Abstract
Reconstructive flap surgery aims to restore the substance and function losses associated with tumor resection. Automatic flap segmentation could allow quantification of flap volume and correlations with functional outcomes after surgery or post-operative RT (poRT). Flaps being ectopic tissues of various components (fat, skin, fascia, muscle, bone) of various volume, shape and texture, the anatomical modifications, inflammation and edema of the postoperative bed make the segmentation task challenging. We built a artificial intelligence-enabled automatic soft-tissue flap segmentation method from CT scans of Head and Neck Cancer (HNC) patients. Ground-truth flap segmentation masks were delineated by two experts on postoperative CT scans of 148 HNC patients undergoing poRT. All CTs and flaps (free or pedicled, soft tissue only or bone) were kept, including those with artefacts, to ensure generalizability. A deep-learning nnUNetv2 framework was built using Hounsfield Units (HU) windowing to mimic radiological assessment. A transformer-based 2D "Segment Anything Model" (MedSAM) was also built and fine-tuned to medical CTs. Models were compared with the Dice Similarity Coefficient (DSC) and Hausdorff Distance 95th percentile (HD95) metrics. Flaps were in the oral cavity (N = 102), oropharynx (N = 26) or larynx/hypopharynx (N = 20). There were free flaps (N = 137), pedicled flaps (N = 11), of soft tissue flap-only (N = 92), reconstructed bone (N = 42), or bone resected without reconstruction (N = 40). The nnUNet-windowing model outperformed the nnUNetv2 and MedSam models. It achieved mean DSCs of 0.69 and HD95 of 25.6 mm using 5-fold cross-validation. Segmentation performed better in the absence of artifacts, and rare situations such as pedicled flaps, laryngeal primaries and resected bone without bone reconstruction (p < 0.01). Automatic flap segmentation demonstrates clinical performances that allow to quantify spontaneous and radiation-induced volume shrinkage of flaps. Free flaps achieved excellent performances; rare situations will be addressed by fine-tuning the network.