# Deep Learning for Digital Pathology: Detecting Skin Diseases with Normalizing Flows

**Figure 1.**A digitized glass slide that contains four tissue slices of the skin that are stained with hematoxylin and eosin. The scan is roughly 80,000 pixels by 50,000 pixels in size. Figure courtesy of Centroderm and aisencia.

### Digital Pathology

Pathology laboratories often use tissue samples from an affected area of the skin to diagnose disease. Pathologists cast the tissue in paraffin, cut it into fine slices, apply the slices to glass slides, and use a staining solution to highlight specific structures. Classically, the pathologists would then examine the sample under a microscope. In recent years, however, digital pathology—wherein pathologists generate high-resolution optical images of the slides and investigate them on a computer screen—has become increasingly commonplace. Figure 1 provides an image of tissue slices with a hematoxylin and eosin stain that produces the typical purple and pink color scheme.

Digital pathology invites the possibility of image evaluation via mathematical methods. Several published papers in this field have addressed the detection of various disease patterns in skin [5, 8], breast [10], and prostate samples [1]. Nevertheless, the application of deep learning methods to digital pathology images is complex for several reasons. The first challenge is the large size of the scans, which necessitates their subdivision into smaller image patches. Secondly, users can examine the images at different magnification levels (just like under a microscope), where different image features are visible depending on the level (see Figure 2). Finally, hundreds of distinct diseases affect the skin. The annotation process for supervised deep learning models is tedious, and many diseases are so rare that it is impossible to collect extensive amounts of training data. In order to assist pathologists with diagnoses for all possible cases, we therefore assume that diseases are OOD data points from the distribution of healthy tissue. In this scenario, the model only needs to learn to identify healthy tissue.

**Figure 2.**Three image patches with the same resolution that were extracted at different magnification levels. Figure courtesy of Centroderm and aisencia.

### Out-of-Distribution Detection with Normalizing Flows

We use normalizing flows (NFs) [12] to perform the OOD detection task by calculating the likelihood that a given input patch will fall within the target distribution of patches with healthy tissue. An easy-to-evaluate base distribution \(p_\mathbf{z}\) and an invertible, differentiable transformation \(T\) help with construction of the NFs. For the transformation, we use an invertible neural network \(T_\theta\) that is parameterized by \(\theta\). Our base distribution \(p_\mathbf{z}\) induces a distribution on the image space \(\mathbf{x} = T_\theta(\mathbf{z})\). Though the target distribution of patches with healthy tissue is generally unknown, we can calculate the likelihood via the change of variable theorem

\[p_\theta(x) = p_\mathbf{z}(T_\theta^{-1}(x)) |\det J_{T_\theta^{-1}}(x)|,\tag1\]

where \(J_{T_\theta^{-1}}(x)\) is the Jacobian of \(T_\theta^{-1}\).

Equation \((1)\) allows us to use maximum likelihood estimation to fit the parameters \(\theta\) [3]. In the training phase, we utilize images \(\{x^{(i)}\}_{i=1}^N\) from the unknown target distribution—i.e., the distribution of healthy tissue—to maximize the likelihood

\[\begin{eqnarray} \max L(\theta) &=& \sum_{i=1}^N \log(p_\theta(x^{(i)})) \\

&=& \sum_{i=1}^N \left( \log p(T_\theta^{-1}(x^{(i)})) + \log |\det J_{T_\theta}(T_\theta^{-1}(x^{(i)}))|\right). \end{eqnarray}\]

Doing so is equivalent to minimizing the Kullback-Leibler divergence between the unknown target distribution and the distribution that is induced by the NF [9].

**Figure 3.**Highly magnified view of one tissue slice from Figure 1. The epidermis (dark purple) shows clear signs of actinic keratosis (red annotations), with finger-like proliferation into the dermis. Figure courtesy of Centroderm and aisencia.

### Experiments with Actinic Keratosis

We extract RGB image patches of size 1,000 pixels by 1,000 pixels at magnifications of 50x, 100x, and 200x. We then train a separate NF on each level and choose a standard Gaussian as the base distribution and an invertible U-Net architecture [4] for the transformation \(T_\theta\). The patches for training and validation come from scans of healthy tissue regions; for the test set, we use patches with healthy tissue and patches with actinic keratosis (AK). AK is a precancerous skin lesion that can progress into cutaneous squamous cell carcinoma and represents one of the most common skin lesions in dermatology [6, 11]. Disease spread begins in the epidermis, the outermost layer of the skin (see Figure 3).

**Figure 4.**Number and content of the image patches that we use for the training, validation, and test sets. Figure courtesy of Maximilian Schmidt.

Figure 4 lists the number of patches in each set. Pixel-precise annotations by three medical experts are available as references for the areas with AK. To turn these segmentation masks into a single label for an image patch, we set a threshold for the relative area of AK above which a patch is considered diseased. We then vary this area threshold from one to 95 percent in all experiments to determine whether OOD detection depends on the affected area’s size. At each setting, we calculate the area under the receiver operating characteristic curve (AUROC) with \(\in [0,1]\) and use it as our performance measure to distinguish between healthy and diseased tissue.

Figure 5 illustrates the development of the AUROC scores at the three different magnification levels. The AUROC values remain relatively stable as the area threshold for AK assignment increases. These values almost always sit between 0.7 and 0.9, which is an excellent range for a model that has not seen any examples of AK in its training. The only exception is the model at 50x magnification, as performance drops significantly in AK areas that account for at least 40 percent of the entire patch. However, the data size is minimal — for example, no patches at this magnification level have AK that covers more than 60 percent of the patch area. In contrast, the models at 100x and 200x magnification can sufficiently detect both small and large AK areas in the tissue as OOD.

**Figure 5.**Area under the receiver operating characteristic curve (AUROC) scores (red) for the distinction between healthy tissue and actinic keratosis (AK) at three different magnification levels: 50x, 100x, and 200x. The values are plotted against the respective area thresholds for assignment of image patches to the AK class. The number of diseased samples according to this threshold is shown in blue. Figure courtesy of Maximilian Schmidt.

### Concluding Thoughts

We have presented an OOD detection model based on NFs that can detect skin diseases in histological tissue sections. We tested the model on samples with AK and demonstrated a solid detection rate of the affected areas. In this context, the model had not seen any examples of the disease during training. The excellent performance with AK motivates the investigation of other disease patterns. Looking ahead, the application of saliency techniques could reveal more about the model’s performance and ultimately lead to its incorporation within the pathological routine.

*Maximilian Schmidt delivered a minisymposium presentation on this research at the 2022 SIAM Conference on Mathematics of Data Science, which took place in San Diego, Ca., last year.*

**Ethics Vote and Acknowledgments:**

This study was performed in accordance with the approval of the ethics committee of Witten/Herdecke University (Proposal-No. 105/2022). It retrospectively analyzes patient samples from the clinical routine that have been processed in an anonymized way.

The author thanks Julius Balkenhol, Lutz Schmitz, and Thomas Dirschka for providing data and annotations of AK areas. This research was made possible by support for project “aisencia” from the EXIST Transfer of Research, the Federal Ministry for Economic Affairs and Climate Action of Germany, and the European Social Fund.

**References**

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Maximilian Schmidt completed his Ph.D. on deep learning methods in inverse problems at the University of Bremen’s Center for Industrial Mathematics under the direction of Peter Maass. He is one of the co-founders of “aisencia,” a research project that investigates the transfer of deep learning methods for disease detection in tissue samples. His main area of interest involves linking mathematical models with data-driven approaches. |