We propose a method for estimating the bone mineral density (BMD) from a plain x-ray image. Dual-energy X-ray absorptiometry (DXA) and quantitative computed tomography (QCT) provide high accuracy in diagnosing osteoporosis; however, these modalities require special equipment and scan protocols. Measuring BMD from an x-ray image provides an opportunistic screening, which is potentially useful for early diagnosis. The previous methods that directly learn the relationship between x-ray images and BMD require a large training dataset to achieve high accuracy because of large intensity variations in the x-ray images. Therefore, we propose an approach using the QCT for training a generative adversarial network (GAN) and decomposing an x-ray image into a projection of bone-segmented QCT. The proposed hierarchical learning improved the robustness and accuracy of quantitatively decomposing a small-area target. The evaluation of 200 patients with osteoarthritis using the proposed method, which we named BMD-GAN, demonstrated a Pearson correlation coefficient of 0.888 between the predicted and ground truth DXA-measured BMD. Besides not requiring a large-scale training database, another advantage of our method is its extensibility to other anatomical areas, such as the vertebrae and rib bones.
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