Virtual slide telepathology for an academic teaching hospital surgical pathology quality assurance program

Bridging the Clinical-Computational Transparency Gap in Digital Pathology

CONTEXT.—

Computational pathology combines clinical pathology with computational analysis, aiming to enhance diagnostic capabilities and improve clinical productivity. However, communication barriers between pathologists and developers often hinder the full realization of this potential.

OBJECTIVE.—

To propose a standardized framework that improves mutual understanding of clinical objectives and computational methodologies. The goal is to enhance the development and application of computer-aided diagnostic (CAD) tools.

DESIGN.—

This article suggests pivotal roles for pathologists and computer scientists in the CAD development process. It calls for increased understanding of computational terminologies, processes, and limitations among pathologists. Similarly, it argues that computer scientists should better comprehend the true use cases of the developed algorithms to avoid clinically meaningless metrics.

RESULTS.—

CAD tools improve pathology practice significantly. Some tools have even received US Food and Drug Administration approval. However, improved understanding of machine learning models among pathologists is essential to prevent misuse and misinterpretation. There is also a need for a more accurate representation of the algorithms' performance compared to that of pathologists.

CONCLUSIONS.—

A comprehensive understanding of computational and clinical paradigms is crucial for overcoming the translational gap in computational pathology. This mutual comprehension will improve patient care through more accurate and efficient disease diagnosis.

Advances in Bone Marrow Evaluation

Evaluation of bone marrow aspirate smear and trephine biopsy specimens is critical to the diagnosis of benign and malignant hematologic conditions. Digital pathology has the potential to revolutionize bone marrow assessment through implementation of artificial intelligence for assisted and automated evaluation, but there remain many barriers toward this implementation. This article reviews the current state of digital evaluation of bone marrow aspirate smears and trephine biopsies, recent research using machine learning models for automated specimen analysis, an outline of the advantages and barriers facing clinical implementation of artificial intelligence, and a potential vision of artificial intelligence-associated bone marrow evaluation.

Whole Slide Imaging Technology and Its Applications: Current and Emerging Perspectives

Background. Whole slide imaging (WSI) represents a paradigm shift in pathology, serving as a necessary first step for a wide array of digital tools to enter the field. It utilizes virtual microscopy wherein glass slides are converted into digital slides and are viewed by pathologists by automated image analysis. Its impact on pathology workflow, reproducibility, dissemination of educational material, expansion of service to underprivileged areas, and institutional collaboration exemplifies a significant innovative movement. The recent US Food and Drug Administration approval to WSI for its use in primary surgical pathology diagnosis has opened opportunities for wider application of this technology in routine practice. Main Text. The ongoing technological advances in digital scanners, image visualization methods, and the integration of artificial intelligence-derived algorithms with these systems provide avenues to exploit its applications. Its benefits are innumerable such as ease of access through the internet, avoidance of physical storage space, and no risk of deterioration of staining quality or breakage of slides to name a few. Although the benefits of WSI to pathology practices are many, the complexities of implementation remain an obstacle to widespread adoption. Some barriers including the high cost, technical glitches, and most importantly professional hesitation to adopt a new technology have hindered its use in routine pathology. Conclusions. In this review, we summarize the technical aspects of WSI, its applications in diagnostic pathology, training, and research along with future perspectives. It also highlights improved understanding of the current challenges to implementation, as well as the benefits and successes of the technology. WSI provides a golden opportunity for pathologists to guide its evolution, standardization, and implementation to better acquaint them with the key aspects of this technology and its judicial use. Also, implementation of routine digital pathology is an extra step requiring resources which (currently) does not usually result increased efficiency or payment.

ChatGPT as an aid for pathological diagnosis of cancer

Diagnostic workup of cancer patients is highly reliant on the science of pathology using cytopathology, histopathology, and other ancillary techniques like immunohistochemistry and molecular cytogenetics. Data processing and learning by means of artificial intelligence (AI) has become a spearhead for the advancement of medicine, with pathology and laboratory medicine being no exceptions. ChatGPT, an artificial intelligence (AI)-based chatbot, that was recently launched by OpenAI, is currently a talk of the town, and its role in cancer diagnosis is also being explored meticulously. Pathology workflow by integration of digital slides, implementation of advanced algorithms, and computer-aided diagnostic techniques extend the frontiers of the pathologist's view beyond a microscopic slide and enables effective integration, assimilation, and utilization of knowledge that is beyond human limits and boundaries. Despite of it's numerous advantages in the pathological diagnosis of cancer, it comes with several challenges like integration of digital slides with input language parameters, problems of bias, and legal issues which have to be addressed and worked up soon so that we as a pathologists diagnosing malignancies are on the same band wagon and don't miss the train.

The experience of introducing telepathology in Mongolia

Background

Anatomical pathology care services play an essential role in cancer diagnosis through histological analysis, effective treatment of patients, and determination of prognosis. Therefore, quality control is necessary for the diagnosis of pathology. Based on this need, telepathology technology is rapidly developing in the world. This study aimed to share the experience of implementing telepathology case consultation between Mongolian and Japanese expert pathologists.

Methods

The study included 173 cases that required telepathology consultation, which was complicated and doubtful in diagnosis, submitted by Mongolian pathologists between May 2019 and April 2022. The scanned digital slides were transmitted with the help of the LOOKREC cloud-based system, and the expert pathologists of Hiroshima University Hospital, Japan, browsed the images through the data on the internet and their advice and made a mutual diagnosis.

Results

During the study period, 173 cases were consulted. Out of 58.4% of all cases, consultation reports were released in 2022. The majority of the cases in 2020 had a mean standard deviation turn-around time of 4.2±6.2 days. The most cases were from the lung and mediastinum were 29.4%, followed by head and neck at 12.6%, the bone at 11.9%, lymph nodes at 8.4%, GIT at 7.7%, soft tissues at 6.3%, etc. Comparing the sample submission of biopsy and cytology was significantly higher in the under 10 years of an experienced group than over 10 years of an experienced group (p<.005). The diagnostic agreement between submitter Mongolian pathologists and expert Japanese pathologists was 82.7%, and disagreement was 17.3% of all cases, with a sensitivity of 67.3% and specificity of 85.5%.

Conclusions

Telepathology could save many lost opportunities and play an essential role in developing quality control and surgical pathology in Mongolia. This digital technology and the appropriate strategy and policy of the government could accelerate the overall pathology field development.

WSI validation studies in breast and gynecological pathology

BACKGROUND

In the last two decades, there has been marked development in virtual slide technology as well as its application in various subspecialties of pathology. In particular, there have been several studies examining the utility of whole slide imaging (WSI) in breast and gynecological pathology. The aim of this systematic review is to analyse published evidence regarding validation studies of WSI applied specifically to the female genital tract and breast pathology.

METHODS

A systematic search was carried out in Pubmed and Embase databases and studies dealing with the validation of a WSI system for breast and gynaecological pathology. The topics evaluated concerned expertise of engaged pathologists, varied specimens, scanners, washout period, experience viewing WSI, and diagnostic concordance of WSI to traditional light microscopic diagnoses.

RESULTS

Of 1467 publications retrieved, 23 studies were included. Most of these studies concerned breast pathology. Validation guidelines recommended by the College of American Pathologists pertaining to a dataset of at least 60 cases, washout period, and recording intra-observer variability were followed by most studies. Major challenges encountered with WSI included difficulty identifying high-grade nuclear atypia and mitotic count for borderline ovarian tumors, interpretation of squamous intraepithelial lesions in liquid-based cervical cytology, and grading breast cancer.

DISCUSSION

Published data demonstrates the value of utilizing WSI in breast and gynecological pathology. Key issues reported with WSI systems were problems related to focus, resolution and the contrast and brightness of immunohistochemical staining patterns. Grading breast cancer and mitotic count remained challenging in WSI as in conventional microscopy.

Whole Slide Imaging (WSI) in Pathology: Current Perspectives and Future Directions

Whole slide imaging (WSI), ever since its first introduction about two decades ago, has been validated for a number of applications in the field of pathology. The recent approval of US FDA to a WSI system for use in primary surgical pathology diagnosis has opened avenues for wider acceptance and application of this technology in routine practice. The ongoing technological advances in digital scanners, image visualization methods, and the integration of artificial intelligence-derived algorithms with these systems provide opportunities of its newer applications. Its benefits are innumerable such as ease of access through internet, avoidance of physical storage space, and no risk of deterioration of staining quality or breakage of slides to name a few. Various barriers such as the high cost, technical glitches, and professional hesitation to adopt a new technology have hindered its use in pathology. This review article summarizes the technical aspects of WSI, its applications in diagnostic pathology, training, and research along with future perspectives. It highlights the benefits, limitations, and challenges delaying the use of this technology in routine practice. The review is targeted at students, residents, and budding pathologists to better acquaint them with the key aspects of state-of-the-art technology and enable them to implement WSI judiciously.

Continuing Undergraduate Pathology Medical Education in the Coronavirus Disease 2019 (COVID-19) Global Pandemic: The Johns Hopkins Virtual Surgical Pathology Clinical Elective

CONTEXT.—

In the early months of the response to the coronavirus disease 2019 (COVID-19) pandemic, the Johns Hopkins University School of Medicine (JHUSOM) (Baltimore, Maryland) leadership reached out to faculty to develop and implement virtual clinical clerkships after all in-person medical student clinical experiences were suspended.

OBJECTIVE.—

To develop and implement a digital slide-based virtual surgical pathology (VSP) clinical elective to meet the demand for meaningful and robust virtual clinical electives in response to the temporary suspension of in-person clinical rotations at JHUSOM.

DESIGN.—

The VSP elective was modeled after the in-person surgical pathology elective to include virtual previewing and sign-out with standardized cases supplemented by synchronous and asynchronous pathology educational content.

RESULTS.—

Validation of existing Web communications technology and slide-scanning systems was performed by feasibility testing. Curriculum development included drafting of course objectives and syllabus, Blackboard course site design, electronic-lecture creation, communications with JHUSOM leadership, scheduling, and slide curation. Subjectively, the weekly schedule averaged 35 to 40 hours of asynchronous, synchronous, and independent content, approximately 10 to 11 hours of which were synchronous. As of February 2021, VSP has hosted 35 JHUSOM and 8 non-JHUSOM students, who have provided positive subjective and objective course feedback.

CONCLUSIONS.—

The Johns Hopkins VSP elective provided meaningful clinical experience to 43 students in a time of immense online education need. Added benefits of implementing VSP included increased medical student exposure to pathology as a medical specialty and demonstration of how digital slides have the potential to improve standardization of the pathology clerkship curriculum.

Application of remote online learning in oral histopathology teaching in China

Background

The aim of this study was to investigate the application of remote learning and virtual microscopy in oral histopathology teaching, a unique experience in China. The oral histopathology teaching in Nanjing Medical University has been extraordinary.

Material and Methods

98 third-year dental students of Grade 2016 took oral histopathology theoretical course face-to-face in 2019 (Traditional group). The 94 participants of Grade 2017 took online oral histopathology course using digital methods(E-Learning platform and Virtual Simulation Experiment Teaching Center for Dentistry) in 2020. During the practical laboratory sessions, the students in both Traditional group and Online group observed the same glass slides for morphological learning. A questionnaire survey explored students' attitudes towards the remote online learning. Results: The mean Theory test scores of the Online group (80.93±12.15) were significantly higher than those of the Traditional group (73.65±8.46) (P < 0.01). The mean total scores of the Online group (82.94±10.76) were significantly higher than those of the Traditional group (77.25±7.55) (P < 0.01). The percentage of high total test score (test score > 85) of the Online group (54%) was also significantly higher than that of the Traditional group (15%) (P< 0.01). Furthermore, both remote learning and virtual microscopy courses were well accepted by students according to the questionnaire.

Conclusions

This study found that remote learning and virtual technology have a positive impact on oral histopathology. The findings reveal that the application of remote online learning has enhanced oral histopathology teaching in China.

Key words:Oral histopathology, dental undergraduate students, virtual microscopy, remote online learning, questionnaire.

Barriers and Facilitators to Telemedicine: Can You Hear Me Now?

In its most direct interpretation, telemedicine is medical care provided at a distance. Although telemedicine's use had been steadily increasing, the COVID-19 pandemic prompted an unprecedented interest and urgency among patients, health care professionals, and policymakers to facilitate health care devoid of the need for in-person contact. The growth in personal access to telecommunications technology meant an unprecedented number of people in the United States and around the world had access to the equipment and technology that would make virtual care possible from the home. As the mass implementation of telemedicine unfolded, it became quickly apparent that scaling up the use of telemedicine presented considerable new challenges, some of which worsened disparities. This article describes those challenges by examining the history of telemedicine, its role in both supporting access and creating new barriers to access in trying to get everyone connected, frameworks for thinking about those barriers, and facilitators that may help overcome them, with a particular focus on older adults and patients with cancer in rural communities.

The virtual microscopy database-sharing digital microscope images for research and education

Over the last 20 years, virtual microscopy has become the predominant modus of teaching the structural organization of cells, tissues, and organs, replacing the use of optical microscopes and glass slides in a traditional histology or pathology laboratory setting. Although virtual microscopy image files can easily be duplicated, creating them requires not only quality histological glass slides but also an expensive whole slide microscopic scanner and massive data storage devices. These resources are not available to all educators and researchers, especially at new institutions in developing countries. This leaves many schools without access to virtual microscopy resources. The Virtual Microscopy Database (VMD) is a new resource established to address this problem. It is a virtual image file-sharing website that allows researchers and educators easy access to a large repository of virtual histology and pathology image files. With the support from the American Association of Anatomists (Bethesda, MD) and MBF Bioscience Inc. (Williston, VT), registration and use of the VMD are currently free of charge. However, the VMD site is restricted to faculty and staff of research and educational institutions. Virtual Microscopy Database users can upload their own collection of virtual slide files, as well as view and download image files for their own non-profit educational and research purposes that have been deposited by other VMD clients. Anat Sci Educ 11: 510-515. © 2018 American Association of Anatomists.

Emerging paradigm of virtual-microscopy for histopathology diagnosis: survey of US and Canadian oral pathology trainees

Objectives/Aims:

The application of virtual microscopy (VM) to research, pre-doctoral medical and dental educational training, and diagnostic surgical and anatomic pathology is well-documented but its application to the field of oral and maxillofacial pathology has not been explored. This is the first study to evaluate the enthusiasm and readiness of US-/Canada-based oral and maxillofacial pathology (OMFP) residents toward employing VM use over conventional microscopy (CM) for diagnostic purposes.

Materials and Methods:

All 46 current US-/Canada-based OMFP residents were invited to participate in an anonymous electronic survey via ‘Survey Monkey’ in 2015. The survey comprised sixteen multiple choice questions and two ‘free text’ questions.

Results:

14% of respondents of the 22 (48%) respondents who completed the survey indicated a willingness to substitute CM with VM in <5 years, and 33% within 10 years. 52% reported they would never substitute CM with VM. Approximately 10 and 57% of respondents thought VM will become an acceptable sole diagnostic tool in most centers within 5 and 10 years, respectively. These findings are irrespective of the fact that overall, 90% of respondents reported being familiar with VM use.

Discussion:

VM technology is unlikely to substitute CM in diagnostic oral and maxillofacial histopathology practice among future OMFP practitioners in the foreseeable future.

An update on the validation of whole slide imaging systems following FDA approval of a system for a routine pathology diagnostic service in the United States

Pathologists have used light microscopes and glass slides to interpret the histologic appearance of normal and diseased tissues for more than 150 years. The quality of both microtomes used to cut tissue sections and microscopes has improved significantly during the past few decades, but the process of rendering diagnoses has changed little. By contrast, major advances in digital technology have occurred since the introduction of hand held electronic devices, including the development of whole slide imaging (WSI) systems with software packages that can convert microscope images into virtual (digital) slides that can be viewed on computer monitors and via the internet. To date, however, these technological developments have had minimal impact on the way pathologists perform their daily work, with the exception of using computers to access electronic medical records and scholarly web sites for pertinent information to assist interpretation of cases. Traditional practice is likely to change significantly during the next decade, especially since the Federal Drug Administration in the USA has approved the first WSI system for routine diagnostic practice. I review here the development and slow acceptance of WSI by pathology departments. I focus on recent advances in validation of WSI systems that is required for routine diagnostic reporting of pathology cases using this technology.

The Empirical Foundations of Telepathology: Evidence of Feasibility and Intermediate Effects

INTRODUCTION

Telepathology evolved from video microscopy (i.e., "television microscopy") research in the early 1950s to video microscopy used in basic research in the biological sciences to a basic diagnostic tool in telemedicine clinical applications. Its genesis can be traced to pioneering feasibility studies regarding the importance of color and other image-based parameters for rendering diagnoses and a series of studies assessing concordance of virtual slide and light microscopy diagnoses. This article documents the empirical foundations of telepathology.

METHODS

A selective review of the research literature during the past decade (2005-2016) was conducted using robust research design and adequate sample size as criteria for inclusion.

CONCLUSIONS

The evidence regarding feasibility/acceptance of telepathology and related information technology applications has been well documented for several decades. The majority of evidentiary studies focused on intermediate outcomes, as indicated by comparability between telepathology and conventional light microscopy. A consistent trend of concordance between the two modalities was observed in terms of diagnostic accuracy and reliability. Additional benefits include use of telepathology and whole slide imaging for teaching, research, and outreach to resource-limited countries. Challenges still exist, however, in terms of use of telepathology as an effective diagnostic modality in clinical practice.

Telepathology Impacts and Implementation Challenges: A Scoping Review

CONTEXT

Telepathology is a particular form of telemedicine that fundamentally alters the way pathology services are delivered. Prior reviews in this area have mostly focused on 2 themes, namely technical feasibility issues and diagnosis accuracy.

OBJECTIVES

To synthesize the literature on telepathology implementation challenges and broader organizational and societal impacts and to propose a research agenda to guide future efforts in this domain.

DATA SOURCES

Two complementary databases were systematically searched: MEDLINE (PubMed) and ABI/INFORM (ProQuest). Peer-reviewed articles and conference proceedings were considered. The final sample consisted of 159 papers published between 1992 and 2013.

CONCLUSIONS

This review highlights the diversity of telepathology networks and the importance of considering these distinctions when interpreting research findings. Various network structures are associated with different benefits. Although the dominant rationale in single-site projects is financial, larger centralized and decentralized telepathology networks are targeting a more diverse set of benefits, including extending access to pathology to a whole region, achieving substantial economies of scale in workforce and equipment, and improving quality by standardizing care. Importantly, our synthesis reveals that the nature and scale of encountered implementation challenges also varies depending on the network structure. In smaller telepathology networks, organizational concerns are less prominent, and implementers are more focused on usability issues. As the network scope widens, organizational and legal issues gain prominence.

Utility of telepathology as a consultation tool between an off-site surgical pathology suite and affiliated hospitals in the frozen section diagnosis of lung neoplasms

Background:

Increasingly, as in our institution, operating rooms are located in hospitals and the pathology suite is located at a distant location because of off-site consolidation of pathology services. Telepathology is a technology which bridges the gap between pathologists and offers a means to obtain a consultation remotely. We aimed to evaluate the utility of telepathology as a means to assist the pathologist at the time of intraoperative consultation of lung nodules when a subspecialty pathologist is not available to directly review the slide.

Methods:

Cases of lung nodules suspicious for a neoplasm were included. Frozen sections were prepared in the usual manner. The pathologists on the intraoperative consultation service at two of our system hospitals notified the thoracic pathologist of each case after rendering a preliminary diagnosis. The consultation was performed utilizing a Nikon™ Digital Sight camera and web-based Remote Medical Technologies™ software with live video streaming directed by the host pathologist. The thoracic pathologist rendered a diagnosis without knowledge of the preliminary interpretation then discussed the interpretation with the frozen section pathologist. The interpretations were compared with the final diagnosis rendered after sign-out.

Results:

One hundred and three consecutive cases were included. The frozen section pathologist and a thoracic pathologist had concordant diagnoses in 93 cases (90.2%), discordant diagnoses in nine cases (8.7%), and one case in which both deferred. There was an agreement between the thoracic pathologist's diagnosis and the final diagnosis in 98% of total cases including 8/9 (88.9%) of the total discordant cases. In two cases, if the thoracic pathologist had not been consulted, the patient would have been undertreated.

Conclusions:

We have shown that telepathology is an excellent consultation tool in the frozen section diagnosis of lung nodules.

Overview of Telepathology

Telepathology is the practice of remote pathology using telecommunication links to enable the electronic transmission of digital pathology images. Telepathology can be used for remotely rendering primary diagnoses, second opinion consultations, quality assurance, education, and research purposes. The use of telepathology for clinical patient care has been limited mostly to large academic institutions. Barriers that have limited its widespread use include prohibitive costs, legal and regulatory issues, technologic drawbacks, resistance from pathologists, and above all a lack of universal standards. This article provides an overview of telepathology technology and applications.

A nationwide telepathology consultation and quality control program in China: implementation and result analysis

Background

Telepathology may play an important role in pathology consultation and quality control for cancer diagnosis in China, as the country has the largest population of cancer patients worldwide. In 2011, the Pathology Quality Control Center of China and Ministry of Health developed and implemented a nationwide telepathology consultation and quality control program for cancer diagnosis in China. We here report the results of the two-year implementation and experiences.

Methods

the program built an Internet based telepathology platform to connect participating hospitals and expert consultants. The hardware and software used for the platform were validated in previous validation studies in China. The program had three regional centers consisting of Peking Union Medical College, Huasi Medical College of Sichuan and 2nd affiliated hospital of Zhejiang University. It also had 20 provincial consultation centers based in the provincial referral hospitals. 80 provincial or national pathologists served as expert consultants for the program, providing telepathology consultation for cancer diagnosis for more than 60 participating hospitals.

Results

from 2011 to July 2013, 16,247 pathology cases were submitted to the platform for consultation. Among them, 84% were due to diagnostic difficulty and 16% were due to request by patients. The preliminary diagnosis provided by submitting pathologists were in agreement with expert opinion in 59.8% of cases but was in disagreement with expert opinion in 24.2% of cases. 16.0% of cases were not provided with preliminary diagnosis. The distribution of pathology cases by system or organ were: digestive system, 17.3%; gynecologic system, 16.7%; head and neck, 15.7%; bone and soft tissue, 10.4%; lung and mediastinum, 8.6%; breast, 7.6%; urinary system, 7.5%; hematopathology, 6.4%; skin, 5.2%; neuropathology, 2.5% and cytopathology, 1.3%. Expert consultants also provided assessment of quality of slide preparation and staining, online lectures and guidance for pathology quality control.

Conclusion

our results of two years' implementation indicated that telepathology could solve the problem of uneven distribution of pathology resources and provide a solution for countrywide pathology quality control in China. Telepathology could play an important role in improving pathology diagnosis in China.

Interinstitutional whole slide imaging teleconsultation service development: assessment using internal training and clinical consultation cases

CONTEXT

Assessment of accuracy and feasibility of whole slide imaging (WSI) for interinstitutional consultation in surgical pathology.

OBJECTIVES

To train technical and pathologist staff in WSI technology, establish and evaluate a WSI workflow using training cases and second-opinion consultations, and assess diagnostic accuracy.

DESIGN

First, WSI training and evaluation using selected subspecialty service cases were performed and compared with the clinical glass slide (GS) diagnosis. Second, WSI and GS diagnoses of consecutive, second-opinion consultation cases were compared. Discrepancies underwent adjudication to determine a reference diagnosis. Participant observations on WSI initiation to practice were gathered.

RESULTS

There were 130 cases evaluated, with 123 correlations (94.6%) and 6 minor (4.6%) and 1 major (0.8%) discrepancies. The 74 consultation cases interpreted had 52 correlations (70.3%), and 18 minor (24.3%) and 4 major (5.4%) discrepancies. The WSI and GS adjusted major discrepancy rates in second-opinion consultations were 2.7% (2 of 74) and 4.1% (3 of 74), respectively. Statistical analysis showed that WSI was not inferior to GS interpretation. Pathologists agreed the software was easy to use and the images were adequate, but more time was spent rendering WSI interpretations.

CONCLUSIONS

A significant learning curve was observed in the transition from the training set to clinical consultation cases associated both with WSI interpretation and adjustments to the digital analogs of routine GS workflow. Results from second-opinion consultations indicated that WSI interpretation was as accurate as GS interpretation among properly trained and experienced users. Overall, WSI-based practice appears feasible for second-opinion consultations.

Subspecialty surgical pathologist's performances as triage pathologists on a telepathology-enabled quality assurance surgical pathology service: A human factors study

BACKGROUND

The case triage practice workflow model was used to manage incoming cases on a telepathology-enabled surgical pathology quality assurance (QA) service. Maximizing efficiency of workflow and the use of pathologist time requires detailed information on factors that influence telepathologists' decision-making on a surgical pathology QA service, which was gathered and analyzed in this study.

MATERIALS AND METHODS

Surgical pathology report reviews and telepathology service logs were audited, for 1862 consecutive telepathology QA cases accrued from a single Arizona rural hospital over a 51 month period. Ten university faculty telepathologists served as the case readers. Each telepathologist had an area of subspecialty surgical pathology expertise (i.e. gastrointestinal pathology, dermatopathology, etc.) but functioned largely as a general surgical pathologist while on this telepathology-enabled QA service. They handled all incoming cases during their individual 1-h telepathology sessions, regardless of the nature of the organ systems represented in the real-time incoming stream of outside surgical pathology cases.

RESULTS

The 10 participating telepathologists' postAmerican Board of pathology examination experience ranged from 3 to 36 years. This is a surrogate for age. About 91% of incoming cases were immediately signed out regardless of the subspecialty surgical pathologists' area of surgical pathology expertise. One hundred and seventy cases (9.13%) were deferred. Case concurrence rates with the provisional surgical pathology diagnosis of the referring pathologist, for incoming cases, averaged 94.3%, but ranged from 88.46% to 100% for individual telepathologists. Telepathology case deferral rates, for second opinions or immunohistochemistry, ranged from 4.79% to 21.26%. Differences in concordance rates and deferral rates among telepathologists, for incoming cases, were significant but did not correlate with years of experience as a practicing pathologist. Coincidental overlaps of the area of subspecialty surgical pathology expertise with organ-related incoming cases did not influence decisions by the telepathologists to either defer those cases or to agree or disagree with the referring pathologist's provisional diagnoses.

CONCLUSIONS

Subspecialty surgical pathologists effectively served as general surgical pathologists on a telepathology-based surgical pathology QA service. Concurrence rates with incoming surgical pathology report diagnoses, and case deferral rates, varied significantly among the 10 on-service telepathologists. We found no evidence that the higher deferral rates correlated with improving the accuracy or quality of the surgical pathology reports.

Color standardization in whole slide imaging using a color calibration slide

Background:

Color consistency in histology images is still an issue in digital pathology. Different imaging systems reproduced the colors of a histological slide differently.

Materials and Methods:

Color correction was implemented using the color information of the nine color patches of a color calibration slide. The inherent spectral colors of these patches along with their scanned colors were used to derive a color correction matrix whose coefficients were used to convert the pixels’ colors to their target colors.

Results:

There was a significant reduction in the CIELAB color difference, between images of the same H & E histological slide produced by two different whole slide scanners by 3.42 units, P < 0.001 at 95% confidence level.

Conclusion:

Color variations in histological images brought about by whole slide scanning can be effectively normalized with the use of the color calibration slide.

Multi-institutional comparison of whole slide digital imaging and optical microscopy for interpretation of hematoxylin-eosin-stained breast tissue sections

CONTEXT

Whole slide imaging (WSI) is now used for educational purposes, for consultation, and for archiving and quantitation of immunostains. However, it is not routinely used for the primary diagnosis of hematoxylin-eosin-stained tissue sections.

OBJECTIVE

To compare WSI using the Aperio digital pathology system (Aperio Technologies, Inc, Vista, California) with optical microscopy (OM) for the interpretation of hematoxylin-eosin-stained tissue sections of breast lesions.

DESIGN

The study was conducted at 3 clinical sites; 3 breast pathologists interpreted 150 hematoxylin-eosin-stained slides at each site, 3 times each by WSI and 3 times each by OM. For WSI, slides were scanned using an Aperio ScanScope and interpreted on a computer monitor using Aperio ImageScope software and Aperio Spectrum data management software. Pathologic interpretations were recorded using the College of American Pathologists breast checklist. WSI diagnoses were compared with OM diagnoses for accuracy, precision (interpathologist variation), and reproducibility (intrapathologist variation). Results were considered accurate only if the interpretation matched exactly between WSI and OM. The proportion of accurate results reported by each pathologist was expressed as a percentage for the comparison of the 2 platforms.

RESULTS

The accuracy of WSI for classifying lesions as not carcinoma or as noninvasive (ductal or lobular) or invasive (ductal, lobular, or other) carcinoma was 90.5%. The accuracy of OM was 92.1%. The precision and reproducibility of WSI and OM were determined on the basis of pairwise comparisons (3 comparisons for each slide, resulting in 36 possible comparisons). The overall precision of WSI was 90.5% in comparison with 92.1% for OM; reproducibility of WSI was 91.6% in comparison with 94.5% for OM, respectively.

CONCLUSIONS

In this study, we demonstrated that WSI and OM have similar accuracy, precision, and reproducibility for interpreting hematoxylin-eosin-stained breast tissue sections. Further clinical studies using routine surgical pathology specimens would be useful to confirm these findings and facilitate the incorporation of WSI into diagnostic practice.

Republished: going glass to digital: virtual microscopy as a simulation-based revolution in pathology and laboratory science

The recent technological advance of digital high resolution imaging has allowed the field of pathology and medical laboratory science to undergo a dramatic transformation with the incorporation of virtual microscopy as a simulation-based educational and diagnostic tool. This transformation has correlated with an overall increase in the use of simulation in medicine in an effort to address dwindling clinical resource availability and patient safety issues currently facing the modern healthcare system. Virtual microscopy represents one such simulation-based technology that has the potential to enhance student learning and readiness to practice while revolutionising the ability to clinically diagnose pathology collaboratively across the world. While understanding that a substantial amount of literature already exists on virtual microscopy, much more research is still required to elucidate the full capabilities of this technology. This review explores the use of virtual microscopy in medical education and disease diagnosis with a unique focus on key requirements needed to take this technology to the next level in its use in medical education and clinical practice.

Application of whole slide image markup and annotation for pathologist knowledge capture

Objective:

The ability to transfer image markup and annotation data from one scanned image of a slide to a newly acquired image of the same slide within a single vendor platform was investigated. The goal was to study the ability to use image markup and annotation data files as a mechanism to capture and retain pathologist knowledge without retaining the entire whole slide image (WSI) file.

Methods:

Accepted mathematical principles were investigated as a method to overcome variations in scans of the same glass slide and to accurately associate image markup and annotation data across different WSI of the same glass slide. Trilateration was used to link fixed points within the image and slide to the placement of markups and annotations of the image in a metadata file.

Results:

Variation in markup and annotation placement between WSI of the same glass slide was reduced from over 80 μ to less than 4 μ in the x-axis and from 17 μ to 6 μ in the y-axis (P < 0.025).

Conclusion:

This methodology allows for the creation of a highly reproducible image library of histopathology images and interpretations for educational and research use.

Mouse cursor movement and eye tracking data as an indicator of pathologists' attention when viewing digital whole slide images

CONTEXT

Digital pathology has the potential to dramatically alter the way pathologists work, yet little is known about pathologists' viewing behavior while interpreting digital whole slide images. While tracking pathologist eye movements when viewing digital slides may be the most direct method of capturing pathologists' viewing strategies, this technique is cumbersome and technically challenging to use in remote settings. Tracking pathologist mouse cursor movements may serve as a practical method of studying digital slide interpretation, and mouse cursor data may illuminate pathologists' viewing strategies and time expenditures in their interpretive workflow.

AIMS

To evaluate the utility of mouse cursor movement data, in addition to eye-tracking data, in studying pathologists' attention and viewing behavior.

SETTINGS AND DESIGN

Pathologists (N = 7) viewed 10 digital whole slide images of breast tissue that were selected using a random stratified sampling technique to include a range of breast pathology diagnoses (benign/atypia, carcinoma in situ, and invasive breast cancer). A panel of three expert breast pathologists established a consensus diagnosis for each case using a modified Delphi approach.

MATERIALS AND METHODS

Participants' foveal vision was tracked using SensoMotoric Instruments RED 60 Hz eye-tracking system. Mouse cursor movement was tracked using a custom MATLAB script.

STATISTICAL ANALYSIS USED

Data on eye-gaze and mouse cursor position were gathered at fixed intervals and analyzed using distance comparisons and regression analyses by slide diagnosis and pathologist expertise. Pathologists' accuracy (defined as percent agreement with the expert consensus diagnoses) and efficiency (accuracy and speed) were also analyzed.

RESULTS

Mean viewing time per slide was 75.2 seconds (SD = 38.42). Accuracy (percent agreement with expert consensus) by diagnosis type was: 83% (benign/atypia); 48% (carcinoma in situ); and 93% (invasive). Spatial coupling was close between eye-gaze and mouse cursor positions (highest frequency ∆x was 4.00px (SD = 16.10), and ∆y was 37.50px (SD = 28.08)). Mouse cursor position moderately predicted eye gaze patterns (Rx = 0.33 and Ry = 0.21).

CONCLUSIONS

Data detailing mouse cursor movements may be a useful addition to future studies of pathologists' accuracy and efficiency when using digital pathology.

Digital imaging in pathology: whole-slide imaging and beyond

Digital imaging in pathology has undergone an exponential period of growth and expansion catalyzed by changes in imaging hardware and gains in computational processing. Today, digitization of entire glass slides at near the optical resolution limits of light can occur in 60 s. Whole slides can be imaged in fluorescence or by use of multispectral imaging systems. Computational algorithms have been developed for cytometric analysis of cells and proteins in subcellular locations by use of multiplexed antibody staining protocols. Digital imaging is unlocking the potential to integrate primary image features into high-dimensional genomic assays by moving microscopic analysis into the digital age. This review highlights the emerging field of digital pathology and explores the methods and analytic approaches being developed for the application and use of these methods in clinical care and research settings.

Concordance between whole-slide imaging and light microscopy for routine surgical pathology

The use of high-resolution digital images of histopathology slides as a routine diagnostic tool for surgical pathology was investigated. The study purpose was to determine the diagnostic concordance between pathologic interpretations using whole-slide imaging and standard light microscopy. Two hundred fifty-one consecutive surgical pathology cases (312 parts, 1085 slides) from a single pathology service were included in the study after cases had been signed out and reports generated. A broad array of diagnostic challenges and tissue sources were represented, including 52 neoplastic cases. All cases were digitized at ×20 and presented to 2 pathologists for diagnosis using whole-slide imaging as the sole diagnostic tool. Diagnoses rendered by the whole-slide imaging pathologists were compared with the original light microscopy diagnoses. Overall concordance between whole-slide imaging and light microscopy as determined by a third pathologist and jury panel was 96.5% (95% confidence interval, 94.8%-98.3%). Concordance between whole-slide imaging pathologists was 97.7% (95% confidence interval, 94.7%-99.2%). Five cases were discordant between the whole-slide imaging diagnosis and the original light microscopy diagnosis, of which 2 were clinically significant. Discordance resulted from interpretive criteria or diagnostic error. The whole-slide imaging modality did not contribute to diagnostic differences. Problems encountered by the whole-slide imaging pathologists primarily involved the inability to clearly visualize nuclear detail or microscopic organisms. Technical difficulties associated with image scanning required at least 1 slide be rescanned in 13% of the cases. Technical and operational issues associated with whole-slide imaging scanning devices used in this study were found to be the most significant obstacle to the use of whole-slide imaging in general surgical pathology.

Digital imaging in pathology--current applications and challenges

Conventional histopathology is rapidly shifting towards digital integration. Will microscopes (and pathologists) soon be obsolete? Or are we dealing with just another image modality that leaves the core of tissue diagnosis intact? This article provides an overview of current digital pathology applications and research with emphasis on whole slide imaging (WSI). Static or interactive digital pathology work stations already can be used for many purposes, e.g. telepathology expert consultations, frozen section diagnosis in remote areas, cytology screening, quality assurance, diagnostic validations for clinical trials, quantitation of hormone receptor or HER2 studies in breast cancer, or three-dimensional visualization of anatomical structures, among others. Changes of workflow in histology laboratories are beginning to enable digital image acquisition and WSI in a routine setting. WSI plays an increasing role in pathology education, glass slide boxes in medical schools are being replaced by digital slide collections; digital slide seminars and virtual microscopy are used for postgraduate and continuing medical education in pathology. Research and efforts to validate WSI systems for diagnostic settings are ongoing.

Validation of diagnostic accuracy using digital slides in routine histopathology

Background

Robust hardware and software tools have been developed in digital microscopy during the past years for pathologists. Reports have been advocated the reliability of digital slides in routine diagnostics. We have designed a retrospective, comparative study to evaluate the scanning properties and digital slide based diagnostic accuracy.

Methods

8 pathologists reevaluated 306 randomly selected cases from our archives. The slides were scanned with a 20× Plan-Apochromat objective, using a 3-chip Hitachi camera, resulting 0.465 μm/pixel resolution. Slide management was supported with dedicated Data Base and Viewer software tools. Pathologists used their office PCs for evaluation and reached the digital slides via intranet connection. The diagnostic coherency and uncertainty related to digital slides and scanning quality were analyzed.

Results

Good to excellent image quality of slides was recorded in 96%. In half of the critical 61 digital slides, poor image quality was related to section folds or floatings. In 88.2% of the studied cases the digital diagnoses were in full agreement with the consensus. Out of the overall 36 incoherent cases, 7 (2.3%) were graded relevant without any recorded uncertainty by the pathologist. Excluding the non-field specific cases from each pathologist's record this ratio was 1.76% of all cases.

Conclusions

Our results revealed that: 1) digital slide based histopathological diagnoses can be highly coherent with those using optical microscopy; 2) the competency of pathologists is a factor more important than the quality of digital slide; 3) poor digital slide quality do not endanger patient safety as these errors are recognizable by the pathologist and further actions for correction could be taken.

Virtual slides

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1913324336747310.

Development and use of a genitourinary pathology digital teaching set for trainee education

BACKGROUND

Automated, high-speed, high-resolution whole slide imaging (WSI) robots are becoming increasingly robust and capable. This technology has started to have a significant impact on pathology practice in various aspects including resident education. To be sufficient and adequate, training in pathology requires gaining broad exposure to various diagnostic patterns through teaching sets, which are traditionally composed of glass slides.

METHODS

A teaching set of over 295 glass slides has been used for resident training at the Division of Genitourinary Pathology, Department of Pathology, University of Pittsburgh Medical Center. Whole slide images were prepared from these slides using an Aperio ScanScope CS scanner. These images and case-related information were uploaded on a web-based digital teaching model.

RESULTS

THE WEB SITE IS AVAILABLE AT: https://www.secure.opi.upmc.edu/genitourinary/index.cfm. Once logged in, users can view the list of cases, or search cases with or without diagnoses shown. Each case can be accessed through an option button, where the clinical history, gross findings are initially shown. Whole slide images can be accessed through the links on the page, which allows users to make diagnoses on their own. More information including final diagnosis will display when the diagnosis-button is clicked.

CONCLUSION

The web-based digital study set provides additional educational benefits to using glass slides. Residents or other users can remotely access whole slide images and related information at their convenience. Searching and sorting functions and self-testing mode allow a more targeted study. It would also prepare residents with competence to work with whole slide images. Further, the model can be expanded to include pre-rotation and post-rotation exams, and/or a virtual rotation system, which may potentially make standardization of pathology resident training possible in the future.

Telepathology for patient care: what am I getting myself into?

The vast advancements in telecommunications and converting medical information to a digital format have increased the number of applications within telemedicine. Telepathology, in simplest terms, is the practice of formally rendering a pathologic diagnosis based upon examination of an image rather than of a glass slide through traditional microscopy. The use of telepathology for clinical patient care has so far been limited to relatively few large academic institutions. Although a number of challenges remain, there is increasing demand for the use of information technology in pathology as a whole owing to the expansion of health care networks and the opportunity to enhance the quality of service delivered to patients. The software used to acquire, display, and manage digital images for clinical patient care may be subject to national and federal regulations just as is any other electronic information system. Despite the barriers, telepathology systems possess the capability to help manage pathology cases on a global scale, improve laboratory workload distribution, increase standardization of practice and enable new classes of ancillary studies to facilitate diagnosis and education even in the most remote parts of the earth.

Informatics for practicing anatomical pathologists: marking a new era in pathology practice

Informatics can be defined as using highly advanced technologies to improve patient diagnosis or management. Pathology informatics had evolved as a response to the overwhelming amount of information that was available, in an attempt to better use and maintain them. The most commonly used tools of informatics can be classified into digital imaging, telepathology, as well as Internet and electronic data mining. Digital imaging is the storage of anatomical pathology information, either gross pictures or microscopic slides, in an electronic format. These images can be used for education, archival, diagnosis, and consultation. Virtual microscopy is the more advanced form of digital imaging with enhanced efficiency and accessibility. Telepathology is now increasingly becoming a useful tool in anatomical pathology practice. Different types of telepathology communications are available for both diagnostic and consultation services. The spectrum of applications of informatics in the field of anatomical pathology is broad and encompasses medical education, clinical services, and pathology research. Informatics is now settling on solid ground as an important tool for pathology teaching, with digital teaching becoming the standard tool in many institutions. After a slow start, we now witness the transition of informatics from the research bench to bedside. As we are moving into a new era of extensive pathology informatics utilization, several challenges have to be addressed, including the cost of the new technology, legal issues, and resistance of pathologists. It is clear from the current evidence that pathology informatics will continue to grow and have a major role in the future of our specialty. However, it is also clear that it is not going to fully replace the human factor or the regular microscope.

Overview of telepathology, virtual microscopy, and whole slide imaging: prospects for the future

Telepathology, the practice of pathology at a long distance, has advanced continuously since 1986. Today, fourth-generation telepathology systems, so-called virtual slide telepathology systems, are being used for education applications. Both conventional and innovative surgical pathology diagnostic services are being designed and implemented as well. The technology has been commercialized by more than 30 companies in Asia, the United States, and Europe. Early adopters of telepathology have been laboratories with special challenges in providing anatomic pathology services, ranging from the need to provide anatomic pathology services at great distances to the use of the technology to increase efficiency of services between hospitals less than a mile apart. As to what often happens in medicine, early adopters of new technologies are professionals who create model programs that are successful and then stimulate the creation of infrastructure (ie, reimbursement, telecommunications, information technologies, and so on) that forms the platforms for entry of later, mainstream, adopters. The trend at medical schools, in the United States, is to go entirely digital for their pathology courses, discarding their student light microscopes, and building virtual slide laboratories. This may create a generation of pathology trainees who prefer digital pathology imaging over the traditional hands-on light microscopy. The creation of standards for virtual slide telepathology is early in its development but accelerating. The field of telepathology has now reached a tipping point at which major corporations now investing in the technology will insist that standards be created for pathology digital imaging as a value added business proposition. A key to success in teleradiology, already a growth industry, has been the implementation of standards for digital radiology imaging. Telepathology is already the enabling technology for new, innovative laboratory services. Examples include STAT QA surgical pathology second opinions at a distance and a telehealth-enabled rapid breast care service. The innovative bundling of telemammography, telepathology, and teleoncology services may represent a new paradigm in breast care that helps address the serious issue of fragmentation of breast cancer care in the United States and elsewhere. Legal and regulatory issues in telepathology are being addressed and are regarded as a potential catalyst for the next wave of telepathology advances, applications, and implementations.