Ahmed I. Ghanem

Reza Khanmohammadi, Mohammad M. Ghassemi, Kyle Verdecchia et al.

Natural Language Processing (NLP) is a key technique for developing Medical Artificial Intelligence (AI) systems that leverage Electronic Health Record (EHR) data to build diagnostic and prognostic models. NLP enables the conversion of unstructured clinical text into structured data that can be fed into AI algorithms. The emergence of the transformer architecture and large language models (LLMs) has led to remarkable advances in NLP for various healthcare tasks, such as entity recognition, relation extraction, sentence similarity, text summarization, and question answering. In this article, we review the major technical innovations that underpin modern NLP models and present state-of-the-art NLP applications that employ LLMs in radiation oncology research. However, these LLMs are prone to many errors such as hallucinations, biases, and ethical violations, which necessitate rigorous evaluation and validation before clinical deployment. As such, we propose a comprehensive framework for assessing the NLP models based on their purpose and clinical fit, technical performance, bias and trust, legal and ethical implications, and quality assurance, prior to implementation in clinical radiation oncology. Our article aims to provide guidance and insights for researchers and clinicians who are interested in developing and using NLP models in clinical radiation oncology.

Reza Khanmohammadi, Ahmed I. Ghanem, Kyle Verdecchia et al.

Large Language Models (LLMs) offer significant potential for clinical symptom extraction, but their deployment in healthcare settings is constrained by privacy concerns, computational limitations, and operational costs. This study investigates the optimization of compact LLMs for cancer toxicity symptom extraction using a novel iterative refinement approach. We employ a student-teacher architecture, utilizing Zephyr-7b-beta and Phi3-mini-128 as student models and GPT-4o as the teacher, to dynamically select between prompt refinement, Retrieval-Augmented Generation (RAG), and fine-tuning strategies. Our experiments on 294 clinical notes covering 12 post-radiotherapy toxicity symptoms demonstrate the effectiveness of this approach. The RAG method proved most efficient, improving average accuracy scores from 0.32 to 0.73 for Zephyr-7b-beta and from 0.40 to 0.87 for Phi3-mini-128 during refinement. In the test set, both models showed an approximate 0.20 increase in accuracy across symptoms. Notably, this improvement was achieved at a cost 45 times lower than GPT-4o for Zephyr and 79 times lower for Phi-3. These results highlight the potential of iterative refinement techniques in enhancing the capabilities of compact LLMs for clinical applications, offering a balance between performance, cost-effectiveness, and privacy preservation in healthcare settings.

Nicholas Summerfield, Qisheng He, Alex Kuo et al.

Cardiac substructure delineation is emerging in treatment planning to minimize the risk of radiation-induced heart disease. Deep learning offers efficient methods to reduce contouring burden but currently lacks generalizability across different modalities and overlapping structures. This work introduces and validates a Modality-AGnostic Image Cascade (MAGIC) deep-learning pipeline for comprehensive and multi-modal cardiac substructure segmentation. MAGIC is implemented through replicated encoding and decoding branches of an nnU-Net backbone to handle multi-modality inputs and overlapping labels. First benchmarked on the multi-modality whole-heart segmentation (MMWHS) dataset including cardiac CT-angiography (CCTA) and MR modalities, twenty cardiac substructures (heart, chambers, great vessels (GVs), valves, coronary arteries (CAs), and conduction nodes) from clinical simulation CT (Sim-CT), low-field MR-Linac, and cardiac CT-angiography (CCTA) modalities were delineated to train semi-supervised (n=151), validate (n=15), and test (n=30) MAGIC. For comparison, fourteen single-modality comparison models (two MMWHS modalities and four subgroups across three clinical modalities) were trained. Methods were evaluated for efficiency and against reference contours through the Dice similarity coefficient (DSC) and two-tailed Wilcoxon Signed-Rank test (p<0.05). Average MMWHS DSC scores across CCTA and MR inputs were 0.88(0.08) and 0.87(0.04) respectively with significant improvement over unimodal baselines. Average 20-structure DSC scores were 0.75(0.16) for Sim-CT, 0.68(0.21) for MR-Linac, and 0.80(0.16) for CCTA. Furthermore, >80% and >70% reductions in training time and parameters were achieved, respectively. MAGIC offers an efficient, lightweight solution capable of segmenting multiple image modalities and overlapping structures in a single model without compromising segmentation accuracy.