Utilization of virtual microscopy in cytotechnology educational programs in the United States

COVID and cytopathology training: Impact and innovations

Graduate medical education and training in Cytopathology faced numerous unexpected challenges during the COVID-19 pandemic of 2020. It was caused by the SARS-Co-V2 coronavirus and transmitted by breathing droplets or aerosol particles containing the virus and less commonly by contact with infected surfaces and fomites. To mitigate the rapid spread of disease non-essential services were closed, surgical procedures were prioritized, and "social distancing" was implemented. These measures led to a marked decline in the volume of specimens, number of fine needle aspiration (FNA) and rapid on-site evaluation procedures performed. The trainees in Pathology were required to stay at home either entirely or partly during the early period of the pandemic. This led to re-designing of the cytopathology training program nationwide. Many innovative methods and protocols were put in place to overcome the challenges faced and adjustments made in creating the virtual training program in Cytopathology. On May 5th, 2023, the WHO declared that COVID-19 was no longer a global emergency. Regulations were lifted and healthcare services returned to pre-pandemic era. Graduate medical education and training returned to normal however many changes were incorporated into the training program moving forward. Herein the impacts and innovations that COVID-19 had on Cytopathology training are described.

Virtual microscopy as a teaching-learning tool for histology in a competency-based medical curriculum

Background

Histology forms an important component of first-year medical education. Unfortunately, it is limited to the practical laboratory due to the need for a microscope and good quality slides. Virtual microscopy is a recent advancement, which uses computers as an alternative to microscopes. The aim of the study was to compare virtual microscopy (VM)-based practical classes with traditional microscopy (TM)-based practical classes for two cohorts of first-year medical students, by comparing learning achieved using two different test scores as well as a qualitative assessment of student and faculty perspectives regarding the feasibility and usefulness of VM.

Methods

Each cohort of students was divided into two equal batches and each batch underwent eight histology modules of which, four utilised traditional microscopes and four utilised virtual microscopes. Quantitative analysis was performed using a theory test (which assessed preparation, theory knowledge and understanding) as well as a spotter test (which assessed identification skills, reasoning, and recall). Qualitative analysis was performed using a structured questionnaire and focus group discussions.

Results

Modules using VM were better when compared with those using TM, showing statistically significant and better grades. Qualitative analysis performed, yielded important information as to how this technology can serve as a good adjunct to traditional histology classes in the competency-based curriculum by increasing student interest, enabling self-study, and reducing students dependence on the tutor.

Conclusions

VM forms a good adjunct as well as a standalone modality of learning to TM, as it improves accessibility to slides and promotes self-learning.

Evaluating the use of virtual microscopy in cytology education

INTRODUCTION

Whole slide imaging is a promising tool for cytology. In the present study, we assessed the performance of and user experience with virtual microscopy (VM) to determine its feasibility and usage in an educational setting.

MATERIALS AND METHODS

From January 1 through August 31, 2022, 46 Papanicolaou slides, of which 22 (48%) were abnormal, 23 (50%) were negative, and 1 (2%) was unsatisfactory, were reviewed by the students using both VM and light microscopy (LM) platforms. In addition to assessing VM's overall performance, the SurePath imaged slides' accuracy was reviewed as a potential alternative to ThinPrep because of its cloud storage advantage. Finally, the students' weekly feedback logs were analyzed to gain insights for improving the digital screening experience.

RESULTS

The overall diagnostic concordance difference was significant between the 2 screening platforms (Z = 5.38; P < 0.001), favoring LM (86% correct diagnosis) over VM (70% correct diagnosis). The overall sensitivity of VM and LM was 54.0% and 89.6%, respectively. VM also had an overall higher specificity (91.8%) compared with LM (81.3%). LM performed better than whole slide imaging for the correct identification of an organism when one was present, with 77.6% sensitivity compared with 58.9% for the digital platform. The rate of agreement for the SurePath imaged slides with the reference diagnosis was 74.3% compared with 65.7% for the ThinPrep slides. Finally, 4 themes were discerned from reviewing the user logs, with issues about image quality and the lack of fine focus functionality most frequently mentioned, followed by themes associated with a higher learning curve and novelty associated with the digital screening.

CONCLUSIONS

Although the VM results were poorer than the LM results in our validation, its use in an educational setting is promising considering the continued technological improvements and the renewed focus on improving the digital user experience.

BestCyte® Cell Sorter Imaging System: Primary and Adjudicative Whole Slide Image Rescreening Review Times of 500 ThinPrep Pap Test Thin-layers - An Intra-observer, Time-Surrogate Analysis of Diagnostic Confidence Potentialities

Background

The novel Artificial Intelligence-driven BestCyte® Cell Sorter Imaging System (BestCyte) enables hybrid digital screening through classification and sorting of tiles depicting cells in 8 galleries or whole slide image (WSI) reviews.

Objectives

(1) Analyze expenditures of time (minutes) for primary BestCyte cell sorter screening and adjudicative WSI rescreening of 500 blinded, randomized ThinPrep thin-layers to determine review times per Bethesda nomenclature; (2) Analyze review times for NILM qualifier diagnoses reflecting increasing interpretive complexity (i.e., Inflammation, Reactive/Repair, Bacterial cytolysis, Bacterial vaginosis, Atrophy, and Atrophic vaginitis); (3) Challenge accuracy of primary diagnoses (Downgraded, Upheld, and Upgraded) following adjudicative WSI rescreening to assess correlated review times as surrogate indicators of diagnostic confidence in BestCyte functionality (i.e., learning curve); and (4) Correlate primary and adjudicative diagnoses to calculate intra-observer reproducibility Kappa coefficients per Bethesda nomenclature.

Results

Of 500 thin-layers, the mean [primary/adjudicative rescreening review times (minutes)] were: Overall study [1.38/3.94], NILM [1.23/3.02], ASCUS [1.18/2.53], ASC-H [1.73/4.86], AGUS [1.84/6.34], LSIL [1.49/4.16], HSIL [1.52/4.10], CA [0.65/2.57]. Of 500 primary Bethesda diagnoses: 2 (0.40%) downgraded; 483 (96.6%) upheld; 15 (3.00%) upgraded after adjudicative WSI rescreening. Of 354 NILM diagnoses: 0 downgraded; 344 (97.2%) upheld; 10 (2.82%) upgraded. Of 34 ASCUS diagnoses: 2 (5.88%) downgraded; 28 (82.4%) upheld; 4 (11.8%) upgraded. Of 17 ASC-H diagnoses: 0 downgraded; 16 (94.1%) upheld; 1 (5.88%) upgraded. Of AGUS (n=1), LSIL (n=24), HSIL (n=52), CA (n=1), UNSAT (n=17): 100% upheld. Kappa coefficients with 95% (Confidence Intervals): Overall study 0.9305 (0.8983–0.9627), NILM 0.9429 (0.9110–0.9748), ASCUS 0.8378 (0.7393–0.9363), ASC-H 0.9112 (0.8113–0.9999), AGUS 1.0 (1.0–1.0), LSIL 0.9189 (0.8400–0.9978), HSIL 0.9894 (0.9685–0.9999), CA 1.0 (1.0–1.0), UNSAT 1.0 (1.0–1.0). Primary BestCyte cell image review time trends for NILM, ASCUS, LSIL, and HSIL, revealed plateaus relative to decreasing respective adjudicative WSI rescreening times.

Conclusions

Given innovative robustness, BestCyte accommodates interpretive fundamentals, enabling shorter ThinPrep thin-layer review times with optimal intra-observer concordance per Bethesda nomenclature through classifying, ranking, sorting, and displaying clinically relevant cells efficiently in galleries. BestCyte fosters continuously optimizing diagnostic confidence learning curves; may supplant manual microscopy for primary screening.

Pushed Across the Digital Divide: COVID-19 Accelerated Pathology Training onto a New Digital Learning Curve

Bringing digital teaching materials into residency training programs has seen slow adoption, expected for many new technologies. The COVID-19 pandemic dramatically shifted the paradigm for many resident teaching modalities as institutions instituted social distancing to prevent spread of the novel coronavirus. The impact of this shift on pathology trainee education has not been well studied. We conducted an online survey of pathology trainees, program directors, and faculty to assess pre- and post-COVID-19 use of, and response to, various digital pathology modalities. Responses were solicited through both social media and directed appeals. A total of 261 respondents (112 faculty, 52 program directors, and 97 trainees) reported a dramatic and significant increase in the use of digital pathology-related education tools. A significant majority of faculty and program directors agreed that this shift had adversely affected the quality (59% and 62%, respectively) and effectiveness (66%) of their teaching. This perception was similar among learners relative to the impact on quality (59%) and effectiveness (64%) of learning. Most respondents (70%-92%) anticipate that their use of digital pathology education tools will increase or remain the same post-COVID. The global COVID-19 pandemic created a unique opportunity and challenge for pathology training programs. Digital pathology resources were accordingly readily adopted to continue supporting educational activities. The learning curve and utilization of this technology was perceived to impair the quality and effectiveness of teaching and learning. Since the use of digital tools appears poised to continue to grow post-COVID19, challenges due to impaired quality and effectiveness will need to be addressed.

Learning cytology in times of pandemic: an educational institutional experience with remote teaching

Introduction

As the coronavirus pandemic swept across national and state borders, institutions of higher learning, including cytology, began closing campuses and moving instruction online. We have described a method of remotely teaching cytology in our institution, including using the telecytology concept used with rapid onsite evaluation and remote conferencing and educational tools to conduct eCytology learning. This is a cost-effective method to transition a traditional in-classroom program into online teaching for cytology. It can also be implemented quickly.

Materials and methods

In March 2020, our cytology program developed a method for teaching cytology remotely. The distance-learning teaching method included the use of remote conferencing (Zoom platform) and learning management platforms (Canvas) to present lectures and administer tests. Remote multihead sessions were conducted by adapting the telecytology rapid onsite evaluation concept, which attaches a mobile device to the microscope to transmit live video to remote learners.

Results

When asked about their experience with online learning, the students had responded positively. All the students indicated a willingness to attend classes remotely in the future, even when the traditional in-classroom learning option is available.

Conclusions

We have presented a method for educating students remotely using existing technology that is affordable and can be implemented quickly by nearly all cytology education programs.

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Our experience with teaching eCytology in times of pandemic can serve as a cost-effective way to transition a traditionally in-classroom program, into an online teaching in cytology. It can also be implemented quickly.

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Remote multi-head sessions, conducted by adapting the tele-cytology ROSE concept with an attached mobile device to the microscope, is an effective approach to distance learning in times of social distancing and is a promising tool for the future cytology education.

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The students, when asked about their experiences with online learning, responded positively.

Current state of whole slide imaging use in cytopathology: Pros and pitfalls

Whole slide imaging (WSI) allows generation of large whole slide images and their navigation with zoom in and out like a true virtual microscope. It has become widely used in surgical pathology for many purposes, such as education and training, research activity, teleconsultation, and primary diagnosis. However, in cytopathology, the use of WSI has been lagging behind histology, mainly due to the cytological specimen's characteristics, as groups of cells of different thickness are distributed throughout the slide. To allow the same focusing capability of light microscope, slides have to be scanned at multiple focal planes, at the cost of longer scan times and larger file size. These are the main technical pitfalls of WSI for cytopathology, partly overcome by solutions like liquid-based preparations. Validation studies for the use in primary diagnosis are less numerous and more heterogeneous than in surgical pathology. WSI has been proved effective for training students and successfully used in proficiency testing, allowing the creation of digital cytology atlases. Longer scan times are also a barrier for use in rapid on-site evaluation, but WSI retains its advantages of easy sharing of images for consultation, multiple simultaneous viewing in different locations, the possibility of unlimited annotations and easy integration with medical records. Moreover, digital slides set the laboratory free from reliance on a physical glass slide, with no more concern of fading of stain or slide breakage. Costs are still a problem for small institutions, but WSI can also represent the beginning of a more efficient way of working.

Digital Applications in Cytopathology: Problems, Rationalizations, and Alternative Approaches

OBJECTIVE

The aim of this work was to raise awareness of problems using digital applications for examining, teaching, and applying telecytology at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia; University of Nebraska Medical Center (UNMC), Omaha, NE, USA; and University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA. The objective was to rationalize problems and propose alternative digital approaches.

STUDY DESIGN

We sought to identify solutions to improve the following: (a) interpretive examination scores at KAMC for complex cytological templates (i.e., high-grade squamous intraepithelial lesions [HSIL]) when using static digital images (SDI) of cells in regions of interest (ROI); (b) visualization of cells in 3D clusters when teaching at UNMC using 2D and 3D whole-slide imaging (WSI); and (c) visualization of cells through streaming telecytology at UPMC.

RESULTS

Composite SDI (CSDI) improved test scores for complex interpretations (i.e., HSIL) by converging diagnostic criteria from multiple ROI. Multiplane focusing through z-stacked WSI facilitated the teaching of cytological entities characterized by 3D cell clusters and consultative telecytology through robotic cell analysis.

CONCLUSIONS

Adequately visualized cytomorphology and multiplane focusing are essential for virtual cytopathology examinations, teaching, or consultative telecytology. Visualization of diagnostic criteria through 2D or 3D imaging is critical. Panoptiq panoramic WSI with integrated z-stacked video clips enables optimal applied telecytology.

RecutClub.com: An Open Source, Whole Slide Image-based Pathology Education System

BACKGROUND

Our institution's pathology unknown conferences provide educational cases for our residents. However, the cases have not been previously available digitally, have not been collated for postconference review, and were not accessible to a wider audience. Our objective was to create an inexpensive whole slide image (WSI) education suite to address these limitations and improve the education of pathology trainees.

MATERIALS AND METHODS

We surveyed residents regarding their preference between four unique WSI systems. We then scanned weekly unknown conference cases and study set cases and uploaded them to our custom built WSI viewer located at RecutClub.com. We measured site utilization and conference participation.

RESULTS

Residents preferred our OpenLayers WSI implementation to Ventana Virtuoso, Google Maps API, and OpenSlide. Over 16 months, we uploaded 1366 cases from 77 conferences and ten study sets, occupying 793.5 GB of cloud storage. Based on resident evaluations, the interface was easy to use and demonstrated minimal latency. Residents are able to review cases from home and from their mobile devices. Worldwide, 955 unique IP addresses from 52 countries have viewed cases in our site.

CONCLUSIONS

We implemented a low-cost, publicly available repository of WSI slides for resident education. Our trainees are very satisfied with the freedom to preview either the glass slides or WSI and review the WSI postconference. Both local users and worldwide users actively and repeatedly view cases in our study set.

Digital pathology and its role in cytology education

Digital methods have the potential to greatly expand content availability, accessibility, and quality for pathology education. Use of this technology allows for anywhere/anytime interactions and delivery in a variety of methods to accommodate any learning style. This review introduces basic digital technology, its uses for education, and prospects for the future.