AI-Based Detection of Temporal Changes in MR-Linac Images Acquired During Routine Prostate Radiotherapy

Purpose: To investigate whether an AI-based method can detect subtle inter-fraction changes in MR-Linac images acquired during radiotherapy and explore the broader potential of MRLinac imaging. Methods: This retrospective study included longitudinal 0.35T MR-Linac images from 761 patients. To identify temporal changes, we employed a deep learning model using temporal ordering via pairwise comparison, previously shown effective for longitudinal imaging studies. The model was trained using first-to-last fraction pairs (F1-FL) and all pairs (All-pairs). Performance was assessed using quantitative metrics (accuracy and AUC) and compared against a radiologist's performance. Qualitative evaluation was performed using saliency maps, which identify anatomical regions associated with temporal imaging changes. Results: The F1-FL model demonstrated high performance (AUC=0.99, accuracy=0.95) and outperformed the radiologist in temporal ordering task. The All-pairs model also showed high performance (AUC=0.97, accuracy=0.91). Regions contributing to predictions included the prostate, bladder, and pubic symphysis. The performance was correlated to fractional intervals and was reduced for non-radiation-exposed timepoints (Sim and F1), suggesting that observed changes may reflect both temporal variation and radiation exposure. Conclusion: MR-Linac imaging appears capable of capturing subtle changes during prostate radiotherapy that can be detected by AI models, even over approximately two-day intervals. The model's high performance, together with quantitative and qualitative analyses, supports a potential role for MR-Linac in clinical applications beyond image guidance.