A Convolutional Neural Network Combined With Positional And Textural Attention For The Fully Automatic Delineation Of Primary Nasopharyngeal Carcinoma On Non-Contrast-Enhanced Mri

Background: Convolutional neural networks (CNNs) have the potential to automatically delineate primary nasopharyngeal carcinoma (NPC) on magnetic resonance imaging (MRI), but currently, the literature lacks a module to introduce valuable pre-computed features into a CNN. In addition, most CNNs for primary NPC delineation have focused on contrast-enhanced MRI. To enable the use of CNNs in clinical applications where it would be desirable to avoid contrast agents, such as cancer screening or intra-treatment monitoring, we aim to develop a CNN algorithm with a positional-textural fully-connected attention (FCA) module that can automatically delineate primary NPCs on contrast-free MRI.Methods: This retrospective study was performed in 404 patients with NPC who had undergone staging MRI. A proposed CNN algorithm incorporated with our positional-textural FCA module (A(proposed)) was trained on manually delineated tumours (M-1st) to automatically delineate primary NPCs on non-contrast-enhanced T2-weighted fat-suppressed (NE-T2W-FS) images. The performance of A(proposed), three well-established CNNs, Unet (A(unet)), Attention-Unet (A(att)) and Dense-Unet (A(dense)), and a second manual delineation repeated to evaluate human variability (M-2nd) were measured by comparing to the reference standard M-1st to obtain the Dice similarity coefficient (DSC) and average surface distance (ASD). The Wilcoxon rank test was used to compare the performance of A(proposed) against A(unet), A(att), A(dense) and M-2nd.Results: A(proposed) showed a median DSC of 0.79 (0.10) and ASD of 0.66 (0.84) mm. It performed better than the well-established networks A(unet) [DSC =0.75 (0.12) and ASD =1.22 (1.73) mm], A(att) [DSC =0.75 (0.10) and ASD =0.96 (1.16) mm] and A(dense) [DSC =0.71 (0.14) and ASD =1.67 (1.92) mm] (all P<0.01), but slightly worse when compared to M-2nd [DSC =0.81 (0.07) and ASD =0.56 (0.80) mm] (P<0.001).Conclusions: The proposed CNN algorithm has potential to accurately delineate primary NPCs on non-contrast-enhanced MRI.