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Artificial Intelligence in Adaptive Radiation Therapy
10.3.1 Deep learning for re-planning pipelines
10.3.1.1 Automatic segmentations
Figure 10.5 places auto-segmentation, the topic of chapter 9, near the start of the
workflow, illustrating its relevance. This important step currently benefits from deep
learning, even in commercial systems. Since segmented structures serve as inputs to
subsequent steps in the ART workflow, including re-planning, accurate tools for fast
automatic segmentation are essential. In the last decade, medical image segmentation powered by AI has made remarkable progress, significantly outpacing other
areas integrating AI, including dose prediction. This advancement is supported by
the availability of numerous curated datasets and performance evaluation schemes
for both researchers and enthusiasts. While progress will likely continue at an
accelerated pace, evidence already exists for cases where auto-segmentation tools
matched human performance [96]. Furthermore, these tools have also demonstrated
inherent reductions in both interobserver variability and the time needed for this
labor-intensive and time-consuming step [96, 97].
10.3.1.2 From dose prediction to deliverable plans
Figure 10.6 illustrates a hypothetical scenario where deep learning is integrated into
the re-planning process, with a primary focus on dose prediction. Before predicting
the dose, three essential deep learning applications come into play: generating a set
of structures (see figure 10.5), estimating the orientation of treatment beams when
applicable, and predicting a suitable dose distribution using the outputs of the
previous two steps. By integrating these deep learning components together, each
with the potential for exceptional performance and a high degree of automation, the
pipeline becomes highly autonomous and fast.
Predicting beam orientation, when relevant to the treatment, offers several
benefits. For example, it eliminates the need for a planner to search for an optimal
beam configuration, saving time. As with dose prediction, automating this step can
potentially enhance consistency in plan quality. Using beam geometry information
during dose prediction can also lead to gains in prediction accuracy [49, 76, 82].
Figure 10.6. Flowchart depicting four potential applications of deep learning (indicated by the red outlines)
that could be integrated into re-planning pipelines for online and offline ART.
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Artificial Intelligence in Adaptive Radiation Therapy
Researchers have successfully employed deep learning for automatic beam angle
selection in applications for intensity-modulated radiation therapy (IMRT) and
intensity-modulated proton therapy (IMPT) [98, 99].
Once the dose is predicted based on the desired anatomical information, it serves
as a guide for the optimization process, ultimately leading to a deliverable dose that
meets the clinical objectives for the treatment. The feasibility of using deep learningbased dose prediction to guide plan optimization has been demonstrated in several
studies [39, 48, 77]. Additionally, Mahmood et al showed that the deliverable dose
obtained from optimizing based on deep learning-predicted doses was better at
creating plans that met clinical criteria compared to state-of-the-art knowledgebased planning methods using traditional machine learning and other classical
techniques [39].
Another promising application of deep learning is fluence map prediction, which
involves generating a fluence map from a dose distribution [29, 100, 101]. The aim of
this application is to bypass the need for a separate optimization step. By combining
fluence map prediction with dose and angle prediction, a deep learning-based
algorithm could generate all the necessary treatment parameters in a single step,
potentially resulting in a tremendous reduction in planning time.
Although the approaches mentioned here could plausibly result in highly
accelerated re-planning, it is worth noting that they all represent areas of active
research. While significant progress has been made in recent years, there are still
challenges to overcome before these techniques can be fully and safely integrated
into clinical workflows.
10.3.1.3 Virtualizing the re-planning process with deep reinforcement learning
(DRL)
One of the potential final steps of the flowchart in figure 10.6 shows the use of DRL
to automate and expedite re-planning. DRL is a subfield of deep learning, which has
been proposed as a tool for mimicking the human decision-making process during
treatment planning [102–104]. The resulting networks, known as virtual treatment
planner networks (VTPNs), are trained to intelligently tune the treatment planning
system by making reasonable parameter adjustments to achieve high-quality plans.
In practice, these networks monitor intermediate DVH curves for a developing plan
and decide how to improve the plan by adjusting weights and threshold doses in the
objective function.
Shen et al demonstrated the potential of this approach by training a VTPN on a
small dataset of just 10 patients [103 ]. When applied to a test patient cohort, the
trained network led to a substantial increase in plan quality. A subsequent study by
Sprouts et al further highlighted the ability of VTPNs to improve plan quality and
efficiency [104]. On average, the trained VTPN took less than one minute to reach
the final treatment plan for each case using their in-house treatment planning system
(TPS), while an experienced human planner required about three minutes to finish
the same planning steps. These early applications of reinforcement learning suggest
that by virtualizing the planning process, the speed and efficiency of deep learning
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Artificial Intelligence in Adaptive Radiation Therapy
can be leveraged to produce human-like results in a fraction of the time needed by
human planners.
10.3.1.4 Anticipating change: deep learning for predicting anatomical variations
In addition to speeding up the planning process, deep learning tools could help in
forecasting future anatomical changes for a patient. This possibility is indicated with
a process at the start of figure 10.6. The result of such an algorithm, which serves as
input to the subsequent steps of the flowchart, represents information that can
facilitate the generation of a set of plans with deliverable dose distributions. This
approach would resemble the ‘plan-of-the-day’ scheme used in some offline ART
applications [92, 105 ]. In cases where the anatomical changes are accurately
forecasted and a plan is ready, treatment can begin without delay or with minimal
initial adjustments. The ability to use deep learning to forecast anatomical changes
and potentially create corresponding plans with improved normal tissue sparing
showed promise in a recent study [106]. Lee et al used a sequence-to-sequence
(Seq2Seq) technique based on convolutional long short-term memory (Conv-LSTM)
to predict the longitudinal changes of the esophagus and lung tumor.
10.3.1.5 Summary of deep learning for re-planning pipelines
While the scenarios discussed in relation to figure 10.6 are hypothetical, they are
grounded in recent research findings. However, it is challenging to predict with
certainty which techniques and ideas will drive the ART workflows of the future,
particularly in fields well-positioned to benefit from the rapidly advancing domain of
deep learning.
In our discussion, we omitted the quality assurance steps. Deep learning has led to
impressive outcomes in applications pertinent to quality assurance, e.g. a tool for
sub-second Monte Carlo calculations and similarly fast statistical robustness
evaluation of IMPT dose distributions [107, 108]. The omission of these steps
does not imply the unlikely ideal case of error-free performance by the discussed
deep learning implementations. Indeed, if these methods were implemented, several
quality control checks would be necessary to assess their performance and alert
clinicians when errors or other unwanted circumstances are likely to occur.
10.4 Future directions of AI-assisted dose prediction and re-planning
Deep learning-based dose prediction is a growing field with a lot of untapped
potential. The impressive performance of these techniques and their ability to
automate tasks create many new possibilities. Figure 10.7 shows one such possibility, displaying two dose prediction outputs for a patient: one for a VMAT photon
treatment and one for an IMPT treatment. This kind of volumetric dose information, combined with DVH metrics, could help clinicians compare different treatment
modalities before starting formal treatment planning process. This can also benefit
in situations when treatment machines become unavailable due to unforeseen
circumstances, allowing for quick adaptations and minimizing treatment delays.
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Artificial Intelligence in Adaptive Radiation Therapy
Figure 10.7. Comparison of two treatment modalities for the same patient. The left panel shows dose
distributions predicted by a deep learning model for a VMAT plan (left) and IMPT plan (right).
Another example is real-time re-planning, which could be achieved with the help
of dose prediction algorithms based on high-speed imaging techniques such as those
in MRI-guided radiotherapy. In addition, accurate dose prediction using cone-beam
CT could provide a useful quality assurance tool in online ART pipelines.
Dose prediction and deep learning methods for re-planning may also see
significant performance improvements, driven by emerging trends such as the use
of transformers [109, 110]. Transformer models have achieved remarkable success in
natural language processing and computer vision tasks. These architectures excel at
handling long-range dependencies and capturing complex spatial relationships,
potentially helping achieve new state-of-the-art performance.
Future initiatives to advance collaboration and increase the availability of
standardized, high-quality data will be essential in driving the development and
validation of AI-assisted dose prediction and re-planning tools. Establishing shared
datasets and benchmarks can facilitate the comparison and improvement of different models, while also promoting transparency and reproducibility in research.
Collaborative efforts among institutions and researchers can accelerate this progress
and ensure that the benefits of these technologies are widely accessible to the
radiotherapy community.
Looking ahead, the next steps in AI-powered dose prediction and re-planning will
require close collaboration among medical physicists, radiation oncologists, computer scientists, and industry partners. Continued research and development efforts
are needed to refine AI models, integrate them into clinical workflows, and evaluate
their impact on patient outcomes. By embracing the potential of AI and working
towards its responsible and effective implementation, the radiotherapy community
can bring about a new era of personalized, adaptive, and precise cancer care.
10.5 Summary
The integration of artificial intelligence, particularly deep learning, into adaptive
radiation therapy workflows can have a profound impact on the field of radiation
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Artificial Intelligence in Adaptive Radiation Therapy
oncology. AI-assisted dose prediction and re-planning techniques offer promising
solutions to some of the challenges associated with traditional radiotherapy
planning, such as reducing time for otherwise laborious manual processes, increasing
consistency in plan quality, and enabling rapid adaptations in response to anatomical changes.
Deep learning-based dose prediction methods have demonstrated remarkable
accuracy and speed in estimating volumetric dose distributions across various
anatomical sites and treatment modalities. These AI-powered tools can streamline
the planning process by providing valuable guidance to clinicians as they aim to
create safe and effective treatment plans.
The continued advancement of AI-assisted dose prediction and re-planning
hinges on several key areas. The development of standardized datasets and
evaluation metrics will be crucial for establishing benchmarks and facilitating
meaningful comparisons between different models. Encouraging collaboration
among institutions to share knowledge and data will accelerate progress and
mitigate potential biases. Additionally, the exploration of innovative deep learning
architectures and training strategies holds the promise of unlocking even greater
levels of performance and automation. Crucially, addressing the challenges associated with clinical implementation, such as ensuring robust quality control and
enhancing the interpretability of AI-generated outcomes, will be necessary to
guarantee the safe and effective deployment of these tools in real-world healthcare
settings.
The future of AI in adaptive radiation therapy holds immense promise, and much
is left to be discovered. To fully harness the potential of AI-assisted dose prediction
and re-planning, close collaboration among medical physicists, radiation oncologists, computer scientists, and industry partners is essential. As we look ahead,
embracing the transformative power of AI in radiation oncology will be key to
improving treatment efficacy, enhancing patient outcomes, and ultimately, advancing the fight against cancer.
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