An integrated diffusion-weighted imaging processing and interpretation platform for MR-guided radiotherapy

Yunxiang Li; Yan Dai; Yen-Peng Liao; Jie Deng; Jill B De Vis; You Zhang

physics.med-phAug 20, 2026

An integrated diffusion-weighted imaging processing and interpretation platform for MR-guided radiotherapy

Authors: Yunxiang Li, Yan Dai, Yen-Peng Liao, Jie Deng, Jill B De Vis, You Zhang

Organizations: Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA · Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA

Abstract

Background: Magnetic resonance imaging-guided linear accelerators (MR-Linacs) allow diffusion-weighted imaging (DWI) to be acquired at every treatment fraction, but converting these low-signal-to-noise-ratio acquisitions into clinical decisions requires both reliable quantitative processing and an interpretation that reconciles a scattered and often contradictory literature. Purpose: To describe and evaluate an integrated, web-based platform that carries raw MR-Linac DWI to a structured, literature-grounded clinical interpretation, and to assess its retrieval-augmented generation (RAG) interpretation module by independent expert rating. Methods: The platform couples a deep-learning processing pipeline, comprising distortion correction, denoising, and intravoxel incoherent motion (IVIM)/apparent diffusion coefficient (ADC) fitting, with longitudinal region-of-interest analysis and a RAG interpretation agent. The agent reasons over a two-layer knowledge base of curated publications (a structured catalog index plus line-indexed full text), delegates arithmetic to deterministic tools, and is designed to trace each statement to a source document, section, and line range. One medical physicist and one physician independently rated the agent's reports for nine longitudinal glioblastoma cases on a 1-5 scale across three metrics: clinical-reasoning soundness, literature-citation quality, and overall clinical utility. Results: Across 54 ratings, the pooled mean was 4.65 +/- 0.80, with 93% of ratings >= 4; metric means were 4.6 (reasoning), 4.5 (citation), and 4.8 (utility), and raters agreed within one point on 85% of paired ratings. Conclusions: A single platform can integrate MR-Linac DWI post-processing with traceable, expert-evaluated clinical interpretation, while highlighting the safeguards needed to verify LLM-generated reasoning in radiation oncology.

Figures & tables

Component	Version	Role in the platform
Python	3.10	Implementation language
Flask / Flask-SocketIO	2.3 / 5.5	Web server and real-time progress streaming
PyTorch	2.6 (CUDA 12.6)	Deep-learning models (distortion, denoising, fitting)
pydicom	3.0.1	DICOM reading and metadata extraction
nibabel	5.3.2	NIfTI input/output
SimpleITK	2.4.1	Reorientation, resampling, geometry

Table 1: Principal software components of the platform and their roles. Versions reflect the validated deployment configuration.

Figure 1: End-to-end architecture and data flow of the platform. Raw MR-Linac DICOM data are organized and converted to NIfTI (with $b$ -value separation for DWI and mask extraction for segmentations), processed through a deep-learning pipeline into IVIM/ADC parameter maps, analyzed longitudinally over regions of interest, and finally interpreted by a retrieval-augmented generation (RAG) agent that is designed to trace evidence-supported statements to line-indexed source literature passages. Processed maps can be exported back to DICOM.

Figure 2: The DWI/IVIM processing pipeline. Raw multi- $b$ -value MR-Linac DWI, acquired at each treatment fraction, is processed through six steps; quantitative fitting is performed at native DWI resolution (steps 2–5) and only the final maps are resampled to anatomical resolution before inter-fractional registration (step 6).

Figure 3: The web platform interface, with a brain GBM case shown. (a) The ADC & IVIM processing pipeline, with the DICOM data browser (patient/date/series, left) and the numbered processing steps (right). (b) The analysis tool, showing per-fraction parameter-map overlays on the anatomical image and the corresponding ROI intensity histograms. (c) Longitudinal trend statistics (mean, median, interquartile range, percentiles, skewness, and kurtosis) computed within a fixed ROI across treatment fractions.

Figure 4: The retrieval-augmented interpretation agent. Longitudinal IVIM/ADC trajectories, together with the conventional imaging context, are ingested (stage 1) and characterized (stage 2). Catalog-guided retrieval then shortlists tumor-type- and parameter-matched publications from the two-layer knowledge base and fetches only the anchored passages (stage 3). The LLM integrates the evidence and resolves multi-parameter discordance (stage 4), and a structured report is produced in which evidence-supported statements are traced back to a source document, section, and line range (stage 5).

Figure 5: The clinical-interpretation interface. (a) The one-click AI clinical-interpretation view, where the user selects the target ROIs (e.g., GTV/CTV/PTV imported from RT-STRUCT) and launches an analysis. Prior analysis sessions are retained for review. (b) The retrieval knowledge base (“literature library”), which lists each indexed publication with its tumor types and reported parameters and accepts new papers by PDF upload.

Attribute	Categories (examples)	Coverage
Tumor type	Glioblastoma / glioma / brain metastases	predominant
	Pancreatic adenocarcinoma; head and neck; prostate	secondary
Parameters	ADC	28 papers
	IVIM ( $f_{p}$ , $D_{t}$ , $D_{p}$ )	13 papers
Setting	MR-Linac / MR-guided radiotherapy; chemoradiation
Evidence	Original studies, systematic reviews/meta-analyses, position statements	mixed

Table 2: Composition of the retrieval knowledge base (28 publications). Counts of tumor types and reported parameters exceed 28 because individual papers may span multiple categories.

Figure 6: A representative longitudinal GBM case. (a) GTV-mean trajectories of ADC,

D_{t}

D_{p}

, and

f_{p}

across five longitudinal time points, showing an early diffusivity rise followed by a late decline with preserved/rising perfusion fraction. (b) Excerpt of the agent’s report, in which the interpretation is anchored to specific lines of matched source literature. This case received the maximum rating on all three dimensions from both reviewers.

Figure 7: Independent expert ratings of agent-generated reports by metric and rater (mean

\pm

SD; 1–5 Likert). The dashed line marks the “good” scale anchor (4).Overall clinical utility received the highest and most consistent ratings from both reviewers. The physician’s ratings showed greater variability, driven by a few atypical cases (reasoning scores of 2, 3, and 3 in three cases and one citation score of 1), whereas the physicist assigned a reasoning of 5 to all cases.

Dimension	Physicist	Physician	Pooled
	( $n=9$ )	( $n=9$ )	( $n=18$ )
Clinical-reasoning soundness	$5.00\pm 0.00$	$4.22\pm 1.20$	$4.61\pm 0.92$
Literature-citation quality	$4.56\pm 0.53$	$4.44\pm 1.33$	$4.50\pm 0.99$
Overall clinical utility	$4.78\pm 0.44$	$4.89\pm 0.33$	$4.83\pm 0.38$
Overall	$4.78\pm 0.42$	$4.52\pm 1.05$	$4.65\pm 0.80$

Table 3: Expert evaluation of agent-generated reports on nine longitudinal GBM cases. Values are mean

\pm

standard deviation on a 1–5 Likert scale (higher is better). The pooled column combines both raters (

n=18

per metric).

Diffusion MRI

Diffusion MRI measures water motion in tissue to characterize brain microstructure, white-matter pathways, and disease.

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Mar 12, 2026

Multimodal classification of Radiation-Induced Contrast Enhancements and tumor recurrence using deep learning

The differentiation between tumor recurrence and radiation-induced contrast enhancements in post-treatment glioblastoma patients remains a major clinical challenge. Existing approaches rely on clinically sparsely available diffusion MRI or do not consider radiation maps, which are gaining increasing interest in the tumor board for this differentiation. We introduce RICE-NET, a multimodal 3D deep learning model that integrates longitudinal MRI data with radiotherapy dose distributions for automated lesion classification using conventional T1-weighted MRI data. Using a cohort of 92 patients, the model achieved an F1 score of 0.92 on an independent test set. During extensive ablation experiments, we quantified the contribution of each timepoint and modality and showed that reliable classification largely depends on the radiation map. Occlusion-based interpretability analyses further confirmed the model's focus on clinically relevant regions. These findings highlight the potential of multimodal deep learning to enhance diagnostic accuracy and support clinical decision-making in neuro-oncology.

Robin Peretzke, Marlin Hanstein, Maximilian Fischer +15

Deutsches Krebsforschungszentrum (DKFZ), Division of Medical Image Computing, Heidelberg, Germany · Medical Faculty, Heidelberg University, Heidelberg, Germany · Pattern Analysis and Learning Group, Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany +8

Multimodal Classification Classification Brain Tumor Classification

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Mar 23, 2026

Agentic Automation of BT-RADS Scoring: End-to-End Multi-Agent System for Standardized Brain Tumor Follow-up Assessment

The Brain Tumor Reporting and Data System (BT-RADS) standardizes post-treatment MRI response assessment in patients with diffuse gliomas but requires complex integration of imaging trends, medication effects, and radiation timing. This study evaluates an end-to-end multi-agent large language model (LLM) and convolutional neural network (CNN) system for automated BT-RADS classification. A multi-agent LLM system combined with automated CNN-based tumor segmentation was retrospectively evaluated on 509 consecutive post-treatment glioma MRI examinations from a single high-volume center. An extractor agent identified clinical variables (steroid status, bevacizumab status, radiation date) from unstructured clinical notes, while a scorer agent applied BT-RADS decision logic integrating extracted variables with volumetric measurements. Expert reference standard classifications were established by an independent board-certified neuroradiologist. Of 509 examinations, 492 met inclusion criteria. The system achieved 374/492 (76.0%; 95% CI, 72.1%-79.6%) accuracy versus 283/492 (57.5%; 95% CI, 53.1%-61.8%) for initial clinical assessments (+18.5 percentage points; P<.001). Context-dependent categories showed high sensitivity (BT-1b 100%, BT-1a 92.7%, BT-3a 87.5%), while threshold-dependent categories showed moderate sensitivity (BT-3c 74.8%, BT-2 69.2%, BT-4 69.3%, BT-3b 57.1%). For BT-4, positive predictive value was 92.9%. The multi-agent LLM system achieved higher BT-RADS classification agreement with expert reference standard compared to initial clinical scoring, with high accuracy for context-dependent scores and high positive predictive value for BT-4 detection.

Mohamed Sobhi Jabal, Jikai Zhang, Dominic LaBella +6

Department of Radiology, Duke University Medical Center, Durham, NC · Department of Electrical and Computer Engineering, Duke University, Durham, NC · Duke Center for Artificial Intelligence in Radiology, Duke University Medical Center, Durham, NC +5

Brain Tumor Classification Multi-Agent Systems

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Oct 21, 2026

Reading the Mask: Descriptor-Grounded BI-RADS Rationale Generation for Breast MRI Segmentation

Deep learning based models accurately delineate tumours on dynamic contrast-enhanced MRI (DCE-MRI), but segmentation masks alone do not provide the rationales or reasoning used by radiologists to assess the lesion suspicion. This limits the explainability as well the clinical integration. We investigate whether clinically relevant descriptors can instead be derived from the segmentation masks and their dynamic contrast-enhancement series. We have used Breast Imaging Reporting and Data System (BI-RADS) guidelines as a structured framework. Using these guidelines we designed a BI-RADS decision tree with eight quantitative measurements using radiomics, together with the lesion size and component count, that determine the descriptors at eight nodes. Using these descriptors we generate natural-language rationale using a large language model. The model was constrained to express only the derived records from the decision tree. After applying this framework to the expert and automatic masks of each of the 1,506 cases in the MAMA-MIA dataset, we generated a reproducible corpus of 3,012 BI-RADS grounded rationales. We obtained a faithfulness score of 99.98% and a counterfactual accuracy of 99.3%, indicating that the generated rationales faithfully verbalises the measured descriptors and correctly reflects changes in the underlying record. Agreement between the descriptors from expert and automatic masks falls from 0.832 to 0.549 as mask quality falls from Good to Missed. The generated rationales are intended as draft representations for radiologist review and final sign-off rather than autonomous clinical reports.

Hrishikesh Singh, Aarti Sharma, Divyanshu Kumar +1

Department of Applied Mathematics and Scientific Computing, Indian Institute of Technology Roorkee, Roorkee, India · Indian Institute of Technology Madras, Chennai, India · Also with Mehta Family School of Data Science and Artificial Intelligence, Indian Institute of Technology Roorkee.

Explainable Medical Image Analysis

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Abstract

Diffusion MRI

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