Liron Pantanowitz, MD

Transcription

1 Whole Slide Imaging: Education, Tumor Boards, & Presentations Liron Pantanowitz, MD Associate Professor of Pathology & Biomedical Informatics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Overview: This talk reviews the emerging use of whole slide images (WSI) in education, at tumor boards, and for presentations. WSI are much more interactive than glass slides, easy to share anywhere at anytime, and can help standardize training material. The use of WSI in undergraduate medical education and pathology resident training is highlighted, including the creation of digital slide teaching sets. Unlike a glass slide teaching set, virtual slides will not fade, break or disappear. Virtual slides offer the ability to standardize images, permit annotation, and can provide a wide case range including rare cases. Digital teaching sets are available to multiple users, and can be developed to contain test modules for trainees. Not surprisingly, many medical schools are abandoning the light microscope. Collaboration among students is easier with a WSI, and this technology supports the creation of a virtual-slide laboratory in medical schools. The ability to track and tutor with WSI is discussed with respect to training, trainee assessment and the development of image processing tools. WSI have had a positive impact on tumor boards at several different institutions. This is because WSI offers higher quality images with annotation, greater educational value for clinicians, involves less preparation time than photographing cases, permits real-time flexibility (e.g. easy to add on cases, perform side-by-side viewing, and gives access to the entire slide which allows one to answer on-thespot questions). Apart from the novelty factor, WSI provides a more accurate reflection of cases presented at tumor boards. The utilization of WSI for E-education, virtual workshops, digital images in pathology journals, and for proficiency testing are also highlighted. Content Outline: General benefits of WSI WSI for Undergraduate Education WSI for Pathology Residency Training Digital Slide Teaching Set Creation WSI Tracking & Tutoring WSI & Tumor Boards WSI & DVD Case Send Out e-education & Virtual Workshops WSI in Pathology Journals Online WSI Sharing Digital PT/QA Programs

2 References: Boutonnat J et al. A pilot study in two French medical schools for teaching histology using virtual microscopy. Morphologie. 2006; 90:21-5. Bruch LA et al. Competency assessment of residents in surgical pathology using virtual microscopy. Hum Pathol. 2009; 40: Chen YK et al. An application of virtual microscopy in the teaching of an oral and maxillofacial pathology laboratory course. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 105: Conran R et al. Slide2Go: A virtual slide collection for pathology education. AMIA Symposium Proceedings 2007:918. Dee FR et al. Implementation of virtual microscope slides in the annual pathobiology of cancer workshop laboratory. Hum Pathol. 2003; 34: Foster K. Medical education in the digital age: Digital whole slide imaging as an e-learning tool. J Pathol Inform 2010, 1:14. Harris T et al. Comparison of a virtual microscope laboratory to a regular microscope laboratory for teaching histology. Anat Rec. 2001; 265:10-4. Heffner S. Streamlining tumor board reviews. Advance/Laboratory 2008; July:20. Helin H et al. Web-based virtual microscopy in teaching and standardizing Gleason grading. Hum Pathol. 2005; 36: Li L et al. Development and use of a genitourinary pathology digital teaching set for trainee education. J Pathol Inform 2010, 1:2. Marchevsky AM et al. Virtual microscopy as a tool for proficiency testing in cytopathology: a model using multiple digital images of Papanicolaou tests. Arch Pathol Lab Med. 2003; 127: Marchevsky AM et al. The use of virtual microscopy for proficiency testing in gynecologic cytopathology: a feasibility study using ScanScope. Arch Pathol Lab Med. 2006; 130: Mello-Thoms C et al. Analysis of digital slide exploration characteristics of expert pathologists. 2010; 1:22. Pantanowitz L. Digital images and the future of digital pathology. J Pathol Inform. 2010;1. pii: 1. Rosai J. Digital images of case reports and other articles. Int J Surg Pathol. 2007; 15:5. Sharma G et al. Development of a head and neck pathology slide teaching set for trainee education. J Pathol Inform. 2010; 1:38.

3 Tecotzky R. Digital pathology enhances hospital s tumor board meetings. MLO 2009; Nov:60. Treanor D et al. Tracking with virtual slides: a tool to study diagnostic error in histopathology. Histopathology. 2009; 55: Weaker FJ, Herbert DC. Transition of a dental histology course from light to virtual microscopy. J Dent Educ. 2009; 73: Online Resources:

4 Agenda Topic Presenter Time Introduction Terence Colgan Laura Collins 7:00 PM Whole Slide Imaging: Regulation and Validation Paul Valenstein 7:10 PM Whole Slide Imaging Used for Primary Frozen Section Diagnosis and Remote Pathology Service Coverage Whole Slide Imaging: Education, Tumor Boards, and Presentations Andrew Evans Liron Pantanowitz 7:35 PM 8:00 PM Whole Slide Imaging: Routine Pathological Diagnosis Keith Kaplan 8:25 PM Whole Slide Imaging: Efficiencies and Costs John Pfeifer 8:50 PM Whole Slide Imaging for Pathology Teleconsultations: Applications and Caveats for Service Implementation Closing Comments and Final Q&A David Wilbur 9:15 PM 9:40 PM 2010 College of American Pathologists. Materials are used with the permission of the faculty. 1

5 CAP COMPANION SOCIETY MEETING SYMPOSIUM ON WHOLE SLIDE IMAGING WHOLE SLIDE IMAGING: EDUCATION, TUMOR BOARDS, & PRESENTATIONS LIRON PANTANOWITZ, MD A S S O C I A T E P R O F E S S O R O F P A T H O L O G Y & A S S O C I A T E P R O F E S S O R O F B I O M E D I C A L I N F O R M A T I C S U N I V E R S I T Y O F P I T T S B U R G H M E D I C A L C E N T E R

6 APPLICATION 1 o Diagnosis 2 nd Opinion Telepathology Quality Assurance Education Conference Image Analysis Business Model STATIC ROBOTIC WSI Pantanowitz. J Pathol Informatics 2010; 1:15.

7 WSI are much more interactive. WSI are easy to share (anywhere at anytime). Standardizes training material. Teaching sets (virtual slide box): Don t fade, break or disappear. Availability of a wide case range & rare cases. Ability to provide annotation. Invited grand rounds & slide seminars. Increasingly being used for exams (e.g. ABP). Medical schools abandoning glass slides for WSI.

8 UPMC UNDERGRADUATE EDUCATION Med School Glass Slides 1-3 microscopes/session Quality: old slides, fading, time consuming & costly to replace Med School Digital Slides Med School Digital Slides 86 Hits on Website (more than some lectures) 2-3 Laptops/session WSI facilitated group learning Good quality images

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10 CAP Today Sept 2007 pp 5-12

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12 VIRTUAL HISTOLOGY

13 SLIDES TO GO! AMIA 2007 Symposium Proceedings Page

14 RESIDENT EDUCATION GLASS SLIDE TEACHING SETS DISADVANTAGES Restricted access Loss of stain quality Breakage or loss of slides Limited material: Rare pathology cases Few cytology slides

15 PATHOLOGY RESIDENCY DIGITAL TEACHING SETS ADVANTAGES Available to multiple users Consistent stain quality Standardized teaching Reduced breakage and loss of slides Ability to annotate images Content & testing interface Li et al. J Pathol Informatics 2010; 1:2

16 DIGITAL SLIDE TEACHING SET CREATION Digital slide scanning (by technologist) Hyperlinks (Oracle servers) Case content (ColdFusion)

17 UPMC VIRTUAL TEACHING SETS Currently over 3000 whole slide images. Completed Subspecialties: Genitourinary, Head and neck, Thoracic, & Hempath. General unknowns collection. Subspecialties Under Development: GI, Bone and soft tissue, Pediatric & Cytology teaching sets.

18 TRAINING APPLICATIONS

19 TRACKING, AUDITS & TUTORING WSI + s/w facilitate tracking of viewing Uses: Audits (QA, medicolegal) Training & assessment Development of better image processing tools Acknowledgement: Claudia Mello-Thoms & Rebecca Crowley

20 TRACKING RESIDENTS (SEARCH MAPS) 4x 10x Exploration strategy >10x

21 COMPARING EXPERTS & RESIDENTS

22 SLIDE TUTOR

23 WSI & TUMOR BOARDS Positive impact to date. Higher quality images with annotation. Greater educational value for clinicians. Less preparation time (photographing cases). Real-time flexibility: Easy to add on cases. Side-by-side viewing. Access to entire slide answers on-the-spot questions. More accurate reflection of cases. Novelty factor.

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25 WSI & DVD SEND OUT Slides get sent out per patient request Rare cytology slides DVD with WSI + s/w (includes our report) ~80% still request slides ( - technical issues?) Almost all retain DVDs

26 PATHOLOGY SOCIETIES & MEETINGS E-EDUCATION EDUCATION VIRTUAL WORKSHOPS USCAP: AP Electronic Case Series (APECS)

27 PATHOLOGY JOURNALS

28 ONLINE WSI SHARING Web 2.0 (Pathology 2.0) Online WSI sharing Educational content Teleconsultation Research Collaboration

29 DIGITAL PT/QA PROGRAMS Central Server PIP Scanner Hospital Location C Hospital Location A Hospital Location B Digitize PIP/QA/other slides Web server hosts WSI Many users can access WSI simultaneously Facilitates timely evaluation Diagnostic scores are not compromised

30 WSI & PROFICIENCY TESTING IN CYTOPATHOLOGY Current gold standard is manual screening or review of glass slides Virtual microscopy is being recommended by several investigators Pros: More cost effective; Improved standardization Cons: Prior training required; Lengthy time to examine digital images; May not reflect real-world experience Taylor et al. Acta Cytol 1999; 43: Marchevsky et al. Arch Path Lab Med 2003; 127: Gagnon et al. Acta Cytol 2004; 48: Marchevsky et al. Arch Path Lab Med 2006; 130:

31 TAKE HOME POINTS TECHNICAL Role of an imaging technician is essential WSI + software + network connectivity are required APPLICATION WSI are portable (available anywhere at anytime) WSI provide interactive sharing of digital images WSI trump glass slides for training & education Era of virtual training (e-education) with virtual slide sets & virtual slide-laboratories