Self-supervised learning (SSL) has been successful in building patch embeddings of small histology images (e.g.,$224\times 224$pixels), but scaling these models to learn slide embeddings from the entirety of giga-pixel whole-slide images (WSIs) remains challenging. Here, we leverage complementary information from gene expression profiles to guide slide representation learning using multi-modal pre-training. Expression profiles constitute highly detailed molecular descriptions of a tissue that we hypothesize offer a strong task-agnostic training signal for learning slide embeddings. Our slide and expression (S+E) pre-training strategy, called Tangle, employs modality-specific encoders, the outputs of which are aligned via contrastive learning. Tangle was pre-trained on samples from three different organs: liver (n=6,597 S+E pairs), breast (n=1,020), and lung (n=1,012) from two different species (Homo sapiens and Rattus norvegicus). Across three independent test datasets consisting of 1,265 breast WSIs, 1,946 lung WSIs, and 4,584 liver WSIs, Tangle shows significantly better few-shot performance compared to supervised and SSL baselines. When assessed using prototype-based classification and slide retrieval, Tangle also shows a substantial performance improvement over all baselines. Code available at https://github.com/mahmoodlab/TANGLE.

Integrating whole-slide images (WSIs) and bulk tran-scriptomics for predicting patient survival can improve our understanding of patient prognosis. However, this multi-modal task is particularly challenging due to the different nature of these data: WSIs represent a very high-dimensional spatial description of a tumor, while bulk tran-scriptomics represent a global description of gene expression levels within that tumor. In this context, our work aims to address two key challenges: (1) how can we tokenize transcriptomics in a semantically meaningful and interpretable way?, and (2) how can we capture dense multi-modal interactions between these two modalities? Here, we propose to learn biological pathway tokens from transcriptomics that can encode specific cellular functions. Together with histology patch tokens that encode the slide morphology, we argue that they form appropriate reasoning units for interpretability. We fuse both modalities using a memoryefficient multimodal Transformer that can model interactions between pathway and histology patch tokens. Our model, Survpath, achieves state-of-the-art performance when evaluated against unimodal and multimodal baselines on five datasets from The Cancer Genome Atlas. Our interpretability framework identifies key multimodal prognostic factors, and, as such, can provide valuable insights into the interaction between genotype and phenotype. Code available at https://github.com/mahmoodlab/SurvPath.

Representation learning of pathology whole-slide images (WSIs) has been has primarily relied on weak supervision with Multiple Instance Learning (MIL). However, the slide representations resulting from this approach are highly tailored to specific clinical tasks, which limits their expressivity and generalization, particularly in scenarios with limited data. Instead, we hypothesize that morphological redundancy in tissue can be leveraged to build a task-agnostic slide representation in an unsupervised fashion. To this end, we introduce Panther, a prototype-based approach rooted in the Gaussian mixture model that summarizes the set of WSI patches into a much smaller set of morphological prototypes. Specifically, each patch is assumed to have been generated from a mixture distri-bution, where each mixture component represents a morphological exemplar. Utilizing the estimated mixture parameters, we then construct a compact slide representation that can be readily used for a wide range of downstream tasks. By performing an extensive evaluation of Panther on subtyping and survival tasks using 13 datasets, we show that 1) Panther outperforms or is on par with super-vised MIL baselines and 2) the analysis of morphological prototypes brings new qualitative and quantitative in-sights into model interpretability. The code is available at https://github.com/mahmoodlab/Panther.

Multimodal survival methods combining gigapixel histology whole-slide images (WSIs) and transcriptomic profiles are particularly promising for patient prognostication and stratification. Current approaches involve tokenizing the WSIs into smaller patches ($>10^4$ patches) and transcriptomics into gene groups, which are then integrated using a Transformer for predicting outcomes. However, this process generates many tokens, which leads to high memory requirements for computing attention and complicates post-hoc interpretability analyses. Instead, we hypothesize that we can: (1) effectively summarize the morphological content of a WSI by condensing its constituting tokens using morphological prototypes, achieving more than $300\times$ compression; and (2) accurately characterize cellular functions by encoding the transcriptomic profile with biological pathway prototypes, all in an unsupervised fashion. The resulting multimodal tokens are then processed by a fusion network, either with a Transformer or an optimal transport cross-alignment, which now operates with a small and fixed number of tokens without approximations. Extensive evaluation on six cancer types shows that our framework outperforms state-of-the-art methods with much less computation while unlocking new interpretability analyses. The code is available at https://github.com/mahmoodlab/MMP.

Spatial transcriptomics enables interrogating the molecular composition of tissue with ever-increasing resolution and sensitivity. However, costs, rapidly evolving technology, and lack of standards have constrained computational methods in ST to narrow tasks and small cohorts. In addition, the underlying tissue morphology, as reflected by H&E-stained whole slide images (WSIs), encodes rich information often overlooked in ST studies. Here, we introduce HEST-1k, a collection of 1,229 spatial transcriptomic profiles, each linked to a WSI and extensive metadata. HEST-1k was assembled from 153 public and internal cohorts encompassing 26 organs, two species (Homo Sapiens and Mus Musculus), and 367 cancer samples from 25 cancer types. HEST-1k processing enabled the identification of 2.1 million expression-morphology pairs and over 76 million nuclei. To support its development, we additionally introduce the HEST-Library, a Python package designed to perform a range of actions with HEST samples. We test HEST-1k and Library on three use cases: (1) benchmarking foundation models for pathology (HEST-Benchmark), (2) biomarker exploration, and (3) multimodal representation learning. HEST-1k, HEST-Library, and HEST-Benchmark can be freely accessed at https://github.com/mahmoodlab/hest.

Cancer diagnosis, prognosis, and therapy response predictions from tissue specimens highly depend on the phenotype and topological distribution of constituting histological entities. Thus, adequate tissue representations for encoding histological entities is imperative for computer aided cancer patient care. To this end, several approaches have leveraged cell-graphs, capturing the cell-microenvironment, to depict the tissue. These allow for utilizing graph theory and machine learning to map the tissue representation to tissue functionality, and quantify their relationship. Though cellular information is crucial, it is incomplete alone to comprehensively characterize complex tissue structure. We herein treat the tissue as a hierarchical composition of multiple types of histological entities from fine to coarse level, capturing multivariate tissue information at multiple levels. We propose a novel multi-level hierarchical entity-graph representation of tissue specimens to model the hierarchical compositions that encode histological entities as well as their intra- and inter-entity level interactions. Subsequently, a hierarchical graph neural network is proposed to operate on the hierarchical entity-graph and map the tissue structure to tissue functionality. Specifically, for input histology images, we utilize well-defined cells and tissue regions to build HierArchical Cell-to-Tissue (HACT) graph representations, and devise HACT-Net, a message passing graph neural network, to classify the HACT representations. As part of this work, we introduce the BReAst Carcinoma Subtyping (BRACS) dataset, a large cohort of Haematoxylin & Eosin stained breast tumor regions-of-interest, to evaluate and benchmark our proposed methodology against pathologists and state-of-the-art computer-aided diagnostic approaches. Through comparative assessment and ablation studies, our proposed method is demonstrated to yield superior classification results compared to alternative methods as well as individual pathologists. The code, data, and models can be accessed at https://github.com/histocartography/hact-net.

Explainability of deep learning methods is imperative to facilitate their clinical adoption in digital pathology. However, popular deep learning methods and explainability techniques (explainers) based on pixel-wise processing disregard biological entities’ notion, thus complicating comprehension by pathologists. In this work, we address this by adopting biological entity-based graph processing and graph explainers enabling explanations accessible to pathologists. In this context, a major challenge becomes to discern meaningful explainers, particularly in a standardized and quantifiable fashion. To this end, we propose herein a set of novel quantitative metrics based on statistics of class separability using pathologically measurable concepts to characterize graph explainers. We employ the proposed metrics to evaluate three types of graph explainers, namely the layer-wise relevance propagation, gradient-based saliency, and graph pruning approaches, to explain Cell-Graph representations for Breast Cancer Subtyping. The proposed metrics are also applicable in other domains by using domain-specific intuitive concepts. We validate the qualitative and quantitative findings on the BRACS dataset, a large cohort of breast cancer RoIs, by expert pathologists. The code, data, and models can be accessed here1.