Clinical implications of deep learning based image analysis of whole radical prostatectomy specimens

Prostate cancer (PCa) diagnosis faces significant challenges due to its complex pathological characteristics and insufficient pathologist resources. While deep learning-based image analysis (DLIA) shows promise in enhancing diagnostic accuracy, its application to radical prostatectomy (RP) specimens remains underexplored. In this study, we evaluated the clinical feasibility and prognostic value of a DLIA algorithm for Gleason grading and tumor quantification on whole RP specimens. Using 29,646 digitized H&E-stained slides from 992 patients who underwent RP, we compared the case-level algorithm results with pathologist assessments for the International Society of Urological Pathology grade groups (GG), tumor volumes (TV), and percent tumor volumes (PTV). We also evaluated their prognostic performance in predicting biochemical progression-free survival (BPFS). Pathologists identified cancer in 986 cases and assigned GG in 980, while the DLIA algorithm identified cancer and assigned GG to all cases without omission. DLIA-assigned GG showed fair concordance with pathologist assessments (linear-weighted Cohen's kappa: 0.374) and demonstrated similar efficacy in predicting BPFS (c-index: 0.644 for DLIA vs. 0.654 for pathologists; p = 0.52). In tumor quantification, DLIA-measured TV and PTV were strongly correlated with pathologist-based measurements (Pearson's correlation coefficient: 0.830 and 0.846, respectively), but showed stronger efficacy in BPFS prediction, with c-index values of 0.657 and 0.672 compared to 0.622 and 0.641, respectively. Incorporating DLIA-derived PTV into the CAPRA-S score significantly improved its predictive accuracy for BCR (p = 0.006), increasing the c-index from 0.704 to 0.715. Our findings indicate that DLIA algorithms can enhance the accuracy of Gleason grading and tumor quantification in RP specimens, providing valuable support in clinical decision-making for PCa management.