DICOM Structured Reporting (SR) provides for encoding and interchanging structured information that may reference images, waveforms or other composite objects, in traditional reporting applications as well as for logs, measurements and CAD results. DICOM SR differs from generic content encoding approaches like XML, in that it supports coded entries, values that are strongly typed, and explicit relationships. DICOM structured reports (like images and waveforms) are composite objects that can be stored, transmitted and queried. The traditional DICOM binary encoding is used to encode structured reports. The structure and content of the SR tree should be accessible regardless of the internal or external representation. XML parsers and XSL-T tree transformation engines that can be used for data entry, presentation (display and printing) and trans-coding (to HL7 2.x and HL7 Clinical Document Architecture (CDA)) need to be interfaced with DICOM tools that support encoding, transmission, storage and retrieval. Issues associated with establishing the appropriate boundaries between tools are discussed, as are how and when to internalize a DICOM SR in an actual or virtual XML representation, the characteristics of such a representation, and the use of SAX events or the Document Object Model (DOM) to drive style-sheet driven tree transformation engines.