• Babak Ehteshami Bejnordi, Mitko Veta, Paul Johannes van Diest, Bram van Ginneken, Nico Karssemeijer, Geert Litjens, van der LaakJeroen A W MJAWMDepartment of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands., the CAMELYON16 Consortium, Meyke Hermsen, Quirine F Manson, Maschenka Balkenhol, Oscar Geessink, Nikolaos Stathonikos, Marcory Crf van Dijk, Peter Bult, Francisco Beca, Andrew H Beck, Dayong Wang, Aditya Khosla, Rishab Gargeya, Humayun Irshad, Aoxiao Zhong, Qi Dou, Quanzheng Li, Hao Chen, Huang-Jing Lin, Pheng-Ann Heng, Christian Haß, Elia Bruni, Quincy Wong, Ugur Halici, Mustafa Ümit Öner, Rengul Cetin-Atalay, Matt Berseth, Vitali Khvatkov, Alexei Vylegzhanin, Oren Kraus, Muhammad Shaban, Nasir Rajpoot, Ruqayya Awan, Korsuk Sirinukunwattana, Talha Qaiser, Yee-Wah Tsang, David Tellez, Jonas Annuscheit, Peter Hufnagl, Mira Valkonen, Kimmo Kartasalo, Leena Latonen, Pekka Ruusuvuori, Kaisa Liimatainen, Shadi Albarqouni, Bharti Mungal, Ami George, Stefanie Demirci, Nassir Navab, Seiryo Watanabe, Shigeto Seno, Yoichi Takenaka, Hideo Matsuda, Hady Ahmady Phoulady, Vassili Kovalev, Alexander Kalinovsky, Vitali Liauchuk, Gloria Bueno, M Milagro Fernandez-Carrobles, Ismael Serrano, Oscar Deniz, Daniel Racoceanu, and Rui Venâncio.
• Diagnostic Image Analysis Group, Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.
• JAMA. 2017 Dec 12; 318 (22): 219922102199-2210.

ImportanceApplication of deep learning algorithms to whole-slide pathology images can potentially improve diagnostic accuracy and efficiency.ObjectiveAssess the performance of automated deep learning algorithms at detecting metastases in hematoxylin and eosin-stained tissue sections of lymph nodes of women with breast cancer and compare it with pathologists' diagnoses in a diagnostic setting.Design, Setting, And ParticipantsResearcher challenge competition (CAMELYON16) to develop automated solutions for detecting lymph node metastases (November 2015-November 2016). A training data set of whole-slide images from 2 centers in the Netherlands with (n = 110) and without (n = 160) nodal metastases verified by immunohistochemical staining were provided to challenge participants to build algorithms. Algorithm performance was evaluated in an independent test set of 129 whole-slide images (49 with and 80 without metastases). The same test set of corresponding glass slides was also evaluated by a panel of 11 pathologists with time constraint (WTC) from the Netherlands to ascertain likelihood of nodal metastases for each slide in a flexible 2-hour session, simulating routine pathology workflow, and by 1 pathologist without time constraint (WOTC).ExposuresDeep learning algorithms submitted as part of a challenge competition or pathologist interpretation.Main Outcomes And MeasuresThe presence of specific metastatic foci and the absence vs presence of lymph node metastasis in a slide or image using receiver operating characteristic curve analysis. The 11 pathologists participating in the simulation exercise rated their diagnostic confidence as definitely normal, probably normal, equivocal, probably tumor, or definitely tumor.ResultsThe area under the receiver operating characteristic curve (AUC) for the algorithms ranged from 0.556 to 0.994. The top-performing algorithm achieved a lesion-level, true-positive fraction comparable with that of the pathologist WOTC (72.4% [95% CI, 64.3%-80.4%]) at a mean of 0.0125 false-positives per normal whole-slide image. For the whole-slide image classification task, the best algorithm (AUC, 0.994 [95% CI, 0.983-0.999]) performed significantly better than the pathologists WTC in a diagnostic simulation (mean AUC, 0.810 [range, 0.738-0.884]; P < .001). The top 5 algorithms had a mean AUC that was comparable with the pathologist interpreting the slides in the absence of time constraints (mean AUC, 0.960 [range, 0.923-0.994] for the top 5 algorithms vs 0.966 [95% CI, 0.927-0.998] for the pathologist WOTC).Conclusions And RelevanceIn the setting of a challenge competition, some deep learning algorithms achieved better diagnostic performance than a panel of 11 pathologists participating in a simulation exercise designed to mimic routine pathology workflow; algorithm performance was comparable with an expert pathologist interpreting whole-slide images without time constraints. Whether this approach has clinical utility will require evaluation in a clinical setting.

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