Catching magnetic resonance imaging outliers in artificial intelligence-supported radiotherapy workflows: unsupervised detection and localization of image anomalies using deep learning
Artificial intelligence is increasingly integrated into radiotherapy workflows, yet such pipelines remain vulnerable to out-of-distribution image data that may introduce unexpected behavior in clinical tasks. Deep learning-based anomaly detection for pelvic magnetic resonance imaging (MRI) remains largely unexplored, and transparent evaluation of its feasibility for full automation is limited. We developed and evaluated a fully automated, unsupervised anomaly-detection framework for pelvic and brain MRI. A two-stage framework was trained on reference images from public datasets: LUND-PROBE for pelvic MRI, and IXI, fastMRI, and fastMRI+ for brain MRI. In the first stage, MRI slices were compressed into discrete tokens; in the second, the distribution of normal tokens was modeled. Anomaly evidence was estimated by combining perceptual image differences with token-surprisal scores based on negative log-likelihood. Automated detection was evaluated on pelvic MRI with synthetic global and real clinical anomalies, and on brain MRI with clinically annotated fastMRI+ abnormalities. Sensitivity, specificity, area under the receiver operating characteristic curve (AUC), and false-positive behavior in held-out normal cases were assessed. The framework achieved robust detection across hidden evaluation cohorts, with AUCs of 0.97 (95% CI, 0.95-0.98) and 0.81 (95% CI, 0.74-0.87) for pelvic and brain MRI, respectively. Heatmap analysis showed strong spatial agreement between detected anomalies and ground-truth locations, supporting localization accuracy and interpretability. These results support the potential of unsupervised anomaly detection as an automated MRI quality-control layer for radiotherapy workflows, with transparent visualization of image regions likely to compromise downstream AI-based tasks.