Quantitative Pathologic Analysis of Digitized Images of Colorectal Carcinoma Improves Prediction of Recurrence-Free Survival

Reetesh K. Pai, Imon Banerjee, Sameer Shivji, Suchit Jain, Douglas Hartman, Daniel D. Buchanan, Mark A. Jenkins, David F. Schaeffer, Christophe Rosty, Julia Como, Amanda I. Phipps, Polly A. Newcomb, Andrea N. Burnett-Hartman, Loic Le Marchand, Niloy J. Samadder, Bhavik Patel, Carol Swallow, Noralane M. Lindor, Steven J. Gallinger, Robert C. GrantThomas Westerling-Bui, James Conner, David P. Cyr, Richard Kirsch, Rish K. Pai

Research output: Contribution to journalArticlepeer-review


Background & Aims: To examine whether quantitative pathologic analysis of digitized hematoxylin and eosin slides of colorectal carcinoma (CRC) correlates with clinicopathologic features, molecular alterations, and prognosis. Methods: A quantitative segmentation algorithm (QuantCRC) was applied to 6468 digitized hematoxylin and eosin slides of CRCs. Fifteen parameters were recorded from each image and tested for associations with clinicopathologic features and molecular alterations. A prognostic model was developed to predict recurrence-free survival using data from the internal cohort (n = 1928) and validated on an internal test (n = 483) and external cohort (n = 938). Results: There were significant differences in QuantCRC according to stage, histologic subtype, grade, venous/lymphatic/perineural invasion, tumor budding, CD8 immunohistochemistry, mismatch repair status, KRAS mutation, BRAF mutation, and CpG methylation. A prognostic model incorporating stage, mismatch repair, and QuantCRC resulted in a Harrell's concordance (c)-index of 0.714 (95% confidence interval [CI], 0.702–0.724) in the internal test and 0.744 (95% CI, 0.741–0.754) in the external cohort. Removing QuantCRC from the model reduced the c-index to 0.679 (95% CI, 0.673–0.694) in the external cohort. Prognostic risk groups were identified, which provided a hazard ratio of 2.24 (95% CI, 1.33–3.87, P = .004) for low vs high-risk stage III CRCs and 2.36 (95% CI, 1.07–5.20, P = .03) for low vs high-risk stage II CRCs, in the external cohort after adjusting for established risk factors. The predicted median 36-month recurrence rate for high-risk stage III CRCs was 32.7% vs 13.4% for low-risk stage III and 15.8% for high-risk stage II vs 5.4% for low-risk stage II CRCs. Conclusions: QuantCRC provides a powerful adjunct to routine pathologic reporting of CRC. A prognostic model using QuantCRC improves prediction of recurrence-free survival.

Original languageEnglish (US)
Pages (from-to)1531-1546.e8
Issue number6
StatePublished - Dec 2022


  • Colorectal Cancer
  • Image Analysis
  • Prognosis
  • Stroma
  • Tumor Infiltrating Lymphocytes

ASJC Scopus subject areas

  • Hepatology
  • Gastroenterology


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