Vitrea ®

version 4.1

Lung Analysis
User Guide

VPMC-09970A
Vital Images, Inc. 2008
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-09970A Vitrea® version 4.1 Lung Analysis User Guide

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VPMC-09970A
 Vitrea® version 4.1 Lung Analysis User Guide

Table of Contents
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Safety and Regulatory Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Caution Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Intended Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
HIPAA Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Contact Us. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Licensing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Nodule Probe Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Viewer Window Formats. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Single Lung Format . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Basic Comparative Lung Format . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Advanced Comparative Lung Format . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Viewer Synchronization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Multiple Dataset Viewer Synchronization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Global Link . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Configuration Dialog . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Local Link . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Workflows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Nodule Detection and Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Nodule Boundary Adjustment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Simultaneous Baseline and Follow-up Nodule Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Follow-up Nodule Analysis using Restored Baseline Snapshot . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Nodule Segmentation, Measurements, Characteristics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Nodule Segmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Nodule Bounding Boxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Nodule Measurements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Nodule Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3D Mode Buttons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Nodule Management Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Nodule Management List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Nodule Management Buttons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Nodule Visibility Modes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Automatic Nodule Restoration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Printing and Exporting Images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Restoring Snapshots from the Report Window. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Restoring Multi-volume Snapshots from Study Directory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

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Vitrea® version 4.1 Lung Analysis User Guide

Status and Error Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

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 Vitrea® version 4.1 Lung Analysis User Guide

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 (mm3)
• 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.

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Vitrea® version 4.1 Lung Analysis User Guide

Safety and Regulatory Considerations

PLEASE READ THIS SECTION CAREFULLY BEFORE USING Vitrea.

The Safety and Regulatory Considerations section of the Basic Vitrea® 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® User
Guide.

HIPAA Compliance
Vital Images’ products comply with the Health Insurance Portability and
Accountability Act (HIPAA) of 1996.

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: www.vitalimages.com.
• For customer technical support, contact us using one of these methods:
• In the U.S., call the Customer Support line at 1.800.208.3005.
• Outside the U.S., contact your Vital Images distributor.

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• Go to http://support.vitalimages.com/requestinfo.aspx 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 email to support@vitalimages.com.
• To provide feedback about this document or other Vital Images product
documentation, send an email 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:

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Vitrea® version 4.1 Lung Analysis User Guide

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)

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• 3D POI (point-of-interest) volume

• Semi-transparent 3D lung map
• Nodule characteristics

Basic Comparative You use basic comparative lung format for side-by-side comparison. This format
Lung 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 You use advanced comparative lung format for side-by-side comparison and
Lung Format 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.

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Vitrea® version 4.1 Lung Analysis User Guide

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 When multiple datasets for the same patient are loaded into Vitrea’s multi-
Viewer volume view format, views of the same type across datasets are synchronized.
Synchronization
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 multi-
volume 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 multi-
volume viewer format is selected.
4. Click Global Link.

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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 Set all views to unsynchronized using the Global Link button.
b Realign them to the desired points then synchronize them again.
c 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.

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Vitrea® version 4.1 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 - Segmented view

Local Link button (unlocked) Local Link button (unlocked)

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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 Using the basic nodule detection workflow, you can analyze nodules in one study.
Analysis 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.

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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.

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FIGURE 7. Viewer Window with Multiple Nodules

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.

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Vitrea® version 4.1 Lung Analysis User Guide

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 You can edit nodule boundaries, rename nodules, delete specific nodules, or
Adjustment 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.

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• 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.

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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 You can analyze nodules in baseline and follow-up scans side-by-side,
and Follow-up Nodule simultaneously. To do so, you must complete the basic nodule detection
Analysis 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:

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• 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.

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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.

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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 You can analyze and compare the nodules in a follow-up scan to nodules in a
Analysis using previously analyzed baseline study by restoring a baseline snapshot while the
Restored Baseline follow-up study is loaded.
Snapshot
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

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Nodule Bounding The bounding box of each nodule displays in yellow in the MPR and 3D views. The
Boxes 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.

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FIGURE 13. Nodule Measurements

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.

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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 If you have one loaded volume, the list will contain one column. If you have
List 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.

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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 When Vitrea successfully segments a nodule and places it in the Nodule
Buttons 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.

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• 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

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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 You can print and export images containing nodule segmentation and
Images 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 User Guide.

NOTE: You cannot export primary DICOM images using the Lung Analysis option.

Restoring Snapshots You can create snapshots containing nodule segmentation and measurement
from the Report results. You can restore snapshots containing nodule segmentation and
Window 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 User
Guide.

To restore a single-volume snapshot:

• Follow standard Vitrea procedures.
For detailed information about saving snapshots, see the Basic Vitrea 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.

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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 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

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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.

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NOTE: The volume you chose in step 1 will not be listed, but will be
loaded by default.
OR

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%.

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