Turning the attention to time-resolved EPID-images: treatment error classification with transformer multiple instance learning.

The aim of this work was to develop a novel AI-assisted in vivo dosimetry (IVD) method using time-resolved dose verification data to improve quality of external beam radiotherapy.
Approach. Although threshold classification methods are commonly used in error classification, they may lead to missing errors due to the loss of information resulting from the compression of multi-dimensional electronic portal imaging device (EPID) data into one or a few numbers. Recent research has investigated the classification of errors on time-integrated (TI) in vivo EPID images, with convolutional neural networks showing promise. However, it has been observed previously that TI approaches may cancel out the error presence on γ-maps during dynamic treatments. To address this limitation, simulated time-resolved (TR) γ-maps for each VMAT angle were used to detect treatment errors caused by complex patient geometries and beam arrangements. Typically, such images can be interpreted as a set of segments where only set class labels are provided. Inspired by recent weakly supervised approaches on histopathology images, we implemented a transformer based multiple instance learning (MIL) approach and utilized transfer learning from TI to TR γ-maps. 
Main results. The proposed algorithm performed well on classification of error type and error magnitude. The accuracy in the test set was up to 0.94 and 0.81 for 11 (error type) and 22 (error magnitude) classes of treatment errors, respectively. 
Significance. TR dose distributions can enhance treatment delivery decision-making, however manual data analysis is nearly impossible due to the complexity and quantity of this data. Our proposed model efficiently handles data complexity, substantially improving treatment error classification compared to models that leverage TI data.
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