Florin C. Ghesu

Marc Demoustier, Yue Zhang, Venkatesh Narasimha Murthy et al.

Device tracking is an important prerequisite for guidance during endovascular procedures. Especially during cardiac interventions, detection and tracking of guiding the catheter tip in 2D fluoroscopic images is important for applications such as mapping vessels from angiography (high dose with contrast) to fluoroscopy (low dose without contrast). Tracking the catheter tip poses different challenges: the tip can be occluded by contrast during angiography or interventional devices; and it is always in continuous movement due to the cardiac and respiratory motions. To overcome these challenges, we propose ConTrack, a transformer-based network that uses both spatial and temporal contextual information for accurate device detection and tracking in both X-ray fluoroscopy and angiography. The spatial information comes from the template frames and the segmentation module: the template frames define the surroundings of the device, whereas the segmentation module detects the entire device to bring more context for the tip prediction. Using multiple templates makes the model more robust to the change in appearance of the device when it is occluded by the contrast agent. The flow information computed on the segmented catheter mask between the current and the previous frame helps in further refining the prediction by compensating for the respiratory and cardiac motions. The experiments show that our method achieves 45% or higher accuracy in detection and tracking when compared to state-of-the-art tracking models.

Marvin Tom Teichmann, Manasi Datar, Lisa Kratzke et al.

The precision of contouring target structures and organs-at-risk (OAR) in radiotherapy planning is crucial for ensuring treatment efficacy and patient safety. Recent advancements in deep learning (DL) have significantly improved OAR contouring performance, yet the reliability of these models, especially in the presence of out-of-distribution (OOD) scenarios, remains a concern in clinical settings. This application study explores the integration of epistemic uncertainty estimation within the OAR contouring workflow to enable OOD detection in clinically relevant scenarios, using specifically compiled data. Furthermore, we introduce an advanced statistical method for OOD detection to enhance the methodological framework of uncertainty estimation. Our empirical evaluation demonstrates that epistemic uncertainty estimation is effective in identifying instances where model predictions are unreliable and may require an expert review. Notably, our approach achieves an AUC-ROC of 0.95 for OOD detection, with a specificity of 0.95 and a sensitivity of 0.92 for implant cases, underscoring its efficacy. This study addresses significant gaps in the current research landscape, such as the lack of ground truth for uncertainty estimation and limited empirical evaluations. Additionally, it provides a clinically relevant application of epistemic uncertainty estimation in an FDA-approved and widely used clinical solution for OAR segmentation from Varian, a Siemens Healthineers company, highlighting its practical benefits.

Isabella Poles, Simon Arberet, Riqiang Gao et al.

Volumetric Modulated Arc Therapy (VMAT) is a cornerstone of modern radiation therapy, enabling highly conformal tumor irradiation and healthy-tissue sparing. Yet, its planning solves inverse and nested optimization for multi-leaf collimators, monitor units and dose parameters, while enforcing their consistency to ensure mechanical deliverability. Nevertheless, this process often requires repeated re-optimization when treatment configurations change, resulting in substantial planning time per patient. To address these problems, we present a diffusion-driven Learning-to-Optimize (L2O) method for end-to-end VMAT planning. A distribution-matching distilled diffusion model learns a clinically feasible manifold of fluence maps, enabling their one-shot generation. On top of this, an LSTM-based L2O module learns gradient update dynamics to swiftly refine fluence maps toward prescribed dose objectives during inference. Experimental results on clinical and public prostate cancer cohorts demonstrate improved planning efficiency, flexibility, and machine deliverability over currently available end-to-end VMAT planners.

Riqiang Gao, Mamadou Diallo, Han Liu et al.

Radiotherapy (RT) planning is complex, subjective, and time-intensive. Advances with artificial intelligence (AI) promise to improve its precision and efficiency, but progress is often limited by the scarcity of large, standardized datasets. To address this, we introduce the Automated Iterative RT Planning (AIRTP) system, a scalable solution for generating high-quality treatment plans. This scalable solution is designed to generate substantial volumes of consistently high-quality treatment plans, overcoming a key obstacle in the advancement of AI-driven RT planning. Our AIRTP pipeline adheres to clinical guidelines and automates essential steps, including organ-at-risk (OAR) contouring, helper structure creation, beam setup, optimization, and plan quality improvement, using AI integrated with RT planning software like Varian Eclipse. Furthermore, a novel approach for determining optimization parameters to reproduce 3D dose distributions, i.e. a method to convert dose predictions to deliverable treatment plans constrained by machine limitations is proposed. A comparative analysis of plan quality reveals that our automated pipeline produces treatment plans of quality comparable to those generated manually, which traditionally require several hours of labor per plan. Committed to public research, the first data release of our AIRTP pipeline includes nine cohorts covering head-and-neck and lung cancer sites to support an AAPM 2025 challenge. To our best knowledge, this dataset features more than 10 times number of plans compared to the largest existing well-curated public dataset. Repo: https://github.com/RiqiangGao/GDP-HMM_AAPMChallenge.

Abdoul Aziz Amadou, Vivek Singh, Florin C. Ghesu et al.

Transesophageal echocardiography (TEE) plays a pivotal role in cardiology for diagnostic and interventional procedures. However, using it effectively requires extensive training due to the intricate nature of image acquisition and interpretation. To enhance the efficiency of novice sonographers and reduce variability in scan acquisitions, we propose a novel ultrasound (US) navigation assistance method based on contrastive learning as goal-conditioned reinforcement learning (GCRL). We augment the previous framework using a novel contrastive patient batching method (CPB) and a data-augmented contrastive loss, both of which we demonstrate are essential to ensure generalization to anatomical variations across patients. The proposed framework enables navigation to both standard diagnostic as well as intricate interventional views with a single model. Our method was developed with a large dataset of 789 patients and obtained an average error of 6.56 mm in position and 9.36 degrees in angle on a testing dataset of 140 patients, which is competitive or superior to models trained on individual views. Furthermore, we quantitatively validate our method's ability to navigate to interventional views such as the Left Atrial Appendage (LAA) view used in LAA closure. Our approach holds promise in providing valuable guidance during transesophageal ultrasound examinations, contributing to the advancement of skill acquisition for cardiac ultrasound practitioners.

Simon Arberet, Florin C. Ghesu, Riqiang Gao et al.

Volumetric Modulated Arc Therapy (VMAT) revolutionizes cancer treatment by precisely delivering radiation while sparing healthy tissues. Fluence maps generation, crucial in VMAT planning, traditionally involves complex and iterative, and thus time consuming processes. These fluence maps are subsequently leveraged for leaf-sequence. The deep-learning approach presented in this article aims to expedite this by directly predicting fluence maps from patient data. We developed a 3D network which we trained in a supervised way using a combination of L1 and L2 losses, and RT plans generated by Eclipse and from the REQUITE dataset, taking the RT dose map as input and the fluence maps computed from the corresponding RT plans as target. Our network predicts jointly the 180 fluence maps corresponding to the 180 control points (CP) of single arc VMAT plans. In order to help the network, we pre-process the input dose by computing the projections of the 3D dose map to the beam's eye view (BEV) of the 180 CPs, in the same coordinate system as the fluence maps. We generated over 2000 VMAT plans using Eclipse to scale up the dataset size. Additionally, we evaluated various network architectures and analyzed the impact of increasing the dataset size. We are measuring the performance in the 2D fluence maps domain using image metrics (PSNR, SSIM), as well as in the 3D dose domain using the dose-volume histogram (DVH) on a validation dataset. The network inference, which does not include the data loading and processing, is less than 20ms. Using our proposed 3D network architecture as well as increasing the dataset size using Eclipse improved the fluence map reconstruction performance by approximately 8 dB in PSNR compared to a U-Net architecture trained on the original REQUITE dataset. The resulting DVHs are very close to the one of the input target dose.

Saahil Islam, Venkatesh N. Murthy, Dominik Neumann et al.

An accurate detection and tracking of devices such as guiding catheters in live X-ray image acquisitions is an essential prerequisite for endovascular cardiac interventions. This information is leveraged for procedural guidance, e.g., directing stent placements. To ensure procedural safety and efficacy, there is a need for high robustness no failures during tracking. To achieve that, one needs to efficiently tackle challenges, such as: device obscuration by contrast agent or other external devices or wires, changes in field-of-view or acquisition angle, as well as the continuous movement due to cardiac and respiratory motion. To overcome the aforementioned challenges, we propose a novel approach to learn spatio-temporal features from a very large data cohort of over 16 million interventional X-ray frames using self-supervision for image sequence data. Our approach is based on a masked image modeling technique that leverages frame interpolation based reconstruction to learn fine inter-frame temporal correspondences. The features encoded in the resulting model are fine-tuned downstream. Our approach achieves state-of-the-art performance and in particular robustness compared to ultra optimized reference solutions (that use multi-stage feature fusion, multi-task and flow regularization). The experiments show that our method achieves 66.31% reduction in maximum tracking error against reference solutions (23.20% when flow regularization is used); achieving a success score of 97.95% at a 3x faster inference speed of 42 frames-per-second (on GPU). The results encourage the use of our approach in various other tasks within interventional image analytics that require effective understanding of spatio-temporal semantics.

Simon Arberet, Riqiang Gao, Martin Kraus et al.

Artificial intelligence-based radiation therapy (RT) planning has the potential to reduce planning time and inter-planner variability, improving efficiency and consistency in clinical workflows. Most existing automated approaches rely on multiple dose evaluations and corrections, resulting in plan generation times of several minutes. We introduce AIRT (Artificial Intelligence-based Radiotherapy), an end-to-end deep-learning framework that directly infers deliverable treatment plans from CT images and structure contours. AIRT generates single-arc VMAT prostate plans, from imaging and anatomical inputs to leaf sequencing, in under one second on a single Nvidia A100 GPU. The framework includes a differentiable dose feedback, an adversarial fluence map shaping, and a plan generation augmentation to improve plan quality and robustness. The model was trained on more than 10,000 intact prostate cases. Non-inferiority to RapidPlan Eclipse was demonstrated across target coverage and OAR sparing metrics. Target homogeneity (HI = 0.10 $\pm$ 0.01) and OAR sparing were similar to reference plans when evaluated using AcurosXB. These results represent a significant step toward ultra-fast standardized RT planning and a streamlined clinical workflow.

Saahil Islam, Venkatesh N. Murthy, Dominik Neumann et al.

To restore proper blood flow in blocked coronary arteries via angioplasty procedure, accurate placement of devices such as catheters, balloons, and stents under live fluoroscopy or diagnostic angiography is crucial. Identified balloon markers help in enhancing stent visibility in X-ray sequences, while the catheter tip aids in precise navigation and co-registering vessel structures, reducing the need for contrast in angiography. However, accurate detection of these devices in interventional X-ray sequences faces significant challenges, particularly due to occlusions from contrasted vessels and other devices and distractions from surrounding, resulting in the failure to track such small objects. While most tracking methods rely on spatial correlation of past and current appearance, they often lack strong motion comprehension essential for navigating through these challenging conditions, and fail to effectively detect multiple instances in the scene. To overcome these limitations, we propose a self-supervised learning approach that enhances its spatio-temporal understanding by incorporating supplementary cues and learning across multiple representation spaces on a large dataset. Followed by that, we introduce a generic real-time tracking framework that effectively leverages the pretrained spatio-temporal network and also takes the historical appearance and trajectory data into account. This results in enhanced localization of multiple instances of device landmarks. Our method outperforms state-of-the-art methods in interventional X-ray device tracking, especially stability and robustness, achieving an 87% reduction in max error for balloon marker detection and a 61% reduction in max error for catheter tip detection.

Riqiang Gao, Florin C. Ghesu, Simon Arberet et al.

In contemporary radiotherapy planning (RTP), a key module leaf sequencing is predominantly addressed by optimization-based approaches. In this paper, we propose a novel deep reinforcement learning (DRL) model termed as Reinforced Leaf Sequencer (RLS) in a multi-agent framework for leaf sequencing. The RLS model offers improvements to time-consuming iterative optimization steps via large-scale training and can control movement patterns through the design of reward mechanisms. We have conducted experiments on four datasets with four metrics and compared our model with a leading optimization sequencer. Our findings reveal that the proposed RLS model can achieve reduced fluence reconstruction errors, and potential faster convergence when integrated in an optimization planner. Additionally, RLS has shown promising results in a full artificial intelligence RTP pipeline. We hope this pioneer multi-agent RL leaf sequencer can foster future research on machine learning for RTP.

Florin C. Ghesu, Bogdan Georgescu, Awais Mansoor et al.

Building accurate and robust artificial intelligence systems for medical image assessment requires not only the research and design of advanced deep learning models but also the creation of large and curated sets of annotated training examples. Constructing such datasets, however, is often very costly -- due to the complex nature of annotation tasks and the high level of expertise required for the interpretation of medical images (e.g., expert radiologists). To counter this limitation, we propose a method for self-supervised learning of rich image features based on contrastive learning and online feature clustering. For this purpose we leverage large training datasets of over 100,000,000 medical images of various modalities, including radiography, computed tomography (CT), magnetic resonance (MR) imaging and ultrasonography. We propose to use these features to guide model training in supervised and hybrid self-supervised/supervised regime on various downstream tasks. We highlight a number of advantages of this strategy on challenging image assessment problems in radiography, CT and MR: 1) Significant increase in accuracy compared to the state-of-the-art (e.g., AUC boost of 3-7% for detection of abnormalities from chest radiography scans and hemorrhage detection on brain CT); 2) Acceleration of model convergence during training by up to 85% compared to using no pretraining (e.g., 83% when training a model for detection of brain metastases in MR scans); 3) Increase in robustness to various image augmentations, such as intensity variations, rotations or scaling reflective of data variation seen in the field.

Sebastian Gündel, Arnaud A. A. Setio, Florin C. Ghesu et al.

Chest radiography is the most common radiographic examination performed in daily clinical practice for the detection of various heart and lung abnormalities. The large amount of data to be read and reported, with more than 100 studies per day for a single radiologist, poses a challenge in consistently maintaining high interpretation accuracy. The introduction of large-scale public datasets has led to a series of novel systems for automated abnormality classification. However, the labels of these datasets were obtained using natural language processed medical reports, yielding a large degree of label noise that can impact the performance. In this study, we propose novel training strategies that handle label noise from such suboptimal data. Prior label probabilities were measured on a subset of training data re-read by 4 board-certified radiologists and were used during training to increase the robustness of the training model to the label noise. Furthermore, we exploit the high comorbidity of abnormalities observed in chest radiography and incorporate this information to further reduce the impact of label noise. Additionally, anatomical knowledge is incorporated by training the system to predict lung and heart segmentation, as well as spatial knowledge labels. To deal with multiple datasets and images derived from various scanners that apply different post-processing techniques, we introduce a novel image normalization strategy. Experiments were performed on an extensive collection of 297,541 chest radiographs from 86,876 patients, leading to a state-of-the-art performance level for 17 abnormalities from 2 datasets. With an average AUC score of 0.880 across all abnormalities, our proposed training strategies can be used to significantly improve performance scores.

Eduardo Mortani Barbosa, Warren B. Gefter, Rochelle Yang et al.

Purpose: To leverage volumetric quantification of airspace disease (AD) derived from a superior modality (CT) serving as ground truth, projected onto digitally reconstructed radiographs (DRRs) to: 1) train a convolutional neural network to quantify airspace disease on paired CXRs; and 2) compare the DRR-trained CNN to expert human readers in the CXR evaluation of patients with confirmed COVID-19. Materials and Methods: We retrospectively selected a cohort of 86 COVID-19 patients (with positive RT-PCR), from March-May 2020 at a tertiary hospital in the northeastern USA, who underwent chest CT and CXR within 48 hrs. The ground truth volumetric percentage of COVID-19 related AD (POv) was established by manual AD segmentation on CT. The resulting 3D masks were projected into 2D anterior-posterior digitally reconstructed radiographs (DRR) to compute area-based AD percentage (POa). A convolutional neural network (CNN) was trained with DRR images generated from a larger-scale CT dataset of COVID-19 and non-COVID-19 patients, automatically segmenting lungs, AD and quantifying POa on CXR. CNN POa results were compared to POa quantified on CXR by two expert readers and to the POv ground-truth, by computing correlations and mean absolute errors. Results: Bootstrap mean absolute error (MAE) and correlations between POa and POv were 11.98% [11.05%-12.47%] and 0.77 [0.70-0.82] for average of expert readers, and 9.56%-9.78% [8.83%-10.22%] and 0.78-0.81 [0.73-0.85] for the CNN, respectively. Conclusion: Our CNN trained with DRR using CT-derived airspace quantification achieved expert radiologist level of accuracy in the quantification of airspace disease on CXR, in patients with positive RT-PCR for COVID-19.

Florin C. Ghesu, Bogdan Georgescu, Awais Mansoor et al.

The interpretation of medical images is a challenging task, often complicated by the presence of artifacts, occlusions, limited contrast and more. Most notable is the case of chest radiography, where there is a high inter-rater variability in the detection and classification of abnormalities. This is largely due to inconclusive evidence in the data or subjective definitions of disease appearance. An additional example is the classification of anatomical views based on 2D Ultrasound images. Often, the anatomical context captured in a frame is not sufficient to recognize the underlying anatomy. Current machine learning solutions for these problems are typically limited to providing probabilistic predictions, relying on the capacity of underlying models to adapt to limited information and the high degree of label noise. In practice, however, this leads to overconfident systems with poor generalization on unseen data. To account for this, we propose a system that learns not only the probabilistic estimate for classification, but also an explicit uncertainty measure which captures the confidence of the system in the predicted output. We argue that this approach is essential to account for the inherent ambiguity characteristic of medical images from different radiologic exams including computed radiography, ultrasonography and magnetic resonance imaging. In our experiments we demonstrate that sample rejection based on the predicted uncertainty can significantly improve the ROC-AUC for various tasks, e.g., by 8% to 0.91 with an expected rejection rate of under 25% for the classification of different abnormalities in chest radiographs. In addition, we show that using uncertainty-driven bootstrapping to filter the training data, one can achieve a significant increase in robustness and accuracy.

Siqi Liu, Arnaud Arindra Adiyoso Setio, Florin C. Ghesu et al.

Detecting malignant pulmonary nodules at an early stage can allow medical interventions which may increase the survival rate of lung cancer patients. Using computer vision techniques to detect nodules can improve the sensitivity and the speed of interpreting chest CT for lung cancer screening. Many studies have used CNNs to detect nodule candidates. Though such approaches have been shown to outperform the conventional image processing based methods regarding the detection accuracy, CNNs are also known to be limited to generalize on under-represented samples in the training set and prone to imperceptible noise perturbations. Such limitations can not be easily addressed by scaling up the dataset or the models. In this work, we propose to add adversarial synthetic nodules and adversarial attack samples to the training data to improve the generalization and the robustness of the lung nodule detection systems. To generate hard examples of nodules from a differentiable nodule synthesizer, we use projected gradient descent (PGD) to search the latent code within a bounded neighbourhood that would generate nodules to decrease the detector response. To make the network more robust to unanticipated noise perturbations, we use PGD to search for noise patterns that can trigger the network to give over-confident mistakes. By evaluating on two different benchmark datasets containing consensus annotations from three radiologists, we show that the proposed techniques can improve the detection performance on real CT data. To understand the limitations of both the conventional networks and the proposed augmented networks, we also perform stress-tests on the false positive reduction networks by feeding different types of artificially produced patches. We show that the augmented networks are more robust to both under-represented nodules as well as resistant to noise perturbations.

Florin C. Ghesu, Bogdan Georgescu, Eli Gibson et al.

The interpretation of chest radiographs is an essential task for the detection of thoracic diseases and abnormalities. However, it is a challenging problem with high inter-rater variability and inherent ambiguity due to inconclusive evidence in the data, limited data quality or subjective definitions of disease appearance. Current deep learning solutions for chest radiograph abnormality classification are typically limited to providing probabilistic predictions, relying on the capacity of learning models to adapt to the high degree of label noise and become robust to the enumerated causal factors. In practice, however, this leads to overconfident systems with poor generalization on unseen data. To account for this, we propose an automatic system that learns not only the probabilistic estimate on the presence of an abnormality, but also an explicit uncertainty measure which captures the confidence of the system in the predicted output. We argue that explicitly learning the classification uncertainty as an orthogonal measure to the predicted output, is essential to account for the inherent variability characteristic of this data. Experiments were conducted on two datasets of chest radiographs of over 85,000 patients. Sample rejection based on the predicted uncertainty can significantly improve the ROC-AUC, e.g., by 8% to 0.91 with an expected rejection rate of under 25%. Eliminating training samples using uncertainty-driven bootstrapping, enables a significant increase in robustness and accuracy. In addition, we present a multi-reader study showing that the predictive uncertainty is indicative of reader errors.

Sebastian Guendel, Florin C. Ghesu, Sasa Grbic et al.

Chest X-ray (CXR) is the most common X-ray examination performed in daily clinical practice for the diagnosis of various heart and lung abnormalities. The large amount of data to be read and reported, with 100+ studies per day for a single radiologist, poses a challenge in maintaining consistently high interpretation accuracy. In this work, we propose a method for the classification of different abnormalities based on CXR scans of the human body. The system is based on a novel multi-task deep learning architecture that in addition to the abnormality classification, supports the segmentation of the lungs and heart and classification of regions where the abnormality is located. We demonstrate that by training these tasks concurrently, one can increase the classification performance of the model. Experiments were performed on an extensive collection of 297,541 chest X-ray images from 86,876 patients, leading to a state-of-the-art performance level of 0.883 AUC on average for 12 different abnormalities. We also conducted a detailed performance analysis and compared the accuracy of our system with 3 board-certified radiologists. In this context, we highlight the high level of label noise inherent to this problem. On a reduced subset containing only cases with high confidence reference labels based on the consensus of the 3 radiologists, our system reached an average AUC of 0.945.