Analyzing Tumors by Synthesis

Computer-aided tumor detection has shown great potential in enhancing the interpretation of over 80 million CT scans performed annually in the United States. However, challenges arise due to the rarity of CT scans with tumors, especially early-stage tumors. Developing AI with real tumor data faces issues of scarcity, annotation difficulty, and low prevalence. Tumor synthesis addresses these challenges by generating numerous tumor examples in medical images, aiding AI training for tumor detection and segmentation. Successful synthesis requires realistic and generalizable synthetic tumors across various organs. This chapter reviews AI development on real and synthetic data and summarizes two key trends in synthetic data for cancer imaging research: modeling-based and learning-based approaches. Modeling-based methods, like Pixel2Cancer, simulate tumor development over time using generic rules, while learning-based methods, like DiffTumor, learn from a few annotated examples in one organ to generate synthetic tumors in others. Reader studies with expert radiologists show that synthetic tumors can be convincingly realistic. We also present case studies in the liver, pancreas, and kidneys reveal that AI trained on synthetic tumors can achieve performance comparable to, or better than, AI only trained on real data. Tumor synthesis holds significant promise for expanding datasets, enhancing AI reliability, improving tumor detection performance, and preserving patient privacy.

LiverUSRecon: Automatic 3D Reconstruction and Volumetry of the Liver with a Few Partial Ultrasound Scans

3D reconstruction of the liver for volumetry is important for qualitative analysis and disease diagnosis. Liver volumetry using ultrasound (US) scans, although advantageous due to less acquisition time and safety, is challenging due to the inherent noisiness in US scans, blurry boundaries, and partial liver visibility. We address these challenges by using the segmentation masks of a few incomplete sagittal-plane US scans of the liver in conjunction with a statistical shape model (SSM) built using a set of CT scans of the liver. We compute the shape parameters needed to warp this canonical SSM to fit the US scans through a parametric regression network. The resulting 3D liver reconstruction is accurate and leads to automatic liver volume calculation. We evaluate the accuracy of the estimated liver volumes with respect to CT segmentation volumes using RMSE. Our volume computation is statistically much closer to the volume estimated using CT scans than the volume computed using Childs' method by radiologists: p-value of 0.094 (>0.05) says that there is no significant difference between CT segmentation volumes and ours in contrast to Childs' method. We validate our method using investigations (ablation studies) on the US image resolution, the number of CT scans used for SSM, the number of principal components, and the number of input US scans. To the best of our knowledge, this is the first automatic liver volumetry system using a few incomplete US scans given a set of CT scans of livers for SSM.

A Classification-Based Adaptive Segmentation Pipeline: Feasibility Study Using Polycystic Liver Disease and Metastases from Colorectal Cancer CT Images

Automated segmentation tools often encounter accuracy and adaptability issues when applied to images of different pathology. The purpose of this study is to explore the feasibility of building a workflow to efficiently route images to specifically trained segmentation models. By implementing a deep learning classifier to automatically classify the images and route them to appropriate segmentation models, we hope that our workflow can segment the images with different pathology accurately. The data we used in this study are 350 CT images from patients affected by polycystic liver disease and 350 CT images from patients presenting with liver metastases from colorectal cancer. All images had the liver manually segmented by trained imaging analysts. Our proposed adaptive segmentation workflow achieved a statistically significant improvement for the task of total liver segmentation compared to the generic single segmentation model (non-parametric Wilcoxon signed rank test, n=100, p-value << 0.001). This approach is applicable in a wide range of scenarios and should prove useful in clinical implementations of segmentation pipelines.

MFA-Net: Multi-Scale feature fusion attention network for liver tumor segmentation

Segmentation of organs of interest in medical CT images is beneficial for diagnosis of diseases. Though recent methods based on Fully Convolutional Neural Networks (F-CNNs) have shown success in many segmentation tasks, fusing features from images with different scales is still a challenge: (1) Due to the lack of spatial awareness, F-CNNs share the same weights at different spatial locations. (2) F-CNNs can only obtain surrounding information through local receptive fields. To address the above challenge, we propose a new segmentation framework based on attention mechanisms, named MFA-Net (Multi-Scale Feature Fusion Attention Network). The proposed framework can learn more meaningful feature maps among multiple scales and result in more accurate automatic segmentation. We compare our proposed MFA-Net with SOTA methods on two 2D liver CT datasets. The experimental results show that our MFA-Net produces more precise segmentation on images with different scales.

The ULS23 Challenge: a Baseline Model and Benchmark Dataset for 3D Universal Lesion Segmentation in Computed Tomography

Size measurements of tumor manifestations on follow-up CT examinations are crucial for evaluating treatment outcomes in cancer patients. Efficient lesion segmentation can speed up these radiological workflows. While numerous benchmarks and challenges address lesion segmentation in specific organs like the liver, kidneys, and lungs, the larger variety of lesion types encountered in clinical practice demands a more universal approach. To address this gap, we introduced the ULS23 benchmark for 3D universal lesion segmentation in chest-abdomen-pelvis CT examinations. The ULS23 training dataset contains 38,693 lesions across this region, including challenging pancreatic, colon and bone lesions. For evaluation purposes, we curated a dataset comprising 775 lesions from 284 patients. Each of these lesions was identified as a target lesion in a clinical context, ensuring diversity and clinical relevance within this dataset. The ULS23 benchmark is publicly accessible via uls23.grand-challenge.org, enabling researchers worldwide to assess the performance of their segmentation methods. Furthermore, we have developed and publicly released our baseline semi-supervised 3D lesion segmentation model. This model achieved an average Dice coefficient of 0.703 $\pm$ 0.240 on the challenge test set. We invite ongoing submissions to advance the development of future ULS models.

Multi-target and multi-stage liver lesion segmentation and detection in multi-phase computed tomography scans

Multi-phase computed tomography (CT) scans use contrast agents to highlight different anatomical structures within the body to improve the probability of identifying and detecting anatomical structures of interest and abnormalities such as liver lesions. Yet, detecting these lesions remains a challenging task as these lesions vary significantly in their size, shape, texture, and contrast with respect to surrounding tissue. Therefore, radiologists need to have an extensive experience to be able to identify and detect these lesions. Segmentation-based neural networks can assist radiologists with this task. Current state-of-the-art lesion segmentation networks use the encoder-decoder design paradigm based on the UNet architecture where the multi-phase CT scan volume is fed to the network as a multi-channel input. Although this approach utilizes information from all the phases and outperform single-phase segmentation networks, we demonstrate that their performance is not optimal and can be further improved by incorporating the learning from models trained on each single-phase individually. Our approach comprises three stages. The first stage identifies the regions within the liver where there might be lesions at three different scales (4, 8, and 16 mm). The second stage includes the main segmentation model trained using all the phases as well as a segmentation model trained on each of the phases individually. The third stage uses the multi-phase CT volumes together with the predictions from each of the segmentation models to generate the final segmentation map. Overall, our approach improves relative liver lesion segmentation performance by 1.6% while reducing performance variability across subjects by 8% when compared to the current state-of-the-art models.

MDNet: Multi-Decoder Network for Abdominal CT Organs Segmentation

Accurate segmentation of organs from abdominal CT scans is essential for clinical applications such as diagnosis, treatment planning, and patient monitoring. To handle challenges of heterogeneity in organ shapes, sizes, and complex anatomical relationships, we propose a \textbf{\textit{\ac{MDNet}}}, an encoder-decoder network that uses the pre-trained \textit{MiT-B2} as the encoder and multiple different decoder networks. Each decoder network is connected to a different part of the encoder via a multi-scale feature enhancement dilated block. With each decoder, we increase the depth of the network iteratively and refine segmentation masks, enriching feature maps by integrating previous decoders' feature maps. To refine the feature map further, we also utilize the predicted masks from the previous decoder to the current decoder to provide spatial attention across foreground and background regions. MDNet effectively refines the segmentation mask with a high dice similarity coefficient (DSC) of 0.9013 and 0.9169 on the Liver Tumor segmentation (LiTS) and MSD Spleen datasets. Additionally, it reduces Hausdorff distance (HD) to 3.79 for the LiTS dataset and 2.26 for the spleen segmentation dataset, underscoring the precision of MDNet in capturing the complex contours. Moreover, \textit{\ac{MDNet}} is more interpretable and robust compared to the other baseline models.

An Empirical Study on the Fairness of Foundation Models for Multi-Organ Image Segmentation

The segmentation foundation model, e.g., Segment Anything Model (SAM), has attracted increasing interest in the medical image community. Early pioneering studies primarily concentrated on assessing and improving SAM's performance from the perspectives of overall accuracy and efficiency, yet little attention was given to the fairness considerations. This oversight raises questions about the potential for performance biases that could mirror those found in task-specific deep learning models like nnU-Net. In this paper, we explored the fairness dilemma concerning large segmentation foundation models. We prospectively curate a benchmark dataset of 3D MRI and CT scans of the organs including liver, kidney, spleen, lung and aorta from a total of 1056 healthy subjects with expert segmentations. Crucially, we document demographic details such as gender, age, and body mass index (BMI) for each subject to facilitate a nuanced fairness analysis. We test state-of-the-art foundation models for medical image segmentation, including the original SAM, medical SAM and SAT models, to evaluate segmentation efficacy across different demographic groups and identify disparities. Our comprehensive analysis, which accounts for various confounding factors, reveals significant fairness concerns within these foundational models. Moreover, our findings highlight not only disparities in overall segmentation metrics, such as the Dice Similarity Coefficient but also significant variations in the spatial distribution of segmentation errors, offering empirical evidence of the nuanced challenges in ensuring fairness in medical image segmentation.

PAM-UNet: Shifting Attention on Region of Interest in Medical Images

Computer-aided segmentation methods can assist medical personnel in improving diagnostic outcomes. While recent advancements like UNet and its variants have shown promise, they face a critical challenge: balancing accuracy with computational efficiency. Shallow encoder architectures in UNets often struggle to capture crucial spatial features, leading in inaccurate and sparse segmentation. To address this limitation, we propose a novel \underline{P}rogressive \underline{A}ttention based \underline{M}obile \underline{UNet} (\underline{PAM-UNet}) architecture. The inverted residual (IR) blocks in PAM-UNet help maintain a lightweight framework, while layerwise \textit{Progressive Luong Attention} ($\mathcal{PLA}$) promotes precise segmentation by directing attention toward regions of interest during synthesis. Our approach prioritizes both accuracy and speed, achieving a commendable balance with a mean IoU of 74.65 and a dice score of 82.87, while requiring only 1.32 floating-point operations per second (FLOPS) on the Liver Tumor Segmentation Benchmark (LiTS) 2017 dataset. These results highlight the importance of developing efficient segmentation models to accelerate the adoption of AI in clinical practice.

Class-Aware Cartilage Segmentation for Autonomous US-CT Registration in Robotic Intercostal Ultrasound Imaging

Ultrasound imaging has been widely used in clinical examinations owing to the advantages of being portable, real-time, and radiation-free. Considering the potential of extensive deployment of autonomous examination systems in hospitals, robotic US imaging has attracted increased attention. However, due to the inter-patient variations, it is still challenging to have an optimal path for each patient, particularly for thoracic applications with limited acoustic windows, e.g., intercostal liver imaging. To address this problem, a class-aware cartilage bone segmentation network with geometry-constraint post-processing is presented to capture patient-specific rib skeletons. Then, a dense skeleton graph-based non-rigid registration is presented to map the intercostal scanning path from a generic template to individual patients. By explicitly considering the high-acoustic impedance bone structures, the transferred scanning path can be precisely located in the intercostal space, enhancing the visibility of internal organs by reducing the acoustic shadow. To evaluate the proposed approach, the final path mapping performance is validated on five distinct CTs and two volunteer US data, resulting in ten pairs of CT-US combinations. Results demonstrate that the proposed graph-based registration method can robustly and precisely map the path from CT template to individual patients (Euclidean error: $2.21\pm1.11~mm$).