Background: Over half a million individuals are diagnosed with head and neck cancer each year globally. Radiotherapy is an important curative treatment for this disease, but it requires manual time to delineate radiosensitive organs at risk. This planning process can delay treatment while also introducing interoperator variability, resulting in downstream radiation dose differences. Although auto-segmentation algorithms offer a potentially time-saving solution, the challenges in defining, quantifying, and achieving expert performance remain.
Objective: Adopting a deep learning approach, we aim to demonstrate a 3D U-Net architecture that achieves expert-level performance in delineating 21 distinct head and neck organs at risk commonly segmented in clinical practice.
Methods: The model was trained on a data set of 663 deidentified computed tomography scans acquired in routine clinical practice and with both segmentations taken from clinical practice and segmentations created by experienced radiographers as part of this research, all in accordance with consensus organ at risk definitions.
Results: We demonstrated the model’s clinical applicability by assessing its performance on a test set of 21 computed tomography scans from clinical practice, each with 21 organs at risk segmented by 2 independent experts. We also introduced surface Dice similarity coefficient, a new metric for the comparison of organ delineation, to quantify the deviation between organ at risk surface contours rather than volumes, better reflecting the clinical task of correcting errors in automated organ segmentations. The model’s generalizability was then demonstrated on 2 distinct open-source data sets, reflecting different centers and countries to model training.
Conclusions: Deep learning is an effective and clinically applicable technique for the segmentation of the head and neck anatomy for radiotherapy. With appropriate validation studies and regulatory approvals, this system could improve the efficiency, consistency, and safety of radiotherapy pathways.

/pdf/clinically-applicable-segmentation-of-head-and-neck-anatomy-4giajeog60.pdf

Clinically Applicable Segmentation of Head and Neck Anatomy for Radiotherapy: Deep Learning Algorithm Development and Validation Study

Transformers have dominated the field of natural language processing and have recently made an impact in the area of computer vision. In the field of medical image analysis, transformers have also been successfully used in to full-stack clinical applications, including image synthesis/reconstruction, registration, segmentation, detection, and diagnosis. This paper aims to promote awareness of the applications of transformers in medical image analysis. Specifically, we first provide an overview of the core concepts of the attention mechanism built into transformers and other basic components. Second, we review various transformer architectures tailored for medical image applications and discuss their limitations. Within this review, we investigate key challenges including the use of transformers in different learning paradigms, improving model efficiency, and coupling with other techniques. We hope this review will provide a comprehensive picture of transformers to readers with an interest in medical image analysis. 

Transformers in Medical Image Analysis: A Review

An overview of deep learning in medical imaging

Recent advances in transformer-based models have drawn attention to exploring these techniques in medical image segmentation, especially in conjunction with the U-Net model (or its variants), which has shown great success in medical image segmentation, under both 2D and 3D settings. Current 2D based methods either directly replace convolutional layers with pure transformers or consider a transformer as an additional intermediate encoder between the encoder and decoder of U-Net. However, these approaches only consider the attention encoding within one single slice and do not utilize the axial-axis information naturally provided by a 3D volume. In the 3D setting, convolution on volumetric data and transformers both consume large GPU memory. One has to either downsample the image or use cropped local patches to reduce GPU memory usage, which limits its performance. In this paper, we propose Axial Fusion Transformer UNet (AFTer-UNet), which takes both advantages of convolutional layers' capability of extracting detailed features and transformers' strength on long sequence modeling. It considers both intra-slice and inter-slice long-range cues to guide the segmentation. Meanwhile, it has fewer parameters and takes less GPU memory to train than the previous transformer-based models. Extensive experiments on three multi-organ segmentation datasets demonstrate that our method outperforms current state-of-the-art methods.

AFTer-UNet: Axial Fusion Transformer UNet for Medical Image Segmentation.

Recent advances in transformer-based models have drawn attention to exploring these techniques in medical image segmentation, especially in conjunction with the UNet model (or its variants), which has shown great success in medical image segmentation, under both 2D and 3D settings. Current 2D based methods either directly replace convolutional layers with pure transformers or consider a transformer as an additional intermediate encoder between the encoder and decoder of U-Net. However, these approaches only consider the attention encoding within one single slice and do not utilize the axial-axis information naturally provided by a 3D volume. In the 3D setting, convolution on volumetric data and transformers both consume large GPU memory. One has to either downsample the image or use cropped local patches to reduce GPU memory usage, which limits its performance. In this paper, we propose Axial Fusion Transformer UNet (AFTer-UNet), which takes both advantages of convolutional layers’ capability of extracting detailed features and transformers’ strength on long sequence modeling. It considers both intra-slice and inter-slice long-range cues to guide the segmentation. Meanwhile, it has fewer parameters and takes less GPU memory to train than the previous transformer-based models. Extensive experiments on three multi-organ segmentation datasets demonstrate that our method outperforms current state-of-the-art methods. 

/pdf/after-unet-axial-fusion-transformer-unet-for-medical-image-1ko9twi2.pdf

AFTer-UNet: Axial Fusion Transformer UNet for Medical Image Segmentation

A deep learning-based auto-segmentation system for organs-at-risk on whole-body computed tomography images for radiation therapy.

Although having achieved great success in medical image segmentation, deep convolutional neural networks usually require a large dataset with manual annotations for training and are difficult to generalize to unseen classes. Few-shot learning has the potential to address these challenges by learning new classes from only a few labeled examples. In this work, we propose a new framework for few-shot medical image segmentation based on prototypical networks. Our innovation lies in the design of two key modules: 1) a context relation encoder (CRE) that uses correlation to capture local relation features between foreground and background regions; and 2) a recurrent mask refinement module that repeatedly uses the CRE and a prototypical network to recapture the change of context relationship and refine the segmentation mask iteratively. Experiments on two abdomen CT datasets and an abdomen MRI dataset show the proposed method obtains substantial improvement over the state-of-the-art methods by an average of 16.32%, 8.45% and 6.24% in terms of DSC, respectively. Code is publicly available.

/pdf/recurrent-mask-refinement-for-few-shot-medical-image-1qipga1y0u.pdf

Recurrent Mask Refinement for Few-Shot Medical Image Segmentation

Multi-organ segmentation is one of most successful applications of deep learning in medical image analysis. Deep convolutional neural nets (CNNs) have shown great promise in achieving clinically applicable image segmentation performance on CT or MRI images. State-of-the-art CNN segmentation models apply either 2D or 3D convolutions on input images, with pros and cons associated with each method: 2D convolution is fast, less memory-intensive but inadequate for extracting 3D contextual information from volumetric images, while the opposite is true for 3D convolution. To fit a 3D CNN model on CT or MRI images on commodity GPUs, one usually has to either downsample input images or use cropped local regions as inputs, which limits the utility of 3D models for multi-organ segmentation. In this work, we propose a new framework for combining 3D and 2D models, in which the segmentation is realized through high-resolution 2D convolutions, but guided by spatial contextual information extracted from a low-resolution 3D model. We implement a self-attention mechanism to control which 3D features should be used to guide 2D segmentation. Our model is light on memory usage but fully equipped to take 3D contextual information into account. Experiments on multiple organ segmentation datasets demonstrate that by taking advantage of both 2D and 3D models, our method is consistently outperforms existing 2D and 3D models in organ segmentation accuracy, while being able to directly take raw whole-volume image data as inputs.

/pdf/spatial-context-aware-self-attention-model-for-multi-organ-1qvi19rbew.pdf

Shanlin Sun

Papers

A deep learning-based auto-segmentation system for organs-at-risk on whole-body computed tomography images for radiation therapy.

AFTer-UNet: Axial Fusion Transformer UNet for Medical Image Segmentation.

Recurrent Mask Refinement for Few-Shot Medical Image Segmentation

Spatial Context-Aware Self-Attention Model For Multi-Organ Segmentation

Spatial Context-Aware Self-Attention Model For Multi-Organ Segmentation