dicom tls on Digi Hunch

DICOM testing over TLS

Sat, 18 Feb 2023 01:05:00 -0400

I have two open-source projects to deploy a medical imaging application on different platforms. In both of them, I define DICOM validation scenario, and provide steps to test DICOM traffic with TLS. The steps have been working well, until a recent change in Envoy broke the testing, and led me to revisit the test scenario.

In a nutshell, I changed from dcm4che to dcmtk binary builds. I’ve also expanded the test case from a self-signed server certificate to one involving a self-signed CA. Although this test is about TLS for DICOM traffic, the principles apply to any traffic at TCP level. If you just need instruction for DICOM validation on Orthweb or Korthweb projects, skip the Background section.

Background

To test DICOM traffic with command line tool, I was investigating between dcm4che and dcmtk. Both are open-source projects with builds for multiple platforms. My DICOM test is as simple as a C-Echo command and a C-Store command using the tool, with TLS enabled. Once they work, other DICOM commands usually work as well.

I have been primarily using dcm4che as I was familiar with its previous version from my old job. For example, I can issue a C-ECHO with TLS using storescu command:

./storescu -c ORTHANC@ec2-54-243-91-148.compute-1.amazonaws.com:11112 --tls12 --tls-aes --trust-store server.truststore --trust-store-pass Password123!

To turn that test into a C-Store test, simply add a DCM file as input:

./storescu -c ORTHANC@ec2-54-243-91-148.compute-1.amazonaws.com:11112 --tls12 --tls-aes --trust-store server.truststore --trust-store-pass Password123! MY.DCM

The C-Store output tracks each DIMSE command and return codes. Note that in the command, we specify –tls12 as the version, and with –tls-aes switch we enabled AES or 3DES encryption. We also specified a file for trust store and password to the trust store.

This is when I first frowned over dcm4che. The dcm4che utility is a Java-based program we have to take an extra step of turning certificate into Java trust store. Different JVM versions may also cause different behaviours in the test. What later prompted me to switch to dcmtk is that with dcm4che I came across a weird error since Envoy proxy version 1.23, which impacted both Orthweb (Envoy proxy) and Korthweb (Istio Ingress).

Moreover, dcmtk is available as a HomeBrew package, Ubuntu package, and Debian package.

The test case, data and the tool

We can install dcmtk utility simply with brew install dcmtk, and then we need its echoscu and storescu commands with correct TLS options. The DICOM data I used for testing is a CT exam available for download here.

Before mocking with dcmtk‘s TLS options, we first need to understand what would be a good test. Previously I have used a single self-signed certificate on server. It is an over-simplified scenario that is far from a real-life certificate chain, and also does not test client certificate. If I also self-sign the client certificate, the client and server certificates are signed by entirely different parties and have no trust relationship, making it an invalid test case for client certificate.

For a full-blown testing with TLS, we should have two levels of CA as below:

The chart represents a typical hierarchy of three-level certificate authorities. Sometimes we need simplicity in our testing, and it is reasonable to simplify the diagram to the following, with one CA that issues certificate for both client and server:

Our DICOM validation testing will be based on both approaches depending on the project and deployment option. For Orthweb project and the Helm-chart driven option in Korthweb, we have one level of CA. For the GitOps and manual option in Korthweb, we have two levels of CA. When configuring testing, it is important to have the diagram above in mind.

In addition, we should also be aware of the limitation of the testing. As a personal project I will not pay for the certificates. I have to self-sign the certificate of the CA so there is no way to derive trust on this CA from another level. As a result, we must tell the client and server to trust the CA. The steps to create the needed certificates are:

Generate a key pair for Test CA. Generate the certificate for Test CA by self-signing its own public key
Generate a key pair for the (DICOM) server. Generate the certificate for the server by signing its public key with Test CA’s private key
Generate a key pair for the (DICOM) client. Generate the certificate for the client by signing its public key with Test CA’s private key

Because the client now also has its certificate, we can test with and without client certificate, using the following dcmtck switches:

-d (shorthand for –debug): print out detailed DICOM communication log. For succinct output, use -v (shorthand for –verbose) instead.
+tla (shorthand for –anonymous-tls): enable anonymous TLS (without client certificate)
+tls (shorthand for –enable-tls): enable full TLS (with client certificate), followed by client key and certificate files
-rc (shorthand for –require-peer-cert): –require-peer-cert, require peer (server) certificate
+cf (shorhand for –add-cert-file): –add-cert-file, add server certificate so client can trust it.

For C-ECHO, the testing commands with and without client certificate look like:

$ echoscu -aet TESTER -aec ORTHANC -d +tla -rc +cf ca.crt ec2-3-98-241-51.ca-central-1.compute.amazonaws.com 11112
$ echoscu -aet TESTER -aec ORTHANC -d +tls client.key client.crt -rc +cf ca.crt ec2-3-98-241-51.ca-central-1.compute.amazonaws.com 11112

For C-STORE, the testing commands with and without client certificate look like:

$ storescu -aet TESTER -aec ORTHANC -d +tla -rc +cf ca.crt ec2-3-98-241-51.ca-central-1.compute.amazonaws.com 11112 DICOM_Images/COVID/56364823.dcm
$ storescu -aet TESTER -aec ORTHANC -d +tls client.key client.crt -rc +cf ca.crt ec2-3-98-241-51.ca-central-1.compute.amazonaws.com 11112 DICOM_Images/COVID/56364823.dcm

As to how to create the certificates, in the post Creating X.509 TLS certificate in Kubernetes, I discussed different ways to create certificates for testing, including using openssl. In the next two sections, I will discuss them in further details.

Orthweb Test

The orthweb project runs Docker containers on an EC2 instance. In the cloud-init script of the EC2 instance, we self-sign a test CA with openssl. Then we create key and certificate for server and client respectively:

IssuerComName=issuer.orthweb.digihunch.com
ClientComName=dcmclient.orthweb.digihunch.com
ServerComName=ca-central-1.compute.amazonaws.com

openssl11 req -x509 -sha256 -newkey rsa:4096 -days 365 -nodes -subj /C=CA/ST=Ontario/L=Waterloo/O=Digihunch/OU=Imaging/CN=$IssuerComName/emailAddress=info@www.digihunch.com -keyout /tmp/ca.key -out /tmp/ca.crt

openssl11 req -new -newkey rsa:4096 -nodes -subj /C=CA/ST=Ontario/L=Waterloo/O=Digihunch/OU=Imaging/CN=$ServerComName/emailAddress=orthweb@www.digihunch.com -addext extendedKeyUsage=serverAuth -addext subjectAltName=DNS:orthweb.digihunch.com,DNS:$IssuerComName -keyout /tmp/server.key -out /tmp/server.csr
openssl11 x509 -req -sha256 -days 365 -in /tmp/server.csr -CA /tmp/ca.crt -CAkey /tmp/ca.key -set_serial 01 -out /tmp/server.crt

openssl11 req -new -newkey rsa:4096 -nodes -subj /C=CA/ST=Ontario/L=Waterloo/O=Digihunch/OU=Imaging/CN=$ClientComName/emailAddress=orthweb@www.digihunch.com -keyout /tmp/client.key -out /tmp/client.csr
openssl11 x509 -req -sha256 -days 365 -in /tmp/client.csr -CA /tmp/ca.crt -CAkey /tmp/ca.key -set_serial 01 -out /tmp/client.crt

When simulating DICOM activities from the client side, we supply the three files (ca.key, client.crt and client.key) to the echoscu and storescu executables, to issue DIMSE commands on top of TLS from client side, as shown in the previous section.

Korthweb Test

Currently, the Korthweb project deploys to Kubernetes cluster in three approaches, including two types of ingress controllers: Istio CRD (manual and GitOps deployment options) and Traefik CRD (Helm Chart driven deployment options). With both approaches, it is fairly straightforward to validate the HTTPS port. We export the CA certificate and run a curl command such as:

curl -HHost:web.orthweb.com -k -X GET https://web.orthweb.com:443/app/explorer.html -u admin:orthanc --cacert ca.crt

Note that by default, the curl command adds SNI (server name indication) extension by default to its TLS ClientHello Message (even without -HHost switch). It acts like a modern browser.

On the ingress controller side, most ingress controllers use SNI to drive request routing (because Host field in payload is encrypted). For example, Traefik Proxy has HostSNI matching rule. With Istio, the document states that: TLS implies the connection will be routed based on the SNI header to the destination. With DICOM traffic the Ingress also expects the client to make use of SNI extension in the TLS ClientHello message. The ingress supports multiple sites so the SNI even has an impact of which TLS certificate the ingress serves to the client. We can use openssl to examine which certificate an ingress serves. For example:

openssl s_client -showcerts -connect dicom.orthweb.com:11112 -servername dicom.orthweb.com < /dev/null
openssl s_client -showcerts -connect dicom.orthweb.com:11112 < /dev/null

The second command without -servername switch constructs an ClientHello message without SNI. The ingress may not have a clue of what certificate to serve, depending on its own implementation of TLS protocol. We can also force TLS version with a switch such as -tls1_2.

When it comes to open-source DICOM client, neither dcm4che or dcmtk puts SNI in the TLS request. This created some limitation with my testing. Luckily I do not have multiple routing destinations for now so I only need to direct all DICOM traffic to a service. When I use Istio ingress, I was able to set hosts to “*” so the Ingress does not care missing SNI extension in the client request. With Traefik proxy, I had to set sniStrict to false, and also forgo client certificate check.

The workaround is different per ingress implementation. Even worse, depending on what the available workaround can achieve, the testing steps vary as well.

For example, I perform DICOM validation (Istio ingress) with the steps below:

# bhs: generate client key pair
openssl req -new -newkey rsa:4096 -nodes -subj /C=CA/ST=Ontario/L=Waterloo/O=Digihunch/OU=Imaging/CN=dcmclient.bhs.orthweb.com/emailAddress=dcmclient@www.digihunch.com -keyout bhs.client.key -out bhs.client.csr

# bhs: export intermediate CA credentials
kubectl -n bhs-orthweb get secret int-ca-secret -o jsonpath='{.data.tls\.key}' | base64 -d > bhs.int.ca.key
kubectl -n bhs-orthweb get secret int-ca-secret -o jsonpath='{.data.tls\.crt}' | base64 -d > bhs.int.ca.crt

# bhs: get intermediate CA to sign client cert 
openssl x509 -req -sha256 -days 365 -in bhs.client.csr -CA bhs.int.ca.crt -CAkey bhs.int.ca.key -set_serial 01 -out bhs.client.crt

# bhs: validate web request (without client certificate)
curl -HHost:web.bhs.orthweb.com -k -X GET https://web.bhs.orthweb.com:443/app/explorer.html -u admin:orthanc --cacert bhs.int.ca.crt

# bhs: validate DICOM c-echo request (with client certificate)
echoscu -aet TESTER -aec ORTHANC -d +tls bhs.client.key bhs.client.crt -rc +cf bhs.int.ca.crt dicom.bhs.orthweb.com 11112

# bhs: validate DICOM c-store request (with client certificate)
storescu -aet TESTER -aec ORTHANC -d +tls bhs.client.key bhs.client.crt -rc +cf bhs.int.ca.crt dicom.bhs.orthweb.com 11112 DICOM_CT/0001.dcm

On the other hand, for Traefik ingress, I have to use anonymous TLS without client certificate:

echoscu -aet TESTER -aec ORTHANC -d +tla -ic dicom.orthweb.com 11112
storescu -aet TESTER -aec ORTHANC -d +tla -ic dicom.orthweb.com 11112 DICOM_CT/123.dcm

The complexities with different test paths are consequences of the missing SNI capability in both DICOM toolkits. Unfortunately, the developers of the two DICOM tools are not aware of these consequences. I tried to contact dcmtk about this and will see what happens.

TLS profile

Another setting to pay close attention to is the security profile for TLS communication. These profiles defines the behaviours of dcmtk when it establishes TLS connection. The dcmtk has the following security profiles:

–profile-bcp195-nd (+py default): Non-downgrading BCP 195 TLS Profile
–profile-bcp195 (+px): BCP 195 TLS Profile
–profile-bcp195-ex (+pz): Extended BCP 195 TLS Profile
–profile-aes (+pa): AES TLS Secure Transport Connection Profile (retired)
–profile-null (+pn): Authenticated unencrypted communication (retired, was used in IHE ATNA)

The two at the bottom have been retired. The current profiles are all based on BCP195. BCP (best current practice) are sub-series of the corresponding RFC document series. The current revision of DICOM standard discusses bcp195-nd, bcp195 and bcp195-ex profiles in DICOM standard chapter PS 3.15 (B.9-B.11). For example, bcp195-nd requires that:

Implementation shall not negotiate TLS 1.0 or 1.1
Client and server shall prefer strict TLS configuration (as opposed to startTLS)
Ciphers that should be supported.
Recommend port 2762

These BCP profiles were incorporated into DICOM standard since 2018 and are all based on BCP195. BCP 195 states in section 3.6

3.6. Server Name Indication
TLS implementations MUST support the Server Name Indication (SNI)
extension defined in Section 3 of [RFC6066] for those higher-level
protocols that would benefit from it, including HTTPS. However, the
actual use of SNI in particular circumstances is a matter of local
policy.
Rationale: SNI supports deployment of multiple TLS-protected virtual
servers on a single address, and therefore enables fine-grained
security for these virtual servers, by allowing each one to have its
own certificate.

So technically, missing SNI is considered incompliant.

Summary

I find myself switching between dcmtk and dcm4che back and forth in the past. This time, I spent some time hoping to settle with the better tool this time. The effort is insightful but not fruitful. It is unfortunate to realize that neither supports SNI so I had to compromise the feature of my deployment. Hopefully one of those tools will catch up.

Automatic deployment of Orthanc on AWS

Sun, 08 Nov 2020 00:54:06 -0400

[Update] I changed reverse proxy from Nginx to Envoy. Here‘s the detail.

[Update] Some security improvement was introduced in may 2021. Here‘s detail.

[Update] Here’s the link to the orthweb repository.

In this project we introduce a medical imaging web service based on Orthanc, an open-source project of DICOM server, and a pipeline to deploy such server automatically and consistently. We deploy Orthanc on AWS automatically. This little project involves a number of technical deets in DevOps, to deliver a web application prototype with an automated deployment pipeline.

A brief on imaging

In medical imaging, scanning devices are the data collectors. It consists of various categories of scanners, such as Computed Tomography (CT), and Ultrasound (US). They are collectively referred to as modality, but vary significantly in terms of image generation and hardware manufacturing. The challenges to exchange data between these heterogeneous scanning devices and centralized computers came around as early as the 1980s, which brought about ACR-NEMA standard in 1985, under the initiative between American College Radiology (ACR) and National Electrical Manufacturers Association (NEMA). The standard lately evolved into DICOM (Digital Imaging Communication in Medicine), a comprehensive set of standard in the ISO framework that governs modern imaging data storage and exchange across several disciplines (radiology, cardiology, pathology, etc) that operate around images in medicine.

In addition to defining a file format to store imaging data, DICOM also includes an upper layer protocol that dictates how two compliant devices (referred as application entity, each identified by AE title) can negotiate a common syntax to transfer objects (e.g. an image, a report or a discovery). Upper layer refers to layer 5-7 in OSI model, or application layer in TCP/IP model.

Imaging server

Once scanner acquires images from patient, they stores the exams to imaging server for persistent storage. The functionalities of such server expands overtime since 1990s and hence go by different names in different eras, such as PACS (Picture Archive and Communication Systems), VNA (Vendor Neutral Archive) and EI (enterprise imaging) archive. Regardless of naming, they can be generally seen as a highly specialized variation of enterprise content management system. They are usually hosted with a centralized database to index clinical information at patient, exam and image levels. The other key component is the persistent storage devices, usually in the form of a NAS.

Orthanc is an open-source initiative for such imaging servers. It provides a DICOM endpoint, allowing scanning devices to store medical images. It also provides a web viewer allowing users to see the images stored. It is released for many platforms, including Docker images.

Infrastructure as code

We use Amazon Web Service (AWS) for infrastructure as service, and Terraform as the tool to provision resources off AWS, in a reliable and consistent mechanism, known as Infrastructure-as-Code. Terraform is an alternative to CloudFormation, AWS’s proprietary infrastructure-as-code technology. Terraform is developed by Hashicorp as an open-source project, and therefore is vendor neutral. It supports multiple public cloud vendor through different providers. Each provider accesses the vendor specific SDK. For example, the AWS provider integrates with AWS SDK. As a result, the code used in one vendor cannot just be applied to a different vendor without a major overhaul. Terraform’s current version is 0.13 as of Oct 2020, and has gone through some syntax changes since version 0.11. Terraform also produces files for state management locally in the working directory.

When executing, Terraform combines all files in the working directory to assess variables, and create required resources. It is compatible with the most of AWS resources. For example, you can specify user data with templates when creating EC2 instances. You can also create managed service instance as long as it is supported by the provider.

Architecture

Orthanc web server stores data in sqlite by default, but also has a plugin to support PostgreSQL, an open-source relational database. AWS has managed service (RDS) based on PostgreSQL. In this project, we create an RDS instance that span across two availability zones for minimum high availability. Orthanc also supports storing imaging data including pixels in PostgreSQL, which obviates the need for a dedicated file storage system.

We deploy the application in Docker’s containers for compatibility and portability. The Orthanc server is shipped in Docker images, available in Docker hub registry. The docker environment is configured as part of EC2 instance bootstrapping, including installing packages with YUM, initializing and customizing environment variables. The docker-compose file, and the auxiliary configuration files are provided in the repo. The bootstrapping script installs git and pulls required files from this GitHub repo.

This demo project does not include load balancing, DNS management, or container orchestration.

Security

Orthanc’s web browser natively supports HTTPS. However, the DICOM port does not support TLS natively, as their development has made clear in the FAQ. This leaves a severe security vulnerability because all patient data (protected health information in HIPPA context) would be sent across the Internet in the clear, visible to every network interface along the route. To address this issue we brought in Nginx as a reverse proxy to work at TCP layer to terminate encrypted traffic for Orthanc’s DICOM end point. DICOM upper layer works on top of TCP layer.

In Nginx literature, this use case is referred to as SSL Termination for TCP Upstream Servers. Note that Nginx is providing layer 4 capability in this use case so the certificate and key configuration should not be placed under http section of the configuration file. This layer 4 capability in fact enables security configurations of all protocol that operates in upper layers and can be used in a broad range of situations. It is also noteworthy that Nginx can re-encrypt the traffic on the way out to upstream, for even tighter security control measure as outlined in this use case.

user nginx;
worker_processes 1;

error_log /var/log/nginx/error.log warn;
pid /var/run/nginx.pid;

events {
 worker_connections 1024;
}

stream {
 upstream dicom_backend {
 server orthanc-backend:4242;
 }

 server {
 listen 11112 ssl;
 proxy_pass dicom_backend;

 ssl_certificate conf.d/site.pem;
 ssl_certificate_key conf.d/site.pem;
 ssl_protocols SSLv3 TLSv1 TLSv1.2 TLSv1.3;
 ssl_ciphers HIGH:!aNULL:!MD5:ECDH+AESGCM;
 ssl_session_cache shared:SSL:20m;
 ssl_session_timeout 4h;
 ssl_handshake_timeout 30s;
 }
}

It is also helpful to use Nginx to terminate HTTPS traffic, using a pair of certificate and key. When testing with self-signed certificate I realized that Chrome browser has specific requirement on self-signed certificate, or it won’t load the page. So the certificate has to be created as instructed here.

For better security, it is advisable that the RDS instance is provisioned in private subnet, with its data encrypted both in-transit and at-rest. Docker service should also manage sensitive information as secrets.

Summary

The deliverable is stored in this Github repo. The docker part of it can be executed on MacBook with PostgreSQL. The entire hardware stack represented by terraform code, can be executed against AWS to create required resources. Checkout README for further instruction. To emulate a modality, one will need a TLS supported DICOM application entity, Horos is a great project on MacOS to serve this purpose, both as DICOM-compliant sender and a viewer. Alternatively, consider some command-line based DICOM toolkit such as dcmtk, or grassroot dicom.