AI-guided deep visual proteomics reveals recurrence-associated morpho-molecular signatures within triple-negative breast cancers

Abstract

Outcome informed AI can localize prognostically relevant regions in digital pathology, but directly characterizing the molecular basis of these spatial predictions remains challenging. Here, we developed an outcome informed, AI-guided deep visual proteomics framework that uses recurrence-risk heatmaps to guide physical tissue sampling and mass spectrometry-based spatial proteomics in triple-negative breast cancer (TNBC). In 156 patients, high- and low-risk regions coexisted within the tumor compartment and showed distinct nuclear and architectural features, indicating intratumoral variation beyond broad tissue identity. Guided by these maps, we physically isolated and profiled 46 AI-defined high- and low-risk tumor regions from two recurrent cases. High-risk regions were enriched for mitotic programs, whereas low-risk regions showed immune- and antigen-presentation-associated programs. We used proteins that consistently differed between high- and low-risk regions to construct a 13-protein composite. The composite showed a significant effect to discriminate highly recurrent patients from less recurrent patients in an expanded TNBC cohort, while the corresponding transcript-based score showed a similar trend in METABRIC. Integrating the protein composite with the H&E-derived risk score improved out-of-bag discrimination, increasing the C-index from 0.679 to 0.739 and the 5-year time-dependent AUC from 0.675 to 0.770. These findings establish outcome-informed H&E risk maps as spatial guides for molecular discovery, extending prognostic AI from prediction toward direct biological interrogation of recurrence-associated tissue states.