# Anatomy-Change-Aware Bidirectional Selective State-Space Memory for Clinically Deployed Thoracic Radiotherapy Auto-Contouring

arXiv: https://arxiv.org/abs/2609.16036 · HTML: https://mlsanity.com/paper/2609.16036/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Placed in Mamba for medical image analysis, one of 10 directions in State-space sequence models (S4, Mamba).
- Builds on 25 of its 56 references that are in the map.
- First posted on arXiv 11 Sep 2026.

## Placed in

- State-space sequence models (S4, Mamba) / [Mamba for medical image analysis](https://mlsanity.com/ssm/mamba-for-medical-image-analysis/)

## Builds on (most cited first, 25 of 25)

- [Attention Is All You Need](https://mlsanity.com/paper/1706.03762/) (2017)
- [An Image is Worth 16x16 Words: Transformers for Image Recognition at Scale](https://mlsanity.com/paper/2010.11929/) (2020)
- [U-Net: Convolutional Networks for Biomedical Image Segmentation](https://mlsanity.com/paper/1505.04597/) (2015)
- [Swin Transformer: Hierarchical Vision Transformer using Shifted Windows](https://mlsanity.com/paper/2103.14030/) (2021)
- [Mamba: Linear-Time Sequence Modeling with Selective State Spaces](https://mlsanity.com/paper/2312.00752/) (2023)
- [Dropout as a Bayesian Approximation: Representing Model Uncertainty in Deep Learning](https://mlsanity.com/paper/1506.02142/) (2015)
- [Simple and Scalable Predictive Uncertainty Estimation using Deep Ensembles](https://mlsanity.com/paper/1612.01474/) (2016)
- [What Uncertainties Do We Need in Bayesian Deep Learning for Computer Vision?](https://mlsanity.com/paper/1703.04977/) (2017)
- [3D U-Net: Learning Dense Volumetric Segmentation from Sparse Annotation](https://mlsanity.com/paper/1606.06650/) (2016)
- [Convolutional LSTM Network: A Machine Learning Approach for Precipitation Nowcasting](https://mlsanity.com/paper/1506.04214/) (2015)
- [Attention U-Net: Learning Where to Look for the Pancreas](https://mlsanity.com/paper/1804.03999/) (2018)
- [Swin-Unet: Unet-like Pure Transformer for Medical Image Segmentation](https://mlsanity.com/paper/2105.05537/) (2021)
- [VMamba: Visual State Space Model](https://mlsanity.com/paper/2401.10166/) (2024)
- [Swin UNETR: Swin Transformers for Semantic Segmentation of Brain Tumors in MRI Images](https://mlsanity.com/paper/2201.01266/) (2022)
- [A Survey of Uncertainty in Deep Neural Networks](https://mlsanity.com/paper/2107.03342/) (2021)
- [U-Mamba: Enhancing Long-range Dependency for Biomedical Image Segmentation](https://mlsanity.com/paper/2401.04722/) (2024)
- [VM-UNet: Vision Mamba UNet for Medical Image Segmentation](https://mlsanity.com/paper/2402.02491/) (2024)
- [UNETR++: Delving into Efficient and Accurate 3D Medical Image Segmentation](https://mlsanity.com/paper/2212.04497/) (2022)
- [AnatomyNet: Deep Learning for Fast and Fully Automated Whole-volume Segmentation of Head and Neck Anatomy](https://mlsanity.com/paper/1808.05238/) (2018)
- [nnMamba: 3D Biomedical Image Segmentation, Classification and Landmark Detection with State Space Model](https://mlsanity.com/paper/2402.03526/) (2024)
- [A review of uncertainty quantification in medical image analysis: probabilistic and non-probabilistic methods](https://mlsanity.com/paper/2310.06873/) (2023)
- [An Exploration of 2D and 3D Deep Learning Techniques for Cardiac MR Image Segmentation](https://mlsanity.com/paper/1709.04496/) (2017)
- [A deep learning-based framework for segmenting invisible clinical target volumes with estimated uncertainties for post-operative prostate cancer radiotherapy](https://mlsanity.com/paper/2004.13294/) (2020)
- [Deep Sequential Segmentation of Organs in Volumetric Medical Scans](https://mlsanity.com/paper/1807.02437/) (2018)
- [BAT-RM: A Boundary-Aware Transformer with Region-Aware Multi-Directional Mamba for Clinically Deployed Cervical Cancer Radiotherapy Auto-Contouring](https://mlsanity.com/paper/2607.11949/) (2026)

## Abstract (arXiv)

We developed DAMM-Net++, a 2.5D architecture for thoracic OAR and target volume segmentation that addresses three persistent challenges in radiotherapy auto-contouring: inter-slice surface incoherence, systematic failure on small low-contrast targets, and the absence of per-case reliability signals. The central component is an anatomy-change-aware bidirectional selective state-space memory that models through-plane anatomical change and selectively propagates context along the axial slice sequence. A boundary-aware decoder sharpens near-surface predictions, and an uncertainty head provides calibrated per-voxel confidence for clinical triage. We evaluated 2,146 patients across four centers, an independent external cohort of 112 patients, and a multicenter reader study involving 17 radiation oncologists on 305 cases. The model achieves a mean Dice of 0.955 and HD95 of 3.78 mm, with the largest gains on low-contrast organs-at-risk (OARs) and target volumes where through-plane context is most critical. The uncertainty head is well-calibrated and supports case-level triage. In the reader study, AI assistance reduced contouring time by 75-80% across experience levels and raised junior-reader IoU from 0.861 to 0.925, matching the unedited model. External validation showed a modest internal-to-external drop (< 5%) with calibrated uncertainty transferring without recalibration. The complete deployment pipeline from DICOM ingestion to TPS-compatible RTSTRUCT export has been integrated into the clinical workflow at a partner hospital, where it is used to assist with contouring. These results suggest that anatomically motivated inter-slice memory, paired with uncertainty-guided review, offers a clinically viable path for thoracic auto-contouring.