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: Email: pantanowitzl@upmc.edu 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
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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; 55:37-45. Weaker FJ, Herbert DC. Transition of a dental histology course from light to virtual microscopy. J Dent Educ. 2009; 73:1213-21. Online Resources: http://www.jpathinformatics.org/browse.asp?sabs=n http://slidetutor.upmc.edu/ http://images.nlm.nih.gov/pathlab/ http://vmic.unibas.ch/patho/index.html
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
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
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.
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.
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
CAP Today Sept 2007 pp 5-12
VIRTUAL HISTOLOGY
SLIDES TO GO! AMIA 2007 Symposium Proceedings Page - 918 http://images.nlm.nih.gov/pathlab/
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
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
DIGITAL SLIDE TEACHING SET CREATION Digital slide scanning (by technologist) Hyperlinks (Oracle servers) Case content (ColdFusion)
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.
TRAINING APPLICATIONS
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
TRACKING RESIDENTS (SEARCH MAPS) 4x 10x Exploration strategy >10x
COMPARING EXPERTS & RESIDENTS
SLIDE TUTOR HTTP://SLIDETUTOR.UPMC.EDU/
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.
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
PATHOLOGY SOCIETIES & MEETINGS E-EDUCATION EDUCATION VIRTUAL WORKSHOPS USCAP: AP Electronic Case Series (APECS)
PATHOLOGY JOURNALS
ONLINE WSI SHARING Web 2.0 (Pathology 2.0) Online WSI sharing Educational content Teleconsultation Research Collaboration
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
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; 43:1045-51. Marchevsky et al. Arch Path Lab Med 2003; 127:1320-4. Gagnon et al. Acta Cytol 2004; 48:788-94. Marchevsky et al. Arch Path Lab Med 2006; 130:349-55.
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