. 2023 Nov;78(11):1067-1079.

doi: 10.1136/thorax-2022-219158. Epub 2023 Jun 2.

Pulmonary emphysema subtypes defined by unsupervised machine learning on CT scans

Elsa D Angelini^#^{1

2

3}, Jie Yang^#¹, Pallavi P Balte⁴, Eric A Hoffman⁵, Ani W Manichaikul⁶, Yifei Sun⁷, Wei Shen^{8

9}, John H M Austin¹⁰, Norrina B Allen¹¹, Eugene R Bleecker¹², Russell Bowler¹³, Michael H Cho^{14

15}, Christopher S Cooper¹⁶, David Couper¹⁷, Mark T Dransfield¹⁸, Christine Kim Garcia⁴, MeiLan K Han¹⁹, Nadia N Hansel²⁰, Emlyn Hughes²¹, David R Jacobs²², Silva Kasela^{23

24}, Joel Daniel Kaufman²⁵, John Shinn Kim^{4

26}, Tuuli Lappalainen²³, Joao Lima²⁰, Daniel Malinsky⁷, Fernando J Martinez²⁷, Elizabeth C Oelsner⁴, Victor E Ortega²⁸, Robert Paine²⁹, Wendy Post²⁰, Tess D Pottinger⁴, Martin R Prince³⁰, Stephen S Rich⁶, Edwin K Silverman¹⁴, Benjamin M Smith^{4

31}, Andrew J Swift^{4

32}, Karol E Watson¹⁶, Prescott G Woodruff³³, Andrew F Laine^#^{1

9

10}, R Graham Barr^#^{34

35}

Affiliations

¹ Department of Biomedical Engineering, Columbia University, New York, New York, USA.
² LTCI, Institut Polytechnique de Paris, Telecom Paris, Palaiseau, France.
³ NIHR Imperial Biomedical Research Centre, ITMAT Data Science Group, Imperial College, London, UK.
⁴ Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA.
⁵ Departments of Radiology, Medicine and Biomedical Engineering, University of Iowa, Iowa City, Iowa, USA.
⁶ Center for Public Health Genomics, University of Virginia, Charlottesville, Virginia, USA.
⁷ Department of Biostatistics, Columbia University Irving Medical Center, New York, New York, USA.
⁸ Department of Pediatrics, Institute of Human Nutrition, Columbia University Irving Medical Center, New York, New York, USA.
⁹ Columbia Magnetic Resonance Research Center (CMRRC), Columbia University Irving Medical Center, New York, New York, USA.
¹⁰ Department of Radiology, Columbia University Irving Medical Center, New York, New York, USA.
¹¹ Institute for Public Health and Medicine (IPHAM) - Center for Epidemiology and Population Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
¹² Department of Medicine, University of Arizona Health Sciences, Tucson, Arizona, USA.
¹³ Department of Medicine, National Jewish Health, Denver, Colorado, USA.
¹⁴ Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
¹⁵ Harvard Medical School, Boston, Massachusetts, USA.
¹⁶ Department of Medicine, University of California, Los Angeles, California, USA.
¹⁷ Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, USA.
¹⁸ Lung Health Center, University of Alabama, Birmingham, Alabama, USA.
¹⁹ Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA.
²⁰ Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
²¹ Department of Physics, Columbia University, New York, New York, USA.
²² Division of Epidemiology and Community Public Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA.
²³ Department of Systems Biology, Columbia University Irving Medical Center, New York, New York, USA.
²⁴ New York Genome Center, New York, New York, USA.
²⁵ Departments of Environmental & Occupational Health Sciences, Medicine, and Epidemiology, University of Washington, Seattle, Washington, USA.
²⁶ Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA.
²⁷ Department of Medicine, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA.
²⁸ Department of Pulmonary Medicine, Mayo Clinic, Phoenix, Arizona, USA.
²⁹ Department of Medicine, University of Utah, Salt Lake City, Utah, USA.
³⁰ Department of Radiology, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA.
³¹ Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
³² Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK.
³³ Department of Medicine, University of California, San Francisco, California, USA.
³⁴ Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA rgb9@columbia.edu.
³⁵ Department of Epidemiology, Columbia University Irving Medical Center, New York, New York, USA.

^# Contributed equally.

PMID: 37268414
PMCID: PMC10592007
DOI: 10.1136/thorax-2022-219158

Pulmonary emphysema subtypes defined by unsupervised machine learning on CT scans

Elsa D Angelini et al. Thorax. 2023 Nov.

. 2023 Nov;78(11):1067-1079.

doi: 10.1136/thorax-2022-219158. Epub 2023 Jun 2.

Authors

Affiliations

¹ Department of Biomedical Engineering, Columbia University, New York, New York, USA.
² LTCI, Institut Polytechnique de Paris, Telecom Paris, Palaiseau, France.
³ NIHR Imperial Biomedical Research Centre, ITMAT Data Science Group, Imperial College, London, UK.
⁴ Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA.
⁵ Departments of Radiology, Medicine and Biomedical Engineering, University of Iowa, Iowa City, Iowa, USA.
⁶ Center for Public Health Genomics, University of Virginia, Charlottesville, Virginia, USA.
⁷ Department of Biostatistics, Columbia University Irving Medical Center, New York, New York, USA.
⁸ Department of Pediatrics, Institute of Human Nutrition, Columbia University Irving Medical Center, New York, New York, USA.
⁹ Columbia Magnetic Resonance Research Center (CMRRC), Columbia University Irving Medical Center, New York, New York, USA.
¹⁰ Department of Radiology, Columbia University Irving Medical Center, New York, New York, USA.
¹¹ Institute for Public Health and Medicine (IPHAM) - Center for Epidemiology and Population Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
¹² Department of Medicine, University of Arizona Health Sciences, Tucson, Arizona, USA.
¹³ Department of Medicine, National Jewish Health, Denver, Colorado, USA.
¹⁴ Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
¹⁵ Harvard Medical School, Boston, Massachusetts, USA.
¹⁶ Department of Medicine, University of California, Los Angeles, California, USA.
¹⁷ Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, USA.
¹⁸ Lung Health Center, University of Alabama, Birmingham, Alabama, USA.
¹⁹ Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA.
²⁰ Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
²¹ Department of Physics, Columbia University, New York, New York, USA.
²² Division of Epidemiology and Community Public Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA.
²³ Department of Systems Biology, Columbia University Irving Medical Center, New York, New York, USA.
²⁴ New York Genome Center, New York, New York, USA.
²⁵ Departments of Environmental & Occupational Health Sciences, Medicine, and Epidemiology, University of Washington, Seattle, Washington, USA.
²⁶ Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA.
²⁷ Department of Medicine, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA.
²⁸ Department of Pulmonary Medicine, Mayo Clinic, Phoenix, Arizona, USA.
²⁹ Department of Medicine, University of Utah, Salt Lake City, Utah, USA.
³⁰ Department of Radiology, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA.
³¹ Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
³² Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK.
³³ Department of Medicine, University of California, San Francisco, California, USA.
³⁴ Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA rgb9@columbia.edu.
³⁵ Department of Epidemiology, Columbia University Irving Medical Center, New York, New York, USA.

^# Contributed equally.

PMID: 37268414
PMCID: PMC10592007
DOI: 10.1136/thorax-2022-219158

Abstract

Background: Treatment and preventative advances for chronic obstructive pulmonary disease (COPD) have been slow due, in part, to limited subphenotypes. We tested if unsupervised machine learning on CT images would discover CT emphysema subtypes with distinct characteristics, prognoses and genetic associations.

Methods: New CT emphysema subtypes were identified by unsupervised machine learning on only the texture and location of emphysematous regions on CT scans from 2853 participants in the Subpopulations and Intermediate Outcome Measures in COPD Study (SPIROMICS), a COPD case-control study, followed by data reduction. Subtypes were compared with symptoms and physiology among 2949 participants in the population-based Multi-Ethnic Study of Atherosclerosis (MESA) Lung Study and with prognosis among 6658 MESA participants. Associations with genome-wide single-nucleotide-polymorphisms were examined.

Results: The algorithm discovered six reproducible (interlearner intraclass correlation coefficient, 0.91-1.00) CT emphysema subtypes. The most common subtype in SPIROMICS, the combined bronchitis-apical subtype, was associated with chronic bronchitis, accelerated lung function decline, hospitalisations, deaths, incident airflow limitation and a gene variant near DRD1, which is implicated in mucin hypersecretion (p=1.1 ×10^-8). The second, the diffuse subtype was associated with lower weight, respiratory hospitalisations and deaths, and incident airflow limitation. The third was associated with age only. The fourth and fifth visually resembled combined pulmonary fibrosis emphysema and had distinct symptoms, physiology, prognosis and genetic associations. The sixth visually resembled vanishing lung syndrome.

Conclusion: Large-scale unsupervised machine learning on CT scans defined six reproducible, familiar CT emphysema subtypes that suggest paths to specific diagnosis and personalised therapies in COPD and pre-COPD.

Keywords: COPD epidemiology; Emphysema; Imaging/CT MRI etc.

PubMed Disclaimer

Conflict of interest statement

Competing interests: EDA, PPB, AM, YS, WS, JHMA, MHC, DC, EH, DRJ, SK, JDK, TL, JL, ECO, WP, MRP, SSR, EKS, KEW and AFL reports receiving grants from the National Institutes of Health (NIH). JY performed the work at Columbia University but is now an employee of Google. EAH reports receiving grants from the NIH; being a founder and shareholder of VIDA Diagnostics; and holding patents for an apparatus for analysing CT images to determine the presence of pulmonary tissue pathology, an apparatus for image display and analysis, and a method for multiscale meshing of branching biological structures. EBA reports receiving grants from the American Heart Association and the NIH. CBC reports receiving personal fees from GlaxoSmithKline. MTD reports receiving a grant from the NHLBI and personal fees from AstraZeneca, GlaxoSmithKline, Pulmonx, PneumRx/BTG and Quark. MKH reports consulting for GlaxoSmithKline, AstraZeneca and Boehringer Ingelheim receiving research support from Novartis and Sunovion. NNH reports receiving grants from the NIH, Boehringer Ingelheim, and the COPD Foundation. JDK reports receiving grants from US Environmental Protection Agency and the NIH. FJM reports serving on COPD advisory boards for AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Sunovion and Teva; serving as a consultant for ProterixBio and Verona; serving on the steering committees of studies sponsored by the NHLBI, AstraZeneca, and GlaxoSmithKline; having served on data safety and monitoring boards of COPD studies supported by Genentech and GlaxoSmithKline. BMS reports receiving grants from the NIH, Canadian Institutes of Health Research (CIHR), Fonds de la recherche en santé du Québec (FRQS), the Research Institute of the McGill University Health Centre, the Quebec Lung Association and AstraZeneca. PGW reports receiving personal fees for consultancy from Theravance, AstraZeneca, Regeneron, Sanofi, Genentech, Roche and Janssen. RGB reports receiving grants from the COPD Foundation, the US Environmental Protection Agency (EPA), the American Lung Association and the NIH.

Figures

**Figure 1.**
Schema of unsupervised machine learning, data reduction, primary descriptive analyses, events analyses and GWAS. Unsupervised machine learning of possible emphysema subtypes was performed in twoindependent training sets in SPIROMICS. Both training sets yielded 10 possible emphysema subtypes, and training was repeated on all of SPIROMICS. The resultant 10 possible emphysema subtypes were labelled on MESA Lung CT scans. Data reduction was performed in SPIROMCS and MESA Lung and yielded six CT emphysema subtypes; data reduction was confirmed longitudinally on coregistered CT scans in a subset of the MESA Lung Study oversampled for COPD and smoking. Primary descriptive analyses of these subtypes were performed in the MESA Lung Study. Cardiac scans in MESA were labelled for the Event Analyses in MESA. GWAS Discovery was performed in SPIROMICS; replication of genetic results occurred on labelled cardiac scans in MESA and MESA SHARe and in COPDGene.

**Figure 2.**
Representative visual illustrations of the six CT emphysema subtypes. Coronal views of lungs on CT scans and the corresponding labelled masks with the discovered CT emphysema subtypes on predominantly affected sample cases (i.e. with proportion of a certain CT emphysema subtype being much larger than any other). Color coding of CT emphysema subtypes is the same across examples; grey labelling denotes non-emphysematous regions. Abbreviation: CPFE=combined pulmonary fibrosis/emphysema

**Figure 3.**
Distributions of the six discovered CT emphysema subtypes in SPIROMICS and the MESA Lung Study. Mean percentages of CT emphysema subtypes in SPIROMICS, a COPD case-control study of 2655 participants with 20 or more packyears of smoking (median packyears 43.0; 66.2% with COPD) and 198 non-smoking controls, and in the MESA Lung Study, a population-based study of 2,949 participants, 54.2% of whom had ever smoked cigarettes (median packyears 14.5) and 16.9% with COPD. Abbreviations: CPFE=combined pulmonary fibrosis/emphysema, COPD=chronic obstructive pulmonary disease

**Figure 4:**
Multivariable associations of CT emphysema subtypes with symptoms, physiology, lung structure, and lung function decline in the MESA Lung Study.* β estimates for continuous outcomes show the effect size per 10% increment in CT emphysema subtype, except for percent emphysema, which is per 1% increment in CT emphysema subtype. The β estimates for chronic bronchitis and interstitial lung abnormalities are the log(odds ratios). All results adjusted for age, sex, race/ethnicity, height, weight, smoking status, pack-years, scanner manufacturer and other CT emphysema subtypes. Abbreviations: CPFE=combined pulmonary fibrosis/emphysema; FEV1= Forced expiratory volume in one second; FVC=Forced expiratory volume in one second.

**Figure 5.**
Manhattan and local association plots for the three genome-wide significant, replicated gene variants for three CT emphysema subtypes in SPIROMICS. The red lines show the level of statistical significance (P = 5×10–8). The genome-wide significant SNP for the Combined Bronchitis-Apical Emphysema subtype replicated among Whites (P=0.01) and the entire replication sample (P=0.04). The genome-wide significant SNP for the restrictive CPFE subtype replicated among Whites (P=0.01) and the entire replication sample (P=0.04). The first genome-wide significant SNP for the obstructive CPFE subtype on chromosome 19 had variance only among Black participants and replicated in this sample (P=0.046). The second genome-wide significant SNP for the obstructive CPFE subtype on chromosome 16 did not replicate. There were no significant replicated genetic associations for the diffuse and senile CT emphysema subtypes (not shown).* Results are shown for the lowest attenuation (most severe) of the three preliminary subtypes that comprise the Combined Bronchitis-Apical Emphysema subtype. Abbreviation: CPFE=combined pulmonary fibrosis/emphysema

See this image and copyright information in PMC

Comment in

Reimagining emphysema for a computational age.
Jacob J. Jacob J. Thorax. 2023 Nov;78(11):1063-1064. doi: 10.1136/thorax-2023-220458. Epub 2023 Aug 17. Thorax. 2023. PMID: 37591700 No abstract available.

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Pulmonary emphysema subtypes defined by unsupervised machine learning on CT scans

Affiliations

Pulmonary emphysema subtypes defined by unsupervised machine learning on CT scans

Authors

Affiliations

Abstract

Conflict of interest statement

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Comment in

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