Spatial Analysis of Tumor-infiltrating Lymphocytes in Histological Sections Using Deep Learning Techniques Predicts Survival in Colorectal Carcinoma

This study aimed to explore the prognostic impact of spatial distribution of tumor-infiltrating lymphocytes (TILs) quantified by deep learning (DL) approaches based on digitalized whole-slide images stained with hematoxylin and eosin in patients with colorectal cancer (CRC). The prognostic impact of spatial distributions of TILs in patients with CRC was explored in the Yonsei cohort (n = 180) and validated in The Cancer Genome Atlas (TCGA) cohort (n = 268). Two experienced pathologists manually measured TILs at the most invasive margin (IM) as 0-3 by the Klintrup-Mäkinen (KM) grading method and this was compared to DL approaches. Inter-rater agreement for TILs was measured using Cohen's kappa coefficient. On multivariate analysis of spatial TIL features derived by DL approaches and clinicopathological variables including tumor stage, microsatellite instability, and KRAS mutation, TIL densities within 200 μm of the IM (f_im200) remained the most significant prognostic factor for progression-free survival (PFS) (hazard ratio [HR] 0.004 [95% confidence interval, CI, 0.0001-0.15], p = 0.0028) in the Yonsei cohort. On multivariate analysis using the TCGA dataset, f_im200 retained prognostic significance for PFS (HR 0.031 [95% CI 0.001-0.645], p = 0.024). Inter-rater agreement of manual KM grading was insignificant in the Yonsei (κ = 0.109) and the TCGA (κ = 0.121) cohorts. The survival analysis based on KM grading showed statistically significant different PFS in the TCGA cohort, but not the Yonsei cohort. Automatic quantification of TILs at the IM based on DL approaches shows prognostic utility to predict PFS, and could provide robust and reproducible TIL density measurement in patients with CRC.