The Handbook of Medical Image Perception and Techniques

A state-of-the-art review of key subjects in medical image perception science and practice, including associated techniques, illustrations and examples. This second edition contains extensive updates and substantial new content. Written by key figures in the field, it covers a wide range of subjects including signal detection, image interpretation and advanced image analysis (e.g. deep learning) techniques for interpretive and computational perception. It provides an overview of the key techniques of medical image perception and observer performance research, and includes examples and applications across clinical disciplines including radiology, pathology and oncology. A final chapter discusses the future prospects of medical image perception and assesses upcoming challenges and possibilities, enabling readers to identify new areas for research. Written for both newcomers to the field and experienced researchers and clinicians, this book provides a comprehensive reference for those interested in medical image perception as means to advance knowledge and Excellerate human health.

'In The Handbook of Medical Image Perception and Techniques, Samei and Krupinski have assembled a group of internationally-recognized experts to address an important but under-emphasized stage in the process of medical imaging.' William Hendee, Distinguished Professor Emeritus, Medical College of Wisconsin

'A concise text that offers a unique collection of chapters from all the leading authors in medical perception. I would highly recommend this text for anyone wanting to know more about medical perception from its historical perspective to current research. A must have reference for anyone wanting to join in this exciting discipline.' Lonie R. Salkowski, University of Wisconsin, Madison

'Drs Elizabeth Krupinski and Ehsan Samei have given us a wonderful new edition of their landmark textbook on medical image perception, with updated chapters throughout and with approximately thirty percent new material added since the first edition was published in 2010. This new volume comprehensively updates and extends the ‘keystone’ publication in the field of medical image perception research. Each chapter is the definitive reference on its topic, authored by a foremost expert. With this new edition, Drs Krupinski and Samei have assembled a compendium of what amounts to decades of research and accumulated wisdom in a compact package-comprehensive and yet still very accessible for a broad audience. … Anyone with an interest in this course will find this book to be an invaluable resource.' Michael A. Bruno, Pennsylvania State University

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1. Medical image perception Ehsan Samei and Elizabeth Krupinski2. A short history of image perception in medical radiology Harold Kundel and Calvin Nodine3. Spatial vision research without noise Arthur Burgess4. Signal detection theory – a brief history Arthur Burgess5. Signal detection in radiology Arthur Burgess6. Lessons from dinners with the giants of modern image science Robert Wagner7. Perception in context David Manning8. Perceptual factors in memorizing medical images Elizabeth A Krupinski9. Cognitive factors in memorizing medical images David Manning10. Satisfaction of search in radiology Kevib Berbaum, Edmund Franken, Robert Caldwell, Kevin Schartz and Mark Madsen11. Acquiring expertise in radiologic image interpretation Calvin F. Nodine and Claudia Mello-Thoms12. The first moments of medical image perception Jeremy M. Wolfe, Karla K. Evans and Trafton Drew13. Image quality and its clinical relevance Justin Solomon, Robert Saunders, Jr and Ehsan Samei14. Designing perception experiments Ehsan Samei15. Receiver operating characteristic analysis: basic concepts and practical applications Georgia Tourassi16. Multireader ROC analysis Stephen L. Hillis17. Memory effects and experimental design Tamara Miner Haygood and Karla K. Evans18. Observer models as a surrogate to perception experiments Craig K. Abbey and Miguel P. Eckstein19. Implementation of observer models Matthew A. Kupinski20. Value and limitations of observer models Lucretiu M. Popescu21. Perception of volumetric data Geoffrey D. Rubin, Trafton Drew and Lauren H. Williams22. Performance exam using standardized data sets: the PERFORMS® scheme in breast screening and other domains Yan Chen and Alastair Gale23. Breast screen reader exam strategy (BREAST): a research infrastructure with a translational objective Patrick Brennan, Lee Warwick and Kriscia Tapia24. CAD: an image perception perspective Maryellen Giger and Weijie Chen25. Common designs of CAD studies Yulei Jiang26. Evaluation of CAD and radiomic tools Berkman Sahiner and Nicholas Petrick27. Quantitative imaging – images to numbers Daniel C. Sullivan and Edward F. Jackson28. Optimization of 2D and 3D radiographic imaging systems Jeffrey H. Siewerdsen29. Display optimization from a physics perspective Alisa Walz-Flannigan and Scott Stekel30. Display optimisation from a perception perspective Mark Mcentee and Rachel Toomey31. Perception and training William F. Auffermann and Maciej Mazurowski32. Ergonomics 2.0: fatigue in medical imaging Sian Taylor-Phillips, Chris Stinton and Elizabeth Krupinski33. Perception issues in pathology Liron Pananowitz, Claudia Mello-Thoms and Elizabeth A. Krupinski34. Medical image perception from a clinical perspective Francine L. Jacobson35. Future of medical image perception Elizabeth A. Krupinski and Ehsan Samei.

Ehsan Samei, Duke University Medical Center, DurhamEhsan Samei is Professor in Radiology, Physics, Biomedical Engineering, Electrical and Computer Engineering, and Medical Physics at Duke University, where he is the Chief of the Clinical Imaging Physics and the Director of the Medical Physics Graduate Program. His current research includes quality and dose metrics that are clinically relevant and that can be used to design and utilize advanced imaging technologies for optimum interpretive and quantitative performance.

Elizabeth A. Krupinski, Emory University, AtlantaElizabeth Krupinski is a Professor and Vice Chair for Research at Emory University, Atlanta, in the Departments of Radiology, Psychology and Biomedical Informatics. Her research interests include medical image perception, exam of observer performance, and human factors issues.

Ehsan Samei, Elizabeth Krupinski, Harold Kundel, Calvin Nodine, Arthur Burgess, Robert Wagner, David Manning, Kevib Berbaum, Edmund Franken, Robert Caldwell, Kevin Schartz, Mark Madsen, Calvin F. Nodine, Claudia Mello-Thoms, Jeremy M. Wolfe, Karla K. Evans, Trafton Drew, Justin Solomon, Robert Saunders, Jr, Georgia Tourassi, Stephen L. Hillis, Tamara Miner Haygood, Craig K. Abbey, Miguel P. Eckstein, Matthew A. Kupinski, Lucretiu M. Popescu, Geoffrey D. Rubin, Lauren H. Williams, Yan Chen, Alastair Gale, Patrick Brennan, Lee Warwick, Kriscia Tapia, Maryellen Giger, Weijie Chen, Yulei Jiang, Berkman Sahiner, Nicholas Petrick, Daniel C. Sullivan, Edward F. Jackson, Jeffrey H. Siewerdsen, Alisa Walz-Flannigan, Scott Stekel, Mark Mcentee, Rachel Toomey, William F. Auffermann, Maciej Mazurowski, Sian Taylor-Phillips, Chris Stinton, Liron Pananowitz, Francine L. Jacobson

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Referring medical practitioners

Radiological imaging is a major and increasing source of radiation exposure worldwide. Computed tomography (CT) is the largest contributor to medical radiation dose patients receive. Typically, CT scans impart doses to organs that are 100 times higher than doses imparted by other lower dose modalities such as chest X-rays. In general, CT examinations may involve doses (typically an average of 8 mSv) which may be equal to the dose received by several hundreds of chest X-rays (about 0.02 mSv/chest X-ray).

During an IAEA consultation on justification in 2007, it was estimated that up to 50% of examinations may not be necessary. It should be anticipated that part of the increase in global annual mean dose that has been observed recently is due to unjustified radiological procedures. Direct epidemiological data suggest that medical exposure to low doses of radiation even as low as 10-50 mSv might be associated with a small risk of cancer induction in the long term. The fact that a considerable percentage of people may undergo repeated high dose examinations , such as CT (sometimes exceeding 10 mSv per examination) dictates that caution should be used when referring a patient for radiological procedures. Health professionals need to make sure the patient benefits from the procedure and risk is kept minimal. 

However, ensuring maximum benefit to risk ratio for the patient is not a trivial task. Referring medical practitioners, in a large part of the world, lack training in radiation protection and in risk estimation. 97% of practitioners who participated in a study underestimated the dose the patient would receive from diagnostic procedures. The average mean dose was about 6 times higher  than the physicians had estimated. The fundamental principles of radiation protection in medicine are justification and optimization of radiological protection. Referring medical practitioners have a major role in justification. They are responsible in terms of weighing the benefit versus the risk of a given radiological procedure.

» What is justification and what is the framework?

Justification requires that the expected net benefit be positive. According to principles established by the International Commission on Radiological Protection (ICRP) and accepted by major international organizations, the principle of justification applies at three levels in the use of radiation in medicine.

» Is the referring medical practitioner responsible for justification of radiological procedures?

Yes, jointly with the radiological practitioner. As stated above, justification at the third level is the responsibility of the referring medical practitioner, as is the awareness about appropriateness criteria for justification at level 2. According to the BSS, the radiological exposure has to be justified through consultation between the radiological medical practitioner and the referring medical practitioner, as appropriate, or be part of an approved health screening programme.

Since referring medical practitioners usually have the most complete picture of the patient’s health, they should be responsible for the guidance of the patient in undergoing only necessary procedures and benefitting from them. Particularly, this responsibility weighs more on generalists such as primary care providers. In order to facilitate justification in the case of radiological procedures, it is desirable that referring medical practitioners are knowledgeable about radiation effects in regard to the various dose ranges. The referring medical practitioners are responsible for keeping their knowledge about radiation up to date. In support of this, they should be provided education in radiation protection during their medical studies.

» How should justification be practiced and what knowledge is required for proper justification of a radiological procedure?

According to the BSS, the justification of medical exposure for an individual patient shall be carried out through consultation between the radiological medical practitioner and the referring medical practitioner, as appropriate, with account taken, in particular for patients who are pregnant or breast-feeding or paediatric, of:

Justification should be patient specific. The referring medical practitioner should take into account all clinical aspects regarding the management of every patient separately. Other possible procedures with lower or no exposure, such as ultrasound or magnetic resonance imaging, should be considered, if and when appropriate, before proceeding to radiological procedures.

» Is the acquisition of patients’ consent important?

According to the BSS, in order for a symptomatic or asymptomatic patient to undergo a medical procedure that involves ionizing radiation, the patient or the patient’s legally authorized representative should be informed in a timely and clear fashion, of the expected diagnostic or therapeutic benefits of the radiological procedure as well as the radiation risks. Thus, the emphasis is on provision of information.

» When is an investigation useful and what are the reasons that cause unnecessary use of radiation?

According to the guidelines published by the Royal College of Radiologists (RCR),  a useful investigation is one in which the result, either positive or negative, will alter a patient’s management or add confidence to the clinician’s diagnosis. According to the RCR guidelines, there are some reasons that lead to wasteful use of radiation. With emphasis on avoiding unjustified irradiation of patients, the RCR report has provided a check list for physicians referring patients for diagnostic radiological procedures:

» What are the reasons for over-investigating?

There are various reasons that may lead medical practitioners to refer patients for more procedures than needed. Practitioners should be aware of that and take action to avoid such situations. Some of the reasons that lead to over-investigation are the following:

» Is there any guidance available?

During the last 20 years international and national organizations published guidelines for proper justification of radiological procedures. The UK Royal College of Radiologists (RCR) publication "Making the best use of clinical radiology services " has been in print since 1989. The American College of Radiology (ACR) published its guidelines as Appropriateness Criteria. Similar efforts have been undertaken by the Department of Health of Western Australia in Diagnostic Imaging Pathways. 

For references of publications from national societies in Europe, Oceania, and other regions please see publication from Remedios. These publications constitute guidelines and aim to guide referring medical practitioners in the selection of the optimum procedure for a certain clinical problem. In case there are alternative procedures that do not utilize radiation but yield results of similar clinical value, these guidelines encourage the avoidance of radiological procedures.The cited publications supply very specific guidance to help practitioners perform justification properly. 

» What is the role of radiation protection experts?

A medical physicist with experience and expertise in radiation protection will be able to provide information and guidance on radiation doses and risks in radiological procedures. In case you do not have an access to the help of radiation protection experts, referring medical practitioners may address their questions to their colleagues who work in radiology departments. However, staff specialized in radiation protection is more likely to provide complete, responsible and up-to-date information for the specific clinical problem. Radiation protection experts are comfortable with dose measurements and quantities which come from the domain of natural sciences and are usually hard to conceive for people outside the field. 

» Which procedures are responsible for the highest doses to the patient?

The referring medical practitioner should be aware about procedures which impart high radiation dose to patients in order to be more cautious in such cases. This does not mean that other procedures should be written without proper justification. A quantitative knowledge of doses of various procedures is useful for the referring medical practitioner. Data given below will help the practitioner in that direction. In diagnostic radiological procedures, dose depends on the modality used. Computed tomography (CT) exposes patients to relatively high doses in comparison to other diagnostic imaging modalities.

Interventional diagnostic and therapeutic procedures that utilize fluoroscopy may also be a source of high radiation doses. Such procedures carry the risk of causing erythema  to patients that receive high dose in single or repeated procedures. Some nuclear medicine procedures are also responsible for high radiation doses to patients.

» What if the patient whom I refer for a radiological procedure is pregnant?

The responsibility to identify patients that might be pregnant and are unaware of it is shared by the patient, referring medical practitioner and the imaging service providers. Safeguards to avoid inadvertent exposures of the foetus should be observed at all times. The “ten day rule” was postulated by ICRP for women of reproductive age. The more exact “28-day rule” allows radiological procedures throughout the complete menstrual cycle unless there is a missed period. When a woman has a missed period, she is considered pregnant unless proven otherwise. 

Even if safeguards are observed, sometimes a pregnant patient may be exposed to radiation. Depending on the radiation dose and the gestation age of the foetus, radiation effects may differ. Radiation risks are most significant during organogenesis in the early foetal period, somewhat less in the second trimester, and least in the third trimester. 

As a rule of thumb one can assume that properly carried out diagnostic radiological  procedures to any part of the body other than the pelvic region or when the primary X-ray beam is not passing through the foetus can be performed throughout pregnancy without significant foetal risk, if clinically necessary and justified. For radiological procedures where the primary beam intercepts the foetus, advice from the medical physicist should be obtained, who will calculate radiation dose to the foetus and, based on that, the practitioner and patient should make a decision. However, doses associated with radiotherapy procedures and interventional procedures are high and they require the attention of experts (including medical or health physicists, practitioners, and sometimes engineers and epidemiologists). In the case when a practitioner is responsible for a patient who has undergone a radiological procedure inadvertently and has subsequently been found to be pregnant, advice from the individuals listed above is needed. For more information, please click here where comprehensive information is provided not only for diagnostic radiology but also for nuclear medicine and radiotherapy.

» Should pregnant patients undergo radiological procedures?

Sometimes it is imperative that pregnant women should undergo radiological procedures. The referring medical practitioner and the imaging provider have to be mindful of risk and benefit and decide whether a radiological procedure should be asked for or if the medical problem may be solved by other non-radiological procedures. Generally, it is preferable that non-radiological procedures, or at least those that do not provide exposure to ionizing radiation, are used whenever possible. However, the use of radiological procedures is not prohibited and, when properly justified, they may be optimized so that these procedures may help to achieve the desired result for the patient while keeping dose to the foetus at low levels. The patient should be made aware about the possible impact of radiation exposure to the foetus. The need for consent must be determined based on individual practice standards, guided by more global professional or regulatory/legislative requirements.

» Can radiological procedures cause acute radiation injury?

Acute injuries such as skin erythema, blistering and hair loss have been recognized as a rare side effect of procedures guided by fluoroscopy. Similar injuries have been long recognized in radiation oncology, which uses much higher doses of radiation than diagnostic imaging. While radiation therapy is administered in fractions and the radiation-inflicted cells may recover in between sessions, fluoroscopy usually imparts a high dose to the skin in a short amount of time and with no dose fractionation. Referring medical practitioners could miss recognizing acute radiation injury resulting from interventional procedures. Such injuries may appear weeks after the interventional procedure and patients may not think of the procedure as being the cause unless they have been instructed accordingly by the interventional facility. Practitioners have often tended to attribute injury to many other causes, including insect bite and allergic reactions, but not to radiation exposure. Awareness about radiation through fluoroscopy being a possible cause can avoid mis-diagnosis and patient suffering. 

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