CEO SUMMARY: Whole slide imaging (WSI) is a niche product today, but it offers the potential to redefine the practice of pathology. That’s the opinion of pathologists presenting at a digital pathology workshop last month. One pathologist explained how WSI significantly improves collaboration between pathologists and referring physicians. Another pathologist explained how regulators soon may require standards for WSI and why such standards are likely to result in a call for standards for light microscopes as well.
IN RESPONSE TO THE STEADY INCREASE in the number of anatomic pathology groups acquiring and using digital scanners and digital pathology systems, Cerner Corporation recently conducted a two-day workshop on the subject. Several innovative pathologists in this field were invited to speak.
“At this time, whole slide imaging (WSI) is a niche product,” stated Susana M. Coelho, Director of Cerner CoPathPlus, in Waltham, Massachusetts. “However, the adoption rate of WSI by our clients makes it clear that WSI is here to stay.
“At this workshop, the consensus among the experts speaking and the pathologists in attendance was that whole slide imaging would only prove successful if it is well-integrated into the workflow of the laboratory and the individual pathologists,” observed Coelho.
“Among other things, this will require seamless integration of the images and data with the information systems,” she added. “We are not there yet, and so to hear the leaders in this field consistently reinforce this idea was significant.”
During the conference, most presenters stressed this point and discussed how whole slide imaging can be used to increase the value pathologists deliver to referring physicians, their patients, and payers. For example, at Pathology, Inc., in Torrance, California, whole slide imaging is dramatically improving collaboration between pathologists and referring physicians.
WSI’s Business Advantage
In an interview with THE DARK REPORT after the conference, Eric F. Glassy, M.D., who is Medical Director at Pathology, Inc., discussed the early benefits derived from his pathology group’s use of WSI. “Whole slide imaging offers several advantages for us in terms of presentations, as well as on the business side,” he said.
“Take tumor boards, for example,” noted Glassy. “Over the years, we tried different ways to present our cases. This ranged from presenting glass slides and showing 35 mm slides with a projector, to running a video feed and using digital still images. Hands down, use of whole slide images has proven the most effective.
“There is always a favorable reaction from the clinicians and surgeons who view these whole slide images,” he noted. “It also raised the profile and contribution of our pathologists who present these cases at tumor boards, during consultations, and in other interactions with colleagues.
“In our practice, the whole slide scanner is owned by the private laboratory that is Pathology, Inc.,” said Glassy. “It provides images to the more than 30 pathologists who are part of our extended business family.
“Besides use of WSI in tumor boards and in consultations with clinicians, we’ve enjoyed other significant business benefits,” he said. “WSI allows us to compete against such national competitors as Clarient and US Labs. This is particularly true in virtual immunohistochemistry, breast marker analysis, and similar types of testing com- monly offered by other national pathology labs.”
Glassy says that Pathology, Inc., is using whole slide images as a way to open the door to more clinical interaction with the physicians who refer cases to his group. This improves client loyalty and fosters a professional relationship where the pathologist is a valued consultant.
“Remote viewing is one solid business case that argues in favor of local pathology groups using WSI,” declared Glassy. “There are always clients who want to review slides directly with the pathologist.
“At Pathology, Inc., we set up a digital consultation system with remote viewing,” he noted. “As the pathologist shows a slide, that same image appears and moves around on the client’s computer desktop. This system allows the pathologist to discuss the finer points of a case.
“For example, when the client physician asks about the specifics of a lesion, our digital consultation system allows the pathologist to quickly respond to diagnostics issues and client concerns.
“This WSI remote viewing service has proven to be so popular that we’ve created a work flow arrangement to schedule consultation time,” stated Glassy. “When a client calls services with a request to discuss a case with the pathologist, an appointment is scheduled.
“To start the consultation, the pathologist and the clinician log in to the web server with name and password, which keeps it private,” he added. “Once they’re logged in, they can talk over the phone while the case is being viewed on the monitor. The control is initiated by the pathologist. But control of the digital image can be passed to the clinician. That gives the clinician the ability to move to different areas of interest or to zoom in on specific areas.
“Use of whole slide imaging in this manner generates two benefits,” explained Glassy. “One, if a clinician calls and wants to be reassured of a diagnosis, then this system is a powerful way to have the whole slide image viewed directly by the clinician.
“Second, there are a number of clinicians—such as gastrointerologists—who like looking at glass slides,” he commented. “These physicians had good training in the basics of histology and they like to review these cases with the pathologists. The remote viewing application of WSI gives them an opportunity to discuss their case and focus in on any areas of concern.
“We’ve just opened up this service,” he said. “We are still learning the different ways that this interaction encourages a new level of collaboration between pathologists and client physicians, particularly if the physician who referred the case is not nearby.
Remote Viewing By Clinician
“Pathologists know that, if the client is close by, he or she may come to the hospital and review a case,” observed Glassy. “However, if the pathologist works at an off site laboratory—like Pathology, Inc.—remote viewing of the whole slide image provides a similar intimacy that occurs when a client and the pathologist review a slide together using a double-headed scope.
“By the way, it needs to be acknowledged that many physicians have never liked using a microscope to view a glass slide,” declared Glassy. “They pretend, but they just don’t have a comfort level with using a microscope to view their case.
“It’s been our experience that these physicians are much happier reviewing material on a computer monitor,” he stated. “In fact, looking at a picture presented on a monitor is much more compelling and meaningful for them.
A More Compelling Story
“In our experience, there is great value for whole slide imaging,” he added. “There is a certain level of novelty, of course, but beneath that there is an experience that can be quite compelling for both sides.
“From the pathologist’s side, a digitized image now allows analysis with algorithms and computer scoring for breast markers, for example,” commented Glassy. “The digital image can be manipulated and evaluated in ways that are not easily accomplished with a glass slide.
“From the referring clinician’s side, the whole slide image creates immediacy and enables a more direct conversation with the pathologist,” pointed out Glassy. “This can be seen at tumor board meetings, where the WSI allows the clinicians to get a better sense of what it is involved in analyzing a case.
Viewing Tumor Margins
“For example, surgeons and radiation therapists often are worried about margins,” Glassy explained. “They ask ‘How close is the tumor to the surgical margin?’ The pathologist can show the area of concern on the whole slide image under very low power, allowing the clinician to see the ink on the surface where the margin of the tumor is. The pathologist can then zoom in at higher power to show the histologic details.
“Clinicians find this very useful,” he continued. “They can see exactly why the pathologist described the margin as, say, only a millimeter away. They can see how close that is. The whole slide image tells a much better story, particularly when compared to reading the pathologist’s findings on the paper report. In this way, clinicians have a greater appreciation for what pathologists do.
“Keep in mind that a tumor board is like telling a story,” he said. “There is a patient who has a problem. Each individual physician brings part of the story to the conference. But it is the pathologists who tie all the pieces of the story together.
“It is the pathologists who explain what the tumor looked like, the degree of differentiation, margin involvement, and the like,” continued Glassy. “The additional molecular tests or special stains add important details to that story.
“Whole slide imaging enables the pathologist to present all the information in a live—even dynamic—fashion as opposed to using static images,” he said. “The pathologist becomes more of a storyteller, weaving the different facts together about how he or she arrived at the diagnosis. And that makes the whole conference much more beneficial to the patient and more interesting to the clinicians.
“At Pathology, Inc., our use of whole slide imaging has caused us to recognize how pathology is about to transform,” continued Glassy. “Now, we are working hard to promote this idea of transformation so that pathologists are truly part of healthcare team and not just sitting off in a basement somewhere looking at glass slides.
“All of these advantages are obvious to us but we’ve only just scratched the surface,” he said. “Digital pathology is going to get faster and better. The experience for the clinician and the pathologist will steadily improve as more digital pathology products come to the market.”
Imaging Expert Predicts Standards Will Be Developed for Whole Slide Images and Light Microscopes
AS WHOLE SLIDE IMAGING (WSI) technology improves, it is likely to trigger a reassessment of light microscopes. That’s the opinion of Michael J. Becich, M.D., Ph.D., Chairman, Department of Biomedical Informatics, a t the University of Pittsburgh Medical School in Pittsburgh, Pennsylvania.
“In the near term, WSI will make its way into practice as an adjunctive tool to the light microscope,” predicted Becich. “There will still be a need for light microscopes in pathology departments. But the real issue is that no standards have ever been established for the light microscope.
“A dizzying variety of choices of light microscopes exists in the market today,” he observed. “In some cases, limited budgets dictate the type of light microscopes that are acquired and used. These are often not of the highest quality.
“In my view, patient care would improve if there was more standardization in light microscopes,” stated Becich. “For example, quality would improve if high-quality, wide-field microscopes—with focusing objectives to account for cover slip thickness and other aberrations—were the standard in pathology.
Quality of Light Microscope
“There is lots of variability in the quality of the light microscopes used across the country, particularly in some community practices,” he added. “By that, I mean microscopes that medical students would not be allowed to use in their laboratory training can be found in regular use at some local pathology labs.
“The pathology profession needs higher quality microscopes,” noted Becich. “It needs to adopt useful standards to ensure that microscopes deliver optimum viewing performance. That would help us all.
“I anticipate that the FDA will look at whole slide imaging as a new instrument,” he continued. “The FDA will insist upon standards for WSI. In turn, that will have a positive effect on the standardization of light microscopes in laboratories.
“The impact of developing standards for WSHI will ensure and verify performance of whole slide imaging systems, as well as light microscopes. In turn, these standards will require such instruments to be appropriately centered, to have the proper light sources, and to have the correct objective so that they are optimized for quality viewing.
Using The Best Tool
“Today’s reality is that the pathologist who works with a high quality microscope that includes wide-field correcting, focusing objectives, and quality optics, has a better tool than the pathologist who is forced to use a microscope that’s been in use for over 40 years—and probably was not manufactured to today’s highest standards,” Becich said.
“Fortunately, I expect that FDA scrutiny of WSI will raise the standards for pathology viewing via microscope in a manner that will be very helpful to patient care,” he added. “However, until that happens, this country has many pathology practices where sub- standard microscopes are used. Why? Because the pathology profession has no practice standard concerning light microscopes that address these important issues.
“At the end of the day, we should have standards for diagnostic pathologists using microscopes,” he said. “They should be binocular scopes and have aberration-correcting lenses above 40x. They should also have focusing objectives and Kohler-illumination corrected light sources. Many in pathology know this and realize its just a matter of time. That’s my prediction.”