Kelvin Szolnoky

Peshawa J. Muhammad Ali, Navin Vincent, Saman S. Abdulla et al.

Background: Artificial intelligence (AI) is improving the efficiency and accuracy of cancer diagnostics. The performance of pathology AI systems has been almost exclusively evaluated on European and US cohorts from large centers. For global AI adoption in pathology, validation studies on currently under-represented populations - where the potential gains from AI support may also be greatest - are needed. We present the first study with an external validation cohort from the Middle East, focusing on AI-based diagnosis and Gleason grading of prostate cancer. Methods: We collected and digitised 339 prostate biopsy specimens from the Kurdistan region, Iraq, representing a consecutive series of 185 patients spanning the period 2013-2024. We evaluated a task-specific end-to-end AI model and two foundation models in terms of their concordance with pathologists and consistency across samples digitised on three scanner models (Hamamatsu, Leica, and Grundium). Findings: Grading concordance between AI and pathologists was similar to pathologist-pathologist concordance with Cohen's quadratically weighted kappa 0.801 vs. 0.799 (p=0.9824). Cross-scanner concordance was high (quadratically weighted kappa > 0.90) for all AI models and scanner pairs, including low-cost compact scanner. Interpretation: AI models demonstrated pathologist-level performance in prostate histopathology assessment. Compact scanners can provide a route for validation studies in non-digitalised settings and enable cost-effective adoption of AI in laboratories with limited sample volumes. This first openly available digital pathology dataset from the Middle East supports further research into globally equitable AI pathology. Funding: SciLifeLab and Wallenberg Data Driven Life Science Program, Instrumentarium Science Foundation, Karolinska Institutet Research Foundation.

Peshawa J. Muhammad Ali, Navin Vincent, Saman S. Abdulla et al.

Artificial intelligence (AI) is increasingly used in digital pathology. Publicly available histopathology datasets remain scarce, and those that do exist predominantly represent Western populations. Consequently, the generalizability of AI models to populations from less digitized regions, such as the Middle East, is largely unknown. This motivates the public release of our dataset to support the development and validation of pathology AI models across globally diverse populations. We present 339 whole-slide images of prostate core needle biopsies from a consecutive series of 185 patients collected in Erbil, Iraq. The slides are associated with Gleason scores and International Society of Urological Pathology grades assigned independently by three pathologists. Scanning was performed using two high-throughput scanners (Leica and Hamamatsu) and one compact scanner (Grundium). All slides were de-identified and are provided in their native formats without further conversion. The dataset enables grading concordance analyses, color normalization, and cross-scanner robustness evaluations. Data will be deposited in the Bioimage Archive (BIA) under accession code: to be announced (TBA), and released under a CC BY 4.0 license.

Nita Mulliqi, Anders Blilie, Xiaoyi Ji et al.

The role of artificial intelligence (AI) in pathology has evolved from aiding diagnostics to uncovering predictive morphological patterns in whole slide images (WSIs). Recently, foundation models (FMs) leveraging self-supervised pre-training have been widely advocated as a universal solution for diverse downstream tasks. However, open questions remain about their clinical applicability and generalization advantages over end-to-end learning using task-specific (TS) models. Here, we focused on AI with clinical-grade performance for prostate cancer diagnosis and Gleason grading. We present the largest validation of AI for this task, using over 100,000 core needle biopsies from 7,342 patients across 15 sites in 11 countries. We compared two FMs with a fully end-to-end TS model in a multiple instance learning framework. Our findings challenge assumptions that FMs universally outperform TS models. While FMs demonstrated utility in data-scarce scenarios, their performance converged with - and was in some cases surpassed by - TS models when sufficient labeled training data were available. Notably, extensive task-specific training markedly reduced clinically significant misgrading, misdiagnosis of challenging morphologies, and variability across different WSI scanners. Additionally, FMs used up to 35 times more energy than the TS model, raising concerns about their sustainability. Our results underscore that while FMs offer clear advantages for rapid prototyping and research, their role as a universal solution for clinically applicable medical AI remains uncertain. For high-stakes clinical applications, rigorous validation and consideration of task-specific training remain critically important. We advocate for integrating the strengths of FMs and end-to-end learning to achieve robust and resource-efficient AI pathology solutions fit for clinical use.

Sol Erika Boman, Nita Mulliqi, Anders Blilie et al.

Tissue detection is a crucial first step in most digital pathology applications. Details of the segmentation algorithm are rarely reported, and there is a lack of studies investigating the downstream effects of a poor segmentation algorithm. Disregarding tissue detection quality could create a bottleneck for downstream performance and jeopardize patient safety if diagnostically relevant parts of the specimen are excluded from analysis in clinical applications. This study aims to determine whether performance of downstream tasks is sensitive to the tissue detection method, and to compare performance of classical and AI-based tissue detection. To this end, we trained an AI model for Gleason grading of prostate cancer in whole slide images (WSIs) using two different tissue detection algorithms: thresholding (classical) and UNet++ (AI). A total of 33,823 WSIs scanned on five digital pathology scanners were used to train the tissue detection AI model. The downstream Gleason grading algorithm was trained and tested using 70,524 WSIs from 13 clinical sites scanned on 13 different scanners. There was a decrease from 116 (0.43%) to 22 (0.08%) fully undetected tissue samples when switching from thresholding-based tissue detection to AI-based, suggesting an AI model may be more reliable than a classical model for avoiding total failures on slides with unusual appearance. On the slides where tissue could be detected by both algorithms, no significant difference in overall Gleason grading performance was observed. However, tissue detection dependent clinically significant variations in AI grading were observed in 3.5% of malignant slides, highlighting the importance of robust tissue detection for optimal clinical performance of diagnostic AI.

Andrea Camilloni, Chiara Micoli, Nita Mulliqi et al.

Biochemical recurrence (BCR) after radical prostatectomy (RP) is a surrogate marker for aggressive prostate cancer with adverse outcomes, yet current prognostic tools remain imprecise. We trained an AI-based model on diagnostic prostate biopsy slides from the STHLM3 cohort (n = 676) to predict patient-specific risk of BCR, using foundation models and attention-based multiple instance learning. Generalizability was assessed across three external RP cohorts: LEOPARD (n = 508), CHIMERA (n = 95), and TCGA-PRAD (n = 379). The image-based approach achieved 5-year time-dependent AUCs of 0.64, 0.70, and 0.70, respectively. Integrating clinical variables added complementary prognostic value and enabled statistically significant risk stratification. Compared with guideline-based CAPRA-S, AI incrementally improved postoperative prognostication. These findings suggest biopsy-trained histopathology AI can generalize across specimen types to support preoperative and postoperative decision making, but the added value of AI-based multimodal approaches over simpler predictive models should be critically scrutinized in further studies.

Kelvin Szolnoky, Anders Blilie, Nita Mulliqi et al.

Background: Cribriform morphology in prostate cancer is a histological feature that indicates poor prognosis and contraindicates active surveillance. However, it remains underreported and subject to significant interobserver variability amongst pathologists. We aimed to develop and validate an AI-based system to improve cribriform pattern detection. Methods: We created a deep learning model using an EfficientNetV2-S encoder with multiple instance learning for end-to-end whole-slide classification. The model was trained on 640 digitised prostate core needle biopsies from 430 patients, collected across three cohorts. It was validated internally (261 slides from 171 patients) and externally (266 slides, 104 patients from three independent cohorts). Internal validation cohorts included laboratories or scanners from the development set, while external cohorts used completely independent instruments and laboratories. Annotations were provided by three expert uropathologists with known high concordance. Additionally, we conducted an inter-rater analysis and compared the model's performance against nine expert uropathologists on 88 slides from the internal validation cohort. Results: The model showed strong internal validation performance (AUC: 0.97, 95% CI: 0.95-0.99; Cohen's kappa: 0.81, 95% CI: 0.72-0.89) and robust external validation (AUC: 0.90, 95% CI: 0.86-0.93; Cohen's kappa: 0.55, 95% CI: 0.45-0.64). In our inter-rater analysis, the model achieved the highest average agreement (Cohen's kappa: 0.66, 95% CI: 0.57-0.74), outperforming all nine pathologists whose Cohen's kappas ranged from 0.35 to 0.62. Conclusion: Our AI model demonstrates pathologist-level performance for cribriform morphology detection in prostate cancer. This approach could enhance diagnostic reliability, standardise reporting, and improve treatment decisions for prostate cancer patients.

Anders Blilie, Nita Mulliqi, Xiaoyi Ji et al.

Prostate cancer diagnosis heavily relies on histopathological evaluation, which is subject to variability. While immunohistochemical staining (IHC) assists in distinguishing benign from malignant tissue, it involves increased work, higher costs, and diagnostic delays. Artificial intelligence (AI) presents a promising solution to reduce reliance on IHC by accurately classifying atypical glands and borderline morphologies in hematoxylin & eosin (H&E) stained tissue sections. In this study, we evaluated an AI model's ability to minimize IHC use without compromising diagnostic accuracy by retrospectively analyzing prostate core needle biopsies from routine diagnostics at three different pathology sites. These cohorts were composed exclusively of difficult cases where the diagnosing pathologists required IHC to finalize the diagnosis. The AI model demonstrated area under the curve values of 0.951-0.993 for detecting cancer in routine H&E-stained slides. Applying sensitivity-prioritized diagnostic thresholds reduced the need for IHC staining by 44.4%, 42.0%, and 20.7% in the three cohorts investigated, without a single false negative prediction. This AI model shows potential for optimizing IHC use, streamlining decision-making in prostate pathology, and alleviating resource burdens.