Automatic hip osteoarthritis grading with uncertainty estimation from computed tomography using digitally-reconstructed radiographs

Progression of hip osteoarthritis (hip OA) leads to pain and disability, likely leading to surgical treatment such as hip arthroplasty at the terminal stage. The severity of hip OA is often classified using the Crowe and Kellgren-Lawrence (KL) classifications. However, as the classification is subjective, we aimed to develop an automated approach to classify the disease severity based on the two grades using digitally-reconstructed radiographs (DRRs) from CT images. Automatic grading of the hip OA severity was performed using deep learning-based models. The models were trained to predict the disease grade using two grading schemes, i.e., predicting the Crowe and KL grades separately, and predicting a new ordinal label combining both grades and representing the disease progression of hip OA. The models were trained in classification and regression settings. In addition, the model uncertainty was estimated and validated as a predictor of classification accuracy. The models were trained and validated on a database of 197 hip OA patients, and externally validated on 52 patients. The model accuracy was evaluated using exact class accuracy (ECA), one-neighbor class accuracy (ONCA), and balanced accuracy.The deep learning models produced a comparable accuracy of approximately 0.65 (ECA) and 0.95 (ONCA) in the classification and regression settings. The model uncertainty was significantly larger in cases with large classification errors (P<6e-3). In this study, an automatic approach for grading hip OA severity from CT images was developed. The models have shown comparable performance with high ONCA, which facilitates automated grading in large-scale CT databases and indicates the potential for further disease progression analysis. Classification accuracy was correlated with the model uncertainty, which would allow for the prediction of classification errors.

Hybrid Representation-Enhanced Sampling for Bayesian Active Learning in Musculoskeletal Segmentation of Lower Extremities

Purpose: Obtaining manual annotations to train deep learning (DL) models for auto-segmentation is often time-consuming. Uncertainty-based Bayesian active learning (BAL) is a widely-adopted method to reduce annotation efforts. Based on BAL, this study introduces a hybrid representation-enhanced sampling strategy that integrates density and diversity criteria to save manual annotation costs by efficiently selecting the most informative samples. Methods: The experiments are performed on two lower extremity (LE) datasets of MRI and CT images by a BAL framework based on Bayesian U-net. Our method selects uncertain samples with high density and diversity for manual revision, optimizing for maximal similarity to unlabeled instances and minimal similarity to existing training data. We assess the accuracy and efficiency using Dice and a proposed metric called reduced annotation cost (RAC), respectively. We further evaluate the impact of various acquisition rules on BAL performance and design an ablation study for effectiveness estimation. Results: The proposed method showed superiority or non-inferiority to other methods on both datasets across two acquisition rules, and quantitative results reveal the pros and cons of the acquisition rules. Our ablation study in volume-wise acquisition shows that the combination of density and diversity criteria outperforms solely using either of them in musculoskeletal segmentation. Conclusion: Our sampling method is proven efficient in reducing annotation costs in image segmentation tasks. The combination of the proposed method and our BAL framework provides a semi-automatic way for efficient annotation of medical image datasets.

Bone mineral density estimation from a plain X-ray image by learning decomposition into projections of bone-segmented computed tomography

Osteoporosis is a prevalent bone disease that causes fractures in fragile bones, leading to a decline in daily living activities. Dual-energy X-ray absorptiometry (DXA) and quantitative computed tomography (QCT) are highly accurate for diagnosing osteoporosis; however, these modalities require special equipment and scan protocols. To frequently monitor bone health, low-cost, low-dose, and ubiquitously available diagnostic methods are highly anticipated. In this study, we aim to perform bone mineral density (BMD) estimation from a plain X-ray image for opportunistic screening, which is potentially useful for early diagnosis. Existing methods have used multi-stage approaches consisting of extraction of the region of interest and simple regression to estimate BMD, which require a large amount of training data. Therefore, we propose an efficient method that learns decomposition into projections of bone-segmented QCT for BMD estimation under limited datasets. The proposed method achieved high accuracy in BMD estimation, where Pearson correlation coefficients of 0.880 and 0.920 were observed for DXA-measured BMD and QCT-measured BMD estimation tasks, respectively, and the root mean square of the coefficient of variation values were 3.27 to 3.79% for four measurements with different poses. Furthermore, we conducted extensive validation experiments, including multi-pose, uncalibrated-CT, and compression experiments toward actual application in routine clinical practice.

MSKdeX: Musculoskeletal (MSK) decomposition from an X-ray image for fine-grained estimation of lean muscle mass and muscle volume

Musculoskeletal diseases such as sarcopenia and osteoporosis are major obstacles to health during aging. Although dual-energy X-ray absorptiometry (DXA) and computed tomography (CT) can be used to evaluate musculoskeletal conditions, frequent monitoring is difficult due to the cost and accessibility (as well as high radiation exposure in the case of CT). We propose a method (named MSKdeX) to estimate fine-grained muscle properties from a plain X-ray image, a low-cost, low-radiation, and highly accessible imaging modality, through musculoskeletal decomposition leveraging fine-grained segmentation in CT. We train a multi-channel quantitative image translation model to decompose an X-ray image into projections of CT of individual muscles to infer the lean muscle mass and muscle volume. We propose the object-wise intensity-sum loss, a simple yet surprisingly effective metric invariant to muscle deformation and projection direction, utilizing information in CT and X-ray images collected from the same patient. While our method is basically an unpaired image-to-image translation, we also exploit the nature of the bone's rigidity, which provides the paired data through 2D-3D rigid registration, adding strong pixel-wise supervision in unpaired training. Through the evaluation using a 539-patient dataset, we showed that the proposed method significantly outperformed conventional methods. The average Pearson correlation coefficient between the predicted and CT-derived ground truth metrics was increased from 0.460 to 0.863. We believe our method opened up a new musculoskeletal diagnosis method and has the potential to be extended to broader applications in multi-channel quantitative image translation tasks. Our source code will be released soon.

Identifying Suspicious Regions of Covid-19 by Abnormality-Sensitive Activation Mapping

This paper presents a fully-automated method for the identification of suspicious regions of a coronavirus disease (COVID-19) on chest CT volumes. One major role of chest CT scanning in COVID-19 diagnoses is identification of an inflammation particular to the disease. This task is generally performed by radiologists through an interpretation of the CT volumes, however, because of the heavy workload, an automatic analysis method using a computer is desired. Most computer-aided diagnosis studies have addressed only a portion of the elements necessary for the identification. In this work, we realize the identification method through a classification task by using a 2.5-dimensional CNN with three-dimensional attention mechanisms. We visualize the suspicious regions by applying a backpropagation based on positive gradients to attention-weighted features. We perform experiments on an in-house dataset and two public datasets to reveal the generalization ability of the proposed method. The proposed architecture achieved AUCs of over 0.900 for all the datasets, and mean sensitivity $0.853 \pm 0.036$ and specificity $0.870 \pm 0.040$. The method can also identify notable lesions pointed out in the radiology report as suspicious regions.

BMD-GAN: Bone mineral density estimation using x-ray image decomposition into projections of bone-segmented quantitative computed tomography using hierarchical learning

We propose a method for estimating the bone mineral density (BMD) from a plain x-ray image. Dual-energy X-ray absorptiometry (DXA) and quantitative computed tomography (QCT) provide high accuracy in diagnosing osteoporosis; however, these modalities require special equipment and scan protocols. Measuring BMD from an x-ray image provides an opportunistic screening, which is potentially useful for early diagnosis. The previous methods that directly learn the relationship between x-ray images and BMD require a large training dataset to achieve high accuracy because of large intensity variations in the x-ray images. Therefore, we propose an approach using the QCT for training a generative adversarial network (GAN) and decomposing an x-ray image into a projection of bone-segmented QCT. The proposed hierarchical learning improved the robustness and accuracy of quantitatively decomposing a small-area target. The evaluation of 200 patients with osteoarthritis using the proposed method, which we named BMD-GAN, demonstrated a Pearson correlation coefficient of 0.888 between the predicted and ground truth DXA-measured BMD. Besides not requiring a large-scale training database, another advantage of our method is its extensibility to other anatomical areas, such as the vertebrae and rib bones.

COVID-19 Infection Segmentation from Chest CT Images Based on Scale Uncertainty

This paper proposes a segmentation method of infection regions in the lung from CT volumes of COVID-19 patients. COVID-19 spread worldwide, causing many infected patients and deaths. CT image-based diagnosis of COVID-19 can provide quick and accurate diagnosis results. An automated segmentation method of infection regions in the lung provides a quantitative criterion for diagnosis. Previous methods employ whole 2D image or 3D volume-based processes. Infection regions have a considerable variation in their sizes. Such processes easily miss small infection regions. Patch-based process is effective for segmenting small targets. However, selecting the appropriate patch size is difficult in infection region segmentation. We utilize the scale uncertainty among various receptive field sizes of a segmentation FCN to obtain infection regions. The receptive field sizes can be defined as the patch size and the resolution of volumes where patches are clipped from. This paper proposes an infection segmentation network (ISNet) that performs patch-based segmentation and a scale uncertainty-aware prediction aggregation method that refines the segmentation result. We design ISNet to segment infection regions that have various intensity values. ISNet has multiple encoding paths to process patch volumes normalized by multiple intensity ranges. We collect prediction results generated by ISNets having various receptive field sizes. Scale uncertainty among the prediction results is extracted by the prediction aggregation method. We use an aggregation FCN to generate a refined segmentation result considering scale uncertainty among the predictions. In our experiments using 199 chest CT volumes of COVID-19 cases, the prediction aggregation method improved the dice similarity score from 47.6% to 62.1%.

Lung infection and normal region segmentation from CT volumes of COVID-19 cases

This paper proposes an automated segmentation method of infection and normal regions in the lung from CT volumes of COVID-19 patients. From December 2019, novel coronavirus disease 2019 (COVID-19) spreads over the world and giving significant impacts to our economic activities and daily lives. To diagnose the large number of infected patients, diagnosis assistance by computers is needed. Chest CT is effective for diagnosis of viral pneumonia including COVID-19. A quantitative analysis method of condition of the lung from CT volumes by computers is required for diagnosis assistance of COVID-19. This paper proposes an automated segmentation method of infection and normal regions in the lung from CT volumes using a COVID-19 segmentation fully convolutional network (FCN). In diagnosis of lung diseases including COVID-19, analysis of conditions of normal and infection regions in the lung is important. Our method recognizes and segments lung normal and infection regions in CT volumes. To segment infection regions that have various shapes and sizes, we introduced dense pooling connections and dilated convolutions in our FCN. We applied the proposed method to CT volumes of COVID-19 cases. From mild to severe cases of COVID-19, the proposed method correctly segmented normal and infection regions in the lung. Dice scores of normal and infection regions were 0.911 and 0.753, respectively.

Automated segmentation of an intensity calibration phantom in clinical CT images using a convolutional neural network

Purpose: To apply a convolutional neural network (CNN) to develop a system that segments intensity calibration phantom regions in computed tomography (CT) images, and to test the system in a large cohort to evaluate its robustness. Methods: A total of 1040 cases (520 cases each from two institutions), in which an intensity calibration phantom (B-MAS200, Kyoto Kagaku, Kyoto, Japan) was used, were included herein. A training dataset was created by manually segmenting the regions of the phantom for 40 cases (20 cases each). Segmentation accuracy of the CNN model was assessed with the Dice coefficient and the average symmetric surface distance (ASD) through the 4-fold cross validation. Further, absolute differences of radiodensity values (in Hounsfield units: HU) were compared between manually segmented regions and automatically segmented regions. The system was tested on the remaining 1000 cases. For each institution, linear regression was applied to calculate coefficients for the correlation between radiodensity and the densities of the phantom. Results: After training, the median Dice coefficient was 0.977, and the median ASD was 0.116 mm. When segmented regions were compared between manual segmentation and automated segmentation, the median absolute difference was 0.114 HU. For the test cases, the median correlation coefficient was 0.9998 for one institution and was 0.9999 for the other, with a minimum value of 0.9863. Conclusions: The CNN model successfully segmented the calibration phantom's regions in the CT images with excellent accuracy, and the automated method was found to be at least equivalent to the conventional manual method. Future study should integrate the system by automatically segmenting the region of interest in bones such that the bone mineral density can be fully automatically quantified from CT images.

Automatic Annotation of Hip Anatomy in Fluoroscopy for Robust and Efficient 2D/3D Registration

Fluoroscopy is the standard imaging modality used to guide hip surgery and is therefore a natural sensor for computer-assisted navigation. In order to efficiently solve the complex registration problems presented during navigation, human-assisted annotations of the intraoperative image are typically required. This manual initialization interferes with the surgical workflow and diminishes any advantages gained from navigation. We propose a method for fully automatic registration using annotations produced by a neural network. Neural networks are trained to simultaneously segment anatomy and identify landmarks in fluoroscopy. Training data is obtained using an intraoperatively incompatible 2D/3D registration of hip anatomy. Ground truth 2D labels are established using projected 3D annotations. Intraoperative registration couples an intensity-based strategy with annotations inferred by the network and requires no human assistance. Ground truth labels were obtained in 366 fluoroscopic images across 6 cadaveric specimens. In a leave-one-subject-out experiment, networks obtained mean dice coefficients for left and right hemipelves, left and right femurs of 0.86, 0.87, 0.90, and 0.84. The mean 2D landmark error was 5.0 mm. The pelvis was registered within 1 degree for 86% of the images when using the proposed intraoperative approach with an average runtime of 7 seconds. In comparison, an intensity-only approach without manual initialization, registered the pelvis to 1 degree in 18% of images. We have created the first accurately annotated, non-synthetic, dataset of hip fluoroscopy. By using these annotations as training data for neural networks, state of the art performance in fluoroscopic segmentation and landmark localization was achieved. Integrating these annotations allows for a robust, fully automatic, and efficient intraoperative registration during fluoroscopic navigation of the hip.