Experiencias en telepatología y digitalización masiva de Centre de Diagnòstic Biomèdic imágenes en el Hospital Clinic Jaume Ordi M.D., Ph.D. Department of Pathology Hospital Clínic Barcelona jordi@clinic.ub.es
Digital Pathology in the Hospital Clinic: Contents WSI in primary routine diagnosis WSI in pre- graduate teaching Remote consultation Hospital Central de Maputo (Mozambique) - 2 -
The Whole Slide Imaging (WSI) project Centre de Diagnòstic Biomèdic in the Hospital Clinic Jaume Ordi M.D., Ph.D. Department of Pathology Hospital Clínic Barcelona jordi@clinic.ub.es
WSI in the Hospital Clinic: Objectives To use WSI in primary routine diagnosis (Final objective: to achieve a complete digitalization of the Department of Pathology) To use WSI in pre- and post-graduate teaching - 4 -
Advantages of WSI Tumor boards and teaching Easiness of filing and retrieving slides Slide work-flow - 5 -
Advantages of WSI Portability Sharing slides with other institutions when patients ask for second opinions Tele-consultation Home working - 6 -
WSI in routine diagnosis: General premises The advantages should exceed the disadvantages Conventional microscope Pathologists are trained to use microscopes More robust and simpler than computers Less expensive Maintenance is cheaper Less technical steps WSI Young generations are computer native Tumor boards and teaching Portability (tele-consultation, home working) Easiness of filing and retrieving slides Slide work-flow - 7 -
WSI at Hospital Clinic: The project starts Routine scanning process and diagnosis implemented in progressive steps GYN pathology (July 2013) Lung Pathology (January 2014) Hematopathology (Sptember 2014) Additional project: WSI in education - 8 -
WSI in routine: Issues to be addressed Integration between the WSI software and LIS Scanning robustness and workload for the technicians Connectivity speed of the access to the images Storage capacity and/or costs of file storage Time spent in the diagnostic process by the pathologist Pathologists workstations Validation for the use for primary diagnosis - 9 -
WSI in routine: Integration LIS - WSI Integration LIS-WSI is a key point in the process (LIS-WSI connection has been a difficult process) - 10 -
WSI in routine: Scanner robustness and work load 2.7% slides require requiring a change of the scanning conditions 2.4% slides rejected by the scanner Rate of complete scanning failure: 0.2% 11 seconds per slide (18 min per 100 slides) - 11 -
WSI in routine: Reliable scanning: lessons learned Mean scanning time per slide: 2 min 15 sec ± 30 sec, (range 32 sec - 3 min 51 sec) Assuming the same scanning conditions for all specimens generated every day at the department would result in 16 hours of scanning per day Need to develop strategies for urgent cases A single scanner is not enough - 12 -
WSI in routine: Connectivity 1. Information sent from LIS to Virtuoso) 4. Access to the case via Virtuoso for diagnosis VIRTUOSO 2. Slides are scanned and the images are sent to Virtuoso iscan HT Server 3.Storage of the images Short-time storage: 4Tb (quick access) Long-time storage: 45Tb (slow access) - 13 -
WSI in routine: Storage capacity and costs Mean weight of each file: 602,089,847 ± 407,592,154 bytes, range 12.5 MB to 2.05 GB) 56.9% of the images weight more than 500 MB and 19% over 1 GB (at 200x) Assuming the same scanning conditions for all specimens generated every year: 65 TB per year Some areas (kidney, liver, etc) will require scanning at 40 x 80-100 terabytes per year: huge investments in hardware (100.000 /year) - 14 -
WSI in routine: Storage capacity and costs File storage requirements can be reduced by deleting unnecessary images Criteria for keeping WSI images: presence of malignant or premalignant lesions or relevance for the diagnosis or the staging 88.4% of the WSI images classified as candidates for deletion Policies of deleting unnecessary WSI images can significantly reduce file storage requirements Saco A, et al. USCAP meeting 2015 (accepted) - 15 -
WSI in routine: Time of the diagnostic process Mean time with microscope: 62 seconds/slide Mean time with WSI: 101 seconds/slide (62% increase) Improvements in the file access strategy and pathologist practice with WSI Mean time 71 seconds/slide (14% increase) - 16 -
WSI in routine: Pathologists workstation - 17 -
WSI in routine: Pathologists workstation (viewer) - 18 -
WSI in routine: Filing and retrieving slides and workflow Clear advantages in terms of retrieving the slides Complication of the task of slide distribution when WSI partially implemented Additional process step - 19 -
WSI in routine: Validation for primary diagnosis To determine the accuracy of interpretation using WSI in the routine diagnosis of gynecological specimens To understand the interpretative pitfalls - 20 -
Validation of WSI in routine GYN diagnosis: Methods All gynecological biopsies (including small biopsies and surgical specimens) received at the department of pathology of the Hospital Clinic of Barcelona in two months: July and August 2013) 452 specimens (9.21% of all GYN specimens in 2013) Blind diagnosis by two gynecological pathologists Pathologist A with WSI Pathologist B using CLM - 21 -
Validation of WSI in routine GYN diagnosis: Methods All discrepancies were reviewed in double headed CLM and a final consensus diagnosis was established Classification for discrepancies: Major (significant differences in clinical management) Minor (no or minor clinical relevance) Complete agreement Results evaluated by weighted Kappa statistics for two observations - 22 -
Validation of WSI in routine GYN diagnosis: Results Interobserver agreement between WSI and CLM was almost perfect (κ value: 0.914; 95% CI 0.879 to 0.949) Ordi J, et al. J Clin Pathol 2014 No discrepancy related to poor quality of the image or to insufficient magnification - 23 -
Validation of WSI in routine GYN diagnosis: Results 7 small lesions underdiagnosed (3 cases) or missed (4 cases) in the WSI evaluation 5 high HSIL lesions of the cervix 1 lymph node metastasis (isolated cells) of an ovarian carcinoma 2 lesions missed or underdiagnosed (one each) in the CLM evaluation HSIL lesions of the cervix - 24 -
Validation of WSI in routine GYN diagnosis: Results - 25 -
Validation of WSI in routine GYN diagnosis: Results - 26 -
Validation of WSI in routine GYN diagnosis: Results Subset of directed biopsies of the cervix (n=127) from patients referred to colposcopy because of abnormal Pap smear: kappa value 0.832 (95%CI: 0.757-0.906) Author Year Interobserver kappa (weighted) Intraobserver kappa (weighted) Cocker et al. 196 8 0.26-0.30 0.82 Ringsted et al. 1978 0. 81 0.82 Bellina et al. 1982 0.24-0.71 0.66 Ismail et al. 1989 0.78 D e Vet et al. 1995 0.71 McCluggage et al. 1996 0.20-0.54 Revised in Malpica A, et al. Gynecol Oncol, 2005; 99: S38-27 -
Validation of WSI in routine GYN diagnosis: Results Increase in the inter- 1 0,983 observer agreement during 0,95 0,945 0,941 the study period (first half samples vs. second half) 0,9 0,85 0,89 0,835 0,899 0,8 0.21-0.40 Fair 0.41-0.60 Moderate 0.61-0.80 Substantial 0.81-1.0 Almost perfect 0,75 First period Second period Ordi J, et al. J Clin Pathol 2014-28 -
WSI in routine: Percentage of revisions with CM 60 50 40 30 20 10 0-29 -
WSI in routine diagnosis: Current situation The advantages are likely to exceed the disadvantages Conventional microscope Pathologists are trained to use microscopes More robust and simpler than computers Less expensive Maintenance is cheaper Less technical step Portability and homework Slide work-flow Easiness of filing and retrieving slides Time spent for diagnosis WSI Even old pathologists can rapidly adapt to WSI Tumor boards and teaching Measures and IHC evaluation More ergonomic workstations - 30 -
WSI in pre-graduate teaching Centre de Diagnòstic Biomèdic Jaume Ordi M.D., Ph.D. Department of Pathology Hospital Clínic Barcelona jordi@clinic.ub.es
WSI in pre-graduate teaching: Methods We evaluated two groups taking the discipline of Pathology in the same course, one using CM and the other VM The slides can be viewed at any time and in any place with the Virtuoso viewer (Roche) For the virtual microscopy course, the viewer registered any access to the virtual slides by any of the students Online test to evaluate the skill level Survey to the students Ordi O, et al. J Pathol Inform 2014 (in press)
WSI in pre-graduate teaching: Methods
WSI in pre-graduate teaching
WSI in pre-graduate teaching
WSI in pre-graduate teaching: Results The mean mark in the online test in the CM course was 9.87 ± 0.34 (range 8.3-10), with all the students passing the exam The mean mark in the VM course was 9.86 ± 0.53 (range 6.7-10) with 91/93 students (97.8%) passing the online test. No differences were observed between the two groups (p=0.880, Student s t test)
WSI in pre-graduate teaching: Results Viewer registry of the accesses to the virtual slides by the students Ordi O, et al. J Pathol Inform 2014 (in press)
WSI in pre-graduate teaching: Results Ordi O, et al. J Pathol Inform 2014 (in press)
Experiencias en telepatología Centre de Diagnòstic Biomèdic Jaume Ordi M.D., Ph.D. Department of Pathology Hospital Clínic Barcelona jordi@clinic.ub.es
Tele-pathology in the Hospital Clinic Tele-pathology consultation between the departments of pathology of the Hospital Central de Maputo and the Hospital Clinic established in 2010 (weekly) Remote sessions between the departments of Obstetrics and Pathology started in 2011 (weekly) Remote sessions/tele-pathology consultation between Hospital de Vic and Hospital Clinic start in 2014
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WSI and telediagnosis in pathology: Conclusions Routine diagnosis of gynecological specimens by WSI may be confidently introduced in departments of pathology Virtual slides can effectively replace the traditional methods of teaching and learning pathology Digital pathology may be a very useful tool in tele-consultation and cooperation - 46 -