PET segmentation of bulky tumors: Strategies and workflows to improve inter-observer variability

Elisabeth Pfaehler, Coreline Burggraaff, Gem Kramer, Josée Zijlstra, Otto S Hoekstra, Mathilde Jalving, Walter Noordzij, Adrienne H Brouwers, Marc G Stevenson, Johan de Jong, Ronald Boellaard

Research output: Contribution to journalArticleAcademicpeer-review

16 Citations (Scopus)


BACKGROUND: PET-based tumor delineation is an error prone and labor intensive part of image analysis. Especially for patients with advanced disease showing bulky tumor FDG load, segmentations are challenging. Reducing the amount of user-interaction in the segmentation might help to facilitate segmentation tasks especially when labeling bulky and complex tumors. Therefore, this study reports on segmentation workflows/strategies that may reduce the inter-observer variability for large tumors with complex shapes with different levels of user-interaction.

METHODS: Twenty PET images of bulky tumors were delineated independently by six observers using four strategies: (I) manual, (II) interactive threshold-based, (III) interactive threshold-based segmentation with the additional presentation of the PET-gradient image and (IV) the selection of the most reasonable result out of four established semi-automatic segmentation algorithms (Select-the-best approach). The segmentations were compared using Jaccard coefficients (JC) and percentage volume differences. To obtain a reference standard, a majority vote (MV) segmentation was calculated including all segmentations of experienced observers. Performed and MV segmentations were compared regarding positive predictive value (PPV), sensitivity (SE), and percentage volume differences.

RESULTS: The results show that with decreasing user-interaction the inter-observer variability decreases. JC values and percentage volume differences of Select-the-best and a workflow including gradient information were significantly better than the measurements of the other segmentation strategies (p-value<0.01). Interactive threshold-based and manual segmentations also result in significant lower and more variable PPV/SE values when compared with the MV segmentation.

CONCLUSIONS: FDG PET segmentations of bulky tumors using strategies with lower user-interaction showed less inter-observer variability. None of the methods led to good results in all cases, but use of either the gradient or the Select-the-best workflow did outperform the other strategies tested and may be a good candidate for fast and reliable labeling of bulky and heterogeneous tumors.

Original languageEnglish
Article numbere0230901
Pages (from-to)e0230901
Issue number3
Publication statusPublished - 2020


  • Algorithms
  • Humans
  • Image Processing, Computer-Assisted/methods
  • Neoplasms/diagnostic imaging
  • Observer Variation
  • Positron-Emission Tomography
  • Tumor Burden
  • Workflow

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