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Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer
Open accessAbstract
Importance: Application of deep learning algorithms to whole-slide pathology images can potentially improve diagnostic accuracy and efficiency. Objective: Assess 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 Participants: Researcher 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). Exposures: Deep learning algorithms submitted as part of a challenge competition or pathologist interpretation. Main Outcomes and Measures: The 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. Results: The 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 Relevance: In 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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In the paper
“At the slide level in task 2, the pathologist WOTC achieved a sensitivity of 93.8% (95% CI, 86.9%-100.0%), a specificity of 98.7% (95% CI, 96.0%-100.0%),and an AUC of 0.966 (95% CI, 0.927-0.998).”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Results
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In the paper
“On the slide level, the leading algorithms performed better than the pathologists WTC in the simulation exercise.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Discussion
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes- Rests on an assumption: The simulated time-constrained exercise mimics routine diagnostic pathology workflow.
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In the paper
“Pathologist WOTC | 0.724 | 0.966 | | | | Expert pathologist who assessed”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Conclusions
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In the paper
“They achieved a mean sensitivity of 62.8% (95% CI, 58.9%-71.9%)with a mean specificity of 98.5% (95% CI, 97.9%-99.1%).The mean AUC was 0.810 (range, 0.738-0.884)”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Results
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In the paper
“No false-positives were produced in task 1 (ie, nontumorous tissue indicated as metastasis) by the pathologist WOTC”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Results
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In the paper
“This AUC exceeded the mean performance of the pathologists WTC (mean AUC, 0.810 [range, 0.738-0.884]) in the diagnostic simulation exercise (P < .001,calculated using MRMC ROC analysis 33 ) (Table 2).”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Task 2: Whole-Slide Image Classification
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“Algorithms based on manually engineered features performed less well.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Discussion
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In the paper
“At the slide level in task 2, the pathologist WOTC achieved a sensitivity of 93.8% (95% CI, 86.9%-100.0%), a specificity of 98.7% (95% CI, 96.0%-100.0%),and an AUC of 0.966 (95% CI, 0.927-0.998).”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Results
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In the paper
“In 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”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Conclusions
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In the paper
“This algorithm achieved an overall AUC of 0.976 (95% CI, 0.941-0.999),and yielded the highest AUC in detecting macrometastases (AUC, 1.0).”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Task 2: Whole-Slide Image Classification
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- Probably not a substantial claim. 16
- The quote only partly states this claim. 3
- It may state two separate claims as one. 11
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“All of the 32 algorithms submitted to CAMELYON16 used a discriminative learning approach to identify metastases in whole-slide images.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Discussion
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In the paper
“Mean pathologists WTC | | 0.810 | | | | The mean performance of 11”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Conclusions
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In the paper
“Overall, deep learning-based algorithms performed significantly better than other methods: the 19 topperforming algorithms in both tasks all used deep convolutional neural networks as the underlying methodology (Table 2).”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Algorithm Performance
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“An earlier submission by this team, HMS and MGH I, achieved an overall AUC of 0.964 (95% CI, 0.928-0.989)and ranked third.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Task 2: Whole-Slide Image Classification
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In the paper
“but 27.6% of individual metastases were not identified (lesion level, truepositive fraction, 72.4% [95% CI, 64.3%-80.4%])that manifested when IHC staining was performed.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Results
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In the paper
“The pathologist did not produce any false-positives and achieved a true-positive fraction of 0.724 for detecting and localizing metastatic regions.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Discussion
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In the paper
“In cross-sectional analyses that evaluated 32 algorithms submitted as part of a challenge competition, 7 deep learning algorithms showed greater discrimination than a panel of 11 pathologists in a simulated time-constrained diagnostic setting, with an area under the curve of 0.994 (best algorithm) vs 0.884 (best pathologist).”
- Also stated in: § Task 2: Whole-Slide Image Classification · plain
“Overall, 7 of the 32 submitted algorithms had significantly higher AUCs than the pathologists WTC (see Table 2 for the individual P values calculated using MRMC ROC analysis).”
- Also stated in: § Discussion · boosted
“The CAMELYON16 challenge demonstrated that some deep learning algorithms were able to achieve a better AUC than a panel of 11 pathologists WTC participating in a simulation exercise for detection of lymph node metastases of breast cancer.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Key Points
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- Also stated in: § Task 2: Whole-Slide Image Classification · plain
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In the paper
“The best algorithm achieved similar true-positive fraction as the pathologist WOTC when producing a mean of 1.25 false-positive lesions in 100 whole-slide images and performed better when allowing for slightly more falsepositive findings.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Discussion
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In the paper
“The set of images was randomly divided into a training (n = 270) and a test set (n = 129; details in Table 1).”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Reference Standard
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In the paper
“system generalization and performance seemed more important.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Downloaded From: by a Radboud University Nijmegen User on 12/12/2017
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In the paper
“Previous studies on diagnostic imaging tasks in which deep learning reached human-level performance, such as detection of diabetic retinopathy in retinal fundus photographs, used a reference standard based on the consensus of human experts.3”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Downloaded From: by a Radboud University Nijmegen User on 12/12/2017
What the sources say
- Not checked yetcites [3]
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In the paper
“The test data set on which algorithms and pathologists were evaluated was enriched with cases containing metastases and, specifically, micrometastases and, thus, is not directly comparable with the mix of cases pathologists encounter in clinical practice.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Limitations
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
- Rests on an assumption: Most sentinel lymph nodes do not contain metastases.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“pathologists may rely on IHC staining and the knowledge that all hematoxylin and eosin-slides with negative findings will undergo additional review with the use of IHC.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Limitations
Strength:hedged· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
- Rests on an assumption: In most hospitals, pathologists request additional immunohistochemical staining in equivocal cases.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“Assessment without time constraint does not yield a fair measure of the accuracy of the routine diagnostic process.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Panel of Pathologists With Time Constraint
Tests✓ Asserted: passes✗ Checkable: fails✓ Load-bearing: passes✗ Based: failsProbably not a substantial claim. It may be too vague to check against evidence. The paper may give no reason why it holds.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“staining, yielding an independent reference against which human pathologists could also be compared.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Downloaded From: by a Radboud University Nijmegen User on 12/12/2017
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one. The quote only partly states this claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Less time constraint on task completion may increase the accuracy of SLN diagnostic review.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Limitations
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What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“algorithm runtime was not recorded nor included as a factor in the evaluation, but it might influence the suitability for use in, for example, frozen section analysis.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Limitations
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In the paper
“the simulation exercise invited pathologists WTC to review a series of 129 hematoxylin and eosinstained slides in about 2 hours to determine the presence of macroscopic or microscopic SLN metastasis.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Limitations
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In the paper
“Thepercentilebootstrapmethod was used to construct 95% CIs for FROC true-positive fraction scores (FROC scores) and AUCs.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Conclusions
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In the paper
“The funders and sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Funding
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In the paper
“The pathologists WTC assessed the same set of glass slides used for testing the algorithms (which used digitized whole-slide images of these glass slides).”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Panel of Pathologists With Time Constraint
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In the paper
“IHC is the most accurate method for metastasis evaluation and has little interpretation variability. [7][8]][9]”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Reference Standard
What the sources say
- Not checked yetcites [7][8]][9]
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What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“algorithms were specifically trained to discriminate between normal and cancerous tissue in the background of lymph node histological architecture, but they might be unable to identify rare events such as co-occurring pathologies (eg, lymphoma, sarcoma, or infection).”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Limitations
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What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“The detection of other pathologies in the SLN, which is relevant in routine diagnostics, was not included in this study.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Limitations
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What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“No prior data were available for the performance of algorithms in this task.Therefore, no power analysis was used to predetermine the sample size.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Statistical Analysis
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- Rests on an assumption: No prior data were available for algorithm performance in this task.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“In this study, every pathologist was given 1 single hematoxylin and eosin-stained slide per patient to determine the presence or absence of breast cancer metastasis.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Limitations
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What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“The P values were adjusted for multiple comparisons using the Bonferroni correction, in which the P values are multiplied by the number of comparisons (32; comparison of the 32 submitted algorithms with the panel of pathologists).”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Conclusions
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In the paper
“Although feasible in the context of this simulation, this does not represent the work pace in other settings.”
§ Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer > Limitations
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The paper relies on this without support.
The clinical value of isolated tumor cells in a sentinel lymph node is disputed.
“Because the clinical value of having only isolated tumor cells in an SLN is disputed, we did not include such slides in our study”
The paper relies on this without support.
The simulated time-constrained exercise mimics routine diagnostic pathology workflow.
“To mimic routine diagnostic pathology workflow, we asked 11 pathologists to independently assess the 129 slides in the test set in”
The paper relies on this without support.
The panel of 11 pathologists is representative of pathologists in routine practice.
“The panel of the 11 pathologists (mean age, 47.7 years [range, 31-61]) included 1 resident pathologist (3-year resident) and 10 practicing pathologists”
The paper relies on this without support.
Comparing algorithms on whole-slide images with pathologists on glass slides is valid despite the different modalities.
“The panel of 11 pathologists with time constraint (pathologists WTC), however, did their assessment on the corresponding glass slides for those images because diagnosing is most commonly done using a microscope in pathology labs.”
The paper relies on this without support.
In the Netherlands, use of immunohistochemistry is mandatory for cases with negative findings on H&E-stained slides.
“The setting resembled diagnostic practice in the Netherlands, where use of IHC is mandatory for cases with negative findings on hematoxylin and eosin-stained slides.”
The paper relies on this without support.
No prior data were available for algorithm performance in this task.
“No prior data were available for the performance of algorithms in this task.Therefore, no power analysis was used to predetermine the sample size.”
The paper relies on this without support.
Most sentinel lymph nodes do not contain metastases.
“Given the reality that most SLNs do not contain metastases, the data set curation was needed to achieve a well-rounded representation of what is encountered in clinical practice without including an exorbitant number of slides.”
The paper relies on this without support.
In real clinical settings, sections from multiple levels are evaluated for every lymph node.
“In a real clinical setting, sections from multiple levels are evaluated for every lymph node.”
The paper relies on this without support.
In most hospitals, pathologists request additional immunohistochemical staining in equivocal cases.
“in most hospitals pathologists request additional IHC staining in equivocal cases.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
The cited source says what the claim attributes to it.
In the citing paper
“Medical research is no exception, as CNN has achieved expert-level performances in various fields. Gulshan et al. [4], Esteva et al. [5], and Ehteshami Bejnordi et al. [6] demonstrated the potential of deep learning for diabetic retinopathy screening, skin lesion classification, and lymph node metastasis detection, respectively.”
From Convolutional neural networks: an overview and application in radiology (2018) · cites this paper as [6]
The cited source says what the claim attributes to it.
In the citing paper
“In a notable study, Bejnordi et al. (2017) found that certain deep learning algorithms surpassed a group of 11 pathologists in detecting lymph node metastases in breast cancer patients.”
From A perspective on integrating digital pathology, proteomics, clinical data and AI analytics in cancer research (2025) · cites this paper as [24]
In the citing paper
“This evaluation includes comparison with a reference panel of pathologists working on the same data set with predefined time constraints designed to mimic routine pathology workflows, where many of the models in the challenge exhibited higher performance than the panel of pathologists.”
From Artificial Intelligence in Oncology: Current Landscape, Challenges, and Future Directions (2024) · cites this paper as [45]
In the citing paper
“The second option is deidentification and public release of data, usually via a consortium model.”
From Artificial Intelligence in Oncology: Current Landscape, Challenges, and Future Directions (2024) · cites this paper as [45]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Figure caption reverses the pathologist groups' slide formats
MinorThe Figure 3 caption says the time-constrained pathologist assessed whole-slide images and the 11 pathologists without time constraints assessed glass slides. The methods state the opposite: the single pathologist without a time constraint assessed whole-slide images, while the panel of 11 with time constraints assessed glass slides.
“Task 2 was measured on the 129 whole-slide images (for algorithms and the pathologist WTC) and corresponding glass slides (for 11 pathologists WOTC) in the test data set”
“Algorithms assessed whole-slide images, as did the pathologist WOTC.The panel of 11 pathologists with time constraint (pathologists WTC), however, did their assessment on the corresponding glass slides”
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Metadata
- Authors
- Ehteshami Bejnordi, B., Veta, M., Johannes van Diest, P., van Ginneken, B., Karssemeijer, N., Litjens, G., van der Laak, J. A. W. M., and the CAMELYON16 Consortium, Hermsen, M., Manson, Q. F., Balkenhol, M., Geessink, O., Stathonikos, N., van Dijk, M. C., Bult, P., Beca, F., Beck, A. H., Wang, D., Khosla, A., Gargeya, R., Irshad, H., Zhong, A., Dou, Q., Li, Q., Chen, H., Lin, H.-J., Heng, P.-A., Haß, C., Bruni, E., Wong, Q., Halici, U., Öner, M. Ü., Cetin-Atalay, R., Berseth, M., Khvatkov, V., Vylegzhanin, A., Kraus, O., Shaban, M., Rajpoot, N., Awan, R., Sirinukunwattana, K., Qaiser, T., Tsang, Y.-W., Tellez, D., Annuscheit, J., Hufnagl, P., Valkonen, M., Kartasalo, K., Latonen, L., Ruusuvuori, P., Liimatainen, K., Albarqouni, S., Mungal, B., George, A., Demirci, S., Navab, N., Watanabe, S., Seno, S., Takenaka, Y., Matsuda, H., Ahmady Phoulady, H., Kovalev, V., Kalinovsky, A., Liauchuk, V., Bueno, G., Fernandez-Carrobles, M. M., Serrano, I., Deniz, O., Racoceanu, D., & Venâncio, R.
- Affiliations
- Diagnostic Image Analysis Group, Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
- Eindhoven University of Technology (NL)
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
- Radboud University Medical Center (NL)
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
- University Medical Center Utrecht (NL)
- Rijnstate Hospital, Arnhem, the Netherlands
- BeckLab, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Beth Israel Deaconess Medical Center (US)
- PathAI (United States) (US)
- Harker School, San Jose, California
- Harvard University (US)
- Chinese University of Hong Kong (HK)
- Chinese University of Hong Kong, Hong Kong, China
- ExB Research and Development GmbH, Munich, Germany
- Munich Business School (DE)
- Department of Electrical and Electronics Engineering, Middle East Technical University, Ankara, Turkey
- Middle East Technical University (TR)
- Cancer System Biology Laboratory, Graduate School of Informatics, Middle East Technical University, Ankara, Turkey
- NLP LOGIX, Jacksonville, Florida
- Smart Imaging Technologies, Houston, Texas
- University of Toronto (CA)
- University of Warwick (GB)
- University Hospital Coventry (GB)
- Qatar University (QA)
- HTW Berlin - University of Applied Sciences (DE)
- Tampere University of Technology (FI)
- Tampere University (FI)
- Technical University of Munich (DE)
- The University of Osaka (JP)
- University of South Florida, Tampa, Florida
- National Academy of Sciences of Belarus (BY)
- University of Castilla-La Mancha (ES)
- Visilab, University of Castilla-La Mancha, Ciudad Real, Spain
- Inserm (FR)
- Sorbonne Université (FR)
- ORCID
- Veta, Mitko
- Karssemeijer, Nico
- Litjens, Geert
- Hermsen, Meyke
- Manson, Quirine F
- Balkenhol, Maschenka
- Geessink, Oscar
- Bult, Peter
- Beck, Andrew H
- Irshad, Humayun
- Zhong, Aoxiao
- Dou, Qi
- Li, Quanzheng
- Chen, Hao
- Heng, Pheng-Ann
- Öner, Mustafa Ümit
- Kraus, Oren
- Shaban, Muhammad
- Rajpoot, Nasir
- Awan, Ruqayya
- Sirinukunwattana, Korsuk
- Qaiser, Talha
- Tsang, Yee-Wah
- Tellez, David
- Annuscheit, Jonas
- Hufnagl, Peter
- Kartasalo, Kimmo
- Latonen, Leena
- Ruusuvuori, Pekka
- Liimatainen, Kaisa
- Albarqouni, Shadi
- Navab, Nassir
- Seno, Shigeto
- Matsuda, Hideo
- Kovalev, Vassili
- Liauchuk, Vitali
- Bueno, Gloria
- Serrano, Ismael
- Racoceanu, Daniel
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2017-12-12
- Volume
- 318
- Issue
- 22
- Pages
- 2199
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- PMC
- PMC5820737
- OpenAlex
- W2772723798
- Semantic Scholar
- ba913e2c03ece1c75f0af4d16dd11c7ffbc6e3ba
- Cited by
- 3,293
- References
- 40
- Citations by year
- 2026: 301 · 2025: 388 · 2024: 430 · 2023: 414 · 2022: 429 · 2021: 457 · 2020: 421 · 2019: 321 · 2018: 119 · 2017: 4
- FWCI
- 141.10
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- other-oa
- Locations
- JAMA (publishedVersion, other-oa)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Warwick Research Archive Portal (University of Warwick) (acceptedVersion)
- Rare & Special e-Zone (The Hong Kong University of Science and Technology) (submittedVersion)
- HAL (submittedVersion, other-oa)
- Utrecht University Repository (Utrecht University) (submittedVersion, other-oa)
- OpenMETU (Middle East Technical University) (submittedVersion, cc-by-nc-nd)
- TU/e Research Portal (submittedVersion)
- Qatar University QSpace (Qatar University) (submittedVersion)
- Radboud Repository (Radboud University) (submittedVersion)
- Radboud Repository (Radboud University) (submittedVersion, other-oa)
- Utrecht University Repository (Utrecht University) (submittedVersion)
- Funders
- European Commission (601040)
- Japan Society for the Promotion of Science (15K00403)
- Topics
- Physical Sciences › Computer Science › Artificial Intelligence › AI in cancer detection
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Radiomics and Machine Learning in Medical Imaging
- Health Sciences › Medicine › Health Informatics › Artificial Intelligence in Healthcare and Education
- Keywords
- lymph node metastasis, breast cancer, whole slide images, deep learning, computer-aided diagnosis, H&E staining, diagnostic accuracy, immunohistochemistry validation, breast cancer staging, lymph node staging, false positives, diagnostic confidence
- MeSH terms
- Machine Learning, Pathologists, Algorithms, Breast Neoplasms, Female, Humans, Lymphatic Metastasis, Pathology, Clinical, ROC Curve
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
A language model drew the claims from the paper on 2026-10-07, under version 3 of the claim definition (model deepseek-v4.1-flash, prompt extract-v3).
A second model labelled each claim on 2026-10-07 (model jev-1.13-20260917, definition revision gold-guideline-v0.2).
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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