Combining natural and artificial intelligence for robust automatic anatomy segmentation: Application in neck and thorax auto-contouring

Jayaram K. Udupa, Tiange Liu, Chao Jin, Liming Zhao, Dewey Odhner, Yubing Tong, Vibhu Agrawal, Gargi Pednekar, Sanghita Nag, Tarun Kotia, Michael Goodman, E. Paul Wileyto, Dimitris Mihailidis, John Nicholas Lukens, Abigail T. Berman, Joann Stambaugh, Tristan Lim, Rupa Chowdary, Dheeraj Jalluri, Salma K. JabbourSung Kim, Meral Reyhan, Clifford G. Robinson, Wade L. Thorstad, Jehee Isabelle Choi, Robert Press, Charles B. Simone, Joe Camaratta, Steve Owens, Drew A. Torigian

Research output: Contribution to journalArticlepeer-review

6 Scopus citations


Background: Automatic segmentation of 3D objects in computed tomography (CT) is challenging. Current methods, based mainly on artificial intelligence (AI) and end-to-end deep learning (DL) networks, are weak in garnering high-level anatomic information, which leads to compromised efficiency and robustness. This can be overcome by incorporating natural intelligence (NI) into AI methods via computational models of human anatomic knowledge. Purpose: We formulate a hybrid intelligence (HI) approach that integrates the complementary strengths of NI and AI for organ segmentation in CT images and illustrate performance in the application of radiation therapy (RT) planning via multisite clinical evaluation. Methods: The system employs five modules: (i) body region recognition, which automatically trims a given image to a precisely defined target body region; (ii) NI-based automatic anatomy recognition object recognition (AAR-R), which performs object recognition in the trimmed image without DL and outputs a localized fuzzy model for each object; (iii) DL-based recognition (DL-R), which refines the coarse recognition results of AAR-R and outputs a stack of 2D bounding boxes (BBs) for each object; (iv) model morphing (MM), which deforms the AAR-R fuzzy model of each object guided by the BBs output by DL-R; and (v) DL-based delineation (DL-D), which employs the object containment information provided by MM to delineate each object. NI from (ii), AI from (i), (iii), and (v), and their combination from (iv) facilitate the HI system. Results: The HI system was tested on 26 organs in neck and thorax body regions on CT images obtained prospectively from 464 patients in a study involving four RT centers. Data sets from one separate independent institution involving 125 patients were employed in training/model building for each of the two body regions, whereas 104 and 110 data sets from the 4 RT centers were utilized for testing on neck and thorax, respectively. In the testing data sets, 83% of the images had limitations such as streak artifacts, poor contrast, shape distortion, pathology, or implants. The contours output by the HI system were compared to contours drawn in clinical practice at the four RT centers by utilizing an independently established ground-truth set of contours as reference. Three sets of measures were employed: accuracy via Dice coefficient (DC) and Hausdorff boundary distance (HD), subjective clinical acceptability via a blinded reader study, and efficiency by measuring human time saved in contouring by the HI system. Overall, the HI system achieved a mean DC of 0.78 and 0.87 and a mean HD of 2.22 and 4.53 mm for neck and thorax, respectively. It significantly outperformed clinical contouring in accuracy and saved overall 70% of human time over clinical contouring time, whereas acceptability scores varied significantly from site to site for both auto-contours and clinically drawn contours. Conclusions: The HI system is observed to behave like an expert human in robustness in the contouring task but vastly more efficiently. It seems to use NI help where image information alone will not suffice to decide, first for the correct localization of the object and then for the precise delineation of the boundary.

Original languageEnglish
Pages (from-to)7118-7149
Number of pages32
JournalMedical physics
Issue number11
StatePublished - Nov 2022


  • anatomy models
  • auto-contouring organs
  • computed tomography
  • deep learning
  • hybrid intelligence
  • image segmentation


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