Vitrea 2. Lung Analysis. version 4.0. User Guide VPMC-8147B

Transcription

1 Vitrea 2 version 4.0 Lung Analysis User Guide VPMC-8147B

2 Vital Images, Inc Protected by U.S. Patents 5,986,662; 6,130,671; 6,219,059; 7,031,504; Other Patents Pending in the U.S. and other countries. VPMC-8147B Vitrea 2 version 4.0 Lung Analysis User Guide No part of this work may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic or mechanical, including photocopying and recording, or by any information storage or retrieval system without permission in writing from Vital Images. Trademarks Vitrea is a registered trademark of Vital Images, Inc. Microsoft, Microsoft Windows, and Microsoft Word are registered trademarks of Microsoft Corporation. Restricted Rights Legend If this software or documentation is delivered to the Department of Defense (DOD) of the U.S. Government, it is delivered with Restricted Rights as follows: Use, duplication or disclosure of the software by the U.S. Government is subject to restrictions as set forth in subparagraph (c)(l)(ii) of the Rights in Technical Data and Computer Software clause at DFARS If this software or documentation is delivered to any unit or agency of the U.S. Government other than DOD, it is delivered with Restricted Rights and use, duplication or disclosure by the U.S. Government is subject to the restrictions as set forth in FAR (c)(2). If the software or documentation is delivered to NASA, it is delivered with Restricted Rights subject to the restrictions set forth in (d) of the NASA FAR Supplement. Limits of Liability and Disclaimer of Warranty VITAL IMAGES SHALL HAVE NO LIABILITY OF ANY KIND FOR ANY DIRECT, INCIDENTAL OR CONSEQUENTIAL DAMAGES BASED ON ANY DEFECT, FAILURE OR MALFUNCTION OF THE SOFTWARE,OR USE OF ANY VITAL IMAGES DOCUMENTATION, WHETHER THE CLAIM IS BASED UPON WARRANTY, CONTRACT, TORT OR OTHERWISE. VITAL IMAGES MAKES NO WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO, ANY WARRANTY OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE WHETHER ARISING FROM STATUTE, COMMON LAW, CUSTOM OR OTHERWISE. Notice of Confidentiality This software and the information in this software including, but not limited to, the ideas, concepts and know-how are proprietary, confidential and trade secret to Vital Images, and the information contained therein shall be maintained as proprietary, confidential and trade secret to Vital Images and shall not be copied or reproduced in any form whatsoever. This software and any information contained therein shall not be disclosed to anyone other than authorized representatives of the user's employer, who is contractually obligated not to disclose same without the express written consent of Vital Images. The user of this software and any information contained therein shall not attempt to discern Vital Images' confidential and trade secret information and shall not reverse compile, disassemble, or otherwise reverse engineer this software or any information contained therein. Software License Notice This software is a licensed product of and is distributed by Vital Images, and may only be used according to the terms of that license on the system identified in the License Agreement. In the event of any conflict between these terms and the terms of any written agreement or agreement assented to through electronic means with Vital Images, the terms of such written or assented agreement shall control. MediMark Europe 11 rue Emile ZOLA, BP 2332, GRENOBLE CEDEX 2, France Tel: Fax: medimark@easynet.fr MediMark Europe is an authorized representative in the European Community and acts on behalf of Vital Images, Inc. in the communication of safety-related incidents and regulatory matters with Competent Authorities in the European Community. Distributors are still the first line of communication with their customers regarding service and complaints. VPMC-8147B

3 Table of Contents Overview Safety and Regulatory Considerations Caution Statements Intended Use HIPAA Compliance Contact Us Licensing Nodule Probe Tools Viewer Window Formats Single Lung Format Basic Comparative Lung Format Advanced Comparative Lung Format Viewer Synchronization Multiple Dataset Viewer Synchronization Global Link Configuration Dialog Local Link Workflows Nodule Detection and Analysis Nodule Boundary Adjustment Simultaneous Baseline and Follow-up Nodule Analysis Follow-up Nodule Analysis using Restored Baseline Snapshot Nodule Segmentation, Measurements, Characteristics Nodule Segmentation Nodule Bounding Boxes Nodule Measurements Nodule Characteristics D Mode Buttons Nodule Management Area Nodule Management List Nodule Management Buttons Nodule Visibility Modes Automatic Nodule Restoration Reporting Printing and Exporting Images Restoring Snapshots from the Report Window Restoring Multi-volume Snapshots from Study Directory VPMC-8147B i of ii

4 Status and Error Messages ii of ii VPMC-8147B

5 Overview The Vitrea Lung Analysis software is intended to be used by thoracic CT radiologists for semi-automatic segmentation and quantification of lung nodules. This separately-licensed option provides tools to manually characterize and classify nodules for lung cancer detection and follow-up. The Lung Analysis software will generate a report summarizing nodule findings and measurements for communication with clinicians, and provide the capability to view side-by-side comparison formats and temporal measurements to evaluate changes in nodule characteristics over time. When segmenting nodules, the Lung Analysis software separates the nodule from vessels and from the chest wall. It can segment Solitary Pulmonary Nodules (SPNs), nodules fed by vessels, and nodules attached to the chest wall. It can segment nodules less than 30mm in diameter. It cannot segment Ground Glass Opacifications (GGOs). For each segmented nodule, Vitrea automatically calculates the following measurements: Volume (mm 3 ) Effective diameter (mm): Diameter of a sphere with the same volume Average/Minimum/Maximum densities (Hounsfield units (HU)) In addition, you can manually specify the following characteristics for each nodule: Lobe Location Shape Border You can also enter and edit observations on each nodule. Using the comparison feature, you can establish correspondence between nodules in two or more studies. Once you establish the correspondence, Vitrea automatically calculates the following temporal measurements between the most recent follow-up scan and the baseline scan: Elapsed time in days Doubling time in days Percent (%) growth in nodule volume You can manually edit the nodule segmentation contour lines. All of the measurements are automatically recalculated when you are done editing. Overview VPMC-8147B 1 of 26

6 Safety and Regulatory Considerations PLEASE READ THIS SECTION CAREFULLY BEFORE USING VITREA. The Safety and Regulatory Considerations section of the Basic Vitrea 2 User Guide contains information that is essential for the safe, effective use of the Vitrea Lung Analysis option. You must understand this information before using this application. Caution Statements CAUTION: You are responsible for reviewing the placement and accuracy of all system-generated nodule boundary contour lines and editing them, deleting them, and drawing new boundary lines wherever necessary. Intended Use Lung Analysis The separately-licensed Lung Analysis option is intended for the review and analysis of thoracic CT images for the purposes of characterizing nodules in the lung in a single study, or over the time course of several thoracic studies. Characterizations include diameter, volume and volume over time. Vitrea automatically performs the measurements, allowing lung nodules and measurements to be displayed. User Guide This manual is intended to be used by customers who have purchased the separately-licensed Vitrea Lung Analysis option. It assumes a working knowledge of Vitrea and familiarity with the concepts covered in the Basic Vitrea 2 User Guide. HIPAA Compliance Vital Images products comply with the Health Insurance Portability and Accountability Act (HIPAA) of It is your responsibility to comply with your organization s HIPAA policies. Contact Us For general, non-technical support questions, contact us through our Web site: For customer technical support, contact us using one of these methods: In the U.S., call the Customer Support line at Outside the U.S., contact your Vital Images distributor. 2 of 26 VPMC-8147B Safety and Regulatory Considerations

7 Go to and: a In the Destination field, select Technical Questions and Support Issues. b Fill out the rest of the form. c Click Send. Send an to support@vitalimages.com. To provide feedback about this document or other Vital Images product documentation, send an to feedback@vitalimages.com. Licensing To use the Lung Analysis software, you must be licensed for Lung Analysis. If you are not properly licensed, a dialog box displays when you try to select the Nodule Analysis preset on the Gallery window. NOTE: If your workstation is not properly licensed for Lung Analysis, you will NOT be able to restore snapshots created on a licensed workstation from the Study Directory or the Report window. FIGURE 1. Protocol and Preset Nodule Probe Tools When you select the Lung CT protocol and Nodule Analysis preset, the following buttons display on the Analysis tab of the Viewer window: Licensing VPMC-8147B 3 of 26

8 FIGURE 2. Nodule Probe Tools Viewer Window Formats Vitrea provides these new Viewer window formats for lung nodule detection: Single lung (volume-by-volume analysis) format Basic comparative lung (side-by-side comparison) format Advanced comparative lung (side-by-side comparison) format NOTE: The basic and advanced comparative lung format buttons are displayed only if you load more than one volume. FIGURE 3. Viewer Window Formats Single Lung Format You use single lung format for slice-by-slice or volume-by-volume review and analysis. This format contains the following views for a single loaded study: MPR views (axial, coronal, and sagittal) 4 of 26 VPMC-8147B Viewer Window Formats

9 3D POI (point-of-interest) volume Semi-transparent 3D lung map Nodule characteristics Basic Comparative Lung Format You use basic comparative lung format for side-by-side comparison. This format contains the following views for a maximum of three loaded studies or volumes: Axial MPR view only Semi-transparent 3D lung map (for two volume display only) NOTE: In comparative lung format, all the views corresponding to the current volume are enclosed by a yellow rectangle. Advanced Comparative Lung Format You use advanced comparative lung format for side-by-side comparison and analysis. This format contains the following views for a maximum of three loaded studies or volumes: Axial MPR view only 3D POI volume Semi-transparent 3D lung map Nodule characteristics NOTE: In comparative lung format, all the views corresponding to the current volume are enclosed by a yellow rectangle. Viewer Synchronization Viewer synchronization (linking) allows you to lock views so visualization and spatial operations can be replicated across views in a locked set. When views are synchronized any manipulations made in one view are immediately reflected in the other synchronized view(s). NOTE: The viewer synchronization feature only applies to MPR views and 3D views. Cine, window/level, pan, zoom, and crosshair can be linked for MPR viewers. Window/level, pan, zoom, crosshair, and rotate can be linked for 3D views. Viewer Synchronization VPMC-8147B 5 of 26

10 Specific presets may have additional link choices. The preset file determines how a particular manipulation is linked. The two choices are: Manual link- you must manually align viewers across datasets to the desired starting points. Auto link - you can start manipulating in one dataset and the other dataset will either take the same value of the first dataset or come up with a corresponding value based on an algorithm. NOTE: When Vitrea is installed, synchronization options in each available preset (with multi-volume view format) in Vitrea are configured based on an estimate of your specific clinical requirements. To change this configuration, contact your System Administrator or Technical Support. Multiple Dataset Viewer Synchronization When multiple datasets for the same patient are loaded into Vitrea s multivolume view format, views of the same type across datasets are synchronized. EXAMPLE: Axial MPR views are linked together and 3D views are linked together. To use multiple dataset manual synchronization/unsynchronization: 1. Load two or three datasets into Vitrea. 2. Select the Basic Comparative Lung (side-by-side comparison) or Advanced Comparative Lung (side-by-side comparison and analysis) Viewer window format. Global Link The Global Link button and dropdown arrow appear when you select a multivolume viewer format. Click the Global Link button on the left panel to set all available views linked or unlinked. FIGURE 4. Global Link Button Global Link Button NOTE: When set, and every view is linked, manipulations performed with Auto Link will have the active dataset as the reference value, and the other datasets take the active dataset s value. 3. Use pan, cine, or crosshair on the same type of MPR view across all datasets to align them to the desired starting points. To use Global Link: NOTE: The Global Link button and dropdown arrow appear only when a multivolume viewer format is selected. 4. Click Global Link. 6 of 26 VPMC-8147B Viewer Synchronization

11 5. The button icon changes to a closed lock, indicating all views in the layout are linked. NOTE: You can also click each Local Link button to link all views. 6. In one of the MPR or 3D views, use pan, cine, crosshair, or another manipulation. 7. The other MPR views or volume views of the same type (but displaying a different dataset) change according to the MPR view being manipulated. EXAMPLE: After going through the datasets halfway, you may decide they need to be realigned. a b c Set all views to unsynchronized using the Global Link button. Realign them to the desired points then synchronize them again. Continue with your workflow. Configuration Dialog The Configuration dialog includes settings found in the loaded preset. Use this dialog to change defaults set in the preset by checking or clearing options shown. To use the Configuration dialog box: 1. Click the dropdown arrow next to the Global Link button. 2. Select Configure. 3. The Configuration dialog box opens, showing settings in the loaded preset. FIGURE 5. Configuration Dialog To save the configuration for use in the current session, clear the Save as default (modified preset) box and click Apply. Viewer Synchronization VPMC-8147B 7 of 26

12 Vitrea 2 version 4.0 Lung Analysis User Guide To save the configuration in a modified preset that is persistent across sessions and Vitrea upgrades, either check the Save as default (modified preset) box and click Apply or press CTRL-P. The configuration applies to all types of viewers in the layout. The Configuration dialog box only shows a subset of the possible configurations that can be set on viewer configuration. You can configure what is linked using the checkboxes displayed but not how these settings are linked they are set in the preset file. NOTE: Zoom and Pan are set to be linked in the preset and cannot be changed using the Configuration dialog. Local Link Each view has a Link/Unlink button in the lower left corner. This button controls the view the button belongs to, adding it or removing it from a link set. Manipulations performed with the Auto Link feature have the active dataset as the reference value, and other datasets take on the active dataset s value. FIGURE 6. Local Link Button Axial view Local Link button (locked) Axial view - Local Link button (locked) Segmented view Local Link button (unlocked) Segmented view Local Link button (unlocked) 8 of 26 VPMC-8147B Viewer Synchronization

13 1. Click on the open lock symbol to add a view to a link. The button icon changes to a closed lock symbol. 2. Click on the button again to remove the view from the link set. The button icon changes to an open lock symbol. Workflows Use the Vitrea Lung Analysis option to perform these workflows: Nodule Detection and Analysis Nodule Boundary Adjustment Simultaneous Baseline and Follow-up Nodule Analysis Follow-up Nodule Analysis using Restored Baseline Snapshot Nodule Detection and Analysis Using the basic nodule detection workflow, you can analyze nodules in one study. The basic nodule detection workflow contains the following tasks: Loading the study and activating the tools Scrolling through axial MPR images Selecting nodules Reviewing nodule measurements and specifying characteristics Changing the nodule displayed in the views Taking snapshots Creating reports To load the study and activate the Lung Analysis tools: 1. On the Study Directory, load the volume. 2. On the Gallery window, select the Lung CT protocol, and the Nodule Analysis preset. Vitrea displays the Viewer window in single lung format. 3. On the Analysis tab, click Select. The cursor changes to a pointed finger. To select or manually add nodules: 4. Locate the nodule in the 3D or MPR view. NOTE: Visual detection is easier on thick MPRs in MIP mode. 5. Click the nodule. Workflows VPMC-8147B 9 of 26

14 NOTE: To select a nodule in a 3D view, press and hold ALT 3D TOOL [left ALT] when you click the nodule. If the area where you click does not contain a nodule, Vitrea displays a message in the status bar: Select another point or CTRL-Select to add an ROI. To manually add a nodule, press CTRL, then click. NOTE: If you want to manually add a nodule in a 3D view, press and hold ALT 3D TOOL [left ALT] + CTRL, then click. Vitrea draws a circle approximately 5 mm in diameter. Repeat steps 4 and 5 as necessary. The cursor changes shape to an hourglass while Vitrea segments the nodule and calculates its measurements. It uniquely labels the nodule and adds it to the Nodule Management list. Vitrea displays a yellow bounding box around the current nodule, displays nodule contour lines on axial MPR slices, and repositions the crosshairs to the center of the nodule. Vitrea displays a green bounding box around all other nodules. To review the nodule measurements and specify characteristics: 6. Review the nodule measurements in the lower right corner of the views. 7. In the Nodule Characteristics view, click the dropdown arrow in any of the following fields to display a list of choices, then select a value: (Lobe) Location: Unspecified (default), Left upper, Left lower, Lingula, Right upper, Right middle, Right lower Shape: Unspecified, Spherical, Triangular, Linear, Oval, Irregular Border: Unspecified, Spiculated, Smooth, Lobulated NOTE: To customize the Shape or Border values, contact your System Administrator or Technical Support. 8. Click in the Comments field to position the cursor, then enter observations about the nodule. 9. Repeat steps 4-8 for other nodules. 10 of 26 VPMC-8147B Workflows

15 FIGURE 7. Viewer Window with Multiple Nodules Vitrea 2 version 4.0 Lung Analysis User Guide To change the nodule displayed in the views: 10. In any view, click within the bounding box of any detected nodule. OR Select a nodule in the Nodule Management list. The views update to display the currently selected nodule. Vitrea highlights the currently selected nodule with a yellow bounding box, and repositions the crosshairs to the center of the nodule. 11. In any view, click within the bounding box of another nodule. OR Press the SPACEBAR to select the next nodule in the Nodule Management list. The views update to display the next selected nodule. 12. Repeat as necessary. Workflows VPMC-8147B 11 of 26

16 When you reach the end of the list, press the SPACEBAR to select the first nodule in the list. To turn off nodule bounding boxes: Clear the Nodule Overlay box. To take snapshots: 13. Click Snap. To save the image in one view as a snapshot, click on the view you want to save. To save the whole window, press and hold CTRL, then click anywhere on the Viewer window. To take a key image snapshot: 14. Click KeyImg. To save the image in one view as a snapshot, click on the view you want to save. To save the whole window, press and hold CTRL, then click anywhere on the Viewer window. The snapshot is listed under the keyimage heading in the Findings list of the Report window. To filter key image snapshots, click the keyimage heading in the Findings list. To create a report: 15. Select the Report tab. 16. Enter Risk Factors, Smoking History, observations and exam impressions. 17. Add snapshots. 18. Create, export, print, or post the report as you would for any other study. Nodule Boundary Adjustment You can edit nodule boundaries, rename nodules, delete specific nodules, or clear all segmentation results using the nodule boundary adjustment workflow. To edit the nodule boundary contour lines: 1. Select the nodule from the Nodule Management list or in one of the views. 2. Click Add. Vitrea displays the nodule boundary contour lines on all of the MPR images in which you can see the nodule. 3. Scroll to an image showing the nodule and examine the contour line. 12 of 26 VPMC-8147B Workflows

17 If the line does not accurately trace the boundary of the nodule, edit it as you would edit a freehand ROI contour line in standard Vitrea. When the mouse cursor changes to a pen shape, it indicates the contour edit is active. FIGURE 8. Editing a Contour Line If an MPR image containing part of the nodule does not contain a contour line, draw a new contour line as you would draw a freehand ROI contour line in standard Vitrea. FIGURE 9. Drawing a Contour Line Vitrea recomputes the segmentation, measurements, and if necessary, any temporal comparison measurements, and updates the display. 4. Review the new nodule measurements. Optional If necessary, edit the nodule characteristics. To step forward or backward through recently performed contour line edits: Click Undo or press UNDO [F11] to step backward or press REDO [F12] to step forward through any recently performed nodule boundary contour line edits. To rename a nodule: 1. Select the nodule you want to rename from the Nodule Management list, or in one of the views. NOTE: You cannot rename matched nodules. 2. Click Rename. The Rename dialog box displays. 3. In the New Name field, enter the new nodule name. 4. Click OK. Workflows VPMC-8147B 13 of 26

18 Vitrea verifies the new name is unique. If the name is valid, Vitrea updates the name. Otherwise, an error message displays. To delete a nodule: 1. Select the nodule you want to delete from the Nodule Management list, or in one of the views. 2. Click Delete or press DELETE or BACKSPACE. Vitrea removes the current nodule from the list. To clear all nodule segmentation results: Click Clear. OR Click Restore. OR Go to the Gallery window and select a different protocol. OR Go to the Study Directory, then load a different study (or) volume. OR Go to the Study Directory, then reload the same volume. Simultaneous Baseline and Follow-up Nodule Analysis You can analyze nodules in baseline and follow-up scans side-by-side, simultaneously. To do so, you must complete the basic nodule detection workflow in all of the scans, then switch to comparative lung format to establish the correspondence between nodules in the separate scans. Once you establish correspondence, Vitrea automatically calculates and displays the temporal measurements. To prepare the volumes for comparison: 1. Load all of the volumes you want to compare. NOTE: You can load a maximum of three volumes. 2. Select the Single Lung (volume-by-volume analysis) Viewer window format button. 3. Complete the basic nodule detection workflow for the baseline scan. 4. Complete the basic nodule detection workflow for the follow-up scan(s). To match nodules: 5. Select the Basic Comparative Lung (side-by-side comparison) or Advanced Comparative Lung (side-by-side comparison and analysis) Viewer window format button. 6. Click Select. 7. Do one of the following: 14 of 26 VPMC-8147B Workflows

19 Vitrea 2 version 4.0 Lung Analysis User Guide In the axial MPR view for the baseline scan, scroll to an image containing the nodule, then click the nodule. OR In the baseline scan, select a nodule from the Nodule Management list. Vitrea highlights the nodule in the Nodule Management list, repositions the crosshairs to the center of the nodule in the baseline scan view, and highlights the nodule bounding box in yellow. Optional You can adjust the baseline scan and follow-up scan to match up in spatial location, zoom level, window/level, etc. by clicking the Link button located on both the baseline and follow-up scans. When you use cine, zoom, pan, window/level, or rotation, these operations are then synchronized between the baseline and follow-up scans. 8. In the follow-up scan(s), press SPACEBAR until you reach the corresponding nodule. Vitrea highlights the nodule in the Nodule Management list, repositions the crosshairs to the center of the nodule in the follow-up scan views, and highlights the nodule in yellow. FIGURE 10. Before Matching 9. In the Nodule Management area, click Match. Workflows VPMC-8147B 15 of 26

20 Vitrea 2 version 4.0 Lung Analysis User Guide Vitrea establishes correspondence, re-labels the follow-up nodules with the corresponding nodule names from the baseline study and horizontally aligns matched nodules in the Nodule Management list. Vitrea calculates and displays the following temporal measurements: Elapsed time in days Percent (%) growth in nodule volume Doubling time in days Temporal measurements display under the individual nodule measurements in all MPR views and, when in 1-up format, in the POI (point-of-interest) view for the most recent scan. NOTE: If you match nodules from three separate volumes, Vitrea calculates two sets of temporal measurements: the first set compares the baseline scan to the first follow-up scan, and the second set compares the first follow-up scan to the most recent follow-up scan. FIGURE 11. After Matching To unmatch nodules: 1. Click a matched nodule in the Nodule Management list. 16 of 26 VPMC-8147B Workflows

21 Vitrea selects all matched nodules and highlights the selected nodules in blue. If you are matching nodules from three volumes, to unmatch only some nodules, click the nodules you do not want to unmatch. Clicking a selected nodule deselects it. 2. Click UnMatch. Vitrea removes the correspondence and re-labels the nodules to their original unique names. Temporal measurements are discarded and cleared. Follow-up Nodule Analysis using Restored Baseline Snapshot You can analyze and compare the nodules in a follow-up scan to nodules in a previously analyzed baseline study by restoring a baseline snapshot while the follow-up study is loaded. To prepare the studies for comparison: 1. Load the baseline and up to two follow-up studies. 2. Restore the baseline study snapshot from the Report window to restore its visualization parameters. NOTE: You restore the snapshot from the Report window after loading all of the volumes so you can keep multiple volumes loaded simultaneously. If you restored the baseline snapshot directly from the Study Directory, Vitrea would only load the baseline study. 3. Complete the basic nodule detection workflow in the follow-up scan(s). 4. Follow the Simultaneous Baseline and Follow-up Nodule Analysis workflow, starting at the comparison portion of the workflow, which starts at step 5. Nodule Segmentation, Measurements, Characteristics When you successfully select a nodule, Vitrea automatically segments the nodule, identifies its boundaries, and draws a bounding box in both the MPR and 3D lung map views, draws contour lines tracing its boundaries on each slice in the study, and calculates and displays nodule measurements from the segmentation results. For each nodule, you can manually enter characteristics and comments. Nodule Segmentation During nodule segmentation, Vitrea performs these tasks: Shows the nodule segmentation in the views, based on the current visualization settings Displays nodule measurements in the MPR views Displays a bounding box of the nodule in axial MPR and 3D views Repositions the crosshair to the center of the nodule in all views Labels and adds the nodule to the Nodule Management list Nodule Segmentation, Measurements, Characteristics VPMC-8147B 17 of 26

22 Nodule Bounding Boxes The bounding box of each nodule displays in yellow in the MPR and 3D views. The bounding box of the current nodule displays in yellow. All other nodule bounding boxes are displayed in green. You can turn the nodule bounding boxes on or off by checking or clearing the Nodule Overlay box. FIGURE 12. Bounding Box in MPR View Nodule Measurements The nodule measurements are displayed in the lower right corner of all MPR or POI views displaying the corresponding volume. 18 of 26 VPMC-8147B Nodule Segmentation, Measurements, Characteristics

23 FIGURE 13. Nodule Measurements Vitrea 2 version 4.0 Lung Analysis User Guide Nodule Characteristics Nodule characteristics are displayed in a separate view: FIGURE 14. Lobe Location Dropdown List 3D Mode Buttons To switch the image displayed in the 3D views between 3D lung map and POI view, click the mode button in the lower right corner of the view. Nodule Segmentation, Measurements, Characteristics VPMC-8147B 19 of 26

24 FIGURE 15. Mode Button in 3D Lung Map View Mode Button Nodule Management Area The Nodule Management Area contains the Nodule Management list and buttons. All segmented nodules are labeled and listed in the Nodule Management list. The Nodule Management area also includes the following three buttons: Rename, Delete, Match/UnMatch. FIGURE 16. Nodule Management Area Nodule Management List If you have one loaded volume, the list will contain one column. If you have multiple loaded volumes, the list will contain multiple columns. Each column contains nodules from its corresponding loaded volume. You can load a maximum of three volumes simultaneously, so the list can contain a maximum of three columns. The columns are organized in chronological order. The oldest scan displays on the left. The newest scan displays on the right. A yellow rectangle highlights the column corresponding to the active or current volume. 20 of 26 VPMC-8147B Nodule Management Area

25 In each column, the currently displayed nodule is highlighted in blue. As you add nodules, the most recently added nodule automatically becomes the current nodule. NOTE: You can navigate sequentially through nodules in the current volume using the SPACEBAR. Nodule Management Buttons When Vitrea successfully segments a nodule and places it in the Nodule Management list, it assigns it a sequential nodule name. You use the Rename button if you want to give it a unique name. You use the Delete button to remove a nodule from the list. You use the Match/UnMatch buttons to establish or remove correspondence between nodules from one volume or scan and nodules from another volume or scan. Correspondence is most often established to compare nodules in baseline and follow-up scans to track change in a nodule over time. Nodule Visibility Modes You can view the segmented nodules independently and in reference to other anatomy by changing Object Visibility options on the Visual tab. When the Nodule Analysis preset is selected, the Object Visibility area includes these tabs: Standard Vitrea Sculpt tab Nodules tab FIGURE 17. Nodules Tab The Nodules tab contains these visibility options: Transparent Background - Nodules display normally. The segmented volume is visible. Nodules Only - Nodules display normally. The rest of the image is transparent. Semi-Transparent Background - Nodules display normally. The segmented volume is semi-transparent. Nodule Visibility Modes VPMC-8147B 21 of 26

26 Tinted Nodules - The nodules are tinted cyan. The rest of the image displays normally. Show All - (Default) The entire image displays normally. NOTE: The Object Visibility option you select always impacts the volume in the 3D view. If you want the MPR images to reflect this option as well, check the Show Seg box on the Visual tab. Automatic Nodule Restoration If you load a scan with worked up results, Vitrea detects the results available and places a Restore Nodules button in the area of the appropriate scan. FIGURE 18. Restore Nodules 1. Click Restore Nodules to restore the list of previously detected nodules. 2. When the results of more than one scan are available, Vitrea restores the most recent previous scan. If the second scan was worked up with the first scan loaded, then nodules of both scans are restored, including temporal measurements of matched nodules. NOTE: Automatic restore is independent of the snapshot restore feature. You can still restore any snapshots. If the snapshot contains a list of nodules and is restored before you click the Restore Nodules button, then the Restore Nodules button disappears. Reporting You can create Vitrea reports of studies worked up using the Lung Analysis software. The Lung Analysis option generates a lung report that contains patient information, Patient Risk Factors and Smoking History text areas, an overall summary, nodule-by-nodule findings, and measurements. All of the automatic nodule measurements, manually entered characteristics, and temporal data 22 of 26 VPMC-8147B Automatic Nodule Restoration

27 collected during the analysis workflow(s) automatically populates fields in the report template. You can also manually add pages, images, and annotations to the report like you would in standard Vitrea. Printing and Exporting Images You can print and export images containing nodule segmentation and measurements in secondary capture format the same way you would for standard Vitrea images. For detailed information about printing and exporting images, see the Basic Vitrea 2 User Guide. NOTE: You cannot export primary DICOM images using the Lung Analysis option. Restoring Snapshots from the Report Window You can create snapshots containing nodule segmentation and measurement results. You can restore snapshots containing nodule segmentation and measurements results. You can restore snapshots on the same workstation or on a different workstation. You save and restore single-volume snapshots the same way you would for any study in Vitrea. You save multi-volume snapshots the same way you would for any single volume in Vitrea. However, when you restore a multi-volume snapshot, you must be sure the same volumes are loaded as when you saved the original snapshot, or the results could be different. CAUTION: When you restore the workflow to the Viewer window, you lose all manually added pages, images, and annotations. To save a snapshot: Follow standard Vitrea procedures. For detailed information about saving snapshots, see the Basic Vitrea 2 User Guide. To restore a single-volume snapshot: Follow standard Vitrea procedures. For detailed information about saving snapshots, see the Basic Vitrea 2 User Guide. To restore a multiple-volume snapshot: 1. Load all of the appropriate volumes before restoring the snapshot. If you try to restore the snapshot when NOT all of the appropriate volumes are loaded, the following dialog box displays. Reporting VPMC-8147B 23 of 26

28 FIGURE 19. Too Few Volumes Loaded 2. Click Cancel. CAUTION: Attempting to restore the snapshot without loading all of the associated volumes may yield different results than the original calculations. 3. Load all of the appropriate volumes. 4. Restore the snapshot. For detailed information about restoring snapshots, see the Basic Vitrea 2 User Guide. Restoring Multi-volume Snapshots from Study Directory You can restore a multi-volume snapshot from the Study Directory. However, you should be sure you select all of the associated volumes when restoring the snapshot. To restore a multi-volume snapshot from the Study Directory: 1. In the patient list select the study you want to load. All available snapshots for the selected study display in the preview pane. 2. In the preview pane, select the snapshot you want to restore. 3. Click Restore Snapshot. Vitrea loads all volumes associated with the snapshot (volumes that were loaded when the snapshot was saved) and restores the workflow. Or, if any of the associated volumes are no longer available on the workstation, the following warning dialog box displays. If you receive this 24 of 26 VPMC-8147B Restoring Multi-volume Snapshots from Study Directory

29 dialog box, click OK to load the available volumes, or click Cancel to return to the Study Directory. CAUTION: It is possible to restore a snapshot associated with multiple volumes without loading all of the associated volumes. Doing so may yield different results. FIGURE 20. Notification of Missing Volumes To restore select volumes from a multi-volume snapshot: 1. In the patient list on the Study Directory, select the volume you want to load. All available snapshots for the selected volume display in the preview pane. 2. In the preview pane, select the snapshot you want to restore. 3. Click Snapshot Volumes. This dialog box displays: FIGURE 21. Volume Selection Notification 4. Select the volume(s) you want to load. Restoring Multi-volume Snapshots from Study DirectoryVPMC-8147B 25 of 26

30 OR NOTE: The volume you chose in step 1 will not be listed, but will be loaded by default. Check Select All to select all volumes listed. 5. Click Restore. Status and Error Messages Status and error messages are displayed in the status bar at the bottom of the window. As you load studies, Vitrea displays a progress bar to indicate segmentation progress. You can begin scrolling through the slices before segmentation is complete, but you cannot select nodules until the progress bar reaches 100%. 26 of 26 VPMC-8147B Status and Error Messages