Deep learning aided oropharyngeal cancer segmentation with adaptive thresholding for predicted tumor probability in FDG PET and CT images.

 Tumor segmentation is a fundamental step for radiotherapy treatment planning. To define an accurate segmentation of the primary tumor (GTVp) of oropharyngeal cancer patients (OPC) each image volume is explored slice-by-slice from different orientations on different image modalities. However, the manual fixed boundary of segmentation neglects the spatial uncertainty known to occur in tumor delineation. This study proposes a novel deep learning-based method that generates probability maps which capture the model uncertainty in the segmentation task. We included 138 OPC patients treated with (chemo)radiation in our institute. Sequences of 3 consecutive 2D slices of concatenated FDG-PET/CT images and GTVp contours were used as input. Our framework exploits inter and intra-slice context using attention mechanisms and bi-directional long short term memory (Bi-LSTM). Each slice resulted in three predictions that were averaged. A 3-fold cross validation was performed on sequences extracted from the axial, sagittal, and coronal plane. 3D volumes were reconstructed and single- and multi-view ensembling were performed to obtain final results. The output is a tumor probability map determined by averaging multiple predictions. Model performance was assessed on 25 patients at different probability thresholds. Predictions were the closest to the GTVp at a threshold of 0.9 (mean surface DSC of 0.81, median HDof 3.906 mm). The promising results of the proposed method show that is it possible to offer the probability maps to radiation oncologists to guide them in a in a slice-by-slice adaptive GTVp segmentation.