In this tutorial we will build a classifier that distinguishes between chest X-rays with pneumothorax and chest X-rays without pneumothorax. The image data is loaded directly from the DICOM source files, so no prior DICOM data handling is needed. This tutorial also goes through what DICOM images are and review at a high level how to evaluate the results of the classifier.

To use fastai.medical.imaging you'll need to:

conda install pyarrow
pip install pydicom kornia opencv-python scikit-image

To run this tutorial on Google Colab, you'll need to uncomment the following two lines and run the cell:

#!pip install pydicom kornia opencv-python scikit-image nbdev
from fastai.basics import *
from fastai.callback.all import *
from fastai.vision.all import *
from fastai.medical.imaging import *

import pydicom

import pandas as pd

Download and import of X-ray DICOM files

First, we will use the untar_data function to download the _siimsmall folder containing a subset (250 DICOM files, ~30MB) of the SIIM-ACR Pneumothorax Segmentation [1] dataset. The downloaded _siimsmall folder will be stored in your ~/.fastai/data/ directory. The variable pneumothorax-source will store the absolute path to the _siimsmall folder as soon as the download is complete.

pneumothorax_source = untar_data(URLs.SIIM_SMALL)

The _siimsmall folder has the following directory/file structure:

siim_folder_structure.jpg

What are DICOMs?

DICOM(Digital Imaging and COmmunications in Medicine) is the de-facto standard that establishes rules that allow medical images(X-Ray, MRI, CT) and associated information to be exchanged between imaging equipment from different vendors, computers, and hospitals. The DICOM format provides a suitable means that meets health infomation exchange (HIE) standards for transmision of health related data among facilites and HL7 standards which is the messaging standard that enables clinical applications to exchange data

DICOM files typically have a .dcm extension and provides a means of storing data in separate ‘tags’ such as patient information as well as image/pixel data. A DICOM file consists of a header and image data sets packed into a single file. By extracting data from these tags one can access important information regarding the patient demographics, study parameters, etc.

16 bit DICOM images have values ranging from -32768 to 32768 while 8-bit greyscale images store values from 0 to 255. The value ranges in DICOM images are useful as they correlate with the Hounsfield Scale which is a quantitative scale for describing radiodensity

Plotting the DICOM data

To analyze our dataset, we load the paths to the DICOM files with the get_dicom_files function. When calling the function, we append train/ to the pneumothorax_source path to choose the folder where the DICOM files are located. We store the path to each DICOM file in the items list.

items = get_dicom_files(pneumothorax_source/f"train/")

Next, we split the items list into a train trn and validation val list using the RandomSplitter function:

trn,val = RandomSplitter()(items)

Pydicom is a python package for parsing DICOM files, making it easier to access the header of the DICOM as well as coverting the raw pixel_data into pythonic structures for easier manipulation. fastai.medical.imaging uses pydicom.dcmread to load the DICOM file.

To plot an X-ray, we can select an entry in the items list and load the DICOM file with dcmread.

patient = 7
xray_sample = items[patient].dcmread()

To view the header

xray_sample
Dataset.file_meta -------------------------------
(0002, 0000) File Meta Information Group Length  UL: 200
(0002, 0001) File Meta Information Version       OB: b'\x00\x01'
(0002, 0002) Media Storage SOP Class UID         UI: Secondary Capture Image Storage
(0002, 0003) Media Storage SOP Instance UID      UI: 1.2.276.0.7230010.3.1.4.8323329.4025.1517875180.707076
(0002, 0010) Transfer Syntax UID                 UI: JPEG Baseline (Process 1)
(0002, 0012) Implementation Class UID            UI: 1.2.276.0.7230010.3.0.3.6.0
(0002, 0013) Implementation Version Name         SH: 'OFFIS_DCMTK_360'
-------------------------------------------------
(0008, 0005) Specific Character Set              CS: 'ISO_IR 100'
(0008, 0016) SOP Class UID                       UI: Secondary Capture Image Storage
(0008, 0018) SOP Instance UID                    UI: 1.2.276.0.7230010.3.1.4.8323329.4025.1517875180.707076
(0008, 0020) Study Date                          DA: '19010101'
(0008, 0030) Study Time                          TM: '000000.00'
(0008, 0050) Accession Number                    SH: ''
(0008, 0060) Modality                            CS: 'CR'
(0008, 0064) Conversion Type                     CS: 'WSD'
(0008, 0090) Referring Physician's Name          PN: ''
(0008, 103e) Series Description                  LO: 'view: PA'
(0010, 0010) Patient's Name                      PN: '0cf5d3e1-5e53-4978-b9da-46c184b31068'
(0010, 0020) Patient ID                          LO: '0cf5d3e1-5e53-4978-b9da-46c184b31068'
(0010, 0030) Patient's Birth Date                DA: ''
(0010, 0040) Patient's Sex                       CS: 'F'
(0010, 1010) Patient's Age                       AS: '58'
(0018, 0015) Body Part Examined                  CS: 'CHEST'
(0018, 5101) View Position                       CS: 'PA'
(0020, 000d) Study Instance UID                  UI: 1.2.276.0.7230010.3.1.2.8323329.4025.1517875180.707075
(0020, 000e) Series Instance UID                 UI: 1.2.276.0.7230010.3.1.3.8323329.4025.1517875180.707074
(0020, 0010) Study ID                            SH: ''
(0020, 0011) Series Number                       IS: "1"
(0020, 0013) Instance Number                     IS: "1"
(0020, 0020) Patient Orientation                 CS: ''
(0028, 0002) Samples per Pixel                   US: 1
(0028, 0004) Photometric Interpretation          CS: 'MONOCHROME2'
(0028, 0010) Rows                                US: 1024
(0028, 0011) Columns                             US: 1024
(0028, 0030) Pixel Spacing                       DS: [0.14300000000000002, 0.14300000000000002]
(0028, 0100) Bits Allocated                      US: 8
(0028, 0101) Bits Stored                         US: 8
(0028, 0102) High Bit                            US: 7
(0028, 0103) Pixel Representation                US: 0
(0028, 2110) Lossy Image Compression             CS: '01'
(0028, 2114) Lossy Image Compression Method      CS: 'ISO_10918_1'
(7fe0, 0010) Pixel Data                          OB: Array of 147696 elements

Explanation of each element is beyond the scope of this tutorial but this site has some excellent information about each of the entries

Some key pointers on the tag information above:

  • Pixel Data (7fe0 0010) - This is where the raw pixel data is stored. The order of pixels encoded for each image plane is left to right, top to bottom, i.e., the upper left pixel (labeled 1,1) is encoded first
  • Photometric Interpretation (0028, 0004) - also known as color space. In this case it is MONOCHROME2 where pixel data is represented as a single monochrome image plane where low values=dark, high values=bright. If the colorspace was MONOCHROME then the low values=bright and high values=dark info.
  • Samples per Pixel (0028, 0002) - This should be 1 as this image is monochrome. This value would be 3 if the color space was RGB for example
  • Bits Stored (0028 0101) - Number of bits stored for each pixel sample. Typical 8 bit images have a pixel range between 0 and 255
  • Pixel Represenation(0028 0103) - can either be unsigned(0) or signed(1)
  • Lossy Image Compression (0028 2110) - 00 image has not been subjected to lossy compression. 01 image has been subjected to lossy compression.
  • Lossy Image Compression Method (0028 2114) - states the type of lossy compression used (in this case ISO_10918_1 represents JPEG Lossy Compression)
  • Pixel Data (7fe0, 0010) - Array of 161452 elements represents the image pixel data that pydicom uses to convert the pixel data into an image.

What does PixelData look like?

xray_sample.PixelData[:200]
b'\xfe\xff\x00\xe0\x00\x00\x00\x00\xfe\xff\x00\xe0\[email protected]\x02\x00\xff\xd8\xff\xdb\x00C\x00\x03\x02\x02\x02\x02\x02\x03\x02\x02\x02\x03\x03\x03\x03\x04\x06\x04\x04\x04\x04\x04\x08\x06\x06\x05\x06\t\x08\n\n\t\x08\t\t\n\x0c\x0f\x0c\n\x0b\x0e\x0b\t\t\n\x11\n\x0e\x0f\x10\x10\x11\x10\n\x0c\x12\x13\x12\x10\x13\x0f\x10\x10\x10\xff\xc0\x00\x0b\x08\x04\x00\x04\x00\x01\x01\x11\x00\xff\xc4\x00\x1d\x00\x00\x02\x03\x01\x01\x01\x01\x01\x00\x00\x00\x00\x00\x00\x00\x00\x04\x05\x02\x03\x06\x00\x01\x07\x08\t\xff\xc4\x00Q\x10\x00\x02\x01\x03\x03\x03\x02\x03\x04\x08\x03\x06\x02\x07\x04\x0b\x01\x02\x11\x00\x03!\x04\x121\x05AQ"a\x06\x13q2\x81\x91\xa1\x07\x14#B\xb1\xc1\xd1\xf0\x08R\xe1\x15\x163b\x92\xf1$r\x17%4CT\x82\xb2\x18'

Because of the complexity in interpreting PixelData, pydicom provides an easy way to get it in a convenient form: pixel_array which returns a numpy.ndarray containing the pixel data:

xray_sample.pixel_array, xray_sample.pixel_array.shape
(array([[223, 221, 221, ..., 240, 254, 167],
        [220, 218, 218, ..., 237, 250, 163],
        [217, 215, 215, ..., 238, 250, 164],
        ...,
        [ 13,  13,  13, ..., 109, 122,  79],
        [ 13,  13,  13, ..., 108, 121,  79],
        [ 13,  13,  13, ..., 108, 122,  81]], dtype=uint8),
 (1024, 1024))

You can then use the show function to view the image

xray_sample.show()

You can also conveniently create a dataframe with all the tag information as columns for all the images in a dataset by using from_dicoms

dicom_dataframe = pd.DataFrame.from_dicoms(items)
dicom_dataframe[:5]
SpecificCharacterSet SOPClassUID SOPInstanceUID StudyDate StudyTime AccessionNumber Modality ConversionType ReferringPhysicianName SeriesDescription ... LossyImageCompression LossyImageCompressionMethod fname MultiPixelSpacing PixelSpacing1 img_min img_max img_mean img_std img_pct_window
0 ISO_IR 100 1.2.840.10008.5.1.4.1.1.7 1.2.276.0.7230010.3.1.4.8323329.14520.1517875252.506179 19010101 000000.00 CR WSD view: PA ... 01 ISO_10918_1 /home/moritz/.fastai/data/siim_small/train/No Pneumothorax/000022.dcm 1 0.143 0 255 126.147706 66.981243 0.298586
1 ISO_IR 100 1.2.840.10008.5.1.4.1.1.7 1.2.276.0.7230010.3.1.4.8323329.13525.1517875246.457830 19010101 000000.00 CR WSD view: PA ... 01 ISO_10918_1 /home/moritz/.fastai/data/siim_small/train/No Pneumothorax/000194.dcm 1 0.143 0 244 117.188172 69.298477 0.333524
2 ISO_IR 100 1.2.840.10008.5.1.4.1.1.7 1.2.276.0.7230010.3.1.4.8323329.6720.1517875199.820401 19010101 000000.00 CR WSD view: AP ... 01 ISO_10918_1 /home/moritz/.fastai/data/siim_small/train/No Pneumothorax/000248.dcm 1 0.168 0 255 111.189523 47.556943 0.206560
3 ISO_IR 100 1.2.840.10008.5.1.4.1.1.7 1.2.276.0.7230010.3.1.4.8323329.4121.1517875181.215836 19010101 000000.00 CR WSD view: PA ... 01 ISO_10918_1 /home/moritz/.fastai/data/siim_small/train/No Pneumothorax/000163.dcm 1 0.143 0 249 106.537169 76.319995 0.391648
4 ISO_IR 100 1.2.840.10008.5.1.4.1.1.7 1.2.276.0.7230010.3.1.4.8323329.2013.1517875170.692242 19010101 000000.00 CR WSD view: AP ... 01 ISO_10918_1 /home/moritz/.fastai/data/siim_small/train/No Pneumothorax/000147.dcm 1 0.168 0 255 107.269248 52.738122 0.300745

5 rows × 42 columns

Next, we need to load the labels for the dataset. We import the labels.csv file using pandas and print the first five entries. The file column shows the relative path to the .dcm file and the label column indicates whether the chest x-ray has a pneumothorax or not.

df = pd.read_csv(pneumothorax_source/f"labels.csv")
df.head()
file label
0 train/No Pneumothorax/000000.dcm No Pneumothorax
1 train/Pneumothorax/000001.dcm Pneumothorax
2 train/No Pneumothorax/000002.dcm No Pneumothorax
3 train/Pneumothorax/000003.dcm Pneumothorax
4 train/Pneumothorax/000004.dcm Pneumothorax

Now, we use the DataBlock class to prepare the DICOM data for training.

As we are dealing with DICOM images, we need to use PILDicom as the ImageBlock category. This is so the DataBlock will know how to open the DICOM images. As this is a binary classification task we will use CategoryBlock

pneumothorax = DataBlock(blocks=(ImageBlock(cls=PILDicom), CategoryBlock),
                   get_x=lambda x:pneumothorax_source/f"{x[0]}",
                   get_y=lambda x:x[1],
                   batch_tfms=aug_transforms(size=224))

dls = pneumothorax.dataloaders(df.values, num_workers=0)

Additionally, we plot a first batch with the specified transformations:

dls = pneumothorax.dataloaders(df.values)
dls.show_batch(max_n=16)

Training

We can then use the cnn_learner function and initiate the training.

learn = cnn_learner(dls, resnet34, metrics=accuracy)

Note that if you do not select a loss or optimizer function, fastai will try to choose the best selection for the task. You can check the loss function by calling loss_func

learn.loss_func
FlattenedLoss of CrossEntropyLoss()

And you can do the same for the optimizer by calling opt_func

learn.opt_func
<function fastai.optimizer.Adam(params, lr, mom=0.9, sqr_mom=0.99, eps=1e-05, wd=0.01, decouple_wd=True)>

Use lr_find to try to find the best learning rate

learn.lr_find()
SuggestedLRs(lr_min=0.006918309628963471, lr_steep=0.009120108559727669)
learn.fit_one_cycle(1)
epoch train_loss valid_loss accuracy time
0 1.277167 1.147675 0.500000 00:03
learn.predict(pneumothorax_source/f"train/Pneumothorax/000004.dcm")
('No Pneumothorax', tensor(0), tensor([0.6861, 0.3139]))

When predicting on an image learn.predict returns a tuple (class, class tensor and [probabilities of each class]).In this dataset there are only 2 classes No Pneumothorax and Pneumothorax hence the reason why each probability has 2 values, the first value is the probability whether the image belongs to class 0 or No Pneumothorax and the second value is the probability whether the image belongs to class 1 or Pneumothorax

tta = learn.tta(use_max=True)
learn.show_results(max_n=16)
interp = Interpretation.from_learner(learn)
interp.plot_top_losses(2)

Result Evaluation

Medical models are predominantly high impact so it is important to know how good a model is at detecting a certain condition.

This model has an accuracy of 56%. Accuracy can be defined as the number of correctly predicted data points out of all the data points. However in this context we can define accuracy as the probability that the model is correct and the patient has the condition PLUS the probability that the model is correct and the patient does not have the condition

There are some other key terms that need to be used when evaluating medical models:

False Positive & False Negative

  • False Positive is an error in which a test result improperly indicates presence of a condition, such as a disease (the result is positive), when in reality it is not present
  • False Negative is an error in which a test result improperly indicates no presence of a condition (the result is negative), when in reality it is present

Sensitivity & Specificity

  • Sensitivity or True Positive Rate is where the model classifies a patient has the disease given the patient actually does have the disease. Sensitivity quantifies the avoidance of false negatives

Example: A new test was tested on 10,000 patients, if the new test has a sensitivity of 90% the test will correctly detect 9,000 (True Positive) patients but will miss 1000 (False Negative) patients that have the condition but were tested as not having the condition

  • Specificity or True Negative Rate is where the model classifies a patient as not having the disease given the patient actually does not have the disease. Specificity quantifies the avoidance of false positives

Understanding and using sensitivity, specificity and predictive values is a great paper if you are interested in learning more about understanding sensitivity, specificity and predictive values.

PPV and NPV

Most medical testing is evaluated via PPV (Positive Predictive Value) or NPV (Negative Predictive Value).

PPV - if the model predicts a patient has a condition what is the probability that the patient actually has the condition

NPV - if the model predicts a patient does not have a condition what is the probability that the patient actually does not have the condition

The ideal value of the PPV, with a perfect test, is 1 (100%), and the worst possible value would be zero

The ideal value of the NPV, with a perfect test, is 1 (100%), and the worst possible value would be zero

Confusion Matrix

The confusion matrix is plotted against the valid dataset

interp = ClassificationInterpretation.from_learner(learn)
losses,idxs = interp.top_losses()
len(dls.valid_ds)==len(losses)==len(idxs)
interp.plot_confusion_matrix(figsize=(7,7))

You can also reproduce the results interpreted from plot_confusion_matrix like so:

upp, low = interp.confusion_matrix()
tn, fp = upp[0], upp[1]
fn, tp = low[0], low[1]
print(tn, fp, fn, tp)
23 13 12 2

Note that Sensitivity = True Positive/(True Positive + False Negative)

sensitivity = tp/(tp + fn)
sensitivity
0.14285714285714285

In this case the model has a sensitivity of 40% and hence is only capable of correctly detecting 40% True Positives (i.e. who have Pneumothorax) but will miss 60% of False Negatives (patients that actually have Pneumothorax but were told they did not! Not a good situation to be in).

This is also know as a Type II error

Specificity = True Negative/(False Positive + True Negative)

specificity = tn/(fp + tn)
specificity
0.6388888888888888

The model has a specificity of 63% and hence can correctly detect 63% of the time that a patient does not have Pneumothorax but will incorrectly classify that 37% of the patients have Pneumothorax (False Postive) but actually do not.

This is also known as a Type I error

Positive Predictive Value (PPV)

ppv = tp/(tp+fp)
ppv
0.13333333333333333

In this case the model performs poorly in correctly predicting patients with Pneumothorax

Negative Predictive Value (NPV)

npv = tn/(tn+fn)
npv
0.6571428571428571

This model is better at predicting patients with No Pneumothorax

Calculating Accuracy

The accuracy of this model as mentioned before was 56% but how was this calculated? We can consider accuracy as:

accuracy = sensitivity x prevalence + specificity * (1 - prevalence)

Where prevalence is a statistical concept referring to the number of cases of a disease that are present in a particular population at a given time. The prevalence in this case is how many patients in the valid dataset have the condition compared to the total number.

To view the files in the valid dataset you call dls.valid_ds.cat

val = dls.valid_ds.cat
#val[0]