JDMS

RESEARCH ARTICLES
Image
Segmentation
for Evaluating
Axillary Lymph
Nodes
KEVIN D. EVANS, PHD, RT, RDMS, RVS, FSDMS
STEFFEN SAMMET, MD, PHD
YVETTE RAMOS, RDMS, RVT
MICHAEL V. KNOPP, MD, PHD

From The Ohio State University, School of Allied Medical

Professions, Columbus, Ohio.
Correspondence: Kevin D. Evans, PhD, RT, RDMS, RVS,
FSDMS, The Ohio State University, School of Allied Medical
Professions, 410 W. 10th Avenue, 340 A. Atwell Hall, Columbus, OH
43210. E-mail: Evans.36@osu.edu.
The authors thank GE Healthcare Ultrasound for providing the
equipment, transducers, and software to conduct this research.
DOI: 10.1177/8756479308324954

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329

A review is provided of the literature that has

been published on image segmentation relative
to sonography. Manual and automatic techniques
for partitioning a sonogram are highlighted. In
addition, a preliminary set of results is provided
on the interrater reliability of the manual
segmentation of axillary lymph nodes that have
been sonographically imaged. A correlation
between sonographers conducting manual
segmentation is very high (r = 0.9 with P < .00 at
the .01 alpha level). This work is set to provide
additional information on lymph node cubic
volume and the agreement between manual and
automatic segmentation of axillary lymph nodes.
Key words: image segmentation, breast sonography, axillary lymph nodes

The use of computer algorithms for the delineation of anatomical structures or other regions of
interest (ROIs) is called image segmentation.1
Image segmentation is not a new evaluation technique, but the use has proliferated to provide more
information that is locked inside a medical image.
Segmenting a medical image can be extremely
helpful in quantifying tissue volumes, diagnosis,
localization of pathology, and the study of anatomical structures.25 Unfortunately, image segmentation has been conducted with only a limited
number of sonographic cases. Examples of successful clinical research using image segmentation
of sonography images are those determining heel
density, ovarian cysts, breast cysts, and fetal, liver,
and cardiac pathology.615
The ability to segment anatomic and pathologic information from an image is only possible
because of the composition of voxels. Extracting

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information from within the image is done by

partitioning the image into nonoverlapping,
homogeneous regions based on the intensity of
reflected acoustic energy. The clinical application of image segmentation has yielded a number
of more effective techniques for conducting this
process with sonograms. The following image
segmentation techniques are commonly used
with sonograms: textural classifiers, manual
interaction to place ROIs, and deformable models.1 A brief description is provided of the image
segmentation techniques that were considered for
this feasibility study.

Segmentation Methods
1. Textural classifiers
Clustering: Clustering is a form of textural classifying that depends on training data. In essence,
the algorithm trains itself during the data analysis process.1 Once the region on the image is
selected for extraction, the pixels within the
extracted area are evaluated for a mean intensity,
and subsequent segmentations are made based
on finding like mean intensities.16
2. Regions of interest
Region growing: Region growing requires that
a manual interaction be made with the image
and a seed placed in the area of interest. The
algorithm moves outward from the seed to
encompass voxels that are of like intensity and
extracts them for the background image.1
3. Deformable models: Deformable models are a
graphic representation of elastic theory that
permits graphic molding around a selected voxel
composition and deforms by responding to
17
energy internally. Deformable models can be
manual or automated. Obviously, the reliability
and consistency of automated deformable models
are ideal to reduce bias and time.17
The snake is the most popular deformable model that has been used for image
segmentation.18
Level-set segmentation allows a 3D image
volume set to be extracted using a deformable
surface model and adjusts throughout the
volume.

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Literature Review
Mammography is an imaging modality in which
segmentation techniques have been used extensively. In this area of research, a combination of
multiple image segmentation techniques has been
evaluated. An early study that was conducted with
2D digital mammography used segmentation of
breast tumors in two steps.19 In this study, regions of
interest were first extracted after a histogram was
created, based on the frequency of pixel magnitude.
The pixel frequency spanned a range of intensities
from 70 to 120. Those pixel magnitudes that were
greater than the threshold were deemed to be the
breast tissue. After breast tissue was isolated, a
modified Markov random field model was used to
separate the tumor based on the extremely high
pixel value that exceeded the typical breast tissue
pixel density. Markov random field (MRF) models
are considered advanced segmentation techniques,
and this low-level model is based on the individual
behavior of pixels relative to one another in the
matrix.20 MRF models are classified as a form of
clustering.21 These sets of segmentation steps were
able to successfully isolate minimal breast cancers
that were <10 mm.
Another landmark study in this area was conducted to extract morphologic features of malignant and benign breast masses. This study used a
combination of clustering, a deformable model,
and a hybrid technique called speculation detection stages.22 One of the problems with this study
was the need to digitize the film to begin the
process of extraction. This allows the possibility of
noise in the image and degrades the ability to discretely assess the pixels within the selected region.
Breast imaging has embraced the use of computer-aided detection (CAD) software specifically
developed for digital mammography. CAD makes
use of layers of analysis that are focused on specific ROIs and classifies them for potential pathology. CADs primary function is to reduce the
false-positive diagnoses that are made during
breast imaging. CAD makes use of image analysis
techniques that aid in making a diagnosis. The first

IMAGE SEGMENTATION FOR EVALUATING AXILLARY LYMPH NODES / Evans et al

layer of analysis is contrast enhancement, and the

next progressive layer is optimal image segmentation.23 In studies to develop optimum segmentation methods for CAD, an unsupervised Gaussian
mixture method model and a hidden MRF model
developed by Zang et al.24 were used. These analytical models were fused with a template of
model images that represent normal pixel densities. The template model was considered a supervised test that was used to find the optimum
segmentation maneuver to accentuate the CAD
diagnosis. The study used 400 digital mammograms to determine the best mix of segmentation
strategies with the CAD program. The result of the
experiment demonstrated that a supervised segmentation method, as developed by Zang et al.,24
was a superior technique for CAD.23 This study
was based on 2D images and building a system
that was sensitive to gray-scale pixel differences.
Calcifications in breast tissue also have been
explored as a target for image segmentation and
enhancement during the use of CAD. An experiment was conducted using 260 single-view film
screen mammograms that were digitized and ready
for CAD. In addition, image segmentation was performed using symmlet wavelet and a new technique
called the donut filter.25 ROIs were placed over
the 138 benign calcifications and 122 microcalcifications, and the signals that emanated from these
particular pixels were used to cue segmentation.
The study provided promising results and should be
replicated with images from a variety of digitizers
as well as digital mammography. The researchers
also felt that other clinical applications could be
found for this type of 2D image segmentation.
Level-set segmentation, a specific method used
with 3D volume image sets, can be affected by
inherent noise from the imaging technique. The
problem with noisy images within a 3D volume set
is that smoothing or enhancing the data causes distortion of the anatomy, which has been targeted for
segmentation. The trick is to find a method that
strikes a balance between 3D resolution and inherent digital noise. The use of level-set segmentation
relies on a surface-fitting strategy that helps in
dealing with small-scale noise from the modality

331

and smoothes the intensity of the signal fluctuations in the volume data.26 There are many
deformable models for segmenting 3D volume
data. Using an implicit model, which specifies the
surface as a level set and allows for the variation
descending through the volume, would be ideal.27
This allows the data set to be defined by the
deformable surface and vary dynamically over
time. An additional concern is that volume data
sets are collected in the X, Y, and Z planes. The Z
plane has the lowest resolution due to data being
collected in the axial direction. The introduction of
this kind of inherent noise can be the source of
inaccuracy within the targeted anatomy for segmentation. A group of researchers dealt with this
problem by using multiple sets of scans on an
object and merging them prior to segmentation.
This hybrid image volume set was composed of
individually higher resolution planes of information. The use of level-set segmentation on a hybrid
3D image volume was conducted using a magnetic
resonance (MR) scan of a mouse embryo, a laser
scan of a figurine, and an MR scan of a zucchini.26
The result was a high-resolution level-set model
that contained all the significant features of the
original scan for all three items. Because sonography is traditionally considered an imaging modality fraught with a certain level of digital noise, this
segmentation technique could be quite helpful.
Work conducted in Japan with image segmentation used 3D volume sets with the intent to better
plan breast cancer surgeries.28,29 The 3D images
were created from volume-rendered 2D sonograms
and manually selected ROIs chosen from a histogram of pixel intensities. These 3D models were
created while the patient was prepared for surgery.
Creating these segmented models of the tumor
helped to direct the surgeon to minimize the amount
of tissue removed while maintaining appropriate
borders. This work demonstrated the translational
value of working with segmentation of 3D breast
images and the potential to minimize the invasiveness of surgery.
Previous research that has been conducted with
the segmentation of sonographic images has
demonstrated the value of increasing our diagnostic

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capability and assisting the radiologist with additional diagnostic data. The evaluation of axillary
lymph nodes has yet to be demonstrated with this
set of imaging techniques, and the feasibility of
creating these images remains to be explored. To
fill this gap in the literature, we devised a feasibility study to explore the use of a manual technique
for segmenting the sonographic voxel density of
axillary lymph nodes.

Materials and Methods

Image segmentation has been used more extensively with computed tomography (CT), magnetic
resonance imaging (MRI), and now digital mammography. These techniques have developed in
response to the increasing ability to capture large
volume sets of imaging information. Data sets
have varied anatomic and pathologic information
that may need to be located and segmented away
for the larger data set. A robust set of maneuvers is
needed to determine the coordinates of the item
that will be segmented away from the background
image. Predominately, sonography images are
captured in 2D frames that are composed of pixels.
This can limit the ability to accurately capture an
images boundaries for segmentation. A volume
set of image data, which is provided with 3D sonographic imaging, provides more digital information but has added complexities for conducting
accurate image segmentation.
Presently, the focus of this research team
has been an attempt to use both manual and automated deformable models (snakes and level sets) to
determine the best method for conducting segmentation of axillary lymph nodes. Attempts have been
made to perform automated image segmentation
with an existing data set to provide either a pixel
count or a voxel count. The secondary data segmentation with automated techniques was attempted on
the following sample images:
a.
b.
c.
d.

A 2D lymph node with color Doppler imaging

A 2D lymph node without color Doppler imaging
A 3D lymph node with color Doppler imaging
A 3D lymph node without color Doppler imaging

FIGURE 1. 3D axillary lymph node image with color Doppler

that was problematic for automatic image segmentation.

In addition, a manual deformable model of image

segmentation was used to provide a voxel count
on a sample 3D lymph node image without color
Doppler imaging (see Figure 1). Unfortunately,
these attempts were not successful, in part, because
these images were not collected for this expressed
purpose. A fresh data collection was needed
to properly determine the feasibility of these
techniques to isolate lymph nodes from surrounding
breast tissue.
PROTOCOL FOR SEGMENTATION

The proposal was to use normal female volunteers

to allow for a collection of images of lymph nodes in
the axilla. This allowed for a manual segmentation
with a sonographic transducer that was specifically
built to make volume measurements and segment the
image at the time it was collected. The TRU
3D/Vocal transducer setup was provided by General
Electric Healthcare along with a GE Logic 9
(Milwaukee, Wisconsin). This equipment allowed
the segmentation to be done manually using the
deformable model techniques. The Institutional
Review Board of Ohio State University approved this
project. The number of volunteers was set at 40 to
achieve a moderate effect size of .5 at an alpha of .05
with a power of .59.

IMAGE SEGMENTATION FOR EVALUATING AXILLARY LYMPH NODES / Evans et al

333

FIGURE 2. Image segmentation of an axillary lymph node

using the deformable model snake technique.

FIGURE 4. Small node that would be classified as abnormal

and the model created with the snake technique.

FIGURE 3. Larger, more oval node segmented with a

deformable model snake technique.

FIGURE 5. Image segmentation of a small node with image

optimization prior to manual segmentation.

Each normal female volunteer consented to

have 20 minutes of diagnostic medical sonography, and after three lymph nodes were imaged in
volume sets, they were dismissed. The volume sets
of lymph node images were then manually
segmented using the deformable model snake (see
Figures 25). Once the images had been through

the segmentation process, a cubic volume was

determined, and the voxel density was determined
mathematically. All the images were de-identified
and retained on a flash drive that was kept in a
locked office and used only for transferring the
volume data sets to Dr. Sammets computer lab for
future automated processing.

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Results
Preliminary results are provided on 23 participants who provided a total of 45 lymph nodes for
evaluation. The mean age of these 23 participants is
24 years of age, with the hope that younger participants would provide more normal-shaped nodes
free of inflammatory or chronic disease changes.
One of the key initiatives at this juncture in the
research was to use these 45 lymph nodes for
manual segmentation but to check for interrater
reliability. The principal investigator (KE) and the
application specialist sonographer (YR) worked
independently to perform manual image segmentation for each node. The resulting 3D model that
was created was recorded and the cubic volume
compared for consistency. A mean cubic volume
of .28 m3 (SD .26) was determined for the 45
nodes that were manually segmented by the principal investigator. The application specialist provided a mean cubic volume of .31 m3 (SD .27) for
those nodes that she manually segmented.
The Pearson correlation coefficient was chosen
to determine the statistical correlation of measures
that were made by the two sonographers per node.
The set of nodes was compared between sonographers, according to the order in which the nodes
were captured (node 1, node 2, and node 3). For
node 1 in the series, the correlation coefficient was
r = 0.91, which indicates a very high positive correlation between the sonographers measurements
for all those first nodes segmented in the series.
The statistical significance of this agreement was
P < .00 at the .01 alpha level. The scatterplot for
those manually segmented nodal volumes is
depicted in Figure 6. For node 2 in the series, the
correlation coefficient was r = 0.97, which indicates a very high positive correlation between the
sonographers measurements for all those second
nodes segmented in the series. The statistical significance of this agreement was P < .00 at the .01
alpha level. The scatterplot for those manually
segmented nodal volumes is depicted in Figure 7.
For node 3 in the series, the correlation coefficient
was r = 0.99, which again indicates a very high
positive correlation between the sonographers

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measurements for all those third nodes segmented

in the series. The statistical significance of this
agreement was P < .00 at the .01 alpha level. The
scatterplot for those manually segmented nodal
volumes is depicted in Figure 8.

Discussion
The very high correlation between the sonographers measurements for manual segmentation of
the axillary lymph nodes imaged is a promising

FIGURE 6. Scatterplot of the manual segmentation of the

cubic volume of the first axillary lymph node imaged.

FIGURE 7. Scatterplot of the manual segmentation of the

cubic volume of the second axillary lymph node imaged.

IMAGE SEGMENTATION FOR EVALUATING AXILLARY LYMPH NODES / Evans et al

335

sonographic breast lesions in a study of 400 sonograms that spanned a variety of pathologies.31 The
researchers concluded that automated and manual
segmentation were similar in their ability to consistently delineate borders of breast masses. The
next phase of the current research will be to complete a comparison between automated and manual segmentation with the existing data set. The
limitations inherent with a feasibility study of this
size are that the results are unique and may not
generalize to a larger population.

Conclusion
FIGURE 8. Scatterplot of the manual segmentation of the
cubic volume of the third axillary lymph node imaged.

early result for the continuation of this research.

One criticism of manual segmentation is that the
variability of the models is attributed to the operator; however, this does not appear to be a factor in
the research that we are conducting. The scatterplots are highly effective tools that can be used to
look for those nodal volumes that do not line up
close to 1.0. These may be nodes that need to be
reviewed to determine what caused the sonographers to disagree on their method of manual
segmentation of the cubic volume.
The impact of this research will be boosted by
securing all 40 volunteers and completing the manual segmentation of axillary lymph nodes that are
visualized. Once these nodes are segmented, the
data set will be segmented automatically using
automated level sets or region-growing algorithms.
Interestingly, a study was done using a mixed
model of image segmentation in which sonographic
images were partitioned using a method of outlining
the contour of the image, with the automated regiongrowing technique completing the segmentation.30
The software was trained to be more accurate by
incorporating the contour outlines provided by the
operator. In this study, the gallbladder and kidney
were the organs segmented on sample sonograms.
In addition, segmentation with both automated
and manual techniques was conducted with

Continued use of manual segmentation with

sonographic images will help build a body of evidence-based research and promote translational
implementation. The next specific aim is not only
to demonstrate consistency with segmenting
lymph nodes but also to compute the normal mean
volume of a lymph node. This will allow the
research team to compute the number of voxels
that are expected to comprise a nodes normal
cubic volume.

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SDMS-JDMS CME TEST

Article: Image Segmentation for Evaluating Axillary Lymph
Nodes
Authors: Kevin D. Evans, PhD, RT, RDMS, RVS, FSDMS
Steffen Sammet, MD, PhD
Yvette Ramos, RDMS, RVT
Michael V. Knopp, MD, PhD
Category: Other
Credit: 1.0 CME
Objectives: After studying the article titled Image
Segmentation for Evaluating Axillary Lymph Nodes, you
will be able to:
1. Describe how image segmentation can be used to partition a 3D digital image of axillary lymph nodes.
2. Discuss how image segmentation can be accomplished
with either manual or automatic processes.
3. Define image segmentation.
1. Image segmentation is defined by which of the following?
a. The slicing of images for making digital maps
b. The use of computer algorithms for the delineation
of anatomical structures
c. The compression of images to load on the PACS
to conserve memory
d. The joining of images to create a 2D image
2. Image segmentation has been conducted in which of
the following sonography examinations?
a. To study cardiac pathology
b. To determine gestational age based on the nasal
bone
c. Several solid breast masses
d. The adult liver
3. Which of the following image segmentation processes
makes use of the electronic snake?
a. Textural classifiers
b. Regions of interest
c. Deformable models
d. Clustering
4. What was the mean age of the female participants
involved in this study?
a. 40 years of age
b. 20 years of age

c. 65 years of age
d. 24 years of age
5. What was the correlation coefficient of agreement
between the two sonographers involved in manual
image segmentation of axillary lymph nodes?
a. 1.0
b. 0.5
c. 2.0
d. 0.9
6. The use of CAD is a form of image segmentation that
used which of the following as an innovative filter in a
2005 research study?
a. Wire mesh
b. A digitizer
c. A donut
d. Electronic manipulation
7. Which of the following image sets were not used for
automatic image segmentation?
a. A 2D lymph node with power Doppler imaging
b. A 2D lymph node without color Doppler imaging
c. A 3D lymph node with color Doppler imaging
d. A 3D lymph node without color Doppler imaging
8. Which image segmentation method uses a seed for
region growing automatically in the image?
a. Textural classifiers
b. Regions of interest
c. Deformable models
d. Clustering
9. Which image segmentation method can be grossly
affected by digital noise?
a. Textural classifiers
b. Regions of interest
c. Deformable models
d. Clustering
10. What was the mean cubic volume of the lymph nodes
that were extracted in the research by Evans et al.?
a. 10 cm3
b. 0.50 cm3
c. 0.28 cm3
d. 1.0 cm3