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Article

Review Article

Progress in Medical Physics 2019; 30(2): 49-58

Published online June 30, 2019
https://doi.org/10.14316/pmp.2019.30.2.49
Copyright © Korean Society of Medical Physics.

Medical Image Analysis Using Artificial Intelligence

Hyun Jin Yoon1,2, Young Jin Jeong1,2, Hyun Kang2, Ji Eun Jeong1, Do-Young Kang1,2
1
Department of Nuclear Medicine, Dong-A University Medical Center, Dong-A University
College of Medicine, 2Institute of Convergence Bio-Health, Dong-A University, Busan,
Korea

Correspondence to:Do-Young Kang (dykang@dau.ac.kr)

Tel: 82-51-240-5630
Fax: 82-51-242-7237

Received: May 2, 2019; Revised: May 21, 2019; Accepted: May 21, 2019

This is an Open-Access article distributed under the terms of the Creative Commons
Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0)
which permits unrestricted non-commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited.

Abstract

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Automated analytical systems have begun to emerge as a database system that enables the
scanning of medical images to be performed on computers and the construction of big data.
Deep-learning artificial intelligence (AI) architectures have been developed and applied to
medical images, making high-precision diagnosis possible. For diagnosis, the medical images
need to be labeled and standardized. After pre-processing the data and entering them into the
deep-learning architecture, the final diagnosis results can be obtained quickly and accurately.
To solve the problem of overfitting because of an insufficient amount of labeled data, data
augmentation is performed through rotation, using left and right flips to artificially increase
the amount of data. Because various deeplearning architectures have been developed and
publicized over the past few years, the results of the diagnosis can be obtained by entering a
medical image. Classification and regression are performed by a supervised machine-learning
method and clustering and generation are performed by an unsupervised machine-learning
method. When the convolutional neural network method is applied to the deep-learning layer,
feature extraction can be used to classify diseases very efficiently and thus to diagnose various
diseases. AI, using a deep-learning architecture, has expertise in medical image analysis of the
nerves, retina, lungs, digital pathology, breast, heart, abdomen, and musculo-skeletal system.

Keywords
Artificial Intelligence (AI), Medical images, Deep-learning, Machine-learning, Convolutional
Neural Network (CNN), Big data

Introduction

1. Recent trends in AI research

It is well-established that automated analytical systems have begun to emerge as a database
system capable of scanning medical images with computers and configuring big data. With the
development of back-propagation deep-learning artificial intelligence (AI) architectures,
medical imaging has begun to be applied and it has been reported that accurate diagnosis is
possible. The most efficient model for image analysis is the ‘convolutional neural network’
(CNN), a key block in the configuration of deep networks. CNN involves developing various
optimization algorithms such as LeNet, AlexNet, ZFNet, GoogLeNet, VGGNet, and ResNet. CNN
is a powerful feature extractor with a deep layer that can extract features from images.1,2)
Deep learning algorithms, especially convolutional networks, are rapidly emerging as a
methodology for analyzing medical images. There has been remarkable growth in medical
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imaging analysis of the nerves, retina, lung, digital pathology, breast, heart, abdomen, and
musculo-skeletal system using the AI methods that make up the deep-learning architecture.

2. The need for AI in medical imaging

Finding non-invasive and quantitative assessment techniques for early detection of

Alzheimer’s disease (AD) is fundamentally important for early treatment. Tumor detection,
classification, and quantitative assessment in positron emission tomography (PET) imaging are
important for early diagnosis and treatment planning. A number of techniques have been
proposed for segmenting medical image data through quantitative assessment. However, some
quantitative methods of evaluating medical images are inaccurate and require considerable
computation time to analyze large amounts of data. Analytical methods using AI algorithms
can improve diagnostic accuracy and save time.

3. AI research field

The deep-learning technology, known as the AI method, dramatically improves diagnostic

performance by automatically extracting features of complex and precise medical images, and
comparing their differences.3,4) Image analysis by AI algorithm is superior to the traditional
image analysis method. Automatically classifying skin lesions using images is a challenging
task because the skin lesion shapes differ a lot, but they have successfully categorized skin
cancer successfully.5) When evaluating diabetic retinal fundus photographs, deep-learning
using Inception-v3 architecture enabled diagnosis of diabetic retinopathy with high sensitivity
and specificity.6) Early detection of pulmonary nodules on a chest by computed tomography
(CT) scan was performed using the lung image database consortium (LIDC) and the image
database resource initiative (IDRI) for the diagnosis of lung cancer, and extracted successfully
using the network back propagation algorithm.7) CNN-type deep-learning model, trained for
large mammography lesions, is superior in performance to existing computer-aided diagnosis
(CAD) system.8) An automated detection system has been successfully established by studying
the feasibility of a deep-learning approach for detecting cartilage lesions in the knee joint with
magnetic resonance (MR) images.9) PET images with low spatial resolution overestimated the
volume due to the partial volume effect, but the optimal volume was extracted using the
artificial neural networks algorithm.10) Through the development of AI algorithms, the
diagnostic performance of various medical images has been improved, and it is expected to be
continuously introduced into medical image diagnosis systems because it has a higher
diagnostic performance index than any other quantitative analysis methods so far.

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Medical Image Diagnosis Using AI

For the diagnosis of medical imaging, there should be labeled and standardized big data, as
shown in Fig. 1. AI is generally a concept that includes machine-learning and deep-learning,
and can be analyzed in various ways, depending on the characteristics of images stored in the
database. The data is pre-processed in the same order as in Fig. 2, entered into the deep-
learning architecture, and final diagnosis results are obtained. The hyper-parameter is
changed and the deep-learning result is checked and modified to optimize the parameter. In
order to solve the problem of over-fitting due to lack of the sufficient labeled data, data
augmentation is performed through rotation, left and right flip, and generative adversarial
network (GAN).

1. Data sets
Although medical images are stored in the picture archiving and communication system
(PACS), they are almost useless data for AI analysis. In order to use medical images for AI,
labeling, standardization, bounding box, and segmentation are required. These high quality
images require manual work, which can be time-consuming and can vary, depending on the
skill of the person. Standardized and anonymized well-labeled databases are very important
for developing and testing AI algorithms that require big data. There has been an attempt to
build a large-scale database system through these complex processes, and to improve
diagnostic performance through competition. These attempts have been quite successful and
appear to be most effective in increasing diagnostic accuracy.

In recent years, an anonymous medical image database has been released and researchers are
freely approaching and presenting research results. A database of F-18 fluorodeoxyglucose
(FDG) PET images from participants of the AD neuro-imaging initiative (ADNI) is being
developed to study early detection of AD patients. F-18 FDG PET images of the ADNI database
were used to distinguish AD patients with 88.64% specificity, 87.70% sensitivity, and 88.24%
accuracy.11) Magnetic resonance imaging (MRI) of the knee is the preferred method for
diagnosing a knee injury, but the analysis is time consuming and the likelihood of diagnostic
errors is high. MRNet, a CNN, and logistic regression analysis were performed as a dataset of
1,370 knee MRI scans performed at the Stanford University Medical Center
(https://stanfordmlgroup.github.io). The results of the validation did not show a significant
difference from the analysis of 9 clinical experts at the Stanford University Medical Center.12)
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The leader-board reports the average area under the receiver operating characteristic curve
(AUC; 0.917) of current (Jan 09, 2019) abnormal detection, anterior cruciate ligament tears, and
meniscal tear work (https://stanfordmlgroup.github.io/competitions/mrnet).

To screen for severe pneumothorax, a total of 13,292 frontal chest X-rays were visually labeled
by a radiologist to create a database.13) Candidate images for analysis were identified and
stored in a clinical PACS in the form of ‘digital imaging and communications in medicine’
(DICOM; National Electrical Manufacturers Association, Arlington, VA, USA). These well-
defined data sets can be used to train and evaluate different network architectures. Building
such a well-defined database requires a lot of time and effort. The National Institute of Health
(NIH) has opened the Chest X-ray14 set, so that it is publicly available (available at
https://nihcc.app.box.com/v/ChestXray-NIHCC). The NIH allows students to learn by using
well-organized and labeled data sets, and opens up a database for anyone to challenge and
develop optimized algorithms. LIDC and IDRI databases were created and released for the
diagnosis of lung cancer. For the diagnosis of skin cancer, the database can be opened
(https://isic-archive.com) to participate in the competition.5) The MR knee database is also
available and anyone interested in this field can participate in AI analysis
(https://stanfordmlgroup.github.io/competitions/mrnet). Most problems with large data sets
and public challenge data sets are listed at http://www.grand-challenge.org.

In order to construct a more efficient accurate, and useful database, the Department of
Nuclear Medicine at Dong-A University Medical Center established a database system called
SortDB with IRM (http://www.irm.kr/). The feature of SortDB is some software that allows
researchers to download a desired DICOM file in a specified file format (nii, jpg, gif, etc.) by
entering a manageable list of Excel files. To apply an AI algorithm, big data is needed. It is an
automated database generation program that stores and manages data stored in small and
medium sized hospitals in the necessary format. A database is constructed with the system
configuration shown in Fig. 3, shortening the pre-processing time for creating a standardized
data set.

2. Pre-processing of medical images

For quantitative analysis, an image was normalized using a standard affine model with 12
parameters using SPM5 software.14) In order to use quantitative evaluation using machine
learning, a pre-processing method, including the normalization process of image data must
necessarily be included. Since the accuracy of the normalized image depends on the standard
template or the variety of the process, there are considerable variations among researchers.
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When applying an AI algorithm through a normalized image, the accuracy is generally

increased. However, there is a lack of logical explanations and studies on why normalized
images increase accuracy. Theoretical studies are needed, as well as empirical studies on the
optimal pre-processing method for image analysis using AI.

The accuracy of the quantitative analysis has a considerable impact on the quality of the image
transformation by pre-processing. In particular, the accuracy of AI analysis varies
considerably, depending on the quality of medical images for applying the algorithm. The
image transformation of the DICOM file is linearly transformed using the return value of
GetOuputData function of a library.15) Bits number 8 and the standardized uptake values
(SUV) were linearly converted to 0–255 scales. By using this method of linear transformation,
the image representing the SUV can be reproduced as a jpg file with distortion. It is necessary
to study the image conversion methods so that medical images will suffer only minimal
deformation in the conversion process. It is necessary to maintain the consistency of AI
learning using image-aware CNNs by down-sampling commonly used images.13)

3. Data augmentation, model and parameter optimization

Generally, PET images do not have a large number of data, making it difficult to construct a
database of big data. In this case, data augmentation is performed through image inversion,
enlargement/reduction, shearing, and rotation to randomly distribute data to perform AI
analysis. Too many hyper-parameter optimizations are some of the most important difficulties
in achieving optimal accuracy. This can be done using the open source Future Gadget
Laboratory (https://github.com/Kaixhin/FGLab) framework.13) Evaluation of the validity of
deep-learning can be done by calculation of the AUC, sensitivity, specificity, and positive
predictive value of the entire validation set, and can be done using scikit-learn (https://scikit-
learn.org). Receiver operating characteristic curves can be drawn using matplotlib
(https://matplotlib.org).

Currently, CNN algorithms are implemented in various ways. The recent trend is to use Keras
(version 2.0.3, https://keras.io/) deep-learning library on TensorFlow (version 1.2.1,
https://www.tensorflow.org/?hl=ko) to implement a model of CNN. Deep-learning
architectures for AI analysis are VGG16/19, Xception, Inception, and ResNet models, which are
the best performing algorithms.16-19) The optimal algorithm for image classification may be
an algorithm that can reflect the feature characteristics of each medical image. Currently, the
location of such features is estimated through the activation map. However, at present, only
the experience of repeated execution of each medical image is the method of finding the

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optimal model. The AlexNet algorithm, which won the ImageNet Large Scale Visual
Recognition Challenge in 201220) to classify the chest X-ray image into 5 classes, was used and
successfully classified with 92.10% accuracy.21) AlexNet consists of 5 convolution layers and 3
fully-connected (FC) layers, and the last FC layer uses a softmax activation function. The
researcher21) down-sampled the DICOM file and converted it into a 256×256 pixel png file and
used it as the input image of AlexNet. The mini-batch size is 128, the number of training
iterations is 100, the adaptive learning rate is 1×10−3 for adaptive moment estimation (Adam)
optimizer, and the momentum is 0.5. The rectified linear unit (ReLU) activation functions were
used in the previous step of the max-pooling layers and the L2 regularization was adjusted to
1×10−4.

Machine Learning

One of the most successful methods is the principal component analysis (PCA) method, which
is based on the eigen-image approach.22) After analyzing the images through PCA, support
vector machine (SVM) was used as a classifier to distinguish the boundary between normal
and demented patients and to improve the accuracy by diagnosing and analyzing the initial
dementia. PCA was applied to single photon emission computed tomography (SPECT) images
and the possibility of classification was greatly improved, and the results were presented
through 3-dimensional (3D) scattering.23) Quantitative evaluation and classification is one of
the most efficient and logical methods. The accuracy of classification of AD by applying PCA-
SVM to SPECT and PET images was 96.7% and 89.52%, respectively.24) Using Gaussian mixture
models, a method of automatically selecting the region of interest (ROI) of a 3D functional
brain image containing high and low activation region information was presented.25) Based on
classification using eigenvector decomposition and SVM, including concept extraction by
representative vector separation using principal component analysis, we find that
PCA/independent component analysis for early AD diagnosis by brain image analysis and
pattern disease discrimination CAD is a very useful direction.11)

Application of AI Medical Image Analysis

1. AI in brain imaging
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In brain research using AI, many studies have been conducted in the field of AD classification,
anatomical segmentation of brain regions, and tumor detection. AD/mild cognitive
impairment/healthy control classification was successfully performed by using the Gaussian
restricted Boltzmann machine (RBM) to find feature expressions in volume patches of MRI and
PET images.26) The 3D CNN in AD classification is superior to other algorithm classifiers.27,28)
It automatically segments the MR images of the human brain using CNN.29) Segmentation of
striatum segmentation was performed using deep CNN, and the results were compared with
those of FreeSurfer.30) In the brain area, manual segments are time-consuming, with
individual differences occurring, while automatic segmentation has significant difficulties in
performing in complex structures. Twenty-five deep-layers called the ‘voxel-wise residual
network’ (VoxResNet) were developed and successfully segmented automatically.31) To
demonstrate end-to-end nonlinear mapping from MR images to CT images, a 3D fully CNN
was employed and verified in a real pelvic CT/MRI data set.32) Input and output improved
performance by using two-volume CNNs, and excellent performance was observed by
evaluating the input and output forms in the MRI and PET images of the ADNI database.33)

2. AI in chest imaging
By introducing the multiple-instance learning framework, a de-CNN is constructed to
generate the heat map of suspicious regions.34) A unique set of radiologic datasets of publicly
available chest X-rays and their reports were used to find and report 17 unique patterns by
applying CNN algorithms.35) It has been reported that the presence of interstitial patterns
have been found by applying a segmentation-based label propagation method to a dataset of
interstitial lung disease,36) and it has been reported that lung texture patterns are classified
using CNN.37) A method for classifying frontal and lateral chest X-ray images using deep-
learning methods and automating metadata annotations has been reported.38) A new method
of using a 3D CNN for false positive reduction in automatic pulmonary nodule detection in a
volumetric CT scan has been proposed. 3D CNN is able to enter more spatial information and
extract more representative features through a hierarchical architecture, trained with 3-D
samples. The proposed algorithm has achieved high competition metric scores, has been
extensively tested in the LUNA16 Challenge, and can be applied to 3D PET images.

3. AI in breast imaging
Since most mammograms are 2D and the number of data is large, AI images can be
successfully analyzed using deep-learning in natural images. The discovery of breast cancer is

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the detection and classification of tumor lesions, the detection and classification of micro-
calcifications, and risk-scoring work, which can be effectively analyzed by CNN or RBM
methods. For the measurement of breast density, CNNs for feature extraction were used,39)
and a modified region proposal CNN (R-CNN) has been used for localization. It has been
reported that U-net is used for segmentation breast and fibro-glandular tissue in MRI in a
dataset and accurate breast density calculation results are observed.40) It has been reported
that a short-term risk assessment model has been developed by achieving a predictive
accuracy of 71.4% by calculating the risk score by implementing the mammographic X-ray
image as a risk prediction module multiple layer perception classifier.41)

4. AI in cardiac imaging
Cardiac artificial research fields include left ventricle segmentation, slice classification, image
quality assessment, automated calcium scoring, coronary centerline tracking, and super-
resolution (SR). 2D and 3D CNN techniques are mainly used for classification, and deep-
learning techniques such as U-net segmentation algorithm are used for segmentation. The
high-resolution 3D volume in the 2D image stack has been reconstructed using a novel image
SR approach.42) The image quality is superior to the SR method because the CNN model is
computationally efficient, but SR-CNN is advantageous in image segmentation and motion
tracking.43) Using multi-stream CNN (3 views), it has been reported that low-dose chest CT
can be identified with high accuracy by deep learning when the ROI is considered as a
coronary artery calcification candidate over 130 HU.44) Coronary calcium in gated cardiac CT
angiography was detected using 3D CNN and multi-stream 2D CNN.45)

5. AI in musculo-skeletal imaging

Musculo-skeletal images are analyzed by deep-learning algorithms for segmentation and

identification of bone, joint, and associated soft tissue abnormalities. 3D CNN architecture has
been developed to automatically perform supervised segmentation of vertebral bodies from
3D MR spine images, and a ‘Dice’ similarity coefficient of 93.4% has been reached.23)
Automatic spine recognition, including spine location identification and multiple image
naming, requires large amounts of image data, and is difficult to recognize due to the variety
of spine shapes and postures. By using a deep-learning architecture called transformed deep
convolution network, the posture of the spine was automatically corrected to process the
image.46) A CNN regression has a limitation in that its computation time is long and the
capture range is small for implementing an intensity-based 2D/3D registration technology. It

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is reported that highly accurate real-time 2D/3D registration is possible, even in a greatly
enlarged capture range.47) Several deep-learning methods have been developed for
automatically evaluating the age of skeletal bones using X-ray imaging and their performance
has been verified by showing an average discrepancy of about 0.8 years.48)

Discussion

Diagnosis using AI is quickly performed and its accuracy is very high. AI diagnosis is becoming
an important technology for future diagnostic systems. However, AI diagnosis needs to be
supplemented in several aspects. AI learning using deep-learning architecture requires big
data. However, most medical images are technical and man-powered, making it difficult to
build big data systems. It is also time-consuming to create a database of standardized and
labeled images of medical images. Most people are building databases by manually pre-
processing all medical images for AI application. Performing data augmentation through
rotation, left/right flip, and up/down reversal of a medical image has a positive effect on the
accuracy of learning. Data augmentation using GAN is being applied in various areas of the
medical field.21,49) In liver lesion classification using CT images, it was reported that the
accuracy of 7.1% was increased when the number of data using GAN was increased.21) In chest
pathology classification using X-ray image, accuracy was reported to be increased by 21.23%.4
9) It has been reported that synthesized images using GAN can be a method of data

augmentation in medical image analysis. However, more research is needed to see if synthetic
images can be used for AI learning to determine clinical diagnostics that require rigorous
accuracy. Increasing data through the GAN is still controversial, but it is a field of research
that is needed. It is necessary to make the medical image stored in the PACS system into the
image of the previous step for AI analysis. Research is needed to automatically generate
standard images so that medical images can be used directly in deep-learning.

AI analysis of medical images requires labeled, standardized and optimized images. There is a
clear difference in the accuracy of the final classification between pre-processing and non-
pre-processing medical images. However, since the pre-processed image has noise different
from that of the original image, it is necessary to study the effect of the resulting image on the
accuracy. Deep-learning architecture can have various forms, and new excellent architecture
for image analysis is being released every year through competition. However, it is only
through experience that the most accurate result of any architecture can be used for each

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medical image. Therefore, it is necessary for people to apply various deep-learning

architectures to each medical image and then to discuss each other’s experiences to find the
optimal method. Even if one deep-learning model is determined, there are many hyper-
parameters in it. The composition of parameter combinations is often dependent on user
experience. Optimization of Hyper-parameters is usually done through a time-consuming grid
search and random search, but Bayesian optimization and genetic algorithm optimization can
be used efficiently.

Medical imaging diagnostics using deep-learning architecture have reached expert levels in
the areas of neurons, retina, lung, digital pathology, breast, heart, abdomen, and musculo-
skeletal system. However, when other hospital protocols apply different medical images, their
accuracy is significantly reduced and new optimization parameters must be found. Even with
some resolution and noise changes in medical imaging, AI diagnostics are very fragile. There is
also a lack of logical explanations as to which process to diagnose. Although there is an effort
to maintain consistency through data harmonization, there is the possibility that the overall
quality of the image will deteriorate. It is necessary to study the change of the accuracy by
using the data whose resolution is decreased. It is necessary to develop algorithms that can
recognize and generalize images of medical images with different resolutions or noise, but it
will take a considerable amount of time. Nevertheless, the diagnosis of medical images by the
deep-learning architecture developed up till now is almost at expert diagnosis level. In
addition, many data that have not yet been analyzed can be discovered and studied with AI
diagnosis, and this can accurately and quickly diagnose and improve the quality of medical
care dramatically.

Acknowledgements

This research was supported by the project at Institute of Convergence Bio-Health, Dong-A
University funded by Busan Institute of S&T Evaluation and Planning (Grant no: 2020).

The authors would like to thank Dr. Adrian Ankiewicz of the Australian National University
(Australia) for helpful comments on the manuscript.

Conflicts of Interest

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The authors have nothing to disclose.

Availability of Data and Materials

All relevant data are within the paper and its Supporting Information files.

Ethics Approval and Consent to Participate

The study was approved by the institutional review board (IRB approval number; DAUHIRB-17-
108).

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