Joint chest X-ray diagnosis and clinical visual attention prediction with multi-stage cooperative learning: enhancing interpretability

As deep learning has become the state-of-the-art for computer-assisted diagnosis, interpretability of the automatic decisions is crucial for clinical deployment. While various methods were proposed in this domain, visual attention maps of clinicians during radiological screening offer a unique asset to provide important insights and can potentially enhance the quality of computer-assisted diagnosis. With this paper, we introduce a novel deep-learning framework for joint disease diagnosis and prediction of corresponding visual saliency maps for chest X-ray scans. Specifically, we designed a novel dual-encoder multi-task UNet, which leverages both a DenseNet201 backbone and a Residual and Squeeze-and-Excitation block-based encoder to extract diverse features for saliency map prediction, and a multi-scale feature-fusion classifier to perform disease classification. To tackle the issue of asynchronous training schedules of individual tasks in multi-task learning, we proposed a multi-stage cooperative learning strategy, with contrastive learning for feature encoder pretraining to boost performance. Experiments show that our proposed method outperformed existing techniques for chest X-ray diagnosis and the quality of visual saliency map prediction.

MedCLIP-SAM: Bridging Text and Image Towards Universal Medical Image Segmentation

Medical image segmentation of anatomical structures and pathology is crucial in modern clinical diagnosis, disease study, and treatment planning. To date, great progress has been made in deep learning-based segmentation techniques, but most methods still lack data efficiency, generalizability, and interactability. Consequently, the development of new, precise segmentation methods that demand fewer labeled datasets is of utmost importance in medical image analysis. Recently, the emergence of foundation models, such as CLIP and Segment-Anything-Model (SAM), with comprehensive cross-domain representation opened the door for interactive and universal image segmentation. However, exploration of these models for data-efficient medical image segmentation is still limited, but is highly necessary. In this paper, we propose a novel framework, called MedCLIP-SAM that combines CLIP and SAM models to generate segmentation of clinical scans using text prompts in both zero-shot and weakly supervised settings. To achieve this, we employed a new Decoupled Hard Negative Noise Contrastive Estimation (DHN-NCE) loss to fine-tune the BiomedCLIP model and the recent gScoreCAM to generate prompts to obtain segmentation masks from SAM in a zero-shot setting. Additionally, we explored the use of zero-shot segmentation labels in a weakly supervised paradigm to improve the segmentation quality further. By extensively testing three diverse segmentation tasks and medical image modalities (breast tumor ultrasound, brain tumor MRI, and lung X-ray), our proposed framework has demonstrated excellent accuracy.

CT-based Anatomical Segmentation for Thoracic Surgical Planning: A Benchmark Study for 3D U-shaped Deep Learning Models

Recent rising interests in patient-specific thoracic surgical planning and simulation require efficient and robust creation of digital anatomical models from automatic medical image segmentation algorithms. Deep learning (DL) is now state-of-the-art in various radiological tasks, and U-shaped DL models have particularly excelled in medical image segmentation since the inception of the 2D UNet. To date, many variants of U-shaped models have been proposed by the integration of different attention mechanisms and network configurations. Leveraging the recent development of large multi-label databases, systematic benchmark studies for these models can provide valuable insights for clinical deployment and future model designs, but such studies are still rare. We conduct the first benchmark study for variants of 3D U-shaped models (3DUNet, STUNet, AttentionUNet, SwinUNETR, FocalSegNet, and a novel 3D SwinUnet with four variants) with a focus on CT-based anatomical segmentation for thoracic surgery. Our study systematically examines the impact of different attention mechanisms, number of resolution stages, and network configurations on segmentation accuracy and computational complexity. To allow cross-reference with other recent benchmarking studies, we also included a performance assessment of the BTCV abdominal structural segmentation. With the STUNet ranking at the top, our study demonstrated the value of CNN-based U-shaped models for the investigated tasks and the benefit of residual blocks in network configuration designs to boost segmentation performance.

Is visual explanation with Grad-CAM more reliable for deeper neural networks? a case study with automatic pneumothorax diagnosis

While deep learning techniques have provided the state-of-the-art performance in various clinical tasks, explainability regarding their decision-making process can greatly enhance the credence of these methods for safer and quicker clinical adoption. With high flexibility, Gradient-weighted Class Activation Mapping (Grad-CAM) has been widely adopted to offer intuitive visual interpretation of various deep learning models' reasoning processes in computer-assisted diagnosis. However, despite the popularity of the technique, there is still a lack of systematic study on Grad-CAM's performance on different deep learning architectures. In this study, we investigate its robustness and effectiveness across different popular deep learning models, with a focus on the impact of the networks' depths and architecture types, by using a case study of automatic pneumothorax diagnosis in X-ray scans. Our results show that deeper neural networks do not necessarily contribute to a strong improvement of pneumothorax diagnosis accuracy, and the effectiveness of GradCAM also varies among different network architectures.

VesselShot: Few-shot learning for cerebral blood vessel segmentation

Angiography is widely used to detect, diagnose, and treat cerebrovascular diseases. While numerous techniques have been proposed to segment the vascular network from different imaging modalities, deep learning (DL) has emerged as a promising approach. However, existing DL methods often depend on proprietary datasets and extensive manual annotation. Moreover, the availability of pre-trained networks specifically for medical domains and 3D volumes is limited. To overcome these challenges, we propose a few-shot learning approach called VesselShot for cerebrovascular segmentation. VesselShot leverages knowledge from a few annotated support images and mitigates the scarcity of labeled data and the need for extensive annotation in cerebral blood vessel segmentation. We evaluated the performance of VesselShot using the publicly available TubeTK dataset for the segmentation task, achieving a mean Dice coefficient (DC) of 0.62(0.03).

Dense Error Map Estimation for MRI-Ultrasound Registration in Brain Tumor Surgery Using Swin UNETR

Early surgical treatment of brain tumors is crucial in reducing patient mortality rates. However, brain tissue deformation (called brain shift) occurs during the surgery, rendering pre-operative images invalid. As a cost-effective and portable tool, intra-operative ultrasound (iUS) can track brain shift, and accurate MRI-iUS registration techniques can update pre-surgical plans and facilitate the interpretation of iUS. This can boost surgical safety and outcomes by maximizing tumor removal while avoiding eloquent regions. However, manual assessment of MRI-iUS registration results in real-time is difficult and prone to errors due to the 3D nature of the data. Automatic algorithms that can quantify the quality of inter-modal medical image registration outcomes can be highly beneficial. Therefore, we propose a novel deep-learning (DL) based framework with the Swin UNETR to automatically assess 3D-patch-wise dense error maps for MRI-iUS registration in iUS-guided brain tumor resection and show its performance with real clinical data for the first time.

How inter-rater variability relates to aleatoric and epistemic uncertainty: a case study with deep learning-based paraspinal muscle segmentation

Recent developments in deep learning (DL) techniques have led to great performance improvement in medical image segmentation tasks, especially with the latest Transformer model and its variants. While labels from fusing multi-rater manual segmentations are often employed as ideal ground truths in DL model training, inter-rater variability due to factors such as training bias, image noise, and extreme anatomical variability can still affect the performance and uncertainty of the resulting algorithms. Knowledge regarding how inter-rater variability affects the reliability of the resulting DL algorithms, a key element in clinical deployment, can help inform better training data construction and DL models, but has not been explored extensively. In this paper, we measure aleatoric and epistemic uncertainties using test-time augmentation (TTA), test-time dropout (TTD), and deep ensemble to explore their relationship with inter-rater variability. Furthermore, we compare UNet and TransUNet to study the impacts of Transformers on model uncertainty with two label fusion strategies. We conduct a case study using multi-class paraspinal muscle segmentation from T2w MRIs. Our study reveals the interplay between inter-rater variability and uncertainties, affected by choices of label fusion strategies and DL models.

Weakly supervised segmentation of intracranial aneurysms using a 3D focal modulation UNet

Accurate identification and quantification of unruptured intracranial aneurysms (UIAs) are essential for the risk assessment and treatment decisions of this cerebrovascular disorder. Current assessment based on 2D manual measures of aneurysms on 3D magnetic resonance angiography (MRA) is sub-optimal and time-consuming. Automatic 3D measures can significantly benefit the clinical workflow and treatment outcomes. However, one major issue in medical image segmentation is the need for large well-annotated data, which can be expensive to obtain. Techniques that mitigate the requirement, such as weakly supervised learning with coarse labels are highly desirable. In this paper, we leverage coarse labels of UIAs from time-of-flight MRAs to obtain refined UIAs segmentation using a novel 3D focal modulation UNet, called FocalSegNet and conditional random field (CRF) postprocessing, with a Dice score of 0.68 and 95% Hausdorff distance of 0.95 mm. We evaluated the performance of the proposed algorithms against the state-of-the-art 3D UNet and Swin-UNETR, and demonstrated the superiority of the proposed FocalSegNet and the benefit of focal modulation for the task.

Towards multi-modal anatomical landmark detection for ultrasound-guided brain tumor resection with contrastive learning

Homologous anatomical landmarks between medical scans are instrumental in quantitative assessment of image registration quality in various clinical applications, such as MRI-ultrasound registration for tissue shift correction in ultrasound-guided brain tumor resection. While manually identified landmark pairs between MRI and ultrasound (US) have greatly facilitated the validation of different registration algorithms for the task, the procedure requires significant expertise, labor, and time, and can be prone to inter- and intra-rater inconsistency. So far, many traditional and machine learning approaches have been presented for anatomical landmark detection, but they primarily focus on mono-modal applications. Unfortunately, despite the clinical needs, inter-modal/contrast landmark detection has very rarely been attempted. Therefore, we propose a novel contrastive learning framework to detect corresponding landmarks between MRI and intra-operative US scans in neurosurgery. Specifically, two convolutional neural networks were trained jointly to encode image features in MRI and US scans to help match the US image patch that contain the corresponding landmarks in the MRI. We developed and validated the technique using the public RESECT database. With a mean landmark detection accuracy of 5.88+-4.79 mm against 18.78+-4.77 mm with SIFT features, the proposed method offers promising results for MRI-US landmark detection in neurosurgical applications for the first time.

FocalErrorNet: Uncertainty-aware focal modulation network for inter-modal registration error estimation in ultrasound-guided neurosurgery

In brain tumor resection, accurate removal of cancerous tissues while preserving eloquent regions is crucial to the safety and outcomes of the treatment. However, intra-operative tissue deformation (called brain shift) can move the surgical target and render the pre-surgical plan invalid. Intra-operative ultrasound (iUS) has been adopted to provide real-time images to track brain shift, and inter-modal (i.e., MRI-iUS) registration is often required to update the pre-surgical plan. Quality control for the registration results during surgery is important to avoid adverse outcomes, but manual verification faces great challenges due to difficult 3D visualization and the low contrast of iUS. Automatic algorithms are urgently needed to address this issue, but the problem was rarely attempted. Therefore, we propose a novel deep learning technique based on 3D focal modulation in conjunction with uncertainty estimation to accurately assess MRI-iUS registration errors for brain tumor surgery. Developed and validated with the public RESECT clinical database, the resulting algorithm can achieve an estimation error of 0.59+-0.57 mm.