Automated medical image segmentation suffers from high inter-observer variability, particularly in tasks such as lung nodule delineation, where experts often disagree. Existing approaches either collapse this variability into a consensus mask or rely on separate model branches for each annotator. We introduce ProSona, a two-stage framework that learns a continuous latent space of annotation styles, enabling controllable personalization via natural language prompts. A probabilistic U-Net backbone captures diverse expert hypotheses, while a prompt-guided projection mechanism navigates this latent space to generate personalized segmentations. A multi-level contrastive objective aligns textual and visual representations, promoting disentangled and interpretable expert styles. Across the LIDC-IDRI lung nodule and multi-institutional prostate MRI datasets, ProSona reduces the Generalized Energy Distance by 17% and improves mean Dice by more than one point compared with DPersona. These results demonstrate that natural-language prompts can provide flexible, accurate, and interpretable control over personalized medical image segmentation. Our implementation is available online 1 .

PURPOSE: Incident reports are an important tool for safety and quality improvement in healthcare, but manual review is time-consuming and requires subject matter expertise. Here we present a natural language processing (NLP) screening tool to detect high-severity incident reports in radiation oncology across two institutions. METHODS AND MATERIALS: We used two text datasets to train and evaluate our NLP models: 7,094 reports from our institution (Inst.), and 571 from IAEA SAFRON (SF), all of which had severity scores labeled by clinical content experts. We trained and evaluated two types of models: baseline support vector machines (SVM) and BlueBERT which is a large language model pretrained on PubMed abstracts and hospitalized patient data. We assessed for generalizability of our model in two ways. First, we evaluated models trained using Inst.-train on SF-test. Second, we trained a BlueBERT_TRANSFER model that was first fine-tuned on Inst.-train then on SF-train before testing on SF-test set. To further analyze model performance, we also examined a subset of 59 reports from our Inst. dataset, which were manually edited for clarity. RESULTS Classification performance on the Inst. test achieved AUROC 0.82 using SVM and 0.81 using BlueBERT. Without cross-institution transfer learning, performance on the SF test was limited to an AUROC of 0.42 using SVM and 0.56 using BlueBERT. BlueBERT_TRANSFER, which was fine-tuned on both datasets, improved the performance on SF test to AUROC 0.78. Performance of SVM, and BlueBERT_TRANSFER models on the manually curated Inst. reports (AUROC 0.85 and 0.74) was similar to human performance (AUROC 0.81). CONCLUSION: In summary, we successfully developed cross-institution NLP models on incident report text from radiation oncology centers. These models were able to detect high-severity reports similarly to humans on a curated dataset.

Introduction: Large language models (LLM) have shown great potential in clinical decision support. GPT-5 is a novel LLM system that has been specifically marketed towards oncology use. Methods: Performance was assessed using two complementary benchmarks: (i) the ACR Radiation Oncology In-Training Examination (TXIT, 2021), comprising 300 multiple-choice items, and (ii) a curated set of 60 authentic radiation oncologic vignettes representing diverse disease sites and treatment indications. For the vignette evaluation, GPT-5 was instructed to generate concise therapeutic plans. Four board-certified radiation oncologists rated correctness, comprehensiveness, and hallucinations. Inter-rater reliability was quantified using Fleiss' \k{appa}. Results: On the TXIT benchmark, GPT-5 achieved a mean accuracy of 92.8%, outperforming GPT-4 (78.8%) and GPT-3.5 (62.1%). Domain-specific gains were most pronounced in Dose and Diagnosis. In the vignette evaluation, GPT-5's treatment recommendations were rated highly for correctness (mean 3.24/4, 95% CI: 3.11-3.38) and comprehensiveness (3.59/4, 95% CI: 3.49-3.69). Hallucinations were rare with no case reaching majority consensus for their presence. Inter-rater agreement was low (Fleiss' \k{appa} 0.083 for correctness), reflecting inherent variability in clinical judgment. Errors clustered in complex scenarios requiring precise trial knowledge or detailed clinical adaptation. Discussion: GPT-5 clearly outperformed prior model variants on the radiation oncology multiple-choice benchmark. Although GPT-5 exhibited favorable performance in generating real-world radiation oncology treatment recommendations, correctness ratings indicate room for further improvement. While hallucinations were infrequent, the presence of substantive errors underscores that GPT-5-generated recommendations require rigorous expert oversight before clinical implementation.

Anatomical changes during intensity-modulated proton therapy (IMPT) for head-and-neck cancer (HNC) can shift Bragg peaks, risking tumor underdosing and organ-at-risk overdosing. Treatment replanning is often required to maintain clinically acceptable treatment quality. However, current manual replanning processes are resource-intensive and time-consuming. We propose a patient-specific deep reinforcement learning (DRL) framework for automated IMPT replanning, with a reward-shaping mechanism based on a $150$-point plan quality score addressing competing clinical objectives. We formulate the planning process as a reinforcement learning problem where agents learn control policies to adjust optimization priorities, maximizing plan quality. Unlike population-based approaches, our framework trains agents for each patient using their planning Computed Tomography (CT) and augmented anatomies simulating anatomical changes (tumor progression and regression). This patient-specific approach leverages anatomical similarities along the treatment course, enabling effective plan adaptation. We implemented two DRL algorithms, Deep Q-Network and Proximal Policy Optimization, using dose-volume histograms (DVHs) as state representations and a $22$-dimensional action space of priority adjustments. Evaluation on eight HNC patients using actual replanning CT data showed that both agents improved initial plan scores from $120.78 \pm 17.18$ to $139.59 \pm 5.50$ (DQN) and $141.50 \pm 4.69$ (PPO), surpassing the replans manually generated by a human planner ($136.32 \pm 4.79$). Clinical validation confirms that improvements translate to better tumor coverage and OAR sparing across diverse anatomical changes. This work highlights DRL's potential in addressing geometric and dosimetric complexities of adaptive proton therapy, offering efficient offline adaptation solutions and advancing online adaptive proton therapy.

Effective education in radiotherapy plan quality review requires a robust, regularly updated set of examples and the flexibility to demonstrate multiple possible planning approaches and their consequences. However, the current clinic-based paradigm does not support these needs. To address this, we have developed "Virtual Dosimetrist" models that can both generate training examples of suboptimal treatment plans and then allow trainees to improve the plan quality through simple natural language prompts, as if communicating with a dosimetrist. The dose generation and modification process is accurate, rapid, and requires only modest resources. This work is the first to combine dose distribution prediction with natural language processing; providing a robust pipeline for both generating suboptimal training plans and allowing trainees to practice their critical plan review and improvement skills that addresses the challenges of the current clinic-based paradigm.

Background: The radiation oncology clinical practice involves many steps relying on the dynamic interplay of abundant text data. Large language models have displayed remarkable capabilities in processing complex text information. But their direct applications in specific fields like radiation oncology remain underexplored. Purpose: This study aims to investigate whether fine-tuning LLMs with domain knowledge can improve the performance on Task (1) treatment regimen generation, Task (2) treatment modality selection (photon, proton, electron, or brachytherapy), and Task (3) ICD-10 code prediction in radiation oncology. Methods: Data for 15,724 patient cases were extracted. Cases where patients had a single diagnostic record, and a clearly identifiable primary treatment plan were selected for preprocessing and manual annotation to have 7,903 cases of the patient diagnosis, treatment plan, treatment modality, and ICD-10 code. Each case was used to construct a pair consisting of patient diagnostics details and an answer (treatment regimen, treatment modality, or ICD-10 code respectively) for the supervised fine-tuning of these three tasks. Open source LLaMA2-7B and Mistral-7B models were utilized for the fine-tuning with the Low-Rank Approximations method. Accuracy and ROUGE-1 score were reported for the fine-tuned models and original models. Clinical evaluation was performed on Task (1) by radiation oncologists, while precision, recall, and F-1 score were evaluated for Task (2) and (3). One-sided Wilcoxon signed-rank tests were used to statistically analyze the results. Results: Fine-tuned LLMs outperformed original LLMs across all tasks with p-value <= 0.001. Clinical evaluation demonstrated that over 60% of the fine-tuned LLMs-generated treatment regimens were clinically acceptable. Precision, recall, and F1-score showed improved performance of fine-tuned LLMs.

Purpose: This study aims to use a large language model (LLM) to automate the generation of summaries from the CT simulation orders and evaluate its performance. Materials and Methods: A total of 607 CT simulation orders for patients were collected from the Aria database at our institution. A locally hosted Llama 3.1 405B model, accessed via the Application Programming Interface (API) service, was used to extract keywords from the CT simulation orders and generate summaries. The downloaded CT simulation orders were categorized into seven groups based on treatment modalities and disease sites. For each group, a customized instruction prompt was developed collaboratively with therapists to guide the Llama 3.1 405B model in generating summaries. The ground truth for the corresponding summaries was manually derived by carefully reviewing each CT simulation order and subsequently verified by therapists. The accuracy of the LLM-generated summaries was evaluated by therapists using the verified ground truth as a reference. Results: About 98% of the LLM-generated summaries aligned with the manually generated ground truth in terms of accuracy. Our evaluations showed an improved consistency in format and enhanced readability of the LLM-generated summaries compared to the corresponding therapists-generated summaries. This automated approach demonstrated a consistent performance across all groups, regardless of modality or disease site. Conclusions: This study demonstrated the high precision and consistency of the Llama 3.1 405B model in extracting keywords and summarizing CT simulation orders, suggesting that LLMs have great potential to help with this task, reduce the workload of therapists and improve workflow efficiency.

Thanks to the rapidly evolving integration of LLMs into decision-support tools, a significant transformation is happening across large-scale systems. Like other medical fields, the use of LLMs such as GPT-4 is gaining increasing interest in radiation oncology as well. An attempt to assess GPT-4's performance in radiation oncology was made via a dedicated 100-question examination on the highly specialized topic of radiation oncology physics, revealing GPT-4's superiority over other LLMs. GPT-4's performance on a broader field of clinical radiation oncology is further benchmarked by the ACR Radiation Oncology In-Training (TXIT) exam where GPT-4 achieved a high accuracy of 74.57%. Its performance on re-labelling structure names in accordance with the AAPM TG-263 report has also been benchmarked, achieving above 96% accuracies. Such studies shed light on the potential of LLMs in radiation oncology. As interest in the potential and constraints of LLMs in general healthcare applications continues to rise5, the capabilities and limitations of LLMs in radiation oncology decision support have not yet been fully explored.

Clinical experts employ diverse philosophies and strategies in patient care, influenced by regional patient populations. However, existing medical artificial intelligence (AI) models are often trained on data distributions that disproportionately reflect highly prevalent patterns, reinforcing biases and overlooking the diverse expertise of clinicians. To overcome this limitation, we introduce the Mixture of Multicenter Experts (MoME) approach. This method strategically integrates specialized expertise from diverse clinical strategies, enhancing the AI model's ability to generalize and adapt across multiple medical centers. The MoME-based multimodal target volume delineation model, trained with few-shot samples including images and clinical notes from each medical center, outperformed baseline methods in prostate cancer radiotherapy target delineation. The advantages of MoME were most pronounced when data characteristics varied across centers or when data availability was limited, demonstrating its potential for broader clinical applications. Therefore, the MoME framework enables the deployment of AI-based target volume delineation models in resource-constrained medical facilities by adapting to specific preferences of each medical center only using a few sample data, without the need for data sharing between institutions. Expanding the number of multicenter experts within the MoME framework will significantly enhance the generalizability, while also improving the usability and adaptability of clinical AI applications in the field of precision radiation oncology.

Generating physician letters is a time-consuming task in daily clinical practice. This study investigates local fine-tuning of large language models (LLMs), specifically LLaMA models, for physician letter generation in a privacy-preserving manner within the field of radiation oncology. Our findings demonstrate that base LLaMA models, without fine-tuning, are inadequate for effectively generating physician letters. The QLoRA algorithm provides an efficient method for local intra-institutional fine-tuning of LLMs with limited computational resources (i.e., a single 48 GB GPU workstation within the hospital). The fine-tuned LLM successfully learns radiation oncology-specific information and generates physician letters in an institution-specific style. ROUGE scores of the generated summary reports highlight the superiority of the 8B LLaMA-3 model over the 13B LLaMA-2 model. Further multidimensional physician evaluations of 10 cases reveal that, although the fine-tuned LLaMA-3 model has limited capacity to generate content beyond the provided input data, it successfully generates salutations, diagnoses and treatment histories, recommendations for further treatment, and planned schedules. Overall, clinical benefit was rated highly by the clinical experts (average score of 3.44 on a 4-point scale). With careful physician review and correction, automated LLM-based physician letter generation has significant practical value.