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arXiv · 2512.20586

Automated stereotactic radiosurgery planning using a human-in-the-loop reasoning large language model agent

Humza Nusrat·Luke Francisco·Bing Luo·Hassan Bagher-Ebadian·Joshua Kim·Karen Chin-Snyder·Salim Siddiqui·Mira Shah·Eric Mellon·Mohammad Ghassemi·Anthony Doemer·Benjamin Movsas·Kundan Thind
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Abstract

Stereotactic radiosurgery (SRS) demands precise dose shaping around critical structures, yet black-box AI systems have limited clinical adoption due to opacity concerns. We tested whether chain-of-thought reasoning improves agentic planning in a retrospective cohort of 41 patients with brain metastases treated with 18 Gy single-fraction SRS. We developed SAGE (Secure Agent for Generative Dose Expertise), an LLM-based planning agent for automated SRS treatment planning. Two variants generated plans for each case: one using a non-reasoning model, one using a reasoning model. The reasoning variant showed comparable plan dosimetry relative to human planners on primary endpoints (PTV coverage, maximum dose, conformity index, gradient index; all p > 0.21) while reducing cochlear dose below human baselines (p = 0.022). When prompted to improve conformity, the reasoning model demonstrated systematic planning behaviors including prospective constraint verification (457 instances) and trade-off deliberation (609 instances), while the standard model exhibited none of these deliberative processes (0 and 7 instances, respectively). Content analysis revealed that constraint verification and causal explanation concentrated in the reasoning agent. The optimization traces serve as auditable logs, offering a path toward transparent automated planning.

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Humza Nusrat, Luke Francisco, Bing Luo, Hassan Bagher-Ebadian, Joshua Kim, Karen Chin-Snyder, Salim Siddiqui, Mira Shah, Eric Mellon, Mohammad Ghassemi, Anthony Doemer, Benjamin Movsas, Kundan Thind. 2025-12-23. Automated stereotactic radiosurgery planning using a human-in-the-loop reasoning large language model agent. https://arxiv.org/abs/2512.20586

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