Ensemble Inversion for Brain Tumor Growth Models With Mass Effect.

We propose a method for extracting physics-based biomarkers from a single multiparametric Magnetic Resonance Imaging (mpMRI) scan bearing a glioma tumor. We account for mass effect, the deformation of brain parenchyma due to the growing tumor, which on its own is an important radiographic feature but its automatic quantification remains an open problem. In particular, we calibrate a partial differential equation (PDE) tumor growth model that captures mass effect, parameterized by a single scalar parameter, tumor proliferation, migration, while localizing the tumor initiation site. The single-scan calibration problem is severely ill-posed because the precancerous, healthy, brain anatomy is unknown. To address the ill-posedness, we introduce an ensemble inversion scheme that uses a number of normal subject brain templates as proxies for the healthy precancer subject anatomy. We verify our solver on a synthetic dataset and perform a retrospective analysis on a clinical dataset of 216 glioblastoma (GBM) patients. We analyze the reconstructions using our calibrated biophysical model and demonstrate that our solver provides both global and local quantitative measures of tumor biophysics and mass effect. We further highlight the improved performance in model calibration through the inclusion of mass effect in tumor growth models-including mass effect in the model leads to 10% increase in average dice coefficients for patients with significant mass effect. We further evaluate our model by introducing novel biophysics-based features and using them for survival analysis. Our preliminary analysis suggests that including such features can improve patient stratification and survival prediction.

CLAIRE-Parallelized Diffeomorphic Image Registration for Large-Scale Biomedical Imaging Applications.

We study the performance of CLAIRE-a diffeomorphic multi-node, multi-GPU image-registration algorithm and software-in large-scale biomedical imaging applications with billions of voxels. At such resolutions, most existing software packages for diffeomorphic image registration are prohibitively expensive. As a result, practitioners first significantly downsample the original images and then register them using existing tools. Our main contribution is an extensive analysis of the impact of downsampling on registration performance. We study this impact by comparing full-resolution registrations obtained with CLAIRE to lower resolution registrations for synthetic and real-world imaging datasets. Our results suggest that registration at full resolution can yield a superior registration quality-but not always. For example, downsampling a synthetic image from 10243 to 2563 decreases the Dice coefficient from 92% to 79%. However, the differences are less pronounced for noisy or low contrast high resolution images. CLAIRE allows us not only to register images of clinically relevant size in a few seconds but also to register images at unprecedented resolution in reasonable time. The highest resolution considered are CLARITY images of size 2816×3016×1162. To the best of our knowledge, this is the first study on image registration quality at such resolutions.

Estimating Glioblastoma Biophysical Growth Parameters Using Deep Learning Regression.

Glioblastoma ( GBM ) is arguably the most aggressive, infiltrative, and heterogeneous type of adult brain tumor. Biophysical modeling of GBM growth has contributed to more informed clinical decision-making. However, deploying a biophysical model to a clinical environment is challenging since underlying computations are quite expensive and can take several hours using existing technologies. Here we present a scheme to accelerate the computation. In particular, we present a deep learning ( DL )-based logistic regression model to estimate the GBM's biophysical growth in seconds. This growth is defined by three tumor-specific parameters: 1) a diffusion coefficient in white matter ( Dw ), which prescribes the rate of infiltration of tumor cells in white matter, 2) a mass-effect parameter ( Mp ), which defines the average tumor expansion, and 3) the estimated time ( T ) in number of days that the tumor has been growing. Preoperative structural multi-parametric MRI ( mpMRI ) scans from n = 135 subjects of the TCGA-GBM imaging collection are used to quantitatively evaluate our approach. We consider the mpMRI intensities within the region defined by the abnormal FLAIR signal envelope for training one DL model for each of the tumor-specific growth parameters. We train and validate the DL-based predictions against parameters derived from biophysical inversion models. The average Pearson correlation coefficients between our DL-based estimations and the biophysical parameters are 0.85 for Dw, 0.90 for Mp, and 0.94 for T, respectively. This study unlocks the power of tumor-specific parameters from biophysical tumor growth estimation. It paves the way towards their clinical translation and opens the door for leveraging advanced radiomic descriptors in future studies by means of a significantly faster parameter reconstruction compared to biophysical growth modeling approaches.

Modeling of Glioma Growth With Mass Effect by Longitudinal Magnetic Resonance Imaging.

It is well-known that expanding glioblastomas typically induce significant deformations of the surrounding parenchyma (i.e., the so-called "mass effect"). In this study, we evaluate the performance of three mathematical models of tumor growth: 1) a reaction-diffusion-advection model which accounts for mass effect (RDAM), 2) a reaction-diffusion model with mass effect that is consistent only in the case of small deformations (RDM), and 3) a reaction-diffusion model that does not include the mass effect (RD). The models were calibrated with magnetic resonance imaging (MRI) data obtained during tumor development in a murine model of glioma (n = 9). We obtained T2-weighted and contrast-enhanced T1-weighted MRI at 6 time points over 10 days to determine the spatiotemporal variation in the mass effect and the volume fraction of tumor cells, respectively. We calibrated the three models using data 1) at the first four, 2) only at the first and fourth, and 3) only at the third and fourth time points. Each of these calibrations were run forward in time to predict the volume fraction of tumor cells at the conclusion of the experiment. The diffusion coefficient for the RDAM model (median of 10.65 × 10 -3 mm 2· d -1) is significantly less than those for the RD and RDM models (17.46 × 10 -3 mm 2· d -1 and 19.38 × 10 -3 mm 2· d -1, respectively). The error in the tumor volume fraction for the RD, RDM, and RDAM models have medians of 40.2%, 32.1%, and 44.7%, respectively, for the calibration using data from the first four time points. The RDM model most accurately predicts tumor growth, while the RDAM model presents the least variation in its estimates of the diffusion coefficient and proliferation rate. This study demonstrates that the mathematical models capture both tumor development and mass effect observed in experiments.

Fast GPU 3D diffeomorphic image registration.

3D image registration is one of the most fundamental and computationally expensive operations in medical image analysis. Here, we present a mixed-precision, Gauss-Newton-Krylov solver for diffeomorphic registration of two images. Our work extends the publicly available CLAIRE library to GPU architectures. Despite the importance of image registration, only a few implementations of large deformation diffeomorphic registration packages support GPUs. Our contributions are new algorithms to significantly reduce the run time of the two main computational kernels in CLAIRE: calculation of derivatives and scattered-data interpolation. We deploy (i) highly-optimized, mixed-precision GPU-kernels for the evaluation of scattered-data interpolation, (ii) replace Fast-Fourier-Transform (FFT)-based first-order derivatives with optimized 8th-order finite differences, and (iii) compare with state-of-the-art CPU and GPU implementations. As a highlight, we demonstrate that we can register 2563 clinical images in less than 6 seconds on a single NVIDIA Tesla V100. This amounts to over 20× speed-up over the current version of CLAIRE and over 30× speed-up over existing GPU implementations.

Fully Automatic Calibration of Tumor-Growth Models Using a Single mpMRI Scan.

Our objective is the calibration of mathematical tumor growth models from a single multiparametric scan. The target problem is the analysis of preoperative Glioblastoma (GBM) scans. To this end, we present a fully automatic tumor-growth calibration methodology that integrates a single-species reaction-diffusion partial differential equation (PDE) model for tumor progression with multiparametric Magnetic Resonance Imaging (mpMRI) scans to robustly extract patient specific biomarkers i.e., estimates for (i) the tumor cell proliferation rate, (ii) the tumor cell migration rate, and (iii) the original, localized site(s) of tumor initiation. Our method is based on a sparse reconstruction algorithm for the tumor initial location (TIL). This problem is particularly challenging due to nonlinearity, ill-posedeness, and ill conditioning. We propose a coarse-to-fine multi-resolution continuation scheme with parameter decomposition to stabilize the inversion. We demonstrate robustness and practicality of our method by applying the proposed method to clinical data of 206 GBM patients. We analyze the extracted biomarkers and relate tumor origin with patient overall survival by mapping the former into a common atlas space. We present preliminary results that suggest improved accuracy for prediction of patient overall survival when a set of imaging features is augmented with estimated biophysical parameters. All extracted features, tumor initial positions, and biophysical growth parameters are made publicly available for further analysis. To our knowledge, this is the first fully automatic scheme that can handle multifocal tumors and can localize the TIL to a few millimeters.

CLAIRE: Constrained Large Deformation Diffeomorphic Image Registration on Parallel Computing Architectures.

CLAIRE (Mang & Biros, 2019) is a computational framework for Constrained LArge deformation diffeomorphic Image REgistration (Mang et al., 2019). It supports highly-optimized, parallel computational kernels for (multi-node) CPU (Gholami et al., 2017; Mang et al., 2019; Mang & Biros, 2016) and (multi-node multi-)GPU architectures (Brunn et al., 2020, 2021). CLAIRE uses MPI for distributed-memory parallelism and can be scaled up to thousands of cores (Mang et al., 2019; Mang & Biros, 2016) and GPU devices (Brunn et al., 2020). The multi-GPU implementation uses device direct communication. The computational kernels are interpolation for semi-Lagrangian time integration, and a mixture of high-order finite difference operators and Fast-Fourier-Transforms (FFTs) for differentiation. CLAIRE uses a Newton-Krylov solver for numerical optimization (Mang & Biros, 2015, 2017). It features various schemes for regularization of the control problem (Mang & Biros, 2016) and different similarity measures. CLAIRE implements different preconditioners for the reduced space Hessian (Brunn et al., 2020; Mang et al., 2019) to optimize computational throughput and enable fast convergence. It uses PETSc (Balay et al., n.d.) for scalable and efficient linear algebra operations and solvers and TAO (Balay et al., n.d.; Munson et al., 2015) for numerical optimization. CLAIRE can be downloaded at https://github.com/andreasmang/claire.

IMAGE-DRIVEN BIOPHYSICAL TUMOR GROWTH MODEL CALIBRATION.

We present a novel formulation for the calibration of a biophysical tumor growth model from a single-time snapshot, multiparametric magnetic resonance imaging (MRI) scan of a glioblastoma patient. Tumor growth models are typically nonlinear parabolic partial differential equations (PDEs). Thus, we have to generate a second snapshot to be able to extract significant information from a single patient snapshot. We create this two-snapshot scenario as follows. We use an atlas (an average of several scans of healthy individuals) as a substitute for an earlier, pretumor, MRI scan of the patient. Then, using the patient scan and the atlas, we combine image-registration algorithms and parameter estimation algorithms to achieve a better estimate of the healthy patient scan and the tumor growth parameters that are consistent with the data. Our scheme is based on our recent work (Scheufele et al., Comput. Methods Appl. Mech. Engrg., to appear), but we apply a different and novel scheme where the tumor growth simulation in contrast to the previous work is executed in the patient brain domain and not in the atlas domain yielding more meaningful patient-specific results. As a basis, we use a PDE-constrained optimization framework. We derive a modified Picard-iteration-type solution strategy in which we alternate between registration and tumor parameter estimation in a new way. In addition, we consider an ℓ 1 sparsity constraint on the initial condition for the tumor and integrate it with the new joint inversion scheme. We solve the sub-problems with a reduced space, inexact Gauss-Newton-Krylov/quasi-Newton method. We present results using real brain data with synthetic tumor data that show that the new scheme reconstructs the tumor parameters in a more accurate and reliable way compared to our earlier scheme.

Integrated Biophysical Modeling and Image Analysis: Application to Neuro-Oncology.

Central nervous system (CNS) tumors come with vastly heterogeneous histologic, molecular, and radiographic landscapes, rendering their precise characterization challenging. The rapidly growing fields of biophysical modeling and radiomics have shown promise in better characterizing the molecular, spatial, and temporal heterogeneity of tumors. Integrative analysis of CNS tumors, including clinically acquired multi-parametric magnetic resonance imaging (mpMRI) and the inverse problem of calibrating biophysical models to mpMRI data, assists in identifying macroscopic quantifiable tumor patterns of invasion and proliferation, potentially leading to improved (a) detection/segmentation of tumor subregions and (b) computer-aided diagnostic/prognostic/predictive modeling. This article presents a summary of (a) biophysical growth modeling and simulation,(b) inverse problems for model calibration, (c) these models' integration with imaging workflows, and (d) their application to clinically relevant studies. We anticipate that such quantitative integrative analysis may even be beneficial in a future revision of the World Health Organization (WHO) classification for CNS tumors, ultimately improving patient survival prospects.

Optimal Control Theory for Personalized Therapeutic Regimens in Oncology: Background, History, Challenges, and Opportunities.

Optimal control theory is branch of mathematics that aims to optimize a solution to a dynamical system. While the concept of using optimal control theory to improve treatment regimens in oncology is not novel, many of the early applications of this mathematical technique were not designed to work with routinely available data or produce results that can eventually be translated to the clinical setting. The purpose of this review is to discuss clinically relevant considerations for formulating and solving optimal control problems for treating cancer patients. Our review focuses on two of the most widely used cancer treatments, radiation therapy and systemic therapy, as they naturally lend themselves to optimal control theory as a means to personalize therapeutic plans in a rigorous fashion. To provide context for optimal control theory to address either of these two modalities, we first discuss the major limitations and difficulties oncologists face when considering alternate regimens for their patients. We then provide a brief introduction to optimal control theory before formulating the optimal control problem in the context of radiation and systemic therapy. We also summarize examples from the literature that illustrate these concepts. Finally, we present both challenges and opportunities for dramatically improving patient outcomes via the integration of clinically relevant, patient-specific, mathematical models and optimal control theory.

Multi-Node Multi-GPU Diffeomorphic Image Registration for Large-Scale Imaging Problems.

We present a Gauss-Newton-Krylov solver for large deformation diffeomorphic image registration. We extend the publicly available CLAIRE library to multi-node multi-graphics processing unit (GPUs) systems and introduce novel algorithmic modifications that significantly improve performance. Our contributions comprise (i) a new preconditioner for the reduced-space Gauss-Newton Hessian system, (ii) a highly-optimized multi-node multi-GPU implementation exploiting device direct communication for the main computational kernels (interpolation, high-order finite difference operators and Fast-Fourier-Transform), and (iii) a comparison with state-of-the-art CPU and GPU implementations. We solve a 2563-resolution image registration problem in five seconds on a single NVIDIA Tesla V100, with a performance speedup of 70% compared to the state-of-the-art. In our largest run, we register 20483 resolution images (25 B unknowns; approximately 152× larger than the largest problem solved in state-of-the-art GPU implementations) on 64 nodes with 256 GPUs on TACC's Longhorn system.

Multiatlas Calibration of Biophysical Brain Tumor Growth Models with Mass Effect.

We present a 3D fully-automatic method for the calibration of partial differential equation (PDE) models of glioblastoma (GBM) growth with "mass effect", the deformation of brain tissue due to the tumor. We quantify the mass effect, tumor proliferation, tumor migration, and the localized tumor initial condition from a single multiparameteric Magnetic Resonance Imaging (mpMRI) patient scan. The PDE is a reaction-advection-diffusion partial differential equation coupled with linear elasticity equations to capture mass effect. The single-scan calibration model is notoriously difficult because the precancerous (healthy) brain anatomy is unknown. To solve this inherently ill-posed and illconditioned optimization problem, we introduce a novel inversion scheme that uses multiple brain atlases as proxies for the healthy precancer patient brain resulting in robust and reliable parameter estimation. We apply our method on both synthetic and clinical datasets representative of the heterogeneous spatial landscape typically observed in glioblastomas to demonstrate the validity and performance of our methods. In the synthetic data, we report calibration errors (due to the ill-posedness and our solution scheme) in the 10%-20% range. In the clinical data, we report good quantitative agreement with the observed tumor and qualitative agreement with the mass effect (for which we do not have a ground truth). Our method uses a minimal set of parameters and provides both global and local quantitative measures of tumor infiltration and mass effect.

A DOMAIN DECOMPOSITION PRECONDITIONING FOR AN INVERSE VOLUME SCATTERING PROBLEM.

We propose domain decomposition preconditioners for the solution of an integral equation formulation of the acoustic forward and inverse scattering problems. We study both forward and inverse volume problems and propose preconditioning techniques to accelerate the iterative solvers. For the forward scattering problem, we extend the domain decomposition based preconditioning techniques presented for partial differential equations in "A restricted additive Schwarz preconditioner for general sparse linear systems", SIAM Journal on Scientific Computing, 21 (1999), pp. 792-797, to integral equations. We combine this domain decomposition preconditioner with a low-rank correction, which is easy to construct, forming a new preconditioner. For the inverse scattering problem, we use the forward problem preconditioner as a building block for constructing a preconditioner for the Gauss-Newton Hessian. We present numerical results that demonstrate the performance of both preconditioning strategies.

WHERE DID THE TUMOR START? AN INVERSE SOLVER WITH SPARSE LOCALIZATION FOR TUMOR GROWTH MODELS.

We present a numerical scheme for solving an inverse problem for parameter estimation in tumor growth models for glioblastomas, a form of aggressive primary brain tumor. The growth model is a reaction-diffusion partial differential equation (PDE) for the tumor concentration. We use a PDE-constrained optimization formulation for the inverse problem. The unknown parameters are the reaction coefficient (proliferation), the diffusion coefficient (infiltration), and the initial condition field for the tumor PDE. Segmentation of Magnetic Resonance Imaging (MRI) scans drive the inverse problem where segmented tumor regions serve as partial observations of the tumor concentration. Like most cases in clinical practice, we use data from a single time snapshot. Moreover, the precise time relative to the initiation of the tumor is unknown, which poses an additional difficulty for inversion. We perform a frozen-coefficient spectral analysis and show that the inverse problem is severely ill-posed. We introduce a biophysically motivated regularization on the structure and magnitude of the tumor initial condition. In particular, we assume that the tumor starts at a few locations (enforced with a sparsity constraint on the initial condition of the tumor) and that the initial condition magnitude in the maximum norm is equal to one. We solve the resulting optimization problem using an inexact quasi-Newton method combined with a compressive sampling algorithm for the sparsity constraint. Our implementation uses PETSc and AccFFT libraries. We conduct numerical experiments on synthetic and clinical images to highlight the improved performance of our solver over a previously existing solver that uses standard two-norm regularization for the calibration parameters. The existing solver is unable to localize the initial condition. Our new solver can localize the initial condition and recover infiltration and proliferation. In clinical datasets (for which the ground truth is unknown), our solver results in qualitatively different solutions compared to the two-norm regularized solver.

Coupling brain-tumor biophysical models and diffeomorphic image registration.

We present SIBIA (Scalable Integrated Biophysics-based Image Analysis), a framework for joint image registration and biophysical inversion and we apply it to analyze MR images of glioblastomas (primary brain tumors). We have two applications in mind. The first one is normal-to-abnormal image registration in the presence of tumor-induced topology differences. The second one is biophysical inversion based on single-time patient data. The underlying optimization problem is highly non-linear and non-convex and has not been solved before with a gradient-based approach. Given the segmentation of a normal brain MRI and the segmentation of a cancer patient MRI, we determine tumor growth parameters and a registration map so that if we "grow a tumor" (using our tumor model) in the normal brain and then register it to the patient image, then the registration mismatch is as small as possible. This "coupled problem" two-way couples the biophysical inversion and the registration problem. In the image registration step we solve a large-deformation diffeomorphic registration problem parameterized by an Eulerian velocity field. In the biophysical inversion step we estimate parameters in a reaction-diffusion tumor growth model that is formulated as a partial differential equation (PDE). In SIBIA, we couple these two sub-components in an iterative manner. We first presented the components of SIBIA in "Gholami et al., Framework for Scalable Biophysics-based Image Analysis, IEEE/ACM Proceedings of the SC2017", in which we derived parallel distributed memory algorithms and software modules for the decoupled registration and biophysical inverse problems. In this paper, our contributions are the introduction of a PDE-constrained optimization formulation of the coupled problem, and the derivation of a Picard iterative solution scheme. We perform extensive tests to experimentally assess the performance of our method on synthetic and clinical datasets. We demonstrate the convergence of the SIBIA optimization solver in different usage scenarios. We demonstrate that using SIBIA, we can accurately solve the coupled problem in three dimensions (2563 resolution) in a few minutes using 11 dual-x86 nodes.

Machine learning acceleration of simulations of Stokesian suspensions.

Particulate Stokesian flows describe the hydrodynamics of rigid or deformable particles in Stokes flows. Due to highly nonlinear fluid-structure interaction dynamics, moving interfaces, and multiple scales, numerical simulations of such flows are challenging and expensive. Here, we propose a generic machine-learning-augmented reduced model for these flows. Our model replaces expensive parts of a numerical scheme with regression functions. Given the physical parameters of the particle, our model generalizes to arbitrary geometries and boundary conditions without the need to retrain the regression functions. It is approximately an order of magnitude faster than a state-of-the-art numerical scheme using the same number of degrees of freedom and can reproduce several features of the flow accurately. We illustrate the performance of our model on integral equation formulation of vesicle suspensions in two dimensions.

Simulation of glioblastoma growth using a 3D multispecies tumor model with mass effect.

In this article, we present a multispecies reaction-advection-diffusion partial differential equation coupled with linear elasticity for modeling tumor growth. The model aims to capture the phenomenological features of glioblastoma multiforme observed in magnetic resonance imaging (MRI) scans. These include enhancing and necrotic tumor structures, brain edema and the so-called "mass effect", a term-of-art that refers to the deformation of brain tissue due to the presence of the tumor. The multispecies model accounts for proliferating, invasive and necrotic tumor cells as well as a simple model for nutrition consumption and tumor-induced brain edema. The coupling of the model with linear elasticity equations with variable coefficients allows us to capture the mechanical deformations due to the tumor growth on surrounding tissues. We present the overall formulation along with a novel operator-splitting scheme with components that include linearly-implicit preconditioned elliptic solvers, and a semi-Lagrangian method for advection. We also present results showing simulated MRI images which highlight the capability of our method to capture the overall structure of glioblastomas in MRIs.

The 2019 mathematical oncology roadmap.

Whether the nom de guerre is Mathematical Oncology, Computational or Systems Biology, Theoretical Biology, Evolutionary Oncology, Bioinformatics, or simply Basic Science, there is no denying that mathematics continues to play an increasingly prominent role in cancer research. Mathematical Oncology-defined here simply as the use of mathematics in cancer research-complements and overlaps with a number of other fields that rely on mathematics as a core methodology. As a result, Mathematical Oncology has a broad scope, ranging from theoretical studies to clinical trials designed with mathematical models. This Roadmap differentiates Mathematical Oncology from related fields and demonstrates specific areas of focus within this unique field of research. The dominant theme of this Roadmap is the personalization of medicine through mathematics, modelling, and simulation. This is achieved through the use of patient-specific clinical data to: develop individualized screening strategies to detect cancer earlier; make predictions of response to therapy; design adaptive, patient-specific treatment plans to overcome therapy resistance; and establish domain-specific standards to share model predictions and to make models and simulations reproducible. The cover art for this Roadmap was chosen as an apt metaphor for the beautiful, strange, and evolving relationship between mathematics and cancer.

CLAIRE: A DISTRIBUTED-MEMORY SOLVER FOR CONSTRAINED LARGE DEFORMATION DIFFEOMORPHIC IMAGE REGISTRATION.

With this work we release CLAIRE, a distributed-memory implementation of an effective solver for constrained large deformation diifeomorphic image registration problems in three dimensions. We consider an optimal control formulation. We invert for a stationary velocity field that parameterizes the deformation map. Our solver is based on a globalized, preconditioned, inexact reduced space Gauss‒Newton‒Krylov scheme. We exploit state-of-the-art techniques in scientific computing to develop an eifective solver that scales to thousands of distributed memory nodes on high-end clusters. We present the formulation, discuss algorithmic features, describe the software package, and introduce an improved preconditioner for the reduced space Hessian to speed up the convergence of our solver. We test registration performance on synthetic and real data. We Demonstrate registration accuracy on several neuroimaging datasets. We compare the performance of our scheme against diiferent flavors of the Demons algorithm for diifeomorphic image registration. We study convergence of our preconditioner and our overall algorithm. We report scalability results on state-of-the-art supercomputing platforms. We Demonstrate that we can solve registration problems for clinically relevant data sizes in two to four minutes on a standard compute node with 20 cores, attaining excellent data fidelity. With the present work we achieve a speedup of (on average) 5× with a peak performance of up to 17× compared to our former work.

A SEMI-LAGRANGIAN TWO-LEVEL PRECONDITIONED NEWTON-KRYLOV SOLVER FOR CONSTRAINED DIFFEOMORPHIC IMAGE REGISTRATION.

We propose an efficient numerical algorithm for the solution of diffeomorphic image registration problems. We use a variational formulation constrained by a partial differential equation (PDE), where the constraints are a scalar transport equation. We use a pseudospectral discretization in space and second-order accurate semi-Lagrangian time stepping scheme for the transport equations. We solve for a stationary velocity field using a preconditioned, globalized, matrix-free Newton-Krylov scheme. We propose and test a two-level Hessian preconditioner. We consider two strategies for inverting the preconditioner on the coarse grid: a nested preconditioned conjugate gradient method (exact solve) and a nested Chebyshev iterative method (inexact solve) with a fixed number of iterations. We test the performance of our solver in different synthetic and real-world two-dimensional application scenarios. We study grid convergence and computational efficiency of our new scheme. We compare the performance of our solver against our initial implementation that uses the same spatial discretization but a standard, explicit, second-order Runge-Kutta scheme for the numerical time integration of the transport equations and a single-level preconditioner. Our improved scheme delivers significant speedups over our original implementation. As a highlight, we observe a 20× speedup for a two dimensional, real world multi-subject medical image registration problem.