Sebastian Brandner

James K. Ruffle, Samia Mohinta, Chris Foulon et al.

Despite there now being more than 1,000 FDA-authorised AI medical devices, formal equity assessments -- whether model performance is uniform across patient subgroups -- are rare. Here, we evaluate the equity of 18 open-source brain tumour segmentation models across 648 glioma patients from two independent datasets (n = 11,664 model inferences) along distinct univariate, Bayesian multivariate, spatial, and representational dimensions. We find that patient identity consistently explains more performance variance than model choice, with clinical factors, including molecular diagnosis, tumour grade, and extent of resection, predicting segmentation accuracy more strongly than model architecture. A voxel-wise spatial meta-analysis identifies neuroanatomically localised biases that are compartment-specific yet often consistent across models. Within a high-dimensional latent space of lesion masks and clinic-demographic features, model performance clusters significantly, indicating that the patient feature space contains axes of algorithmic vulnerability. Although newer models tend toward greater equity, none provide a formal fairness guarantee. Lastly, we release Fairboard, an open-source, no-code dashboard that lowers barriers to equitable model monitoring in medical imaging.

James K Ruffle, Samia Mohinta, Kelly Pegoretti Baruteau et al.

The VASARI MRI feature set is a quantitative system designed to standardise glioma imaging descriptions. Though effective, deriving VASARI is time-consuming and seldom used in clinical practice. This is a problem that machine learning could plausibly automate. Using glioma data from 1172 patients, we developed VASARI-auto, an automated labelling software applied to both open-source lesion masks and our openly available tumour segmentation model. In parallel, two consultant neuroradiologists independently quantified VASARI features in a subsample of 100 glioblastoma cases. We quantified: 1) agreement across neuroradiologists and VASARI-auto; 2) calibration of performance equity; 3) an economic workforce analysis; and 4) fidelity in predicting patient survival. Tumour segmentation was compatible with the current state of the art and equally performant regardless of age or sex. A modest inter-rater variability between in-house neuroradiologists was comparable to between neuroradiologists and VASARI-auto, with far higher agreement between VASARI-auto methods. The time taken for neuroradiologists to derive VASARI was substantially higher than VASARI-auto (mean time per case 317 vs. 3 seconds). A UK hospital workforce analysis forecast that three years of VASARI featurisation would demand 29,777 consultant neuroradiologist workforce hours (£1,574,935), reducible to 332 hours of computing time (and £146 of power) with VASARI-auto. The best-performing survival model utilised VASARI-auto features as opposed to those derived by neuroradiologists. VASARI-auto is a highly efficient automated labelling system with equitable performance across patient age or sex, a favourable economic profile if used as a decision support tool, and with non-inferior fidelity in downstream patient survival prediction. Future work should iterate upon and integrate such tools to enhance patient care.

James K Ruffle, Samia Mohinta, Guilherme Pombo et al.

The benefits of artificial intelligence (AI) human partnerships-evaluating how AI agents enhance expert human performance-are increasingly studied. Though rarely evaluated in healthcare, an inverse approach is possible: AI benefiting from the support of an expert human agent. Here, we investigate both human-AI clinical partnership paradigms in the magnetic resonance imaging-guided characterisation of patients with brain tumours. We reveal that human-AI partnerships improve accuracy and metacognitive ability not only for radiologists supported by AI, but also for AI agents supported by radiologists. Moreover, the greatest patient benefit was evident with an AI agent supported by a human one. Synergistic improvements in agent accuracy, metacognitive performance, and inter-rater agreement suggest that AI can create more capable, confident, and consistent clinical agents, whether human or model-based. Our work suggests that the maximal value of AI in healthcare could emerge not from replacing human intelligence, but from AI agents that routinely leverage and amplify it.

James K Ruffle, Samia Mohinta, Guilherme Pombo et al.

Brain tumour imaging assessment typically requires both pre- and post-contrast MRI, but gadolinium administration is not always desirable, such as in frequent follow-up, renal impairment, allergy, or paediatric patients. We aimed to develop and validate a deep learning model capable of predicting brain tumour contrast enhancement from non-contrast MRI sequences alone. We assembled 11089 brain MRI studies from 10 international datasets spanning adult and paediatric populations with various neuro-oncological states, including glioma, meningioma, metastases, and post-resection appearances. Deep learning models (nnU-Net, SegResNet, SwinUNETR) were trained to predict and segment enhancing tumour using only non-contrast T1-, T2-, and T2/FLAIR-weighted images. Performance was evaluated on 1109 held-out test patients using patient-level detection metrics and voxel-level segmentation accuracy. Model predictions were compared against 11 expert radiologists who each reviewed 100 randomly selected patients. The best-performing nnU-Net achieved 83% balanced accuracy, 91.5% sensitivity, and 74.4% specificity in detecting enhancing tumour. Enhancement volume predictions strongly correlated with ground truth (R2 0.859). The model outperformed expert radiologists, who achieved 69.8% accuracy, 75.9% sensitivity, and 64.7% specificity. 76.8% of test patients had Dice over 0.3 (acceptable detection), 67.5% had Dice over 0.5 (good detection), and 50.2% had Dice over 0.7 (excellent detection). Deep learning can identify contrast-enhancing brain tumours from non-contrast MRI with clinically relevant performance. These models show promise as screening tools and may reduce gadolinium dependence in neuro-oncology imaging. Future work should evaluate clinical utility alongside radiology experts.

Omnia Alwazzan, Amaya Gallagher-Syed, Thomas O. Millner et al.

The integration of DNA methylation data with a Whole Slide Image (WSI) offers significant potential for enhancing the diagnostic precision of central nervous system (CNS) tumor classification in neuropathology. While existing approaches typically integrate encoded omic data with histology at either an early or late fusion stage, the potential of reintroducing omic data through dual fusion remains unexplored. In this paper, we propose the use of omic embeddings during early and late fusion to capture complementary information from local (patch-level) to global (slide-level) interactions, boosting performance through multimodal integration. In the early fusion stage, omic embeddings are projected onto WSI patches in latent-space, which generates embeddings that encapsulate per-patch molecular and morphological insights. This effectively incorporates omic information into the spatial representation of the WSI. These embeddings are then refined with a Multiple Instance Learning gated attention mechanism which attends to diagnostic patches. In the late fusion stage, we reintroduce the omic data by fusing it with slide-level omic-WSI embeddings using a Multimodal Outer Arithmetic Block (MOAB), which richly intermingles features from both modalities, capturing their correlations and complementarity. We demonstrate accurate CNS tumor subtyping across 20 fine-grained subtypes and validate our approach on benchmark datasets, achieving improved survival prediction on TCGA-BLCA and competitive performance on TCGA-BRCA compared to state-of-the-art methods. This dual fusion strategy enhances interpretability and classification performance, highlighting its potential for clinical diagnostics.