Materia Medica Malaysiana

Scanning through 3D medical images

AS FAR as software engineering is concerned, 3D medical imaging systems for displaying MRI or CT scan data have become the thing to do, it seems. Apart from the tremendous commercial possibilities, such systems are also proving to be extremely useful to radiologists and surgeons who need to take a peek into a patient without cutting him or her up into little pieces.

Barely a month after we ran a story on such a system (see In.Tech, Sept 9), we’ve stumbled across yet another group of individuals eager to display their very own 3D medical imaging system, called Uppercut3D.

Graphic Imaging Solutions Sdn Bhd, the local marketing agent for Uppercut3D, recently held a demonstration to promote the system to the public (mostly people in the medical field). The press kit and posters littering the exhibition hall showed some rather nice looking computer-rendered images of someone’s spinal cord, flanked by two kidneys. Obviously, the system was capable of producing very high-quality 3D graphics, something which its designers were keen to point out.

Before the presentation, I spoke to Dr Khoo Ee Win, a senior registrar with the Radiology Department at the Queen Elizabeth Hospital, South Australia. He had a big badge with the words “Uppercut3D” in bright colours, which meant that he probably had something to do with the event. After a bit of small talk on the current state of medical imaging and various other things, I asked Dr Khoo if Graphic Imaging Solutions was going to demonstrate the software.

“Sure, I’ll be giving you a demonstration of the software ... from my laptop,” he said.

“You mean you’re going to show me some videoclips and screenshots of Uppercut3D from your laptop, right?” I said, attempting to correct him.

“No, I’ll be running the actual program from my laptop,” he asserted, with a deadpan look.

This was a surprise. Normally, if you want to get your hands on a 3D medical imaging system you’d have to either purchase some exotic, specialised computer hardware or establish links with certain government-funded organisations so that they can buy the system for you, in the likely event that you can’t afford it. And that’s before you even buy the equally pricey imaging software to run on the system.

Now, here I was, standing in front of a very humble looking laptop, watching as Dr Khoo flipped, cropped, sliced and rotated a very highly detailed 3D representation of somebody’s skull in real-time, on his laptop’s monitor.

“This person was involved in a motor accident and smashed his face into a steering wheel. You can clearly see the extent of the fracture and make accurate measurements here and here,” said Dr Khoo, pointing at two gaps on the person’s badly broken jaw. Not only was the image frighteningly realistic, it looked really painful too.

“So, who wrote this software, then?” I asked.

“I did ...” he replied, with a slight grin.

Home-brewed
It turns out that whenever night falls, the mild mannered radiologist reveals his true identity; he’s actually a computer programmer. In fact, he’s the founder of Uppercut.com Pty Ltd in Australia, the company which handles the R&D for Uppercut3D.

Dr Khoo first saw the need for a 3D imaging tool during his undergraduate training, when he saw the difficulty doctors had in manipulating images obtained from CT and MRI scans.

“I took on the challenge of creating a 3D visualisation system, something which the big companies and vendors did not offer at the time. As an undergraduate medical student, I formed a team of programmers with friends to develop 3D volume rendering software. Within a couple of weeks everyone dropped out. Undaunted, I persevered on my own, but slowed down the development to complete my medical studies,” explained Dr Khoo.

“On completion of my medical course, I invited three people to form a team to speed up the programming. Ensuring the product was bug free was a major challenge, as was getting compatible hardware configuration.

“I spent almost all my free time after work and on weekends on the project, very often till the wee hours of the morning. I sacrificed a lot of my social life to singularly focus on the success of this program,” said Dr Khoo.

Like all 3D medical imaging systems, Uppercut3D relies on volume rendering with voxels (individual coloured pixels), rather than surface rendering with polygons. Voxels require far more processing power to render than polygons. A good analogy to explain this is trying to build a house out of sawdust (voxels) rather than with wooden planks (polygons).

The most impressive technical aspect of Uppercut3D is that, even in the absence of specific volume rendering hardware, it is able to render complex 3D volumes rather quickly. Dr Khoo used a progressive rendering technique which displays low-resolution versions of the 3D model while you’re manipulating it on screen (rotation, zoom, cropping, etc), only rendering the final full-detailed version within a couple of seconds after you’ve completed your manipulations.

Dr Khoo pointed out that while other competing 3D medical images are hardware-based, the rendering engine in Uppercut3D is 100% software based, which also drastically reduces development and production costs. It will run on most Pentium 4-equipped PCs.

“Much of the rendering engine uses proprietary algorithms. However, the basic strategy for fast rendering is through optimisation at the lowest level of programming. The general principles of volume rendering have been well known for several decades now,” explained Dr Khoo.

Although it currently runs only on Windows, the software can be ported to other platforms such as Linux and Macintosh, should the need arise. Dr Khoo added that the code can be optimised to take advantage of the new 64-bit processors for Windows-based PCs.

Improving the quality of treatment
Technological accomplishments aside, one thing that Dr Khoo highlighted repeatedly is that Uppercut3D was designed by doctors, for doctors and is therefore very relevant since it is tailored towards the workflow of a radiologist.

“The current workflow of a radiologist is plagued by many inefficiencies,” he said.

“When a patient is scanned, the radiographer is responsible for developing the hard copy films for the radiologist to view. He or she is relying on experience to know what the best standard views are for the radiologist to report on. If the optimal angle and contrast was not achieved, the radiologist would have to request more prints from the radiographer. This is very time consuming.

“In addition, today’s CT scanners can routinely generate hundreds of slices of data (typically 500 slices) and more. The current method of printing the hard copy films of the enormous amount of data is not time effective or cost effective. The workaround at the moment is to not print all the thin slices but to print the thick slices. However, much of the extra information is not looked at. This is dangerous since small lesions and details may be missed,” said Dr Khoo.

He then explained how his software fits into the picture: “Uppercut3D fits perfectly into the workflow because the radiologist can now generate the viewing angles all by himself in real-time, allowing the radiographer to work more efficiently. Alternate contrast and brightness settings can be quickly applied to the images in real-time as well. More importantly, the radiologist has at his/her fingertips, all the thin slices instead of having to report from the thick slices only.

“In addition, 3D volume rendered views of the pathology such as a complex fracture can be generated in real-time as well by the radiologist. These can then be printed and sent to the referring clinician. The endpoint of the workflow is the successful communication of the findings and the diagnosis to the referring clinician,” explained Dr Khoo.

According to him, another advantage of having photo-realistic 3D rendered representations is that it helps both doctors and patients to understand the problems at hand. After all, it’s much simpler to convince somebody if he’s okay or not by showing him what his innards look like.

“This should ultimately improve doctor-patient relationships enormously; they’re less likely to argue if they can see the problem,” quipped Dr Khoo.

The market
Dr Khoo believes that the quality of healthcare for a patient should not be determined by cost. Since Uppercut3D runs on readily available and affordable PC hardware, it can be sold to hospitals at a much lower price than most of its competitors.

Uppercut3D is already available in the market, having undergone extensive and rigorous clinical testings for two years. Dr Khoo claimed that in all trials, no problems had been identified. Indeed, it’s already being used in actual clinical work.

“Two medical institutions are currently using Uppercut3D on a daily basis. They are the Queen Elizabeth Hospital (a large public hospital) and Jones and Partners (a large private national radiology service provider), both in Adelaide, Australia,” he revealed.

Although he currently lives in Australia, Dr Khoo was born in Malaysia and spent his childhood here. His family and relatives set up Graphic Imaging Solutions with the sole purpose of marketing Uppercut3D in Asia.

They plan to sell Uppercut3D for less than RM100,000, as a complete solution offering support, upgrade patches, hardware, warranty and training. They have already spoken to a few hospitals in Malaysia and will be setting up demo units so that the hospitals can evaluate their system. This may seem pricey but, according to Dr Khoo, it is more affordable than any other competing system in the market which typically costs between RM160,000 and RM480,000.

Dr Khoo has also identified medical schools as another possible market. Graphic Imaging Solutions is considering releasing a special edition at a reduced cost, for lecturers and students.

“The ability to view scans from a live patient’s anatomy is very important in the study of diseases. Hopefully, there will be a transition where students can study anatomy from 3D images. Dissections are somewhat artificial in that they do not depict live tissue,” explained Dr Khoo.

Whether or not it achieves the commercial success that its designers and distributors are hoping for, Uppercut3D is a rather impressive piece of software. When asked if there are any improvements planned for Uppercut3D, Dr Khoo said: “Well, we could include an animated 3D fly-by through a patient’s innards ....”