Improving Rectal Tumor Segmentation with Anomaly Fusion Derived from Anatomical Inpainting: A Multicenter Study

Accurate rectal tumor segmentation using magnetic resonance imaging (MRI) is paramount for effective treatment planning. It allows for volumetric and other quantitative tumor assessments, potentially aiding in prognostication and treatment response evaluation. Manual delineation of rectal tumors and surrounding structures is time-consuming and typically. Over the past few years, deep learning has shown strong results in automated tumor segmentation in MRI. Current studies on automated rectal tumor segmentation, however, focus solely on tumoral regions without considering the rectal anatomical entities and often lack a solid multicenter external validation. In this study, we improved rectal tumor segmentation by incorporating anomaly maps derived from anatomical inpainting. This inpainting was implemented using a U-Net-based model trained to reconstruct a healthy rectum and mesorectum from prostate T2-weighted images (T2WI). The rectal anomaly maps were generated from the difference between the original rectal and reconstructed pseudo-healthy slices during inference. The derived anomaly maps were used in the downstream tumor segmentation tasks by fusing them as an additional input channel (AAnnUNet). Alternative methods for integrating rectal anatomical knowledge were evaluated as baselines, including Multi-Target nnUNet (MTnnUNet), which added rectum and mesorectum segmentation as auxiliary tasks, and Multi-Channel nnUNet (MCnnUNet), which utilized rectum and mesorectum masks as an additional input channel. As part of this study, we benchmarked nine models for rectal tumor segmentation on a large multicenter dataset of preoperative T2WI as the baseline and nnUNet outperformed the other eight models on the external dataset. The MTnnUNet demonstrated improvements in both supervised and semi-supervised settings (AI-generated rectum and mesoretum were used) compared to nnUNet, while the MCnnUNet showed benefits only in the semi-supervised setting. Importantly, anomaly maps were strongly associated with tumoral regions, and their integration within AAnnUNet led to the best tumor segmentation results across both settings. The effectiveness of AAnnUNet demonstrated the value of the anomaly maps, indicating a promising direction for improving rectal tumor segmentation and model robustness for multicenter data.