Unleashing the potential of AI for pathology: challenges and recommendations

Closing the gap in the clinical adoption of computational pathology: a standardized, open-source framework to integrate deep-learning models into the laboratory information system

BACKGROUND

Digital pathology (DP) has revolutionized cancer diagnostics and enabled the development of deep-learning (DL) models aimed at supporting pathologists in their daily work and improving patient care. However, the clinical adoption of such models remains challenging. Here, we describe a proof-of-concept framework that, leveraging Health Level 7 (HL7) standard and open-source DP resources, allows a seamless integration of both publicly available and custom developed DL models in the clinical workflow.

METHODS

Development and testing of the framework were carried out in a fully digitized Italian pathology department. A Python-based server-client architecture was implemented to interconnect through HL7 messaging the anatomic pathology laboratory information system (AP-LIS) with an external artificial intelligence-based decision support system (AI-DSS) containing 16 pre-trained DL models. Open-source toolboxes for DL model deployment were used to run DL model inference, and QuPath was used to provide an intuitive visualization of model predictions as colored heatmaps.

RESULTS

A default deployment mode runs continuously in the background as each new slide is digitized, choosing the correct DL model(s) on the basis of the tissue type and staining. In addition, pathologists can initiate the analysis on-demand by selecting a specific DL model from the virtual slide tray. In both cases, the AP-LIS transmits an HL7 message to the AI-DSS, which processes the message, runs DL model inference, and creates the appropriate visualization style for the employed classification model. The AI-DSS transmits model inference results to the AP-LIS, where pathologists can visualize the output in QuPath and/or directly as slide description in the virtual slide tray.

CONCLUSIONS

Taken together, the developed integration framework through the use of the HL7 standard and freely available DP resources offers a standardized, portable, and open-source solution that lays the groundwork for the future widespread adoption of DL models in pathology diagnostics.

Deep Learning-Powered Whole Slide Image Analysis in Cancer Pathology

Pathology is the cornerstone of modern cancer care. With the advancement of precision oncology, the demand for histopathologic diagnosis and stratification of patients is increasing as personalized cancer therapy relies on accurate biomarker assessment. Recently, rapid development of whole slide imaging technology has enabled digitalization of traditional histologic slides at high resolution, holding promise to improve both the precision and efficiency of histopathologic evaluation. In particular, deep learning approaches, such as Convolutional Neural Network, Graph Convolutional Network, and Transformer, have shown great promise in enhancing the sensitivity and accuracy of whole slide image (WSI) analysis in cancer pathology because of their ability to handle high-dimensional and complex image data. The integration of deep learning models with WSIs enables us to explore and mine morphologic features beyond the visual perception of pathologists, which can help automate clinical diagnosis, assess histopathologic grade, predict clinical outcomes, and even discover novel morphologic biomarkers. In this review, we present a comprehensive framework for incorporating deep learning with WSIs, highlighting how deep learning-driven WSI analysis advances clinical tasks in cancer care. Furthermore, we critically discuss the opportunities and challenges of translating deep learning-based digital pathology into clinical practice, which should be considered to support personalized treatment of cancer patients.

Unveiling the risks of ChatGPT in diagnostic surgical pathology

ChatGPT, an AI capable of processing and generating human-like language, has been studied in medical education and care, yet its potential in histopathological diagnosis remains unexplored. This study evaluates ChatGPT's reliability in addressing pathology-related diagnostic questions across ten subspecialties and its ability to provide scientific references. We crafted five clinico-pathological scenarios per subspecialty, simulating a pathologist using ChatGPT to refine differential diagnoses. Each scenario, aligned with current diagnostic guidelines and validated by expert pathologists, was posed as open-ended or multiple-choice questions, either requesting scientific references or not. Outputs were assessed by six pathologists according to. (1) usefulness in supporting the diagnosis and (2) absolute number of errors. We used directed acyclic graphs and structural causal models to determine the effect of each scenario type, field, question modality, and pathologist evaluation. We yielded 894 evaluations. ChatGPT provided useful answers in 62.2% of cases, and 32.1% of outputs contained no errors, while the remaining had at least one error. ChatGPT provided 214 bibliographic references: 70.1% correct, 12.1% inaccurate, and 17.8% non-existing. Scenario variability had the greatest impact on ratings, and latent knowledge across fields showed minimal variation. Although ChatGPT provided useful responses in one-third of cases, the frequency of errors and variability underscores its inadequacy for routine diagnostic use and highlights the need for discretion as a support tool. Imprecise referencing also suggests caution as a self-learning tool. It is essential to recognize the irreplaceable role of human experts in synthesizing images, clinical data, and experience for the intricate task of histopathological diagnosis.

Advancements in pathology: Digital transformation, precision medicine, and beyond

Pathology, a cornerstone of medical diagnostics and research, is undergoing a revolutionary transformation fueled by digital technology, molecular biology advancements, and big data analytics. Digital pathology converts conventional glass slides into high-resolution digital images, enhancing collaboration and efficiency among pathologists worldwide. Integrating artificial intelligence (AI) and machine learning (ML) algorithms with digital pathology improves diagnostic accuracy, particularly in complex diseases like cancer. Molecular pathology, facilitated by next-generation sequencing (NGS), provides comprehensive genomic, transcriptomic, and proteomic insights into disease mechanisms, guiding personalized therapies. Immunohistochemistry (IHC) plays a pivotal role in biomarker discovery, refining disease classification and prognostication. Precision medicine integrates pathology's molecular findings with individual genetic, environmental, and lifestyle factors to customize treatment strategies, optimizing patient outcomes. Telepathology extends diagnostic services to underserved areas through remote digital pathology. Pathomics leverages big data analytics to extract meaningful insights from pathology images, advancing our understanding of disease pathology and therapeutic targets. Virtual autopsies employ non-invasive imaging technologies to revolutionize forensic pathology. These innovations promise earlier diagnoses, tailored treatments, and enhanced patient care. Collaboration across disciplines is essential to fully realize the transformative potential of these advancements in medical practice and research.

Pathology in the artificial intelligence era: Guiding innovation and implementation to preserve human insight

The integration of artificial intelligence in pathology has ignited discussions about the role of technology in diagnostics-whether artificial intelligence serves as a tool for augmentation or risks replacing human expertise. This manuscript explores artificial intelligence's evolving contributions to pathology, emphasizing its potential capacity to enhance, rather than eclipse, the pathologist's role. Through historical comparisons, such as the transition from analog to digital in radiology, this paper highlights how technological advancements have historically expanded professional capabilities without diminishing the essential human element. Current applications of artificial intelligence in pathology-from diagnostic standardization to workflow efficiency-demonstrate its potential to augment diagnostic accuracy, expedite processes, and improve consistency across institutions. However, challenges remain in algorithmic bias, regulatory oversight, and maintaining interpretive skills among pathologists. The discussion underscores the importance of comprehensive governance frameworks, evolving educational curricula, and public engagement initiatives to ensure artificial intelligence in pathology remains a collaborative endeavor that empowers professionals, upholds ethical standards, and enhances patient outcomes. This manuscript ultimately advocates for a balanced approach where artificial intelligence and human expertise work in concert to advance the future of diagnostic medicine.

The current troubled state of the global pathology workforce: a concise review

The histopathology workforce is a cornerstone of cancer diagnostics and is essential to the delivery of cancer services and patient care. The workforce has been subject to significant pressures over recent years, and this review considers them in the UK and internationally. These pressures include declining pathologist numbers, the increasing age of the workforce, and greater workload volume and complexity. Forecasts of the workforce's future in numerous countries are also not favourable - although this is not universal. Some in the field suggest that the effects of these pressures are already coming to bear, such as the financial costs of the additional measures needed to maintain clinical services. There is also some evidence of a detrimental impact on service delivery, patient care and pathologists themselves. Various solutions have been considered, including increasing the number of training places, enhancing recruitment, shortening pathology training and establishing additional support roles within pathology departments. A few studies have examined the effect of some of these solutions. However, the broader extent of their implementation and impact, if any, remains to be determined. In this regard, it is critical that future endeavours should focus on gaining a better understanding of the benefits of implemented workforce solutions, as well as obtaining more detailed and updated pathology workforce numbers. With a concentrated effort in these areas, the future of the pathology workforce could become brighter in the face of the increased demands on its services.

Galileo-an Artificial Intelligence tool for evaluating pre-implantation kidney biopsies

BACKGROUND

Pre-transplant procurement biopsy interpretation is challenging, also because of the low number of renal pathology experts. Artificial intelligence (AI) can assist by aiding pathologists with kidney donor biopsy assessment. Herein we present the "Galileo" AI tool, designed specifically to assist the on-call pathologist with interpreting pre-implantation kidney biopsies.

METHODS

A multicenter cohort of whole slide images acquired from core-needle and wedge biopsies of the kidney was collected. A deep learning algorithm was trained to detect the main findings evaluated in the pre-implantation setting (normal glomeruli, globally sclerosed glomeruli, ischemic glomeruli, arterioles and arteries). The model obtained on the Aiforia Create platform was validated on an external dataset by three independent pathologists to evaluate the performance of the algorithm.

RESULTS

Galileo demonstrated a precision, sensitivity, F1 score and total area error of 81.96%, 94.39%, 87.74%, 2.81% and 74.05%, 71.03%, 72.5%, 2% in the training and validation sets, respectively. Galileo was significantly faster than pathologists, requiring 2 min overall in the validation phase (vs 25, 22 and 31 min by 3 separate human readers, p < 0.001). Galileo-assisted detection of renal structures and quantitative information was directly integrated in the final report.

CONCLUSIONS

The Galileo AI-assisted tool shows promise in speeding up pre-implantation kidney biopsy interpretation, as well as in reducing inter-observer variability. This tool may represent a starting point for further improvements based on hard endpoints such as graft survival.

Implementation of Digital Pathology and Artificial Intelligence in Routine Pathology Practice

The advent of affordable technology has significantly influenced the practice of digital pathology, leading to its growing adoption within the pathology community. This review article aimed to outline the latest developments in digital pathology, the cutting-edge advancements in artificial intelligence (AI) applications within this field, and the pertinent United States regulatory frameworks. The content is based on a thorough analysis of original research articles and official United States Federal guidelines. Findings from our review indicate that several Food and Drug Administration-approved digital scanners and image management systems are establishing a solid foundation for the seamless integration of advanced technologies into everyday pathology workflows, which may reduce device and operational costs in the future. AI is particularly transforming the way morphologic diagnoses are automated, notably in cancers like prostate and colorectal, within screening initiatives, albeit challenges such as data privacy issues and algorithmic biases remain. The regulatory environment, shaped by standards from the Food and Drug Administration, Centers for Medicare & Medicaid Services/Clinical Laboratory Improvement Amendments, and College of American Pathologists, is evolving to accommodate these innovations while ensuring safety and reliability. Centers for Medicare & Medicaid Services/Clinical Laboratory Improvement Amendments have issued policies to allow pathologists to review and render diagnoses using digital pathology remotely. Moreover, the introduction of new digital pathology Current Procedural Terminology codes designed to complement existing pathology Current Procedural Terminology codes is facilitating reimbursement processes. Overall, these advancements are heralding a new era in pathology that promises enhanced diagnostic precision and efficiency through digital and AI technologies, potentially improving patient care as well as bolstering educational and research activities.

Advancing Automatic Gastritis Diagnosis: An Interpretable Multilabel Deep Learning Framework for the Simultaneous Assessment of Multiple Indicators

The evaluation of morphologic features, such as inflammation, gastric atrophy, and intestinal metaplasia, is crucial for diagnosing gastritis. However, artificial intelligence analysis for nontumor diseases like gastritis is limited. Previous deep learning models have omitted important morphologic indicators and cannot simultaneously diagnose gastritis indicators or provide interpretable labels. To address this, an attention-based multi-instance multilabel learning network (AMMNet) was developed to simultaneously achieve the multilabel diagnosis of activity, atrophy, and intestinal metaplasia with only slide-level weak labels. To evaluate AMMNet's real-world performance, a diagnostic test was designed to observe improvements in junior pathologists' diagnostic accuracy and efficiency with and without AMMNet assistance. In this study of 1096 patients from seven independent medical centers, AMMNet performed well in assessing activity [area under the curve (AUC), 0.93], atrophy (AUC, 0.97), and intestinal metaplasia (AUC, 0.93). The false-negative rates of these indicators were only 0.04, 0.08, and 0.18, respectively, and junior pathologists had lower false-negative rates with model assistance (0.15 versus 0.10). Furthermore, AMMNet reduced the time required per whole slide image from 5.46 to 2.85 minutes, enhancing diagnostic efficiency. In block-level clustering analysis, AMMNet effectively visualized task-related patches within whole slide images, improving interpretability. These findings highlight AMMNet's effectiveness in accurately evaluating gastritis morphologic indicators on multicenter data sets. Using multi-instance multilabel learning strategies to support routine diagnostic pathology deserves further evaluation.

Deep learning applications for kidney histology analysis

PURPOSE OF REVIEW

Nephropathology is increasingly incorporating computational methods to enhance research and diagnostic accuracy. The widespread adoption of digital pathology, coupled with advancements in deep learning, will likely transform our pathology practices. Here, we discuss basic concepts of deep learning, recent applications in nephropathology, current challenges in implementation and future perspectives.

RECENT FINDINGS

Deep learning models have been developed and tested in various areas of nephropathology, for example, predicting kidney disease progression or diagnosing diseases based on imaging and clinical data. Despite their promising potential, challenges remain that hinder a wider adoption, for example, the lack of prospective evidence and testing in real-world scenarios.

SUMMARY

Deep learning offers great opportunities to improve quantitative and qualitative kidney histology analysis for research and clinical nephropathology diagnostics. Although exciting approaches already exist, the potential of deep learning in nephropathology is only at its beginning and we can expect much more to come.

Recent Advances in Pathology: the 2023 Annual Review Issue of The Journal of Pathology

The 2023 Annual Review Issue of The Journal of Pathology, Recent Advances in Pathology, contains 12 invited reviews on topics of current interest in pathology. This year, our subjects include immuno-oncology and computational pathology approaches for diagnostic and research applications in human disease. Reviews on the tissue microenvironment include the effects of apoptotic cell-derived exosomes, how understanding the tumour microenvironment predicts prognosis, and the growing appreciation of the diverse functions of fibroblast subtypes in health and disease. We also include up-to-date reviews of modern aspects of the molecular basis of malignancies, and our final review covers new knowledge of vascular and lymphatic regeneration in cardiac disease. All of the reviews contained in this issue are written by expert groups of authors selected to discuss the recent progress in their particular fields and all articles are freely available online (https://pathsocjournals.onlinelibrary.wiley.com/journal/10969896). © 2023 The Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Computational pathology in cancer diagnosis, prognosis, and prediction - present day and prospects

Computational pathology refers to applying deep learning techniques and algorithms to analyse and interpret histopathology images. Advances in artificial intelligence (AI) have led to an explosion in innovation in computational pathology, ranging from the prospect of automation of routine diagnostic tasks to the discovery of new prognostic and predictive biomarkers from tissue morphology. Despite the promising potential of computational pathology, its integration in clinical settings has been limited by a range of obstacles including operational, technical, regulatory, ethical, financial, and cultural challenges. Here, we focus on the pathologists' perspective of computational pathology: we map its current translational research landscape, evaluate its clinical utility, and address the more common challenges slowing clinical adoption and implementation. We conclude by describing contemporary approaches to drive forward these techniques. © 2023 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.