International Congress Series 1256 (2003) 1005 1010

Intelligent computer-aided diagnosis system for

chest radiography
Mira Park a,*, Jesse S. Jin a,b, Laurence S. Wilson c
a

School of Computer Science and Engineering, University of New South Wales, Sydney, NSW 2052, Australia
b
School of Information Technologies, University of Sydney, Sydney, NSW 2006, Australia
c
Telecommunications and Industrial Physics, CSIRO, NSW 1710, Australia
Received 14 March 2003; received in revised form 14 March 2003; accepted 17 March 2003

Abstract
We present an intelligent computer-aided diagnosis (ICAD) system for chest radiography to merge
radiologic findings or the extracted features into a diagnosis using Multiple Classification Ripple
Down Rule (MCRDR) and fuzzy functions. The ICAD system is a semi-automatic system since the
abnormalities in chest radiographs could be detected by a combination of the automatic system and
radiologists. Based on these abnormalities, the ICAD system suggests the possible disease states.
D 2003 Elsevier Science B.V. and CARS. All rights reserved.
Keywords: Intelligent computer-aided diagnosis; Chest radiography; Incremental knowledge

1. Introduction
Computer-aided diagnosis (CAD) may be defined as a diagnosis made by a physician
who takes into account the result of the computer output as a second opinion [1] and the
final diagnosis is left to the radiologist regarding the possible diseases states. However,
CAD may be considered in decision-making in complex situations, such as with multiple
disease states.
There are three problems to be considered to build such a decision-making system based
on the result of the computer output. First, it has become evident that knowledge of an
expert system provided by the radiologists is always context dependent. However,
radiologists do not normally have complete introspective access to their knowledge. They
tend to give justifications of their considerations rather than a complete explanation. That
means, once the knowledge base is built, it should be increased whenever other consid* Corresponding author. Tel.: +61-2-9372-4117; fax: +61-2-9372-4111.
E-mail address: mirap@cse.unsw.edu.au (M. Park).
0531-5131/03 D 2003 Elsevier Science B.V. and CARS. All rights reserved.
doi:10.1016/S0531-5131(03)00486-2

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M. Park et al. / International Congress Series 1256 (2003) 10051010

erations occur. Second, end users for the system are radiologists and they should be able to
easily maintain the system to increase the knowledge base without an engineers assistance.
Third, to diagnose the possible disease states, the decision-making process needs more
information than the radiologic findings by computers. For example, our image processing
tool is not able to detect the texture or medial border behind the heart, but if there are any
abnormalities, the abnormalities should be used as input for decision-making.
To solve these problems, we present an intelligent computer-aided diagnosis (ICAD)
system, which is a knowledge-based system with the application of machine learning
techniques.

2. Methodology
2.1. System overview
ICAD consists of three levels, which are low-, intermediate- and high-level processing
(see Fig. 1). Low-level processing includes all image analysis schemes such as lung
segmentation, texture analysis, ribs and clavicle detection and hilar region detection.
Intermediate-level processing classifies and describes the image features obtained from
low-level processing for recognition and interpretation of image features. All image
features will be represented by symbolic description using fuzzy functions. High-level
processing has a stronger resemblance to what generally is meant by the term intelligent

Fig. 1. System overview.

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cognition. ICAD system adopts Multiple Classification Ripple Down Rules (MCRDR)
[10], which is an incremental knowledge-based scheme.
2.2. Image processing
Image processing produces image features in the form of numeric data from an input
chest radiograph. There are four modules: lung segmentation, texture analysis, ribs
detection and hilar detection.
2.2.1. Lung segmentation
The lung field is extracted to obtain the boundary information of the lung. The
knowledge-based lung field extraction method, developed by Brown et al. [3] and
extended by Park et al. [4], is applied to segment the lung field from the input chest.
2.2.2. Texture analysis
The lung texture is analysed using Quasi-Gabor filter [5,6], multi-scale classification
and Score Block Operation [7] based on the 2D-discrete Fast Fourier Transform power
spectrum. Lung field is formed as right- and left-lung and each lung field is divided into
upper-, middle- and lower-lung. Lung texture is categorized as normal, dots and
grape-like texture.
2.2.3. Ribs detection
The ribs and clavicles are detected to check the density of the ribs using semi-elliptical
cavity and 4 way with 10 neighbours connectivity [8].
2.2.4. Hila detection
We used a very simple method to detect and measure the hilar region [9]. The hilar
regions are represented as normal, big and small.
2.3. Symbolic processing
This process converts the numeric data obtained from the image processing to the
symbolic descriptions using three fuzzy functions, which are Z-function, C-function and
S-function. The descriptions of features are defined so that some of them, such as ratio,
presence, position, width, size, angle, and density can be represented in linguistic terms.
Some descriptions use the crisp function to report yes or no. For example, the
description of the lung texture is normal, dots or grape-like if one of texture
is detected. In this way, the radiologists, who have to provide the chest radiograph
information needed for both delineation and recognition of image features, can work
with statements with which they are familiar, based on nonnumeric descriptions (i.e.,
linguistic terms) of object features. It is important to note that the compatibility scores
used in the fuzzy sets represent a level of human belief rather than frequencies of
occurrence as in classical probability. Since we are approximating an expert level of
belief, we have generated the fuzzy compatibility functions manually with guidance
from a radiologist.

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2.4. Multiple classification ripple down rule

ICAD employs a MCRDR system to facilitate knowledge-based construction to
diagnose the possible diseases based on the symbolic descriptions which describe the
radiologic finding from the chest radiographs. MCRDR is an incremental knowledge
acquisition technique whose aim is to only use the knowledge in the context provided by
the radiologist; this context being the sequence of rules evaluated to give a certain
conclusion. With this approach, rules are never removed or corrected, only added. This
addition only occurs when the radiologists do not agree with a conclusion supplied by the
system and, then, they wish to add such a conclusion.
MCRCR knowledge base (KB) can be described in terms of courteous logic, which is
the king of labelled logic. A courteous logic program contains two parts, namely, labelled
clauses and Overrides statements, which permit the establishment of a priority-based
policy amongst the rules in a KB. A statement Overrides(P, Q) means that the conclusion
of the rule P will take over the conclusion of the rule Q in an inference process. Then, a
multiple conclusion (mc)-rule is characterised by the following two courteous rules:
hRiConclusionpL1^ L2^ L3 . . .^ Ln
hCiRpC1^ C2^ C3 . . .^ Cm
where L1,. . .,Ln are Boolean conditions derived from the input case; are C1,. . .,Cm the
cornerstone cases associated with the rule R. The cornerstone cases of R are recorded
during the addition of new rules. A MCRDR KB is a logical set of mc-rule defined as
indicated. When a new rule RVis added to the system, the rule RVshould contain the
differences among the cornerstone cases that satisfy the rule and the input cases. In order
to exclude a further case when other stored cornerstone cases satisfy the rule, additional
conditions must be added. The process is repeated until there is no stored cornerstone case
satisfying the rule. In case that a conclusion of the new rule RVreplaces the conclusion of
R, we have to add an Overrides(RV,R) statement to the KB. If the conclusion of RVis new,
then no Override statement is added. It should be noticed that the above is the logical
description of MCRDR, since in real implementation of the system, all the rules are
ordered in an n-ary tree hierarchy.

3. ICAD application for chest radiographs

The ICAD user interface consists of three parts, which are image analysis, inferring and
reclassification. Once a chest radiograph is loaded, the system automatically extracts 37
image features by analysis button and the system indicates the boundary of the right- and
left-lung and the hilar region. If there are any interstitial processes, ICAD system indicates
them, such as grape, fine lines and dots and honeycomb texture. The system enables only
those attributes with abnormalities. There are eight more attributes which can be manually
enabled by radiologists if there are any abnormalities.
By infer button, MCRDR is applied to infer the conclusion based on the enabled
attributes to indicate the abnormalities. If a radiologist agrees with the conclusion, the
radiologist just references the conclusion for the final decision. However, if a radiologist

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Fig. 2. ICAD application for chest radiograph.

does not agree with the conclusion, the radiologist reclassifies the case by adding a new
conclusion to the knowledge base.
Fig. 2 shows an example of ICAD system. It displays a chest radiograph with lung
boundaries, hilar region and lung texture. The attribute board enables the abnormalities
found by the system and suggests the possible disease states. Knowledge-Base Viewer
shows the history of the learning for the case 11. The initial conclusion was normal since
the case 11 was a new case and there was no conclusion for this case (see the root node of
the tree). Mucoviscidosis was added as a conclusion for the case 11 and Other disease
11 and Mucoviscidosis were added again as the new conclusion. The new conclusion
has been added for the case 11, but the most final node of the tree is the current conclusion.

4. Results
We can only evaluate the automatic radiologic finding since ICAD system allows user
input and is learning its cases. We tested 33 chest radiographs including 5 normal cases

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and 28 abnormal cases. ICAD detected all 5 normal cases and detected 260 abnormalities
while the radiologist detected 326 abnormalities in abnormal cases. The result included
213 true positives, 74 false positives and 113 false negatives. Therefore, the sensitivity of
the automatic radiologic finding is 65%. This relatively low sensitivity is biased by poor
performance for some abnormalities (e.g., hila detection) while the sensitivity for high rib
density was 100% and for abnormal lung texture was 82%. The knowledge base was
maintained and increased easily by the radiologist without technical assistance.
5. Discussion
We proposed a new approach to merge the radiologic findings or the extracted features
from the chest radiograph into a diagnosis using MCRDR and fuzzy set. As Abe et al. [2]
proved, clinical parameters can be equally or more important than radiologic findings in the
diagnosis of lung diseases. Therefore, the fuzzy function can be improved by adding
clinical parameters and it is very easy to add more attributes to our ICAD system. We
proved that ICAD system can be adopted for decision-making in complex situations with
many possible attributes.
Acknowledgements
We thank Dr. Bruce Doust, Radiology Department, St. Vincents Hopital, Sydney,
Australia for supplying all testing images and valuable medical verification advices.
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