IEEE International Workshop on Imaging
Systems and Techniques – IST 2008
Chania, Greece, September 10–12, 2008
Automatic Segmentation of the Lung Fields in
Portable Chest Radiographs based on Bézier
Interpolation of Salient Control Points
Dimitris K. Iakovidis
Dept. of Informatics and Computer Technology
Technological Educational Institute of Lamia
Lamia, Greece
dimitris.iakovidis@ieee.org
Abstract—Portable chest radiographs are performed on the most
critically-ill patients, who need highly skilled patient care and the
best diagnostic tools. However, such radiographs are usually of
low quality, mainly due to misaligned body positioning during
their acquisition, and subject to a higher misinterpretation rate
than the ones obtained with a non-portable x-ray device. This
paper presents a pioneering computational approach that copes
with the segmentation of the lung fields in portable chest
radiographs. The proposed methodology involves detection of
salient points on the anatomic structures around the lung fields
by subsequent application of simple intensity and edge feature
extraction techniques. The salient points detected are
interpolated using Bézier curves intuitively approximating the
boundaries of the lung fields. Unlike current methodologies, the
proposed one does not exclude the overlapping region of the
heart from the lung fields, where abnormalities can also be
present. The results illustrate the robustness of the proposed
methodology on a set of real portable radiographs of patients
with bacterial pulmonary infections. A qualitative comparison
with a state of the art approach based on graph cuts validates its
effectiveness.
Keywords-image segmentation; portable chest radiography;
salient points, Bézier curves; lung; infections
I. INTRODUCTION
Radiography is a valuable tool to chest screening providing
useful information for the prevention and diagnosis of various
diseases [1]. Plain chest radiographs are usually obtained in a
controlled setup where the patients are positioned in a standard
way at the x-ray device. However, in the case of critically ill
patients, this is not always feasible as they may be in pain or
disabled. To cope with this problem, portable x-ray devices are
commonly used to obtain the radiographs from various relative
distances and angles to the patient who is immobilized in bed -
not necessarily in the preferred position. Portable radiographs
are usually of low quality mainly because of misaligned body
positioning during their acquisition [2]. Consequently, they are
more difficult to read and subject to a higher misinterpretation
rate. A methodology that would automatically analyze such
radiographs would be an asset to the medical community.
A variety of image processing and analysis methodologies
has been proposed for the segmentation of plain chest
This work was supported in part by the European Commission’s Seventh
Framework Information Society Technologies (IST) Programme, Unit ICT for
Health, project DEBUGIT (no. 217139).
978-1-4244-2497-9/08/$20.00 ©2008 IEEE
George Papamichalis
st
1 Dept. of Thoracic Surgery
Chest Hospital of Athens “Sotiria”
Athens, Greece
radiographs. Many of them have focused on the segmentation
of the lung fields, whereas fewer have focused on the
segmentation of the rib cage or other anatomic structures of the
chest [3]. The importance of the segmentation of the lung fields
becomes obvious considering that it is a prerequisite for almost
any computational radiographic image analysis task. Lung field
segmentation approaches that have been proposed include rule-
based methodologies [5]-[10], machine learning algorithms
[11]-[13], active shape models [4][14]-[17], and graph cuts[18].
The studies [5]-[10] indicate that the segmentation
performance of the existing rule-based methodologies usually
degrades if the quality of the radiograph is poor or the
positioning of the patient deviates from the standard. Machine
learning algorithms and active shape models can be less
affected by a patient’s positioning; however, they both require
training, which makes them dependent on the subjective choice
of representative training samples. The methodologies reported
in [14],[16],[17] have been mainly evaluated on radiographs of
normal or minimally distorted lungs. Robustness against the
presence of abnormalities that interfere with the interior
intensities of the lungs has been demonstrated in [4],[15] using
active shape models. The graph cuts algorithm proposed in [18]
is the most recent of the limited approaches coping with
unsupervised segmentation of abnormal lung fields. It is based
on morphological operations for obtaining an initial estimate of
the region of the lung boundaries, and dilates the contour
obtained by graph cuts within a potential contour band. The
evaluation of this algorithm on a limited set of standard
radiographs of patients infected with severe acute respiratory
syndrome (SARS) showed that although it exhibits some
resistance to boundary discontinuities and noise, the detected
boundaries of the lung fields are affected by the edges of the
ribs and result in a rough output contour.
To the best of our knowledge, the problem of lung field
segmentation in portable chest radiographs has not been
previously addressed. In this paper we accept the challenge of
coping with automatic segmentation of the lung fields in
portable chest radiographs, and we propose a novel
methodology that is resistant to patient positioning, to
boundary discontinuities, and to the presence of abnormalities
interfering with the interior intensity of the lungs.
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 The proposed methodology involves detection of salient P2
points on the anatomic structures around the lung fields by Internal control points
subsequent application of simple intensity and edge feature
extraction techniques. The salient points detected, are
P1
interpolated using Bézier curves [19] smoothly approximating
the boundaries of the lung fields.
The rest of this paper consists of three sections. Section II Piecewise linear interpolation
presents the proposed lung field segmentation approach. Its
performance is evaluated in Section III, and a summary of P3
conclusions derived from this study is provided in the last Bézier interpolation
section.
P0
II. PROPOSED APPROACH
Figure 1. Bézier vs piecewise linear interpolation of four points.
A. Overview
ive thresholding algorithm identifies the intensities of the
The proposed methodology assumes that: (1) the patient’s
anatomic structures lying in the region of the spine by accumu-
body may not necessarily be aligned with the portable x-ray
accumulating the most frequent intensities of samples acquired
device, since the patient may be immobilized in bed; (2) the
from the detected spine points. Using only the most frequent
spine lies roughly somewhere in the middle of the radiograph,
intensities from each sample, the possibility of discarding
considering that the radiograph displays both the patient’s
intensities belonging to the lung fields is minimized. Moreover,
lungs; (3) the spine and the bones of the ribcage are the densest
all the intensities that are higher than those belonging to the
structures visible in a chest radiograph [20], and consequently
region of the spine are also set to zero, since they are unlikely
they are generally characterized by higher intensities than other
to belong to the lung fields. It is worth noting that the resulting
anatomic structures.
thresholded image will have zero intensities not only between
Based on these assumptions, points belonging to the densest the lung fields, but also in other regions of similar densities,
structures bounding the lung fields are detected. As indicated in including the diaphragms which define the lower boundaries of
[10] the local maxima of the horizontal and vertical image the lung fields.
profiles - i.e. signals produced by averaging image intensities
The inner lung field boundaries are then determined by the
across columns and rows, respectively - can be useful for the
maximum edge points between the spine and the lung fields
detection of such points. However, in the case of portable
(Subsection II.C: Step 5). The edges are obtained via
radiographs the local maxima corresponding to the structures
convolution with directional Sobel edge detectors [21]. This
bounding the lung fields are not located in particular positions
way, unlike current approaches [3]-[13],[15]-[18], the proposed
as in the case of the stationary radiographs used in [10]. To
one does not exclude the overlapping region of the heart from
cope with this problem, the proposed approach involves
the lung fields, where abnormalities can also be present [1]. A
additional steps (Subsection II.C: Steps 2 and 3) for selecting
similar approach is followed for the detection of the lower lung
local maxima of the horizontal profiles corresponding to the
field boundaries (Subsection II.C: Step 6). In both cases the
spine and to the outer left and right boundaries of the lung
resulting points are plenty but include many outliers, most of
fields. Local maxima with intensities deviating from the
which can be discarded by using a k nearest neighbor approach.
average intensities of each boundary are discarded as outliers.
The remaining salient points from the outer, the inner and
Considering that the region of the spine is typically
the lower boundaries of each lung field are smoothly
characterized by the highest intensities in a radiograph, the
interpolated using Bézier curves. The subsequent curves are
inner lung field boundaries will be more or less identifiable by
finally manipulated so that they form continuous closed curves
their edges. These edges will be less prevalent in regions where
segmenting the lung fields.
the lung fields exhibit higher intensities such as the region of
the heart, and regions with abnormalities appearing as bright
shadows next to the inner lung field boundaries. The B. Bézier interpolation
determination of these edges becomes even more difficult if the Given a set of control points P0, P1, …,Pn, a Bézier curve is
airing of the lungs is poor during the acquisition of the estimated according to the equation
radiograph, which is usually the case in portable radiography as
practiced in intensive care units. However, even if the inner n
⎛n⎞
lung field edges are prevalent they could easily get confused B(t ) = ∑ ⎜⎜ ⎟⎟ Pi (1 − t ) n − i t i (1)
with the edges of the ribs within the lung fields. i =0 ⎝ i ⎠

In order to minimize the likelihood of such confusions, the where t ∈ [0,1] .

intensities of the anatomic structures lying in the region of the
spine are set to zero via a novel selective thresholding
algorithm. This algorithm results in an auxiliary image referred
to as thresholded (Subsection II.C: Step 4) which is utilized in
the subsequent steps of the proposed methodology. The select-
Bézier curves are intuitively controlled by the detected
salient points, in the sense that the curve is attracted by the
internal control points, without necessarily passing through
them (Fig. 1). This provides several advantages over other

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interpolation methods that include insensitivity to outliers, and
production of smoother curves.

C. Algorithmic implementation
The salient control points of a radiograph I of N×M pixels,
are detected and interpolated as follows (Fig. 2):
Step 1. Detect local maxima of horizontal profiles.
a) Acquire sh consecutive non-overlapping rectangular (a) (b)
samples of h×M, h<N pixels from the whole image.
b) For each sample calculate its average horizontal
profile.
c) Detect the local maxima of each profile (white points
in Fig.2b).
Step 2. Detect the central, the left and the right columns
(indicated in black in Fig. 2b)
(c) (d)
a) Acquire sv non-overlapping rectangular samples of
N×w, w<M pixels from the whole image.
b) For each sample calculate the average intensity.
c) The central column C is the one with the maximum
average intensity within columns M/2-M/4 and
M/2+M/4.
d) The left column L is the one with the maximum
average intensity within columns 0 and M/2-M/4.
e) The right column R is the one with the maximum (e) (f)
average intensity within columns M/2+M/4 and M-1.
Step 3. Approximate the spine, and the outer left and right
boundaries of the left and the right lung field
respectively.
a) For each of the sh samples
- The points closest to C are considered as spine
points.
- The points closest to the left side of column L+(C- (g) (h)
L)/2 (left white column in Fig. 2b) are considered
to belong to the outer left boundary of the left lung
field.
- The points closest to the right side of column
R+(R-C)/2 (right white column in Fig. 2b) are
considered to belong to the outer right boundary of
the right lung field.
b) For each set of detected points discard outliers. (i) (j)
c) Interpolate the remaining points of each set (Fig. 2c). Figure 2. Steps of the proposed methodology for the segmentation of
a portable chest radiograph.
Step 4. Threshold all the intensities of I corresponding to
anatomic structures lying in the region of the spine. Step 5. Detect edge points of the inner right and left
a) For each spine point acquire a square sample of x2 boundaries of the left and the right lung field
pixels. respectively.
b) Calculate the intensity histogram of each sample. a) Convolve I with the vertical 3×3 Sobel operator
c) Sum up the largest histogram components of all having the negative signs on the left to obtain a map
samples into a single histogram. Evl(I) of vertical left image edges (Fig. 2e).
d) Find the last non-zero component m of the resulting b) Convolve I with the vertical 3×3 Sobel operator
histogram. having the negative signs on the right to obtain a map
e) Set the intensities that correspond to non-zero Evr(I) of vertical right image edges (Fig. 2f).
histogram components, and the intensities that are c) For each row start from the spine point and move left
larger than m, to zero, to obtain a thresholded image to find the point of Evl(I) with the maximum intensity
T(I) (Fig. 2d). for which T(I) has zero intensity.

84
 100%
d) For each row start from the spine point and move
right to find the point of Evr(I) with the maximum
95%
intensity for which T(I) has zero intensity.
e) Discard points deviating from the average horizontal 90%
position of its k nearest neighbors as outliers.

Accuracy
f) Interpolate the detected points (Fig 2g). 85%

Step 6. Detect edge points of the lower boundaries of the 80%

lung fields.
a) Convolve I with the horizontal 3×3 Sobel operator to 75%
obtain a map Eh(I) of horizontal image edges (Fig.
2h). 70%
b) For each column start from row M-1 and move 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
upwards to find the point of Eh(I) with the maximum h (pixels)

intensity for which T(I) has zero intensity. (a)

c) Discard points deviating from the average vertical
position of its k nearest neighbors as outliers. 100%

d) Interpolate the detected points (Fig 2i).

95%
Finally, the interpolating Bézier curves estimated in steps
3c, 5f and 6d, are cropped or extended so that they form 90%

Sensitivity
continuous closed curves segmenting the lung fields (Fig.2j).
85%
This algorithm was developed in Java using a custom
image processing and analysis framework providing cross- 80%
platform compatibility.
75%
III. RESULTS
70%
The effectiveness of the proposed methodology was 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
evaluated on a set of twenty four anonymous radiographs h (pixels)
obtained with a portable x-ray device from patients with
pulmonary bacterial infections hospitalized in an intensive care (b)
unit of the Chest Hospital of Athens “Sotiria”. Such infections
100%
produce abnormalities most usually manifested as
consolidations that are visible as bright shadows interfering
95%
with the interior intensities of the lungs [1],[2].
The segmentation performance was assessed in terms of 90%
Specificity

accuracy, sensitivity and specificity, which are defined by the

following equations: 85%

TP + TN (2) 80%
accuracy =
TP + TN + FP + FN
75%
TP (3)
sensitivity =
TP + FN 70%
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
TN (4) h (pixels)
specificity =
TN + FP
(c)
where TP is the number of true positive pixels, TN is the Figure 3. Results obtained with the proposed methodology for a
number of true negative pixels, FP is the number of false range of values h, in terms of average (a) accuracy, (b) sensitivity,
positive pixels, and FN is the number of false negative pixels. and (c) specificity. The error bars depict the corresponding standard
The ground truth region of the lung fields has been designated deviations.
by an expert.
error bars, the average segmentation performance is not
All radiographs used in the experiments have been digitized affected significantly by the selection of h. Best segmentations
at 8 bits and have been downscaled to fit a 256×256-pixel were obtained for h=9 and h=17. The sensitivity and the
bounding box. The parameters used in the experimental study specificity in the former case reached 95.3% and 94.3%, and in
presented in this paper include w=h, x=32, and k=5. Figure 3 the latter 95.0% and 93.6%. Indicative segmentations are
illustrates the results obtained with the proposed methodology illustrated in Fig. 2j and Fig. 4. In both cases the lung fields
using different values of h. As indicated by the overlapping appear misaligned; whereas the boundaries of the right lung

85

(a) (b)
Figure 4 Portable radiograph of a patient with bacterial pulmonary
infection. (a) Original. (b) Segmented using the proposed
methodology.
(a) (b)
Figure 5. Segmentation of radiographs obtained from patients
infected with SARS, using the proposed methodology. The original
images have been obtained from [18], where segmentation results
with various methodologies are also provided.
field in Fig. 4 are hardly distinguishable even by an expert. As
noted in the introduction, current lung field segmentation
methodologies do not cope explicitly with the segmentation of
portable chest radiographs. However, the state of the art
methodology presented in [18], which has been proposed for
lung field segmentation in standard radiographs, could be
considered as the most relevant methodology to compare with,
since it is also unsupervised and it copes with infected lung
fields. The results from the application of the proposed
methodology on the images presented in [18] are illustrated in
Fig. 5. The obtained segmentations are less noisy than the ones
presented in [18], illustrate higher sensitivity, whereas the
region of the heart overlapping the lung fields has not been
excluded, enabling the detection of possible abnormalities even
behind the heart.
IV. CONCLUSIONS
We presented a novel methodology for automatic
segmentation of portable chest radiographs. It is capable of
detecting salient points which are intuitively interpolated via
Bézier curves.
The following major conclusions can be derived from the
experimental evaluation of the proposed methodology:
• it produces accurate segmentation of portable
radiographs regardless of the patients’ positioning;
• it generally remains unaffected by the presence of
abnormalities originating from bacterial pulmonary
infections;
86
• it achieves smoother delineation of the lung field
boundaries than the state of the art methodology based
on graph cuts [18];
• unlike current methodologies, it does not exclude the
overlapping region of the heart from the lung fields,
where abnormalities can also be present.
Future objectives include enhancement of the proposed
methodology with shape prior information, further
experimentation with larger datasets and comparisons with
other state of the art methodologies. The perspectives of this
research extend to the development of a multimodal data
mining system for adverse events detection, which will be
capable of co-evaluating radiographic findings of patients with
bacterial infections [22].
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