Deep learning-based model for prediction of early recurrence and therapy response on whole slide images in non-muscle-invasive bladder cancer: a retrospective, multicentre study.

Background: Accurate prediction of early recurrence is essential for disease management of patients with non-muscle-invasive bladder cancer (NMIBC). We aimed to develop and validate a deep learning-based early recurrence predictive model (ERPM) and a treatment response predictive model (TRPM) on whole slide images to assist clinical decision making. Methods: In this retrospective, multicentre study, we included consecutive patients with pathology-confirmed NMIBC who underwent transurethral resection of bladder tumour from five centres. Patients from one hospital (Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China) were assigned to training and internal validation cohorts, and patients from four other hospitals (the Third Affiliated Hospital of Sun Yat-sen University, and Zhujiang Hospital of Southern Medical University, Guangzhou, China; the Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China; Shenshan Medical Centre, Shanwei, China) were assigned to four independent external validation cohorts. Based on multi-instance and ensemble learning, the ERPM was developed to make predictions on haematoxylin and eosin (H&E) staining and immunohistochemistry staining slides. Sharing the same architecture of the ERPM, the TRPM was trained and evaluated by cross validation on patients who received Bacillus Calmette-Guérin (BCG). The performance of the ERPM was mainly evaluated and compared with the clinical model, H&E-based model, and integrated model through the area under the curve. Survival analysis was performed to assess the prognostic capability of the ERPM. Findings: Between January 1, 2017, and September 30, 2023, 4395 whole slide images of 1275 patients were included to train and validate the models. The ERPM was superior to the clinical and H&E-based model in predicting early recurrence in both internal validation cohort (area under the curve: 0.837 vs 0.645 vs 0.737) and external validation cohorts (area under the curve: 0.761-0.802 vs 0.626-0.682 vs 0.694-0.723) and was on par with the integrated model. It also stratified recurrence-free survival significantly (p < 0.0001) with a hazard ratio of 4.50 (95% CI 3.10-6.53). The TRPM performed well in predicting BCG-unresponsive NMIBC (accuracy 84.1%). Interpretation: The ERPM showed promising performance in predicting early recurrence and recurrence-free survival of patients with NMIBC after surgery and with further validation and in combination with TRPM could be used to guide the management of NMIBC. Funding: National Natural Science Foundation of China, the Science and Technology Planning Project of Guangdong Province, the National Key Research and Development Programme of China, the Guangdong Provincial Clinical Research Centre for Urological Diseases, and the Science and Technology Projects in Guangzhou.