Covid-19 detection using chest X-rays: is lung segmentation important for generalization?

Purpose We evaluated the generalization capability of deep neural networks (DNNs) in the task of classifying chest X-rays as Covid-19, normal or pneumonia, when trained in a relatively small and mixed datasets. Methods We proposed a DNN to perform lung segmentation and classification, stacking a segmentation module (U-Net), an original intermediate module and a classification module (DenseNet201). To evaluate generalization capability, we tested the network with an external dataset (from distinct localities) and used Bayesian inference to estimate the probability distributions of performance metrics. Furthermore, we introduce a novel evaluation technique, which uses layer-wise relevance propagation (LRP) and Brixia scores to compare the DNN grounds for decision with radiologists. Results The proposed DNN achieved 0.917 AUC (area under the ROC curve) on the external test dataset, surpassing a DenseNet without segmentation, which showed 0.906 AUC. Bayesian inference indicated mean accuracy of 76.1% and [0.695, 0.826] 95% HDI (high-density interval, which concentrates 95% of the metric’s probability mass) with segmentation and, without segmentation, 71.7% and [0.646, 0.786]. Conclusion Employing an analysis based on LRP and Brixia scores, we discovered that areas where radiologists found strong Covid-19 symptoms are the most important for the stacked DNN classification. External validation showed smaller accuracies than internal, indicating difficulty in generalization, which is positively affected by lung segmentation. Finally, the performance on the external dataset and the analysis with LRP suggest that DNNs can successfully detect Covid-19 even when trained on small and mixed datasets.