunctional R eview ", for example, includes an M SK and surgical planning stage.
"CT Bone MineralAnalysis", previously only available on Philips Extended Brilliance Workspace workstation, helps to track and manage degenerative and metabolic bone diseases.
Philips IntelliSpace Portal automates image processing as well as many o f the manual tasks that can get in the way o f delivering fast, efficient input to patient treatment."Zero-click processing" uses a variety o f automatic tools to begin preparing the case as soon as it is opened.The Portal can pre-fetch all prior studies and transfer them to a local folder with any new studies just obtained and waiting for comperative review for fast comparison.
It's worth mentioning that already for the sixth time, IntelliSpace Portal has been ranked #1 by KLAS in its "Top 20 Best in K L AS Awards: Software & Professional Services" for A dvanced Visualization.
KLAS is an independent, leading research firm with the mission to improve healthcare technology delivery by honestly, accurately, and impartially measuring vendor performance for their provider partners.

European
Centre o f Health Otwock (ECH, Otwock, Poland) is the only private hospital in Poland that includes th re e a c ad em ic c lin ics: O ncology, U ro lo g y and Cardioangiology.The clinics are part o f the Polish Medical Centre o f Postgraduate Education (CMKP).

Fig. 1 .
Fig. 1.W hole Body 3T M RI performed with a custom-made imaging protocol on Philips Achieva 3T TX scanner in ECH Otwock.The original 1200 axial crossections o f 1.7 mm thickness (left) are post-processed and reformatted using advanced algorithms allowing a 3-dimentional assessment in any plane.

Fig. 2
Fig. 2, a, b.M étastasé o f rectal cancer to the liver, a) 3T M RI Tl-w eighted image post paramagnetic contrast agent (Gadolinium) administration (left).b) 3T M RI apparent diffusion coefficient (ADC) map presenting diffusion restriction in metastase but not in it's nectrotic core.

Fig. 3 .
Fig. 3. Login screen o f IntelliSpace Portal application installed on a M icrosoft Windows system.Before the start, user can choose the monitors mode (2 m onitor configuration is available) as well as optimize the image compression options to the available network band.Before the login an extensive network connection test can be performed with a single click.

Fig. 4 .
Fig. 4.An extensive list o f IntelliSpace Portal applications presented after case/series selection.
The server automatically spreads the latest version o f diagnostic tools at client login.Radiologists enj oy one unified view o f patient and can instantly access, review, analyze, diagnose, and present CT, M R, and M I (molecular imaging) images along with US viewing virtually anytime and in any place in the hospital and outside o f it.

IntelliSpace
Fig. 5. "C T Comprehensive Cardiac Analysis" -the fully automated segmentation tool transforms the heart into individual segments within seconds.

Fig. 6 .
Fig. 6. "M R Cardiac" -comperhensive cardiovascular magnetic resonance tool for quantitative ventricular analysis and other advanced cardiac M R post-processing.Client-Server connection speed is tested (lower right corner) in the hospitals local network.
Fig. 7. "M R QFlow" -quantitative analysis o f blood flow in ascending aorta.

SUMMARYFig. 9 .
Fig. 9.European Centre o f Health Otwock -one o f the m ost technically advanced hospitals in Poland, located near Warsaw.