RACR-MIL: Weakly Supervised Skin Cancer Grading using Rank-Aware Contextual Reasoning on Whole Slide Images

Cutaneous squamous cell cancer (cSCC) is the second most common skin cancer in the US. It is diagnosed by manual multi-class tumor grading using a tissue whole slide image (WSI), which is subjective and suffers from inter-pathologist variability. We propose an automated weakly-supervised grading approach for cSCC WSIs that is trained using WSI-level grade and does not require fine-grained tumor annotations. The proposed model, RACR-MIL, transforms each WSI into a bag of tiled patches and leverages attention-based multiple-instance learning to assign a WSI-level grade. We propose three key innovations to address general as well as cSCC-specific challenges in tumor grading. First, we leverage spatial and semantic proximity to define a WSI graph that encodes both local and non-local dependencies between tumor regions and leverage graph attention convolution to derive contextual patch features. Second, we introduce a novel ordinal ranking constraint on the patch attention network to ensure that higher-grade tumor regions are assigned higher attention. Third, we use tumor depth as an auxiliary task to improve grade classification in a multitask learning framework. RACR-MIL achieves 2-9% improvement in grade classification over existing weakly-supervised approaches on a dataset of 718 cSCC tissue images and localizes the tumor better. The model achieves 5-20% higher accuracy in difficult-to-classify high-risk grade classes and is robust to class imbalance.