1
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Jain E, Patel A, Parwani AV, Shafi S, Brar Z, Sharma S, Mohanty SK. Whole Slide Imaging Technology and Its Applications: Current and Emerging Perspectives. Int J Surg Pathol 2024; 32:433-448. [PMID: 37437093 DOI: 10.1177/10668969231185089] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
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.
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Affiliation(s)
- Ekta Jain
- Department of Pathology and Laboratory Medicine, CORE Diagnostics, Gurgaon, India
| | - Ankush Patel
- Department of Pathology, Wexner Medical Center, Columbus, OH, USA
| | - Anil V Parwani
- Department of Pathology, Wexner Medical Center, Columbus, OH, USA
| | - Saba Shafi
- Department of Pathology, Wexner Medical Center, Columbus, OH, USA
| | - Zoya Brar
- Department of Pathology and Laboratory Medicine, CORE Diagnostics, Gurgaon, India
| | - Shivani Sharma
- Department of Pathology and Laboratory Medicine, CORE Diagnostics, Gurgaon, India
| | - Sambit K Mohanty
- Department of Pathology and Laboratory Medicine, CORE Diagnostics, Gurgaon, India
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2
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Rosen DG, de Mello ES, Dhingra S, Dawsey SM, Knapper J, Bowman R, Anandasabapathy S. Utility of a Low-Cost 3-D Printed Microscope for Evaluating Esophageal Biopsies. ANNALS OF 3D PRINTED MEDICINE 2024; 13:100145. [PMID: 38405263 PMCID: PMC10887376 DOI: 10.1016/j.stlm.2024.100145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Abstract
In this manuscript we assessed the utility of a low-cost 3D printed microscope to evaluate esophageal biopsies. We conducted a comparative analysis between the traditional microscope and our 3-D printed microscope, utilizing a set of esophageal biopsy samples obtained from patients undergoing screening endoscopy. Two pathologists independently examined 30 esophageal biopsies by light microscopy and digital images obtained using a low-cost 3D printed microscope (Observer 1 and 2). The glass slide consensus diagnosis was compared to the findings of 2 additional pathologist who independently just reviewed the digital images (Observer 3 and 4). The intra-observer agreement was substantial to almost perfect for observer 1 (k:0.64) and 2 (k:0.84). All four observers had 100% sensitivity and negative predictive value, whereas specificity ranged from 59% to 100% and positive predictive value ranged from 21% to 100%. The PPV and specificity were lower for the two Observers (3 and 4) who just examined the digital images. Overall, our results suggest that telepathology may be used with high sensitivity and specificity, utilizing the pictures produced by our 3D-printed microscope.
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Affiliation(s)
- Daniel G. Rosen
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Tx
- Department of Pathology, Michael E. DeBakey, Veterans Administration Medical Center, Houston, Tx
| | | | - Sadhna Dhingra
- Department of Pathology, Houston Methodist Hospital, Houston, Tx
| | - Sanford M. Dawsey
- Nutritional Epidemiology Branch, Division of Cancer Epidemiology & Genetics, National Cancer Institute, Bethesda, Maryland, United States of America
| | - Joe Knapper
- School of Physics and Astronomy, University of Glasgow, UK
| | - Richard Bowman
- School of Physics and Astronomy, University of Glasgow, UK
| | - Sharmila Anandasabapathy
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
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3
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Barb AC, Fenesan MP, Pirtea M, Margan MM, Tomescu L, Ceban E, Cimpean AM, Melnic E. Reassessing Breast Cancer-Associated Fibroblasts (CAFs) Interactions with Other Stromal Components and Clinico-Pathologic Parameters by Using Immunohistochemistry and Digital Image Analysis (DIA). Cancers (Basel) 2023; 15:3823. [PMID: 37568639 PMCID: PMC10417678 DOI: 10.3390/cancers15153823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 07/18/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Breast cancer (BC) stroma has CD34- and αSMA-positive cancer-associated fibroblasts (CAFs) differently distributed. During malignant transformation, CD34-positive fibroblasts decrease while αSMA-positive CAFs increase. The prevalence of αSMA-positive CAFs in BC stroma makes microscopic examination difficult without digital image analysis processing (DIA). DIA was used to compare CD34- and αSMA-positive CAFs among breast cancer molecular subgroups. DIA-derived data were linked to age, survival, tumor stroma vessels, tertiary lymphoid structures (TLS), invasion, and recurrence. METHODS Double immunostaining for CD34 and αSMA showed different CAF distribution patterns in normal and BC tissues. Single CD34 immunohistochemistry on supplemental slides quantified tumor stroma CD34_CAFs. Digital image analysis (DIA) data on CAF density, intensity, stromal score, and H-score were correlated with clinico-pathologic factors. RESULTS CD34/αSMA CAF proportion was significantly related to age in Luminal A (LA), Luminal B (LB), and HER2 subtypes. CD34_CAF influence on survival, invasion, and recurrence of LA, LB-HER2, and TNBC subtypes was found to be significant. The CD34/αSMA-expressing CAFs exhibited a heterogeneous impact on stromal vasculature and TLS. CONCLUSION BC stromal CD34_CAFs/αSMA_CAFs have an impact on survival, invasion, and recurrence differently between BC molecular subtypes. The tumor stroma DIA assessment may have predictive potential to prognosis and long-term follow-up of patients with breast cancer.
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Affiliation(s)
- Alina Cristina Barb
- Department of Microscopic Morphology/Histology, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.C.B.); (M.P.F.); (M.P.)
- Doctoral School in Medicine, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania;
- Department of Clinical Oncology, OncoHelp Hospital, 300239 Timisoara, Romania
| | - Mihaela Pasca Fenesan
- Department of Microscopic Morphology/Histology, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.C.B.); (M.P.F.); (M.P.)
- Doctoral School in Medicine, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania;
- Department of Clinical Oncology, OncoHelp Hospital, 300239 Timisoara, Romania
| | - Marilena Pirtea
- Department of Microscopic Morphology/Histology, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.C.B.); (M.P.F.); (M.P.)
| | - Mădălin-Marius Margan
- Department of Functional Sciences/Discipline of Public Health, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania;
| | - Larisa Tomescu
- Doctoral School in Medicine, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania;
- Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania
| | - Emil Ceban
- Department of Urology and Surgical Nephrology, Nicolae Testemitanu State University of Medicine and Pharmacy, 2004 Chisinau, Moldova;
- Laboratory of Andrology, Functional Urology and Sexual Medicine, Nicolae Testemitanu State University of Medicine and Pharmacy, 2004 Chisinau, Moldova
| | - Anca Maria Cimpean
- Department of Microscopic Morphology/Histology, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.C.B.); (M.P.F.); (M.P.)
- Center of Expertise for Rare Vascular Disease in Children, Emergency Hospital for Children Louis Turcanu, 300011 Timisoara, Romania
| | - Eugen Melnic
- Department of Pathology, Nicolae Testemitanu State University of Medicine and Pharmacy, 2004 Chisinau, Moldova;
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Idoate Gastearena MA, López-Janeiro Á, Lecumberri Aznarez A, Arana-Iñiguez I, Guillén-Grima F. A Quantitative Digital Analysis of Tissue Immune Components Reveals an Immunosuppressive and Anergic Immune Response with Relevant Prognostic Significance in Glioblastoma. Biomedicines 2022; 10:biomedicines10071753. [PMID: 35885058 PMCID: PMC9313250 DOI: 10.3390/biomedicines10071753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/10/2022] [Accepted: 07/15/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives: Immunostimulatory therapies using immune checkpoint blockers show clinical activity in a subset of glioblastoma (GBM) patients. Several inhibitory mechanisms play a relevant role in the immune response to GBM. With the objective of analyzing the tumor immune microenvironment and its clinical significance, we quantified several relevant immune biomarkers. Design: We studied 76 primary (non-recurrent) GBMs with sufficient clinical follow-up, including a subgroup of patients treated with a dendritic cell vaccine. The IDH-mutation, EGFR-amplification, and MGMT methylation statuses were determined. Several relevant immune biomarkers, including CD163, CD8, PD1, and PDL1, were quantified in representative selected areas by digital image analysis and semiquantitative evaluation. The percentage of each immune expression was calculated with respect to the total number of tumor cells. Results: All GBMs were wild-type IDH, with a subgroup of classical GBMs according to the EGFR amplification (44%). Morphologically, CD163 immunostained microglia and intratumor clusters of macrophages were observed. A significant direct correlation was found between the expression of CD8 and the mechanisms of lymphocyte immunosuppression, in such a way that higher values of CD8 were directly associated with higher values of CD163 (p < 0.001), PDL1 (0.026), and PD1 (0.007). In a multivariate analysis, high expressions of CD8+ (HR = 2.05, 95%CI (1.02−4.13), p = 0.034) and CD163+ cells (HR 2.50, 95%CI (1.29−4.85), p = 0.007), were associated with shorter survival durations. The expression of immune biomarkers was higher in the non-classical (non-EGFR amplified tumors) GBMs. Other relevant prognostic factors were age, receipt of the dendritic cell vaccine, and MGMT methylation status. Conclusions: In accordance with the inverse correlation between CD8 and survival and the direct correlation between effector cells and CD163 macrophages and immune-checkpoint expression, we postulate that CD8 infiltration could be placed in a state of anergy or lymphocytic inefficient activity. Furthermore, the significant inverse correlation between CD163 tissue concentration and survival explains the relevance of this type of immune cell when creating a strong immunosuppressive environment. This information may potentially be used to support the selection of patients for immunotherapy.
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Affiliation(s)
- Miguel A. Idoate Gastearena
- Pathology Department, Clinica Universidad de Navarra and School of Medicine, University of Navarra, 31008 Pamplona, Spain; (Á.L.-J.); (A.L.A.); (I.A.-I.)
- Pathology Department, Virgen Macarena University Hospital and School of Medicine, University of Seville, 41009 Seville, Spain
- Correspondence: ; Tel.: +34-660460714
| | - Álvaro López-Janeiro
- Pathology Department, Clinica Universidad de Navarra and School of Medicine, University of Navarra, 31008 Pamplona, Spain; (Á.L.-J.); (A.L.A.); (I.A.-I.)
| | - Arturo Lecumberri Aznarez
- Pathology Department, Clinica Universidad de Navarra and School of Medicine, University of Navarra, 31008 Pamplona, Spain; (Á.L.-J.); (A.L.A.); (I.A.-I.)
| | - Iñigo Arana-Iñiguez
- Pathology Department, Clinica Universidad de Navarra and School of Medicine, University of Navarra, 31008 Pamplona, Spain; (Á.L.-J.); (A.L.A.); (I.A.-I.)
| | - Francisco Guillén-Grima
- Department of Preventive Medicine, Clinica Universidad de Navarra, University of Navarra, 31008 Pamplona, Spain;
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Rizzo PC, Girolami I, Marletta S, Pantanowitz L, Antonini P, Brunelli M, Santonicco N, Vacca P, Tumino N, Moretta L, Parwani A, Satturwar S, Eccher A, Munari E. Technical and Diagnostic Issues in Whole Slide Imaging Published Validation Studies. Front Oncol 2022; 12:918580. [PMID: 35785212 PMCID: PMC9246412 DOI: 10.3389/fonc.2022.918580] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/24/2022] [Indexed: 01/07/2023] Open
Abstract
ObjectiveDigital pathology with whole-slide imaging (WSI) has many potential clinical and non-clinical applications. In the past two decades, despite significant advances in WSI technology adoption remains slow for primary diagnosis. The aim of this study was to identify common pitfalls of WSI reported in validation studies and offer measures to overcome these challenges.MethodsA systematic search was conducted in the electronic databases Pubmed-MEDLINE and Embase. Inclusion criteria were all validation studies designed to evaluate the feasibility of WSI for diagnostic clinical use in pathology. Technical and diagnostic problems encountered with WSI in these studies were recorded.ResultsA total of 45 studies were identified in which technical issues were reported in 15 (33%), diagnostic issues in 8 (18%), and 22 (49%) reported both. Key technical problems encompassed slide scan failure, prolonged time for pathologists to review cases, and a need for higher image resolution. Diagnostic challenges encountered were concerned with grading dysplasia, reliable assessment of mitoses, identification of microorganisms, and clearly defining the invasive front of tumors.ConclusionDespite technical advances with WSI technology, some critical concerns remain that need to be addressed to ensure trustworthy clinical diagnostic use. More focus on the quality of the pre-scanning phase and training of pathologists could help reduce the negative impact of WSI technical difficulties. WSI also seems to exacerbate specific diagnostic tasks that are already challenging among pathologists even when examining glass slides with conventional light microscopy.
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Affiliation(s)
- Paola Chiara Rizzo
- Department of Pathology and Diagnostics and Public Health, Section of Pathology, University Hospital of Verona, Verona, Italy
| | | | - Stefano Marletta
- Department of Pathology and Diagnostics and Public Health, Section of Pathology, University Hospital of Verona, Verona, Italy
- Department of Pathology, Pederzoli Hospital, Peschiera del Garda, Italy
| | - Liron Pantanowitz
- Department of Pathology & Clinical Labs, University of Michigan, Ann Arbor, MI, United States
| | - Pietro Antonini
- Department of Pathology and Diagnostics and Public Health, Section of Pathology, University Hospital of Verona, Verona, Italy
| | - Matteo Brunelli
- Department of Pathology and Diagnostics and Public Health, Section of Pathology, University Hospital of Verona, Verona, Italy
| | - Nicola Santonicco
- Department of Pathology and Diagnostics and Public Health, Section of Pathology, University Hospital of Verona, Verona, Italy
| | - Paola Vacca
- Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Nicola Tumino
- Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Lorenzo Moretta
- Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Anil Parwani
- Department of Pathology, Ohio State University Medical Center, Columbus, OH, United States
| | - Swati Satturwar
- Department of Pathology, Ohio State University Medical Center, Columbus, OH, United States
| | - Albino Eccher
- Department of Pathology and Diagnostics, University and Hospital Trust of Verona, Verona, Italy
- *Correspondence: Albino Eccher,
| | - Enrico Munari
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
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Temprana-Salvador J, López-García P, Castellví Vives J, de Haro L, Ballesta E, Rojas Abusleme M, Arrufat M, Marques F, Casas JR, Gallego C, Pons L, Mate JL, Fernández PL, López-Bonet E, Bosch R, Martínez S, Ramón y Cajal S, Matias-Guiu X. DigiPatICS: Digital Pathology Transformation of the Catalan Health Institute Network of 8 Hospitals—Planification, Implementation, and Preliminary Results. Diagnostics (Basel) 2022; 12:diagnostics12040852. [PMID: 35453900 PMCID: PMC9025604 DOI: 10.3390/diagnostics12040852] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/17/2022] [Accepted: 03/28/2022] [Indexed: 11/21/2022] Open
Abstract
Complete digital pathology transformation for primary histopathological diagnosis is a challenging yet rewarding endeavor. Its advantages are clear with more efficient workflows, but there are many technical and functional difficulties to be faced. The Catalan Health Institute (ICS) has started its DigiPatICS project, aiming to deploy digital pathology in an integrative, holistic, and comprehensive way within a network of 8 hospitals, over 168 pathologists, and over 1 million slides each year. We describe the bidding process and the careful planning that was required, followed by swift implementation in stages. The purpose of the DigiPatICS project is to increase patient safety and quality of care, improving diagnosis and the efficiency of processes in the pathological anatomy departments of the ICS through process improvement, digital pathology, and artificial intelligence tools.
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Affiliation(s)
- Jordi Temprana-Salvador
- Department of Pathology, Vall d’Hebron University Hospital, CIBERONC, 08035 Barcelona, Spain; (J.C.V.); (S.R.y.C.)
- Correspondence: ; Tel.: +34-93-274-68-09
| | - Pablo López-García
- Functional Competence Center, Information Systems, Catalan Health Institute (Institut Català de la Salut), 08006 Barcelona, Spain; (P.L.-G.); (L.d.H.); (E.B.)
| | - Josep Castellví Vives
- Department of Pathology, Vall d’Hebron University Hospital, CIBERONC, 08035 Barcelona, Spain; (J.C.V.); (S.R.y.C.)
| | - Lluís de Haro
- Functional Competence Center, Information Systems, Catalan Health Institute (Institut Català de la Salut), 08006 Barcelona, Spain; (P.L.-G.); (L.d.H.); (E.B.)
| | - Eudald Ballesta
- Functional Competence Center, Information Systems, Catalan Health Institute (Institut Català de la Salut), 08006 Barcelona, Spain; (P.L.-G.); (L.d.H.); (E.B.)
| | - Matias Rojas Abusleme
- Center for Telecommunications and Information Technology (Centre de Telecomunicacions i Tecnologies de la Informació, CTTI), Catalan Health Institute (Institut Català de la Salut), 08006 Barcelona, Spain;
| | - Miquel Arrufat
- Economic and Financial Management, Catalan Health Institute (Institut Català de la Salut), 08006 Barcelona, Spain;
| | - Ferran Marques
- Image Processing Group, Technical University of Catalonia (UPC), 08034 Barcelona, Spain; (F.M.); (J.R.C.)
| | - Josep R. Casas
- Image Processing Group, Technical University of Catalonia (UPC), 08034 Barcelona, Spain; (F.M.); (J.R.C.)
| | - Carlos Gallego
- Digital Medical Imaging System of Catalonia (SIMDCAT), TIC Salut, 08005 Barcelona, Spain;
| | - Laura Pons
- Department of Pathology, Germans Trias i Pujol University Hospital, 08916 Badalona, Spain; (L.P.); (J.L.M.); (P.L.F.)
| | - José Luis Mate
- Department of Pathology, Germans Trias i Pujol University Hospital, 08916 Badalona, Spain; (L.P.); (J.L.M.); (P.L.F.)
| | - Pedro Luis Fernández
- Department of Pathology, Germans Trias i Pujol University Hospital, 08916 Badalona, Spain; (L.P.); (J.L.M.); (P.L.F.)
| | - Eugeni López-Bonet
- Department of Pathology, Doctor Josep Trueta Hospital of Girona, 17007 Girona, Spain;
| | - Ramon Bosch
- Department of Pathology, Verge de la Cinta Hospital of Tortosa, 43500 Tarragona, Spain;
| | - Salomé Martínez
- Department of Pathology, Joan XXIII University Hospital of Tarragona, 43005 Tarragona, Spain;
| | - Santiago Ramón y Cajal
- Department of Pathology, Vall d’Hebron University Hospital, CIBERONC, 08035 Barcelona, Spain; (J.C.V.); (S.R.y.C.)
| | - Xavier Matias-Guiu
- Department of Pathology, Arnau de Vilanova University Hospital, 25198 Lleida, Spain;
- Department of Pathology, Bellvitge University Hospital, CIBERONC, 08907 Barcelona, Spain
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Bertram CA, Stathonikos N, Donovan TA, Bartel A, Fuchs-Baumgartinger A, Lipnik K, van Diest PJ, Bonsembiante F, Klopfleisch R. Validation of digital microscopy: Review of validation methods and sources of bias. Vet Pathol 2022; 59:26-38. [PMID: 34433345 PMCID: PMC8761960 DOI: 10.1177/03009858211040476] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Digital microscopy (DM) is increasingly replacing traditional light microscopy (LM) for performing routine diagnostic and research work in human and veterinary pathology. The DM workflow encompasses specimen preparation, whole-slide image acquisition, slide retrieval, and the workstation, each of which has the potential (depending on the technical parameters) to introduce limitations and artifacts into microscopic examination by pathologists. Performing validation studies according to guidelines established in human pathology ensures that the best-practice approaches for patient care are not deteriorated by implementing DM. Whereas current publications on validation studies suggest an overall high reliability of DM, each laboratory is encouraged to perform an individual validation study to ensure that the DM workflow performs as expected in the respective clinical or research environment. With the exception of validation guidelines developed by the College of American Pathologists in 2013 and its update in 2021, there is no current review of the application of methods fundamental to validation. We highlight that there is high methodological variation between published validation studies, each having advantages and limitations. The diagnostic concordance rate between DM and LM is the most relevant outcome measure, which is influenced (regardless of the viewing modality used) by different sources of bias including complexity of the cases examined, diagnostic experience of the study pathologists, and case recall. Here, we review 3 general study designs used for previous publications on DM validation as well as different approaches for avoiding bias.
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Affiliation(s)
- Christof A. Bertram
- University of Veterinary Medicine, Vienna, Austria
- Freie Universität Berlin, Berlin, Germany
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Garberis I, Andre F, Lacroix-Triki M. L’intelligence artificielle pourrait-elle intervenir dans l’aide au diagnostic des cancers du sein ? – L’exemple de HER2. Bull Cancer 2022; 108:11S35-11S45. [PMID: 34969514 DOI: 10.1016/s0007-4551(21)00635-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
HER2 is an important prognostic and predictive biomarker in breast cancer. Its detection makes it possible to define which patients will benefit from a targeted treatment. While assessment of HER2 status by immunohistochemistry in positive vs negative categories is well implemented and reproducible, the introduction of a new "HER2-low" category could raise some concerns about its scoring and reproducibility. We herein described the current HER2 testing methods and the application of innovative machine learning techniques to improve these determinations, as well as the main challenges and opportunities related to the implementation of digital pathology in the up-and-coming AI era.
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Affiliation(s)
- Ingrid Garberis
- Inserm UMR 981, Gustave Roussy Cancer Campus, Villejuif, France; Université Paris-Saclay, 94270 Le Kremlin-Bicêtre, France.
| | - Fabrice Andre
- Inserm UMR 981, Gustave Roussy Cancer Campus, Villejuif, France; Université Paris-Saclay, 94270 Le Kremlin-Bicêtre, France; Département d'oncologie médicale, Gustave-Roussy, Villejuif, France
| | - Magali Lacroix-Triki
- Inserm UMR 981, Gustave Roussy Cancer Campus, Villejuif, France; Département d'anatomie et cytologie pathologiques, Gustave-Roussy, Villejuif, France
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9
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Babawale M, Gunavardhan A, Walker J, Corfield T, Huey P, Savage A, Bansal A, Atkinson M, Abdelsalam H, Raweily E, Christian A, Evangelou I, Thomas D, Shannon J, Youd E, Brumwell P, Harrison J, Thompson I, Rashid M, Leopold G, Finall A, Roberts S, Housa D, Nedeva P, Davies A, Fletcher D, Aslam M. Verification and Validation of Digital Pathology (Whole Slide Imaging) for Primary Histopathological Diagnosis: All Wales Experience. J Pathol Inform 2021; 12:4. [PMID: 34012708 PMCID: PMC8112347 DOI: 10.4103/jpi.jpi_55_20] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/03/2020] [Accepted: 10/01/2020] [Indexed: 11/04/2022] Open
Abstract
Aims: The study is aimed to verify Aperio AT2 scanner for reporting on the digital pathology platform (DP) and to validate the cohort of pathologists in the interpretation of DP for routine diagnostic histopathological services in Wales, United Kingdom. Materials, Methods and Results: This was a large multicenter study involving seven hospitals across Wales and unique with 22 (largest number) pathologists participating. 7491 slides from 3001 cases were scanned on Leica Aperio AT2 scanner and reported on digital workstations with Leica software of e-slide manager. A senior pathology fellow compared DP reports with authorized reports on glass slide (GS). A panel of expert pathologists reviewed the discrepant cases under multiheader microscope to establish ground truth. 2745 out of 3001 (91%) cases showed complete concordance between DP and GS reports. Two hundred and fifty-six cases showed discrepancies in diagnosis, of which 170 (5.6%) were deemed of no clinical significance by the review panel. There were 86 (2.9%) clinically significant discrepancies in the diagnosis between DP and GS. The concordance was raised to 97.1% after discounting clinically insignificant discrepancies. Ground truth lay with DP in 28 out of 86 clinically significant discrepancies and with GS in 58 cases. Sensitivity of DP was 98.07% (confidence interval [CI] 97.57–98.56%); for GS was 99.07% (CI 98.72–99.41%). Conclusions: We concluded that Leica Aperio AT2 scanner produces adequate quality of images for routine histopathologic diagnosis. Pathologists were able to diagnose in DP with good concordance as with GS. Strengths and Limitations of this Study: Strengths of this study – This was a prospective blind study. Different pathologists reported digital and glass arms at different times giving an ambience of real-time reporting. There was standardized use of software and hardware across Wales. A strong managerial support from efficiency through the technology group was a key factor for the implementation of the study. Limitations: This study did not include Cytopathology and in situ hybridization slides. Difficulty in achieving surgical pathology practise standardization across the whole country contributed to intra-observer variations.
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Affiliation(s)
- M Babawale
- Department of Cellular Pathology, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Bodelwyddan, Wales
| | - A Gunavardhan
- Department of Cellular Pathology, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Bodelwyddan, Wales
| | - J Walker
- Department of Anaesthetics, Gwynedd Hospital, Betsi Cadwaladr University Health Board, Bangor, Wales
| | - T Corfield
- Department of Cellular Pathology, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Bodelwyddan, Wales
| | - P Huey
- Department of Cellular Pathology, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Bodelwyddan, Wales
| | - A Savage
- Department of Cellular Pathology, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Bodelwyddan, Wales
| | - A Bansal
- Department of Cellular Pathology, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Bodelwyddan, Wales
| | - M Atkinson
- Department of Cellular Pathology, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Bodelwyddan, Wales
| | - H Abdelsalam
- Department of Cellular Pathology, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Bodelwyddan, Wales
| | - E Raweily
- Department of Cellular Pathology, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Bodelwyddan, Wales
| | - A Christian
- Department of Histopathology, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, Wales
| | - I Evangelou
- Department of Histopathology, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, Wales
| | - D Thomas
- Department of Histopathology, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, Wales
| | - J Shannon
- Department of Histopathology, Royal Glamorgan Hospital, Cwm Taf University Health Board, Rhondda Cynon Taff, Wales
| | - E Youd
- Department of Histopathology, Royal Glamorgan Hospital, Cwm Taf University Health Board, Rhondda Cynon Taff, Wales
| | - P Brumwell
- Department of Histopathology, Royal Glamorgan Hospital, Cwm Taf University Health Board, Rhondda Cynon Taff, Wales
| | - J Harrison
- Department of Histopathology, Royal Gwent Hospital, Aneurin Bevan University Health Board, Newport, Wales
| | - I Thompson
- Department of Histopathology, Royal Gwent Hospital, Aneurin Bevan University Health Board, Newport, Wales
| | - M Rashid
- Department of Histopathology, Royal Gwent Hospital, Aneurin Bevan University Health Board, Newport, Wales
| | - G Leopold
- Department of Cellular Pathology, Morriston Hospital Swansea Bay University Health Board, Port Talbot, Wales
| | - A Finall
- Department of Cellular Pathology, Morriston Hospital Swansea Bay University Health Board, Port Talbot, Wales.,Abertawe Bro Morgannwg Health Board, Port Talbot, Wales
| | - S Roberts
- Department of Cellular Pathology, Singleton Hospital, Abertawe Bro Morgannwg Health Board, Port Talbot, Wales
| | - D Housa
- Department of Histopathology, Glangwilli Hospital, Hywel Dda University Health Board, Carmarthen, Wales
| | - P Nedeva
- Department of Histopathology, Glangwilli Hospital, Hywel Dda University Health Board, Carmarthen, Wales
| | - A Davies
- Department of Cellular Pathology, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Bodelwyddan, Wales
| | - D Fletcher
- Department of Cellular Pathology, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Bodelwyddan, Wales
| | - Muhammad Aslam
- Department of Cellular Pathology, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Bodelwyddan, Wales
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10
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Chong Y, Kim DC, Jung CK, Kim DC, Song SY, Joo HJ, Yi SY. Recommendations for pathologic practice using digital pathology: consensus report of the Korean Society of Pathologists. J Pathol Transl Med 2020; 54:437-452. [PMID: 33027850 PMCID: PMC7674756 DOI: 10.4132/jptm.2020.08.27] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/27/2020] [Indexed: 11/17/2022] Open
Abstract
Digital pathology (DP) using whole slide imaging (WSI) is becoming a fundamental issue in pathology with recent advances and the rapid development of associated technologies. However, the available evidence on its diagnostic uses and practical advice for pathologists on implementing DP remains insufficient, particularly in light of the exponential growth of this industry. To inform DP implementation in Korea, we developed relevant and timely recommendations. We first performed a literature review of DP guidelines, recommendations, and position papers from major countries, as well as a review of relevant studies validating WSI. Based on that information, we prepared a draft. After several revisions, we released this draft to the public and the members of the Korean Society of Pathologists through our homepage and held an open forum for interested parties. Through that process, this final manuscript has been prepared. This recommendation contains an overview describing the background, objectives, scope of application, and basic terminology; guidelines and considerations for the hardware and software used in DP systems and the validation required for DP implementation; conclusions; and references and appendices, including literature on DP from major countries and WSI validation studies.
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Affiliation(s)
- Yosep Chong
- Department of Hospital Pathology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Cheol Kim
- Department of Pathology, Dong-A University College of Medicine, Busan, Korea
| | - Chan Kwon Jung
- Department of Hospital Pathology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-chul Kim
- Department of Pathology, Seoul Clinical Laboratories, Yongin, Korea
| | - Sang Yong Song
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Jae Joo
- Department of Pathology, TCM Laboratory, Seongnam, Korea
| | - Sang-Yeop Yi
- Department of Pathology, Catholic Kwandong University College of Medicine, Gangneung, Korea
| | - Medical Informatics Study Group of the Korean Society of Pathologists
- Department of Hospital Pathology, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Department of Pathology, Dong-A University College of Medicine, Busan, Korea
- Department of Pathology, Seoul Clinical Laboratories, Yongin, Korea
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Pathology, TCM Laboratory, Seongnam, Korea
- Department of Pathology, Catholic Kwandong University College of Medicine, Gangneung, Korea
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11
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Shakya R, Nguyen TH, Waterhouse N, Khanna R. Immune contexture analysis in immuno-oncology: applications and challenges of multiplex fluorescent immunohistochemistry. Clin Transl Immunology 2020; 9:e1183. [PMID: 33072322 PMCID: PMC7541822 DOI: 10.1002/cti2.1183] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/04/2020] [Accepted: 09/04/2020] [Indexed: 12/17/2022] Open
Abstract
The tumor microenvironment is an integral player in cancer initiation, tumor progression, response and resistance to anti-cancer therapy. Understanding the complex interactions of tumor immune architecture (referred to as 'immune contexture') has therefore become increasingly desirable to guide our approach to patient selection, clinical trial design, combination therapies, and patient management. Quantitative image analysis based on multiplexed fluorescence immunohistochemistry and deep learning technologies are rapidly developing to enable researchers to interrogate complex information from the tumor microenvironment and find predictive insights into treatment response. Herein, we discuss current developments in multiplexed fluorescence immunohistochemistry for immune contexture analysis, and their application in immuno-oncology, and discuss challenges to effectively use this technology in clinical settings. We also present a multiplexed image analysis workflow to analyse fluorescence multiplexed stained tumor sections using the Vectra Automated Digital Pathology System together with FCS express flow cytometry software. The benefit of this strategy is that the spectral unmixing accurately generates and analyses complex arrays of multiple biomarkers, which can be helpful for diagnosis, risk stratification, and guiding clinical management of oncology patients.
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Affiliation(s)
- Reshma Shakya
- QIMR Berghofer Centre for Immunotherapy and Vaccine Development, Tumour Immunology LaboratoryQIMR Berghofer Medical Research InstituteBrisbaneQLDAustralia
| | - Tam Hong Nguyen
- Flow Cytometry and Imaging FacilityQIMR Berghofer Medical Research InstituteBrisbaneQLDAustralia
| | - Nigel Waterhouse
- Flow Cytometry and Imaging FacilityQIMR Berghofer Medical Research InstituteBrisbaneQLDAustralia
| | - Rajiv Khanna
- QIMR Berghofer Centre for Immunotherapy and Vaccine Development, Tumour Immunology LaboratoryQIMR Berghofer Medical Research InstituteBrisbaneQLDAustralia
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12
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Nam S, Chong Y, Jung CK, Kwak TY, Lee JY, Park J, Rho MJ, Go H. Introduction to digital pathology and computer-aided pathology. J Pathol Transl Med 2020; 54:125-134. [PMID: 32045965 PMCID: PMC7093286 DOI: 10.4132/jptm.2019.12.31] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 12/31/2019] [Indexed: 12/13/2022] Open
Abstract
Digital pathology (DP) is no longer an unfamiliar term for pathologists, but it is still difficult for many pathologists to understand the engineering and mathematics concepts involved in DP. Computer-aided pathology (CAP) aids pathologists in diagnosis. However, some consider CAP a threat to the existence of pathologists and are skeptical of its clinical utility. Implementation of DP is very burdensome for pathologists because technical factors, impact on workflow, and information technology infrastructure must be considered. In this paper, various terms related to DP and computer-aided pathologic diagnosis are defined, current applications of DP are discussed, and various issues related to implementation of DP are outlined. The development of computer-aided pathologic diagnostic tools and their limitations are also discussed.
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Affiliation(s)
- Soojeong Nam
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yosep Chong
- Department of Hospital Pathology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chan Kwon Jung
- Department of Hospital Pathology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | | | - Ji Youl Lee
- Department of Urology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jihwan Park
- Catholic Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Department of Biomedicine & Health Sciences, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Mi Jung Rho
- Catholic Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Heounjeong Go
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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13
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Kuo KH, Leo JM. Optical Versus Virtual Microscope for Medical Education: A Systematic Review. ANATOMICAL SCIENCES EDUCATION 2019; 12:678-685. [PMID: 30414261 DOI: 10.1002/ase.1844] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 10/21/2018] [Accepted: 10/26/2018] [Indexed: 06/08/2023]
Abstract
Many technological innovations have changed the traditional practice of medical education and clinical practice. Whole slide imaging (WSI) technology provided an unique way of viewing conventional glass slides in histology and pathology laboratories. The WSI technology digitalized glass slide images and made them readily accessible via the Internet using tablets or computers. Users utilized the pan-and-zoom function to view digital images of slides, also referred to as the virtual microscope (VM), simulating use of an optical microscope (OM). Several articles have reported various outcomes on the utility of VM in teaching laboratories. Recently, the Royal College of Physicians and Surgeons of Canada certification examinations for anatomical pathologists ha completely adopted VM for the national licensing examination. To better inform medical educators, there is an urgent need for more structured reviews to draw evidence-based conclusions on the effectiveness of VM and learner's perceptions, in comparison to OM. The current study provides a descriptive summary of published outcomes using the systematic review approach. In conclusion, medical students' performance was improved with adoption of VM into the curriculum and recognized as a preferred learning modality, compared to OM. On the contrary, resident learners' performance was comparable between using OM and VM, with OM being the favored slide-viewing modality.
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Affiliation(s)
- Kuo-Hsing Kuo
- Northern Medial Program, University of Northern British Columbia, Prince George, Canada
| | - Joyce M Leo
- Department of Laboratory Medicine, Royal Jubilee Hospital, Victoria, Canada
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14
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Lajara N, Espinosa-Aranda JL, Deniz O, Bueno G. Optimum web viewer application for DICOM whole slide image visualization in anatomical pathology. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2019; 179:104983. [PMID: 31443854 DOI: 10.1016/j.cmpb.2019.104983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 06/20/2019] [Accepted: 07/10/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVE Digital scanners are being increasingly adopt-ed in anatomical pathology, but there is still a lack of a standardized whole slide image (WSI) format. This translates into the need for interoperability and knowledge representation for shareable and computable clinical information. This work describes a robust solution, called Visilab Viewer, able to interact and work with any WSI based on the DICOM standard. METHODS Visilab Viewer is a web platform developed and integrated alongside a proposed web architecture following the DICOM definition. To prepare the information of the pyramid structure proposed in DICOM, a specific module was defined. The same structure is used by a second module that aggregates on the cache browser the adjacent tiles or frames of the current user's viewport with the aim of achieving fast and fluid navigation over the tissue slide. This solution was tested and compared with three different web viewers, publicly available, with 10 WSIs. RESULTS A quantitative assessment was performed based on the average load time per frame together with the number of fully loaded frames. Kruskal-Wallis and Dunn tests were used to compare each web viewer latency results and finally to rank them. Additionally, a qualitative evaluation was done by 6 pathologists based on speed and quality for zooming, panning and usability. The proposed viewer obtained the best performance in both assessments. The entire architecture proposed was tested in the 2nd worldwide DICOM Connectathon, obtaining successful results with all participant scanner vendors. CONCLUSIONS The online tool allows users to navigate and obtain a correct visualization of the samples avoiding any restriction of format and localization. The two strategical modules allow to reduce time in displaying the slide and therefore, offer high fluidity and usability. The web platform manages not only the visualization with the developed web viewer but also includes the insertion, manipulation and generation of new DICOM elements. Visilab Viewer can successfully exchange DICOM data. Connectathons are the ultimate interoperability tests and are therefore required to guarantee that solutions as Visilab Viewer and its architecture can successfully exchange data following the DICOM standard. Accompanying demo video. (Link to Youtube video.).
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Affiliation(s)
- Nieves Lajara
- VISILAB, University of Castilla-La Mancha, Ciudad Real, Spain
| | | | - Oscar Deniz
- VISILAB, University of Castilla-La Mancha, Ciudad Real, Spain
| | - Gloria Bueno
- VISILAB, University of Castilla-La Mancha, Ciudad Real, Spain.
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15
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Whole slide imaging equivalency and efficiency study: experience at a large academic center. Mod Pathol 2019; 32:916-928. [PMID: 30778169 DOI: 10.1038/s41379-019-0205-0] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 11/08/2022]
Abstract
Whole slide imaging is Food and Drug Administration-approved for primary diagnosis in the United States of America; however, relatively few pathology departments in the country have fully implemented an enterprise wide digital pathology system enabled for primary diagnosis. Digital pathology has significant potential to transform pathology practice with several published studies documenting some level of diagnostic equivalence between digital and conventional systems. However, whole slide imaging also has significant potential to disrupt pathology practice, due to the differences in efficiency of manipulating digital images vis-à-vis glass slides, and studies on the efficiency of actual digital pathology workload are lacking. Our randomized, equivalency and efficiency study aimed to replicate clinical workflow, comparing conventional microscopy to a complete digital pathology signout using whole slide images, evaluating the equivalency and efficiency of glass slide to whole slide image reporting, reflective of true pathology practice workloads in the clinical setting. All glass slides representing an entire day's routine clinical signout workload for six different anatomic pathology subspecialties at Memorial Sloan Kettering Cancer Center were scanned on Leica Aperio AT2 at ×40 (0.25 µm/pixel). Integration of whole slide images for each accessioned case is through an interface between the Leica eSlide manager database and the laboratory information system, Cerner CoPathPlus. Pathologists utilized a standard institution computer workstation and viewed whole slide images through an internally developed, vendor agnostic whole slide image viewer, named the "MSK Slide Viewer". Subspecialized pathologists first reported on glass slides from surgical pathology cases using routine clinical workflow. Glass slides were de-identified, scanned, and re-accessioned in the laboratory information system test environment. After a washout period of 13 weeks, pathologists reported the same clinical workload using whole slide image integrated within the laboratory information system. Intraobserver equivalency metrics included top-line diagnosis, margin status, lymphovascular and/or perineural invasion, pathology stage, and the need to order ancillary testing (i.e., recuts, immunohistochemistry). Turnaround time (efficiency) evaluation was defined by the start of each case when opened in the laboratory information system and when the case was completed for that day (i.e., case sent to signout queue or pending ancillary studies). Eight pathologists participated from the following subspecialties: bone and soft tissue, genitourinary, gastrointestinal, breast, gynecologic, and dermatopathology. Glass slides signouts comprised of 204 cases, encompassing 2091 glass slides; and digital signouts comprised of 199 cases, encompassing 2073 whole slide images. The median whole slide image file size was 1.54 GB; scan time/slide, 6 min 24 s; and scan area 32.1 × 18.52 mm. Overall diagnostic equivalency (e.g., top-line diagnosis) was 99.3% between digital and glass slide signout; however, signout using whole slide images showed a median overall 19% decrease in efficiency per case. No significant difference by reader, subspecialty, or specimen type was identified. Our experience is the most comprehensive study to date and shows high intraobserver whole slide image to glass slide equivalence in reporting of true clinical workflows and workloads. Efficiency needs to improve for digital pathology to gain more traction among pathologists.
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16
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Catteau X, Simon P, Jondet M, Vanhaeverbeek M, Noël JC. Quantification of stromal reaction in breast carcinoma and its correlation with tumor grade and free progression survival. PLoS One 2019; 14:e0210263. [PMID: 30897102 PMCID: PMC6428301 DOI: 10.1371/journal.pone.0210263] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 12/19/2018] [Indexed: 12/20/2022] Open
Abstract
Cancer progression results from a complex interplay between tumor cells and the extracellular milieu. In breast carcinoma, the stromal microenvironment has been suggested to play a major role in promoting tumor growth, progression, and invasion. The stroma of 154 resected specimens of invasive breast carcinoma of no special type was quantified using a digital image analyzer. Statistical analyses were performed between the quantity of stroma and survival, as well as between progression-free survival and clinicopathological data. Levels of myofibroblastic stroma varied from 0-46%, with a median of 15.1% and a standard deviation of 7.5. The myofibroblastic stromal reaction was statistically greater in grade 2 and 3 tumors (p = 0.029). Furthermore, there was a trend for worse progression-free survival in the group of node-negative tumors with strong smooth-muscle actin stromal expression (Log rank = 0.075). The present study demonstrates that the myofibroblastic reaction of breast invasive carcinoma of no special type is not merely a passive reaction, but seems to be an integral part of the neoplastic process by facilitating tumor progression and invasion. Additional, larger studies on mechanisms of stromal change are needed and may potentially lead to novel treatments.
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Affiliation(s)
- Xavier Catteau
- Pathology Department, CUREPATH (CHU Tivoli, Chirec), Jumet, Belgium
- Pathology Department, Erasme University Hospital-Université Libre de Bruxelles, Brussels, Belgium
- * E-mail:
| | - Philippe Simon
- Gynaecologic Department, Erasme University Hospital-Université Libre de Bruxelles, Brussels, Belgium
| | | | - Michel Vanhaeverbeek
- Laboratory of Experimental Medicine, Centre Hospitalo-Universitaire de Charleroi, Montigny-Le-Tilleul, Belgium
| | - Jean-Christophe Noël
- Pathology Department, Erasme University Hospital-Université Libre de Bruxelles, Brussels, Belgium
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17
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Cima L, Brunelli M, Parwani A, Girolami I, Ciangherotti A, Riva G, Novelli L, Vanzo F, Sorio A, Cirielli V, Barbareschi M, D'Errico A, Scarpa A, Bovo C, Fraggetta F, Pantanowitz L, Eccher A. Validation of Remote Digital Frozen Sections for Cancer and Transplant Intraoperative Services. J Pathol Inform 2018; 9:34. [PMID: 30450263 PMCID: PMC6187937 DOI: 10.4103/jpi.jpi_52_18] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 08/31/2018] [Indexed: 12/12/2022] Open
Abstract
Introduction Whole-slide imaging (WSI) technology can be used for primary diagnosis and consultation, including intraoperative (IO) frozen section (FS). We aimed to implement and validate a digital system for the FS evaluation of cancer and transplant specimens following recommendations of the College of American Pathologists. Materials and Methods FS cases were routinely scanned at ×20 employing the "Navigo" scanner system. IO diagnoses using glass versus digital slides after a 3-week washout period were recorded. Intraobserver concordance was evaluated using accuracy rate and kappa statistics. Feasibility of WSI diagnoses was assessed by the way of sensitivity, specificity, as well as positive and negative predictive values. Participants also completed a survey denoting scan time, time spent viewing cases, preference for glass versus WSI, image quality, interface experience, and any problems encountered. Results Of the 125 cases submitted, 121 (436 slides) were successfully scanned including 93 oncological and 28 donor-organ FS biopsies. Four cases were excluded because of failed digitalization due to scanning problems or sample preparation artifacts. Full agreement between glass and digital-slide diagnosis was obtained in 90 of 93 (97%, κ = 0.96) oncology and in 24 of 28 (86%, κ = 0.91) transplant cases. There were two major and one minor discrepancy for cancer cases (sensitivity 100%, specificity 96%) and two major and two minor disagreements for transplant cases (sensitivity 96%, specificity 75%). Average scan and viewing/reporting time were 12 and 3 min for cancer cases, compared to 18 and 5 min for transplant cases. A high diagnostic comfort level among pathologists emerged from the survey. Conclusions These data demonstrate that the "Navigo" digital WSI system can reliably support an IO FS service involving complicated cancer and transplant cases.
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Affiliation(s)
- Luca Cima
- Department of Diagnostics and Public Health, Anatomic Pathology Unit, University and Hospital Trust of Verona, Verona, Italy
| | - Matteo Brunelli
- Department of Diagnostics and Public Health, Anatomic Pathology Unit, University and Hospital Trust of Verona, Verona, Italy
| | - Anil Parwani
- Department of Pathology, Ohio State University, Columbus, OH, USA
| | - Ilaria Girolami
- Department of Diagnostics and Public Health, Anatomic Pathology Unit, University and Hospital Trust of Verona, Verona, Italy
| | - Andrea Ciangherotti
- Department of Surgical Science, University and Hospital Trust of Verona, Verona, Italy
| | - Giulio Riva
- Department of Diagnostics and Public Health, Anatomic Pathology Unit, University and Hospital Trust of Verona, Verona, Italy
| | - Luca Novelli
- Department of Pathology, Anatomic Pathology Unit, Careggi University Hospital, Firenze, Italy
| | - Francesca Vanzo
- Veneto's Research Center for eHealth Innovation, Veneto, Italy
| | - Alessandro Sorio
- Department of Diagnostics and Public Health, Anatomic Pathology Unit, University and Hospital Trust of Verona, Verona, Italy
| | - Vito Cirielli
- Department of Diagnostics and Public Health, Forensic Pathology Unit, University and Hospital Trust of Verona, Verona, Italy
| | - Mattia Barbareschi
- Department of Laboratory Medicine, Anatomic Pathology Unit, S. Chiara Hospital, Trento, Italy
| | - Antonietta D'Errico
- Department of Specialised, Experimental and Diagnostic Medicine, Anatomic Pathology Unit, S. Orsola-Malpighi University Hospital of Bologna, Bologna, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Anatomic Pathology Unit, University and Hospital Trust of Verona, Verona, Italy
| | - Chiara Bovo
- Medical Direction, University and Hospital Trust of Verona, Verona, Italy
| | - Filippo Fraggetta
- Department of Pathology, Anatomic Pathology Unit, Cannizzaro Hospital, Catania, Italy
| | - Liron Pantanowitz
- Department of Pathology, University of Pittsburgh Medical Center, PA, Pennsylvania, USA
| | - Albino Eccher
- Department of Diagnostics and Public Health, Anatomic Pathology Unit, University and Hospital Trust of Verona, Verona, Italy
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18
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Tollemar V, Tudzarovski N, Boberg E, Törnqvist Andrén A, Al-Adili A, Le Blanc K, Garming Legert K, Bottai M, Warfvinge G, Sugars R. Quantitative chromogenic immunohistochemical image analysis in cellprofiler software. Cytometry A 2018; 93:1051-1059. [DOI: 10.1002/cyto.a.23575] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 07/14/2018] [Accepted: 07/16/2018] [Indexed: 02/06/2023]
Affiliation(s)
- V. Tollemar
- Division of Oral Diagnostics and Rehabilitation, Department of Dental Medicine; Karolinska Institutet; Huddinge Sweden
| | - N. Tudzarovski
- Division of Oral Diagnostics and Rehabilitation, Department of Dental Medicine; Karolinska Institutet; Huddinge Sweden
| | - E. Boberg
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine; Karolinska Institutet; Stockholm Sweden
| | - A. Törnqvist Andrén
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine; Karolinska Institutet; Stockholm Sweden
| | - A. Al-Adili
- Department of Oral and Maxillofacial Surgery; Karolinska University Hospital; Stockholm Sweden
| | - K. Le Blanc
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine; Karolinska Institutet; Stockholm Sweden
| | - K. Garming Legert
- Division of Oral Diagnostics and Rehabilitation, Department of Dental Medicine; Karolinska Institutet; Huddinge Sweden
| | - M. Bottai
- Unit of Biostatistics, Institute of Environmental Medicine; Karolinska Institutet; Stockholm Sweden
| | - G. Warfvinge
- Department of Oral Pathology, Faculty of Odontology; Malmö University; Malmö Sweden
| | - R.V. Sugars
- Division of Oral Diagnostics and Rehabilitation, Department of Dental Medicine; Karolinska Institutet; Huddinge Sweden
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19
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Siegel G, Regelman D, Maronpot R, Rosenstock M, Nyska A. New Technologies: Real-time Telepathology Systems-Novel Cost-effective Tools for Real-time Consultation and Data Sharing. Toxicol Pathol 2018; 45:1039-1042. [PMID: 29233077 DOI: 10.1177/0192623317743722] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Real-time telepathology for use in investigative and regulated preclinical toxicology studies is now feasible. Newly developed microscope-integrated telepathology systems enable geographically remote stakeholders to view the live histopathology slide as seen by the study pathologist within the microscope. Simultaneous online viewing and dialog between study pathologist and remote colleagues is an efficient and cost-effective means for consultation, pathology working groups, and peer review, facilitating good science and economic benefits by enabling more timely and informed clinical decisions.
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Affiliation(s)
| | | | | | - Moti Rosenstock
- 3 Department of Non-clinical Safety, Teva Pharmaceuticals Ltd., Netanya, Israel
| | - Abraham Nyska
- 4 Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,5 Toxicologic Pathology, Timrat, Israel
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20
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Hart SN. Will Digital Pathology be as Disruptive as Genomics? J Pathol Inform 2018; 9:27. [PMID: 30167342 PMCID: PMC6106127 DOI: 10.4103/jpi.jpi_25_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/20/2018] [Indexed: 11/23/2022] Open
Abstract
Digital pathology is the science of performing traditional pathological assessment in a digital environment. A digital transition is long overdue since histochemical analysis such as hematoxylin and eosin staining has remained unchanged in over 100 years. Importantly, the digitization of whole slide images further lends itself to advances in computational pathology and artificial intelligence to transform qualitative assessment into quantitative assessment. The impact of this transition from a computational infrastructure perspective is reminiscent of a similar transition in the field of genomics. In this article, I describe some of the similarities between genomics and digital pathology as well as highlight some key lessons learned to prevent the same mistakes and delays that slowed the genomics revolution.
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Affiliation(s)
- Steven N Hart
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
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21
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Siegel G, Regelman D, Maronpot R, Rosenstock M, Hayashi SM, Nyska A. Utilizing novel telepathology system in preclinical studies and peer review. J Toxicol Pathol 2018; 31:315-319. [PMID: 30393436 PMCID: PMC6206289 DOI: 10.1293/tox.2018-0032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 06/20/2018] [Indexed: 11/26/2022] Open
Abstract
The demand for board certified toxicologic pathologists and expansion of IT capabilities
has resulted in an increase of “virtual” and “distance” pathology (telepathology), and a
need for greater flexibility in real time consultations. Newly developed
microscope-integrated telepathology systems enable geographically remote stakeholders to
view the live histopathology slide as seen by the microscope user. Simultaneous online
viewing, annotation, and dialog between pathologists and study experts facilitates good
science and economic benefits by enabling more timely and informed clinical decisions.
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Affiliation(s)
- Gabriel Siegel
- Augmentiqs, LIAD building, P.O. Box 10, Techelet Street, Teradion Business Park - D.N. Misgav 2017400, Israel
| | - Dan Regelman
- Augmentiqs, LIAD building, P.O. Box 10, Techelet Street, Teradion Business Park - D.N. Misgav 2017400, Israel
| | - Robert Maronpot
- Maronpot Consulting, LLC, 1612 Medfield Road, Raleigh, North Carolina 27607, USA
| | - Moti Rosenstock
- LEA, Nonclinical Safety Consultancy, Talmei Elazar, 38812, Israel
| | - Shim-Mo Hayashi
- Global Scientific and Regulatory Affairs, San-Ei Gen, F.F.I., Inc., 1-1-11 Sanwa-cho, Toyonaka, Osaka 561-8588, Japan
| | - Abraham Nyska
- Sackler School of Medicine, Tel Aviv University, P.O. Box 39040, Tel Aviv 6997801, Israel.,Toxicologic Pathology, Haharuv 18, P.O. Box 184, Timrat 36576, Israel
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22
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Capitanio A, Dina RE, Treanor D. Digital cytology: A short review of technical and methodological approaches and applications. Cytopathology 2018; 29:317-325. [PMID: 29665178 DOI: 10.1111/cyt.12554] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2018] [Indexed: 12/13/2022]
Abstract
The recent years have been characterised by a rapid development of whole slide imaging (WSI) especially in its applications to histology. The application of WSI technology to cytology is less common because of technological problems related to the three-dimensional nature of cytology preparations (which requires capturing of z-stack information, with an increase in file size and usability issues in viewing cytological preparations). The aim of this study is to provide a review of the literature on the use of digital cytology and provide an overview of cytological applications of WSI in current practice as well as identifying areas for future development.
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Affiliation(s)
- A Capitanio
- Department of Pathology, Linköping University Hospital, Linköping, Sweden
| | - R E Dina
- Department of Histopathology, Imperial College NHS Trust, NorthWest London Pathology Consortium, Hammersmith Hospital, London, UK
| | - D Treanor
- Department of Histopathology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Linköping University, Linköping, Sweden
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23
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Roxanis I, Colling R, Kartsonaki C, Green AR, Rakha EA. The significance of tumour microarchitectural features in breast cancer prognosis: a digital image analysis. Breast Cancer Res 2018; 20:11. [PMID: 29402299 PMCID: PMC5799893 DOI: 10.1186/s13058-018-0934-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 01/10/2018] [Indexed: 12/02/2022] Open
Abstract
Background As only a minor portion of the information present in histological sections is accessible by eye, recognition and quantification of complex patterns and relationships among constituents relies on digital image analysis. In this study, our working hypothesis was that, with the application of digital image analysis technology, visually unquantifiable breast cancer microarchitectural features can be rigorously assessed and tested as prognostic parameters for invasive breast carcinoma of no special type. Methods Digital image analysis was performed using public domain software (ImageJ) on tissue microarrays from a cohort of 696 patients, and validated with a commercial platform (Visiopharm). Quantified features included elements defining tumour microarchitecture, with emphasis on the extent of tumour-stroma interface. The differential prognostic impact of tumour nest microarchitecture in the four immunohistochemical surrogates for molecular classification was analysed. Prognostic parameters included axillary lymph node status, breast cancer-specific survival, and time to distant metastasis. Associations of each feature with prognostic parameters were assessed using logistic regression and Cox proportional models adjusting for age at diagnosis, grade, and tumour size. Results An arrangement in numerous small nests was associated with axillary lymph node involvement. The association was stronger in luminal tumours (odds ratio (OR) = 1.39, p = 0.003 for a 1-SD increase in nest number, OR = 0.75, p = 0.006 for mean nest area). Nest number was also associated with survival (hazard ratio (HR) = 1.15, p = 0.027), but total nest perimeter was the parameter most significantly associated with survival in luminal tumours (HR = 1.26, p = 0.005). In the relatively small cohort of triple-negative tumours, mean circularity showed association with time to distant metastasis (HR = 1.71, p = 0.027) and survival (HR = 1.8, p = 0.02). Conclusions We propose that tumour arrangement in few large nests indicates a decreased metastatic potential. By contrast, organisation in numerous small nests provides the tumour with increased metastatic potential to regional lymph nodes. An outstretched pattern in small nests bestows tumours with a tendency for decreased breast cancer-specific survival. Although further validation studies are required before the argument for routine quantification of microarchitectural features is established, our approach is consistent with the demand for cost-effective methods for triaging breast cancer patients that are more likely to benefit from chemotherapy.
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Affiliation(s)
- I Roxanis
- Department of Cellular Pathology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford, OX3 9DU, UK. .,Present Address: Institute of Cancer Research, London and Royal Free London NHS Foundation Trust, London, UK.
| | - R Colling
- Department of Cellular Pathology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford, OX3 9DU, UK
| | - C Kartsonaki
- Nuffield Department of Population Health, University of Oxford, Big Data Institute Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF, UK
| | - A R Green
- Academic Pathology, Division of Cancer and Stem Cells, The University of Nottingham, Room 2-052-S Academic Unit of Oncology, Nottingham City Hospital, Nottingham, NG5 1PB, UK
| | - E A Rakha
- Department of Cellular Pathology, University of Nottingham and Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, NG5 1PB, UK
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24
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Bongaerts O, Clevers C, Debets M, Paffen D, Senden L, Rijks K, Ruiten L, Sie-Go D, van Diest PJ, Nap M. Conventional Microscopical versus Digital Whole-Slide Imaging-Based Diagnosis of Thin-Layer Cervical Specimens: A Validation Study. J Pathol Inform 2018; 9:29. [PMID: 30197818 PMCID: PMC6120269 DOI: 10.4103/jpi.jpi_28_18] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 06/29/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Whole-slide imaging (WSI) has been implemented in many areas of pathology, but primary diagnostics of cytological specimens are lagging behind. One of the objectives of viewing scanned whole-slide images from histological or cytological specimens is remote exchange of knowledge and expertise of professionals to increase diagnostic accuracy. We compared the scoring results of our team obtained in double readings of two different data sets: conventional light microscopy (CLM) versus CLM and CLM versus WSI. We hypothesized that WSI is noninferior to CLM for primary diagnostics of thin-layer cervical slides. MATERIALS AND METHODS First, we determined the concordance rate at different thresholds of the participating cytotechnicians by double reading with CLM of 500 thin-layer cervical slides (Cohort 1). Next, CLM was compared with WSI examination of another 505 thin-layer cervical slides (Cohort 2) scanned at ×20 in single focus plane. Finally, all major discordant cases of Cohort 1 were evaluated by an external expert in the field of gynecological cytology and of Cohort 2 in the weekly case meetings. RESULTS The overall concordance rate of Cohort 1 (CLM vs. CLM) was 97.8% (95% confidence interval [CI]: 96.0%-98.7%) and of Cohort 2 was 95.3% (95% CI: 93.0%-96.9%). CONCLUSION Concordance rates of WSI versus CLM were comparable with those of CLM versus CLM. We have made a step forward paving the road to implementation of WSI also in routine diagnostic cytology.
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Affiliation(s)
- Odille Bongaerts
- Department of Pathology, Zuyderland Hospital, Heerlen, The Netherlands
- Address for correspondence: Mrs. Odille Bongaerts, Department of Pathology, Zuyderland Hospital, PO Box 6446, 6401 CX Heerlen, The Netherlands. E-mail:
| | - Carla Clevers
- Department of Pathology, Zuyderland Hospital, Heerlen, The Netherlands
| | - Marij Debets
- Department of Pathology, Zuyderland Hospital, Heerlen, The Netherlands
| | - Daniëlle Paffen
- Department of Pathology, Zuyderland Hospital, Heerlen, The Netherlands
| | - Lisanne Senden
- Department of Pathology, Zuyderland Hospital, Heerlen, The Netherlands
| | - Kim Rijks
- Department of Pathology, Zuyderland Hospital, Heerlen, The Netherlands
| | - Linda Ruiten
- Department of Pathology, Zuyderland Hospital, Heerlen, The Netherlands
| | - Daisy Sie-Go
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Paul J van Diest
- Department of Pathology, Zuyderland Hospital, Heerlen, The Netherlands
- Department of Oncology, Johns Hopkins Oncology Center, Baltimore, MD, USA
| | - Marius Nap
- Nap Pathology Consultance bv, Numansdorp, The Netherlands
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25
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Farrell JM, Riben MW, Staerkel GA, Huang ML, Dawlett M, Caraway NP. Efficacy of telecytopathology for preliminary assessment of fine-needle aspirations performed at a remote facility. J Am Soc Cytopathol 2018; 7:22-30. [PMID: 31043247 DOI: 10.1016/j.jasc.2017.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 09/26/2017] [Accepted: 10/03/2017] [Indexed: 06/09/2023]
Abstract
INTRODUCTION The need for real time anatomic pathology services has grown as healthcare systems, traditionally found at large medical centers, expand into smaller communities. The placement of a pathologist is not cost-, time-, or resource-efficient. Telecytopathology can provide rapid offsite evaluation of cytology tissues. This study evaluated the accuracy rate of rendered preliminary assessments for telecytopathology of ultrasound (US)-guided fine-needle aspirations (FNAs) for an offsite facility by comparing preliminary assessment results with the final diagnosis. MATERIALS AND METHODS The pathology database was searched for telecytopathology US-guided FNAs with rapid offsite evaluation performed at a regional care center from August 2014 to June 2016. A total of 674 consecutive US-guided FNAs from 444 patients were obtained. FNA sites included lymph node (345 cases), breast (178 cases), thyroid gland (71 cases), and others (80 cases). RESULTS Preliminary assessments of the 674 FNAs were adequate/benign in 275 (41%) cases, adequate/malignant in 182 (27%) cases, adequate/further review needed in 162 (24%) cases, indeterminate/borderline cellularity in 37 (5%) cases, and nondiagnostic in 18 (3%) cases. Final FNA diagnoses rendered included 391 (58%) negative for malignancy, 205 (30%) malignant, 34 (5%) atypical/suspicious for malignancy, 26 (4%) indeterminate cellularity-favor benign, and 18 (3%) nondiagnostic specimens. Concurrent core biopsy was performed in 42 cases and 83 cases were triaged for ancillary studies. The majority (99%) of US-guided FNAs demonstrated concordant preliminary assessments with the final diagnoses. A major discrepancy occurred in 1 case; 5 cases had minor discrepancies. CONCLUSIONS Remote facility telecytopathology can be utilized as an accurate modality in guiding appropriate tissue acquisition and final diagnosis.
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Affiliation(s)
- Jessica M Farrell
- Section of Cytopathology, Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael W Riben
- Section of Cytopathology, Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gregg A Staerkel
- Section of Cytopathology, Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Monica L Huang
- Department of Diagnostic Radiology-Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marilyn Dawlett
- Section of Cytopathology, Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nancy P Caraway
- Section of Cytopathology, Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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26
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Whole Slide Imaging Versus Microscopy for Primary Diagnosis in Surgical Pathology: A Multicenter Blinded Randomized Noninferiority Study of 1992 Cases (Pivotal Study). Am J Surg Pathol 2017; 42:39-52. [PMID: 28961557 PMCID: PMC5737464 DOI: 10.1097/pas.0000000000000948] [Citation(s) in RCA: 228] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Most prior studies of primary diagnosis in surgical pathology using whole slide imaging (WSI) versus microscopy have focused on specific organ systems or included relatively few cases. The objective of this study was to demonstrate that WSI is noninferior to microscopy for primary diagnosis in surgical pathology. A blinded randomized noninferiority study was conducted across the entire range of surgical pathology cases (biopsies and resections, including hematoxylin and eosin, immunohistochemistry, and special stains) from 4 institutions using the original sign-out diagnosis (baseline diagnosis) as the reference standard. Cases were scanned, converted to WSI and randomized. Sixteen pathologists interpreted cases by microscopy or WSI, followed by a wash-out period of ≥4 weeks, after which cases were read by the same observers using the other modality. Major discordances were identified by an adjudication panel, and the differences between major discordance rates for both microscopy (against the reference standard) and WSI (against the reference standard) were calculated. A total of 1992 cases were included, resulting in 15,925 reads. The major discordance rate with the reference standard diagnosis was 4.9% for WSI and 4.6% for microscopy. The difference between major discordance rates for microscopy and WSI was 0.4% (95% confidence interval, -0.30% to 1.01%). The difference in major discordance rates for WSI and microscopy was highest in endocrine pathology (1.8%), neoplastic kidney pathology (1.5%), urinary bladder pathology (1.3%), and gynecologic pathology (1.2%). Detailed analysis of these cases revealed no instances where interpretation by WSI was consistently inaccurate compared with microscopy for multiple observers. We conclude that WSI is noninferior to microscopy for primary diagnosis in surgical pathology, including biopsies and resections stained with hematoxylin and eosin, immunohistochemistry and special stains. This conclusion is valid across a wide variety of organ systems and specimen types.
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Evans AJ, Salama ME, Henricks WH, Pantanowitz L. Implementation of Whole Slide Imaging for Clinical Purposes: Issues to Consider From the Perspective of Early Adopters. Arch Pathol Lab Med 2017; 141:944-959. [PMID: 28440660 DOI: 10.5858/arpa.2016-0074-oa] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT - There is growing interest in the use of digital pathology, especially whole slide imaging, for diagnostic purposes. Many issues need to be considered when incorporating this technology into a clinical laboratory. The College of American Pathologists (CAP) established a Digital Pathology Committee to support the development of CAP programs related to digital pathology. One of its many initiatives was a panel discussion entitled "Implementing Whole-Slide Imaging for Clinical Use: What to Do and What to Avoid," given for 3 years at the CAP annual meetings starting in 2014. OBJECTIVES - To review major issues to consider when implementing whole slide imaging for clinical purposes as covered during the panel discussion. DESIGN - The views expressed and recommendations given are based primarily on the personal experience of the authors as early adopters of this technology. It is not intended to be an exhaustive review of digital pathology. RESULTS - Implementation is best approached in phases. Early efforts are directed toward identifying initial clinical applications and assembling an implementation team. Scanner selection should be based on intended use and budget. Recognizing pathologist concerns over the use of digital pathology for diagnostic purposes, ensuring adequate training, and performing appropriate validation studies will enhance adoption. Once implemented, the transition period from glass slide to image-based diagnostics will be associated with challenges, especially those related to a hybrid glass slide-digital slide workflow. CONCLUSIONS - With appropriate preparation, planning, and stepwise implementation, whole slide imaging can be used safely and reliably for frozen sections, consultation, quality assurance, and primary diagnosis.
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Affiliation(s)
| | | | | | - Liron Pantanowitz
- From the Department of Pathology, University Health Network, Toronto, Ontario, Canada (Dr Evans); the Department of Pathology, University of Utah and ARUP Laboratories, Reference Laboratory, Salt Lake City (Dr Salama); the Department of Pathology, Cleveland Clinic Foundation, Cleveland, Ohio (Dr Henricks); and the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Pantanowitz)
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28
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Kraft AO. Specimen acquisition: ROSEs, gardeners, and gatekeepers. Cancer Cytopathol 2017; 125:449-454. [DOI: 10.1002/cncy.21870] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 03/16/2017] [Accepted: 03/21/2017] [Indexed: 12/16/2022]
Affiliation(s)
- Adele O. Kraft
- Department of Pathology; Virginia Commonwealth University; Richmond Virginia
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Williams BJ, DaCosta P, Goacher E, Treanor D. A Systematic Analysis of Discordant Diagnoses in Digital Pathology Compared With Light Microscopy. Arch Pathol Lab Med 2017; 141:1712-1718. [PMID: 28467215 DOI: 10.5858/arpa.2016-0494-oa] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT - Relatively little is known about the significance and potential impact of glass-digital discordances, and this is likely to be of importance when considering digital pathology adoption. OBJECTIVE - To apply evidence-based medicine to collect and analyze reported instances of glass-digital discordance from the whole slide imaging validation literature. DESIGN - We used our prior systematic review protocol to identify studies assessing the concordance of light microscopy and whole slide imaging between 1999 and 2015. Data were extracted and analyzed by a team of histopathologists to classify the type, significance, and potential root cause of discordances. RESULTS - Twenty-three studies were included, yielding 8069 instances of a glass diagnosis being compared with a digital diagnosis. From these 8069 comparisons, 335 instances of discordance (4%) were reported, in which glass was the preferred diagnostic medium in 286 (85%), and digital in 44 (13%), with no consensus in 5 (2%). Twenty-eight discordances had the potential to cause moderate/severe patient harm. Of these, glass was the preferred diagnostic medium for 26 (93%). Of the 335 discordances, 109 (32%) involved the diagnosis or grading of dysplasia. For these cases, glass was the preferred diagnostic medium in 101 cases (93%), suggesting that diagnosis and grading of dysplasia may be a potential pitfall of digital diagnosis. In 32 of 335 cases (10%), discordance on digital was attributed to the inability to find a small diagnostic/prognostic object. CONCLUSIONS - Systematic analysis of concordance studies reveals specific areas that may be problematic on whole slide imaging. It is important that pathologists are aware of these areas to ensure patient safety.
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30
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Cheng CL, Tan PH. Digital pathology in the diagnostic setting: beyond technology into best practice and service management. J Clin Pathol 2017; 70:454-457. [PMID: 28062660 DOI: 10.1136/jclinpath-2016-204272] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 12/10/2016] [Indexed: 11/04/2022]
Abstract
Digital pathology (DP) and whole-slide imaging (WSI) technology have matured substantially over the last few years and there is growing evidence from validation studies that WSI is comparable to glass slides for histopathology diagnosis, although with some limitations, which can be appropriately minimised. Whether the controlled environment of validation studies translates to the same level of robustness when WSI is used in the actual diagnostic setting depends on the technical quality of WSI acquisition and on factors that influence the pre-image acquisition variables including the quality of glass slide inputs, and postimage acquisition variables such as access and use of WSI. The concept of 'DP service management' is introduced to fulfil the holistic needs of a laboratory intending to use the DP solution incorporating WSI for diagnostic purposes. The DP service management team should be an integral part of the diagnostic laboratory as it plays a central role undertaking responsibility to address an extensive range of issues from technical and training to governance and accreditation, hence ensuring a viable and sustainable diagnostic DP integration and usage. The pathologist as a specialist in the field and key decision maker of histopathology diagnoses has the duty and responsibility to acquaint and familiarise with DP and WSI when using the technology, especially on their indications and limitations, so as to take full advantage of these tools to enhance diagnostic quality.
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Affiliation(s)
- Chee Leong Cheng
- Division of Pathology, Department of Anatomical Pathology, Singapore General Hospital, Singapore, Republic of Singapore
| | - Puay Hoon Tan
- Division of Pathology, Singapore General Hospital, Singapore, Republic of Singapore
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31
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Griffin J, Treanor D. Digital pathology in clinical use: where are we now and what is holding us back? Histopathology 2016; 70:134-145. [DOI: 10.1111/his.12993] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Jon Griffin
- Sheffield NHS Foundation Trust; Sheffield UK
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32
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Goacher E, Randell R, Williams B, Treanor D. The Diagnostic Concordance of Whole Slide Imaging and Light Microscopy: A Systematic Review. Arch Pathol Lab Med 2016; 141:151-161. [PMID: 27399211 DOI: 10.5858/arpa.2016-0025-ra] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT -Light microscopy (LM) is considered the reference standard for diagnosis in pathology. Whole slide imaging (WSI) generates digital images of cellular and tissue samples and offers multiple advantages compared with LM. Currently, WSI is not widely used for primary diagnosis. The lack of evidence regarding concordance between diagnoses rendered by WSI and LM is a significant barrier to both regulatory approval and uptake. OBJECTIVE -To examine the published literature on the concordance of pathologic diagnoses rendered by WSI compared with those rendered by LM. DATA SOURCES -We conducted a systematic review of studies assessing the concordance of pathologic diagnoses rendered by WSI and LM. Studies were identified following a systematic search of Medline (Medline Industries, Mundelein, Illinois), Medline in progress (Medline Industries), EMBASE (Elsevier, Amsterdam, the Netherlands), and the Cochrane Library (Wiley, London, England), between 1999 and March 2015. CONCLUSIONS -Thirty-eight studies were included in the review. The mean diagnostic concordance of WSI and LM, weighted by the number of cases per study, was 92.4%. The weighted mean κ coefficient between WSI and LM was 0.75, signifying substantial agreement. Of the 30 studies quoting percentage concordance, 18 (60%) showed a concordance of 90% or greater, of which 10 (33%) showed a concordance of 95% or greater. This review found evidence to support a high level of diagnostic concordance. However, there were few studies, many were small, and they varied in quality, suggesting that further validation studies are still needed.
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Affiliation(s)
| | | | | | - Darren Treanor
- From the Faculty of Medicine and Health (Mr Goacher and Dr Treanor) and the School of Healthcare (Dr Randell), University of Leeds, Leeds, West Yorkshire, England; and the Department of Histopathology, Leeds Teaching Hospitals, National Health Service Trust, Leeds (Ms Williams and Dr Treanor)
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33
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Pekmezci M, Uysal SP, Orhan Y, Tihan T, Lee HS. Pitfalls in the use of whole slide imaging for the diagnosis of central nervous system tumors: A pilot study in surgical neuropathology. J Pathol Inform 2016; 7:25. [PMID: 27217975 PMCID: PMC4872474 DOI: 10.4103/2153-3539.181769] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 04/12/2016] [Indexed: 01/28/2023] Open
Abstract
Background: Whole slide imaging (WSI) finds increasingly higher value in everyday surgical pathology in addition to its well-established use for educational and research purposes. However, its diagnostic utility, especially in subspecialty settings such as neuropathology, is not fully validated. Neuropathology practice is unique with smaller overall tissue size and frequent need for high-power evaluation. In addition, tumor grade is an integral part of the initial diagnosis. The purpose of this study is to assess the feasibility of primary pathology diagnosis of surgical neuropathology specimens using WSI. Materials and Methods: We reviewed consecutive surgical neuropathology cases diagnosed in our institution during a 2-month period and identified a single diagnostic slide, which was scanned at 40× magnification. Two neuropathologists who were blinded to the original diagnoses reviewed the whole slide image and rendered a diagnosis including tumor grade when applicable. They reviewed the single diagnostic slide after a wash-out period. Intra- and inter-observer discrepancies, as well as reasons for discrepancies, were evaluated. Results: The concordance rates were 94.9% and 88% for two neuropathologists. Two critical issues leading to discrepancies were identified: (1) identification of mitoses and (2) recognition of nuclear details. Conclusions: Given the current study is exclusively for surgical neuropathology cases, an all-encompassing conclusion about the utility of WSI for diagnostic purposes may not be available. Nevertheless, pathologists should be aware of the potential pitfalls due to identification of mitotic figures and nuclear details. We recommend independent validation for each subspecialty of pathology to identify subspecialty-specific concerns, so they can be properly addressed.
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Affiliation(s)
- Melike Pekmezci
- Department of Pathology, Division of Neuropathology, University of California, San Francisco, CA, USA
| | | | - Yelda Orhan
- School of Medicine, Koc University, Istanbul, Turkey
| | - Tarik Tihan
- Department of Pathology, Division of Neuropathology, University of California, San Francisco, CA, USA
| | - Han Sung Lee
- Department of Pathology, Division of Neuropathology, University of California, San Francisco, CA, USA
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García-Rojo M. International Clinical Guidelines for the Adoption of Digital Pathology: A Review of Technical Aspects. Pathobiology 2016; 83:99-109. [PMID: 27100834 DOI: 10.1159/000441192] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Digital slides, also called whole-slide images, are being evaluated to replace conventional microscopy, and several guidelines have been published. This paper reviews technical specifications of digital pathology systems that have been included in the guidelines and position papers from the Canadian Association of Pathologists, the College of American Pathologists, the American Telemedicine Association, the Digital Pathology Association, the Food and Drug Administration, the Centers for Medicare and Medicaid Services, the Centers for Disease Control and Prevention, the Society of Toxicologic Pathology, the European Commission, the Spanish Society of Anatomic Pathology, The Royal College of Pathologists and The Royal College of Pathologists of Australasia. In conclusion, most technical aspects are well covered by these guidelines, although they offer limited information regarding image quality and compression, and file formats.
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35
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Mirham L, Naugler C, Hayes M, Ismiil N, Belisle A, Sade S, Streutker C, MacMillan C, Rasty G, Popovic S, Joseph M, Gabril M, Barnes P, Hegele RG, Carter B, Yousef GM. Performance of residents using digital images versus glass slides on certification examination in anatomical pathology: a mixed methods pilot study. CMAJ Open 2016; 4:E88-94. [PMID: 27280119 PMCID: PMC4866926 DOI: 10.9778/cmajo.20140075] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND It is anticipated that many licensing examination centres for pathology will begin fully digitizing the certification examinations. The objective of our study was to test the feasibility of a fully digital examination and to assess the needs, concerns and expectations of pathology residents in moving from a glass slide-based examination to a fully digital examination. METHODS We conducted a mixed methods study that compared, after randomization, the performance of senior residents (postgraduate years 4 and 5) in 7 accredited anatomical pathology training programs across Canada on a pathology examination using either glass slides or digital whole-slide scanned images of the slides. The pilot examination was followed by a post-test survey. In addition, pathology residents from all levels of training were invited to participate in an online survey. RESULTS A total of 100 residents participated in the pilot examination; 49 were given glass slides instead of digital images. We found no significant difference in examination results between the 2 groups of residents (estimated marginal mean 8.23/12, 95% confidence interval [CI] 7.72-8.87, for glass slides; 7.84/12, 95% CI 7.28-8.41, for digital slides). In the post-test survey, most of the respondents expressed concerns with the digital examination, including slowly functioning software, blurring and poor detail of images, particularly nuclear features. All of the respondents of the general survey (n = 179) agreed that additional training was required if the examination were to become fully digital. INTERPRETATION Although the performance of residents completing pathology examinations with glass slides was comparable to that of residents using digital images, our study showed that residents were not comfortable with the digital technology, especially given their current level of exposure to it. Additional training may be needed before implementing a fully digital examination, with consideration for a gradual transition.
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Affiliation(s)
- Lorna Mirham
- Department of Laboratory Medicine and Pathobiology (Mirham, Ismiil, Sade, Streutker, MacMillan, Rasty, Hegele, Yousef), University of Toronto, Toronto, Ont.; Department of Pathology and Laboratory Medicine (Naugler), University of Calgary, Calgary, Alta.; Department of Pathology and Laboratory Medicine (Hayes), University of British Columbia, Vancouver, BC; Department of Pathology and Cellular Biology (Belisle), Université de Montréal, Montréal, Que.; Department of Pathology and Molecular Medicine (Popovic), McMaster University, Hamilton, Ont.; Department of Pathology (Joseph, Gabril), Western University, London, Ont.; Department of Pathology and Laboratory Medicine (Barnes), Dalhousie University, Halifax, NS; Department of Pathology (Carter), Memorial University of Newfoundland, St. John's, NL; Department of Laboratory Medicine (Yousef), St. Michael's Hospital, Toronto, Ont
| | - Christopher Naugler
- Department of Laboratory Medicine and Pathobiology (Mirham, Ismiil, Sade, Streutker, MacMillan, Rasty, Hegele, Yousef), University of Toronto, Toronto, Ont.; Department of Pathology and Laboratory Medicine (Naugler), University of Calgary, Calgary, Alta.; Department of Pathology and Laboratory Medicine (Hayes), University of British Columbia, Vancouver, BC; Department of Pathology and Cellular Biology (Belisle), Université de Montréal, Montréal, Que.; Department of Pathology and Molecular Medicine (Popovic), McMaster University, Hamilton, Ont.; Department of Pathology (Joseph, Gabril), Western University, London, Ont.; Department of Pathology and Laboratory Medicine (Barnes), Dalhousie University, Halifax, NS; Department of Pathology (Carter), Memorial University of Newfoundland, St. John's, NL; Department of Laboratory Medicine (Yousef), St. Michael's Hospital, Toronto, Ont
| | - Malcolm Hayes
- Department of Laboratory Medicine and Pathobiology (Mirham, Ismiil, Sade, Streutker, MacMillan, Rasty, Hegele, Yousef), University of Toronto, Toronto, Ont.; Department of Pathology and Laboratory Medicine (Naugler), University of Calgary, Calgary, Alta.; Department of Pathology and Laboratory Medicine (Hayes), University of British Columbia, Vancouver, BC; Department of Pathology and Cellular Biology (Belisle), Université de Montréal, Montréal, Que.; Department of Pathology and Molecular Medicine (Popovic), McMaster University, Hamilton, Ont.; Department of Pathology (Joseph, Gabril), Western University, London, Ont.; Department of Pathology and Laboratory Medicine (Barnes), Dalhousie University, Halifax, NS; Department of Pathology (Carter), Memorial University of Newfoundland, St. John's, NL; Department of Laboratory Medicine (Yousef), St. Michael's Hospital, Toronto, Ont
| | - Nadia Ismiil
- Department of Laboratory Medicine and Pathobiology (Mirham, Ismiil, Sade, Streutker, MacMillan, Rasty, Hegele, Yousef), University of Toronto, Toronto, Ont.; Department of Pathology and Laboratory Medicine (Naugler), University of Calgary, Calgary, Alta.; Department of Pathology and Laboratory Medicine (Hayes), University of British Columbia, Vancouver, BC; Department of Pathology and Cellular Biology (Belisle), Université de Montréal, Montréal, Que.; Department of Pathology and Molecular Medicine (Popovic), McMaster University, Hamilton, Ont.; Department of Pathology (Joseph, Gabril), Western University, London, Ont.; Department of Pathology and Laboratory Medicine (Barnes), Dalhousie University, Halifax, NS; Department of Pathology (Carter), Memorial University of Newfoundland, St. John's, NL; Department of Laboratory Medicine (Yousef), St. Michael's Hospital, Toronto, Ont
| | - Annie Belisle
- Department of Laboratory Medicine and Pathobiology (Mirham, Ismiil, Sade, Streutker, MacMillan, Rasty, Hegele, Yousef), University of Toronto, Toronto, Ont.; Department of Pathology and Laboratory Medicine (Naugler), University of Calgary, Calgary, Alta.; Department of Pathology and Laboratory Medicine (Hayes), University of British Columbia, Vancouver, BC; Department of Pathology and Cellular Biology (Belisle), Université de Montréal, Montréal, Que.; Department of Pathology and Molecular Medicine (Popovic), McMaster University, Hamilton, Ont.; Department of Pathology (Joseph, Gabril), Western University, London, Ont.; Department of Pathology and Laboratory Medicine (Barnes), Dalhousie University, Halifax, NS; Department of Pathology (Carter), Memorial University of Newfoundland, St. John's, NL; Department of Laboratory Medicine (Yousef), St. Michael's Hospital, Toronto, Ont
| | - Shachar Sade
- Department of Laboratory Medicine and Pathobiology (Mirham, Ismiil, Sade, Streutker, MacMillan, Rasty, Hegele, Yousef), University of Toronto, Toronto, Ont.; Department of Pathology and Laboratory Medicine (Naugler), University of Calgary, Calgary, Alta.; Department of Pathology and Laboratory Medicine (Hayes), University of British Columbia, Vancouver, BC; Department of Pathology and Cellular Biology (Belisle), Université de Montréal, Montréal, Que.; Department of Pathology and Molecular Medicine (Popovic), McMaster University, Hamilton, Ont.; Department of Pathology (Joseph, Gabril), Western University, London, Ont.; Department of Pathology and Laboratory Medicine (Barnes), Dalhousie University, Halifax, NS; Department of Pathology (Carter), Memorial University of Newfoundland, St. John's, NL; Department of Laboratory Medicine (Yousef), St. Michael's Hospital, Toronto, Ont
| | - Catherine Streutker
- Department of Laboratory Medicine and Pathobiology (Mirham, Ismiil, Sade, Streutker, MacMillan, Rasty, Hegele, Yousef), University of Toronto, Toronto, Ont.; Department of Pathology and Laboratory Medicine (Naugler), University of Calgary, Calgary, Alta.; Department of Pathology and Laboratory Medicine (Hayes), University of British Columbia, Vancouver, BC; Department of Pathology and Cellular Biology (Belisle), Université de Montréal, Montréal, Que.; Department of Pathology and Molecular Medicine (Popovic), McMaster University, Hamilton, Ont.; Department of Pathology (Joseph, Gabril), Western University, London, Ont.; Department of Pathology and Laboratory Medicine (Barnes), Dalhousie University, Halifax, NS; Department of Pathology (Carter), Memorial University of Newfoundland, St. John's, NL; Department of Laboratory Medicine (Yousef), St. Michael's Hospital, Toronto, Ont
| | - Christina MacMillan
- Department of Laboratory Medicine and Pathobiology (Mirham, Ismiil, Sade, Streutker, MacMillan, Rasty, Hegele, Yousef), University of Toronto, Toronto, Ont.; Department of Pathology and Laboratory Medicine (Naugler), University of Calgary, Calgary, Alta.; Department of Pathology and Laboratory Medicine (Hayes), University of British Columbia, Vancouver, BC; Department of Pathology and Cellular Biology (Belisle), Université de Montréal, Montréal, Que.; Department of Pathology and Molecular Medicine (Popovic), McMaster University, Hamilton, Ont.; Department of Pathology (Joseph, Gabril), Western University, London, Ont.; Department of Pathology and Laboratory Medicine (Barnes), Dalhousie University, Halifax, NS; Department of Pathology (Carter), Memorial University of Newfoundland, St. John's, NL; Department of Laboratory Medicine (Yousef), St. Michael's Hospital, Toronto, Ont
| | - Golnar Rasty
- Department of Laboratory Medicine and Pathobiology (Mirham, Ismiil, Sade, Streutker, MacMillan, Rasty, Hegele, Yousef), University of Toronto, Toronto, Ont.; Department of Pathology and Laboratory Medicine (Naugler), University of Calgary, Calgary, Alta.; Department of Pathology and Laboratory Medicine (Hayes), University of British Columbia, Vancouver, BC; Department of Pathology and Cellular Biology (Belisle), Université de Montréal, Montréal, Que.; Department of Pathology and Molecular Medicine (Popovic), McMaster University, Hamilton, Ont.; Department of Pathology (Joseph, Gabril), Western University, London, Ont.; Department of Pathology and Laboratory Medicine (Barnes), Dalhousie University, Halifax, NS; Department of Pathology (Carter), Memorial University of Newfoundland, St. John's, NL; Department of Laboratory Medicine (Yousef), St. Michael's Hospital, Toronto, Ont
| | - Snezana Popovic
- Department of Laboratory Medicine and Pathobiology (Mirham, Ismiil, Sade, Streutker, MacMillan, Rasty, Hegele, Yousef), University of Toronto, Toronto, Ont.; Department of Pathology and Laboratory Medicine (Naugler), University of Calgary, Calgary, Alta.; Department of Pathology and Laboratory Medicine (Hayes), University of British Columbia, Vancouver, BC; Department of Pathology and Cellular Biology (Belisle), Université de Montréal, Montréal, Que.; Department of Pathology and Molecular Medicine (Popovic), McMaster University, Hamilton, Ont.; Department of Pathology (Joseph, Gabril), Western University, London, Ont.; Department of Pathology and Laboratory Medicine (Barnes), Dalhousie University, Halifax, NS; Department of Pathology (Carter), Memorial University of Newfoundland, St. John's, NL; Department of Laboratory Medicine (Yousef), St. Michael's Hospital, Toronto, Ont
| | - Mariamma Joseph
- Department of Laboratory Medicine and Pathobiology (Mirham, Ismiil, Sade, Streutker, MacMillan, Rasty, Hegele, Yousef), University of Toronto, Toronto, Ont.; Department of Pathology and Laboratory Medicine (Naugler), University of Calgary, Calgary, Alta.; Department of Pathology and Laboratory Medicine (Hayes), University of British Columbia, Vancouver, BC; Department of Pathology and Cellular Biology (Belisle), Université de Montréal, Montréal, Que.; Department of Pathology and Molecular Medicine (Popovic), McMaster University, Hamilton, Ont.; Department of Pathology (Joseph, Gabril), Western University, London, Ont.; Department of Pathology and Laboratory Medicine (Barnes), Dalhousie University, Halifax, NS; Department of Pathology (Carter), Memorial University of Newfoundland, St. John's, NL; Department of Laboratory Medicine (Yousef), St. Michael's Hospital, Toronto, Ont
| | - Manal Gabril
- Department of Laboratory Medicine and Pathobiology (Mirham, Ismiil, Sade, Streutker, MacMillan, Rasty, Hegele, Yousef), University of Toronto, Toronto, Ont.; Department of Pathology and Laboratory Medicine (Naugler), University of Calgary, Calgary, Alta.; Department of Pathology and Laboratory Medicine (Hayes), University of British Columbia, Vancouver, BC; Department of Pathology and Cellular Biology (Belisle), Université de Montréal, Montréal, Que.; Department of Pathology and Molecular Medicine (Popovic), McMaster University, Hamilton, Ont.; Department of Pathology (Joseph, Gabril), Western University, London, Ont.; Department of Pathology and Laboratory Medicine (Barnes), Dalhousie University, Halifax, NS; Department of Pathology (Carter), Memorial University of Newfoundland, St. John's, NL; Department of Laboratory Medicine (Yousef), St. Michael's Hospital, Toronto, Ont
| | - Penny Barnes
- Department of Laboratory Medicine and Pathobiology (Mirham, Ismiil, Sade, Streutker, MacMillan, Rasty, Hegele, Yousef), University of Toronto, Toronto, Ont.; Department of Pathology and Laboratory Medicine (Naugler), University of Calgary, Calgary, Alta.; Department of Pathology and Laboratory Medicine (Hayes), University of British Columbia, Vancouver, BC; Department of Pathology and Cellular Biology (Belisle), Université de Montréal, Montréal, Que.; Department of Pathology and Molecular Medicine (Popovic), McMaster University, Hamilton, Ont.; Department of Pathology (Joseph, Gabril), Western University, London, Ont.; Department of Pathology and Laboratory Medicine (Barnes), Dalhousie University, Halifax, NS; Department of Pathology (Carter), Memorial University of Newfoundland, St. John's, NL; Department of Laboratory Medicine (Yousef), St. Michael's Hospital, Toronto, Ont
| | - Richard G Hegele
- Department of Laboratory Medicine and Pathobiology (Mirham, Ismiil, Sade, Streutker, MacMillan, Rasty, Hegele, Yousef), University of Toronto, Toronto, Ont.; Department of Pathology and Laboratory Medicine (Naugler), University of Calgary, Calgary, Alta.; Department of Pathology and Laboratory Medicine (Hayes), University of British Columbia, Vancouver, BC; Department of Pathology and Cellular Biology (Belisle), Université de Montréal, Montréal, Que.; Department of Pathology and Molecular Medicine (Popovic), McMaster University, Hamilton, Ont.; Department of Pathology (Joseph, Gabril), Western University, London, Ont.; Department of Pathology and Laboratory Medicine (Barnes), Dalhousie University, Halifax, NS; Department of Pathology (Carter), Memorial University of Newfoundland, St. John's, NL; Department of Laboratory Medicine (Yousef), St. Michael's Hospital, Toronto, Ont
| | - Beverley Carter
- Department of Laboratory Medicine and Pathobiology (Mirham, Ismiil, Sade, Streutker, MacMillan, Rasty, Hegele, Yousef), University of Toronto, Toronto, Ont.; Department of Pathology and Laboratory Medicine (Naugler), University of Calgary, Calgary, Alta.; Department of Pathology and Laboratory Medicine (Hayes), University of British Columbia, Vancouver, BC; Department of Pathology and Cellular Biology (Belisle), Université de Montréal, Montréal, Que.; Department of Pathology and Molecular Medicine (Popovic), McMaster University, Hamilton, Ont.; Department of Pathology (Joseph, Gabril), Western University, London, Ont.; Department of Pathology and Laboratory Medicine (Barnes), Dalhousie University, Halifax, NS; Department of Pathology (Carter), Memorial University of Newfoundland, St. John's, NL; Department of Laboratory Medicine (Yousef), St. Michael's Hospital, Toronto, Ont
| | - George M Yousef
- Department of Laboratory Medicine and Pathobiology (Mirham, Ismiil, Sade, Streutker, MacMillan, Rasty, Hegele, Yousef), University of Toronto, Toronto, Ont.; Department of Pathology and Laboratory Medicine (Naugler), University of Calgary, Calgary, Alta.; Department of Pathology and Laboratory Medicine (Hayes), University of British Columbia, Vancouver, BC; Department of Pathology and Cellular Biology (Belisle), Université de Montréal, Montréal, Que.; Department of Pathology and Molecular Medicine (Popovic), McMaster University, Hamilton, Ont.; Department of Pathology (Joseph, Gabril), Western University, London, Ont.; Department of Pathology and Laboratory Medicine (Barnes), Dalhousie University, Halifax, NS; Department of Pathology (Carter), Memorial University of Newfoundland, St. John's, NL; Department of Laboratory Medicine (Yousef), St. Michael's Hospital, Toronto, Ont
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