The development of decision support systems for pathology and their deployment in clinical practice have been hindered by the need for large manually annotated datasets. To overcome this problem, we present a multiple instance learning-based deep learning system that uses only the reported diagnoses as labels for training, thereby avoiding expensive and time-consuming pixel-wise manual annotations. We evaluated this framework at scale on a dataset of 44,732 whole slide images from 15,187 patients without any form of data curation. Tests on prostate cancer, basal cell carcinoma and breast cancer metastases to axillary lymph nodes resulted in areas under the curve above 0.98 for all cancer types. Its clinical application would allow pathologists to exclude 65–75% of slides while retaining 100% sensitivity. Our results show that this system has the ability to train accurate classification models at unprecedented scale, laying the foundation for the deployment of computational decision support systems in clinical practice.

Clinical-grade computational pathology using weakly supervised deep learning on whole slide images.

In the past decade, advances in precision oncology have resulted in an increased demand for predictive assays that enable the selection and stratification of patients for treatment. The enormous divergence of signalling and transcriptional networks mediating the crosstalk between cancer, stromal and immune cells complicates the development of functionally relevant biomarkers based on a single gene or protein. However, the result of these complex processes can be uniquely captured in the morphometric features of stained tissue specimens. The possibility of digitizing whole-slide images of tissue has led to the advent of artificial intelligence (AI) and machine learning tools in digital pathology, which enable mining of subvisual morphometric phenotypes and might, ultimately, improve patient management. In this Perspective, we critically evaluate various AI-based computational approaches for digital pathology, focusing on deep neural networks and 'hand-crafted' feature-based methodologies. We aim to provide a broad framework for incorporating AI and machine learning tools into clinical oncology, with an emphasis on biomarker development. We discuss some of the challenges relating to the use of AI, including the need for well-curated validation datasets, regulatory approval and fair reimbursement strategies. Finally, we present potential future opportunities for precision oncology.

/pdf/artificial-intelligence-in-digital-pathology-new-tools-for-3tat3v4mlq.pdf

Artificial intelligence in digital pathology — new tools for diagnosis and precision oncology

Microsatellite instability determines whether patients with gastrointestinal cancer respond exceptionally well to immunotherapy. However, in clinical practice, not every patient is tested for MSI, because this requires additional genetic or immunohistochemical tests. Here we show that deep residual learning can predict MSI directly from H&E histology, which is ubiquitously available. This approach has the potential to provide immunotherapy to a much broader subset of patients with gastrointestinal cancer.

/pdf/deep-learning-can-predict-microsatellite-instability-2jfwewlqc2.pdf

Deep learning can predict microsatellite instability directly from histology in gastrointestinal cancer.

Analysis of big data by machine learning offers considerable advantages for assimilation and evaluation of large amounts of complex health-care data. However, to effectively use machine learning tools in health care, several limitations must be addressed and key issues considered, such as its clinical implementation and ethics in health-care delivery. Advantages of machine learning include flexibility and scalability compared with traditional biostatistical methods, which makes it deployable for many tasks, such as risk stratification, diagnosis and classification, and survival predictions. Another advantage of machine learning algorithms is the ability to analyse diverse data types (eg, demographic data, laboratory findings, imaging data, and doctors' free-text notes) and incorporate them into predictions for disease risk, diagnosis, prognosis, and appropriate treatments. Despite these advantages, the application of machine learning in health-care delivery also presents unique challenges that require data pre-processing, model training, and refinement of the system with respect to the actual clinical problem. Also crucial are ethical considerations, which include medico-legal implications, doctors' understanding of machine learning tools, and data privacy and security. In this Review, we discuss some of the benefits and challenges of big data and machine learning in health care.

Big data and machine learning algorithms for health-care delivery

Deep-learning methods for computational pathology require either manual annotation of gigapixel whole-slide images (WSIs) or large datasets of WSIs with slide-level labels and typically suffer from poor domain adaptation and interpretability. Here we report an interpretable weakly supervised deep-learning method for data-efficient WSI processing and learning that only requires slide-level labels. The method, which we named clustering-constrained-attention multiple-instance learning (CLAM), uses attention-based learning to identify subregions of high diagnostic value to accurately classify whole slides and instance-level clustering over the identified representative regions to constrain and refine the feature space. By applying CLAM to the subtyping of renal cell carcinoma and non-small-cell lung cancer as well as the detection of lymph node metastasis, we show that it can be used to localize well-known morphological features on WSIs without the need for spatial labels, that it overperforms standard weakly supervised classification algorithms and that it is adaptable to independent test cohorts, smartphone microscopy and varying tissue content.

Data-efficient and weakly supervised computational pathology on whole-slide images.

Translating the vast data generated by genomic platforms into accurate predictions of clinical outcomes is a fundamental challenge in genomic medicine. Many prediction methods face limitations in learning from the high-dimensional profiles generated by these platforms, and rely on experts to hand-select a small number of features for training prediction models. In this paper, we demonstrate how deep learning and Bayesian optimization methods that have been remarkably successful in general high-dimensional prediction tasks can be adapted to the problem of predicting cancer outcomes. We perform an extensive comparison of Bayesian optimized deep survival models and other state of the art machine learning methods for survival analysis, and describe a framework for interpreting deep survival models using a risk backpropagation technique. Finally, we illustrate that deep survival models can successfully transfer information across diseases to improve prognostic accuracy. We provide an open-source software implementation of this framework called SurvivalNet that enables automatic training, evaluation and interpretation of deep survival models.

/pdf/predicting-clinical-outcomes-from-large-scale-cancer-genomic-4drzpfuyva.pdf

Predicting clinical outcomes from large scale cancer genomic profiles with deep survival models

The volume of labeled data is often the primary determinant of success in developing machine learning algorithms. This has increased interest in methods for leveraging crowds to scale data labeling efforts, and methods to learn from noisy crowd-sourced labels. The need to scale labeling is acute but particularly challenging in medical applications like pathology, due to the expertise required to generate quality labels and the limited availability of qualified experts. In this paper we investigate the application of Scalable Variational Gaussian Processes for Crowdsourcing (SVGPCR) in digital pathology. We compare SVGPCR with other crowdsourcing methods using a large multi-rater dataset where pathologists, pathology residents, and medical students annotated tissue regions breast cancer. Our study shows that SVGPCR is competitive with equivalent methods trained using gold-standard pathologist generated labels, and that SVGPCR meets or exceeds the performance of other crowdsourcing methods based on deep learning. We also show how SVGPCR can effectively learn the class-conditional reliabilities of individual annotators and demonstrate that Gaussian-process classifiers have comparable performance to similar deep learning methods. These results suggest that SVGPCR can meaningfully engage non-experts in pathology labeling tasks, and that the class-conditional reliabilities estimated by SVGPCR may assist in matching annotators to tasks where they perform well.

/pdf/learning-from-crowds-in-digital-pathology-using-scalable-12t8zl8fz5.pdf

Learning from crowds in digital pathology using scalable variational Gaussian processes.

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Predicting clinical outcomes from large scale cancer genomic profiles with deep survival models

Learning from crowds in digital pathology using scalable variational Gaussian processes.