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Outside the Lab Digital and computational pathology, Technology and innovation, Profession

Practically Perfect In Every Way

It’s clear that digital pathology is picking up speed. Recent FDA clearances (1) are removing the once-overwhelming regulatory obstacles, and the field is slowly expanding beyond its initial offerings. Previously synonymous with virtual imaging and long-distance consultations, the term “digital pathology” now stands for a range of new technologies, including artificial intelligence and algorithmic decision-making assistance – concepts that sound more like science fiction. Nowadays, these software-based tools are, in some cases, exhibiting precision and accuracy comparable to that of human pathologists. Have we truly reached a point where all of the roadblocks to full digital pathology adoption are removed? And, if so, will these computer-based tools support pathologists – or replace them?

The reality of a modern pathologist’s day-to-day work is this: there are too few laboratory medicine professionals, and too many patients in need of their services. Anything that can lighten the load is welcome – provided, of course, that it is both a feasible and a functional option. Most pathologists already benefit from some form of digital work, be it teleconsultations, automated image analysis to verify a manual diagnosis, or even simply digitizing images for easier presentation or future referencing. But not every laboratory can implement even these basic improvements, let alone more complex ones. Many labs lack the necessary equipment (such as slide scanners, or the hardware and software required to process and analyze large image files), and a significant percentage of them lack the money (measured in hundreds of thousands, if not millions, of dollars) needed to switch to a fully digital workflow. And even in laboratories not limited by material considerations, the amount of time, effort, and staff buy-in required to make the transition from a well-established analog routine to a new, unfamiliar digital one can often prove insurmountable.

A user’s path through a well-designed image-sharing platform – from browsing to contributing.

Figure 1. Pathologists have embraced Twitter as a means of connecting and collaborating – including image sharing.

So with these obstacles still to be overcome, the question is not how much digital pathology is possible – but how much is truly practical? How is digital pathology practised in the labs that use it, and what tools and devices are indispensable?

Collaborating on collections

The first thing that leaps to mind when thinking of digital pathology is the ability to share findings – images, of course, but also the accompanying annotations, ideas and explanations. Digital images captured by whole-slide imaging (WSI) scanners, microscope cameras, and smartphones are used in many practices as quick references, for lectures and presentations, to consult with other medical professionals, or even for casual purposes like posting “pathology artwork” on social media.

In recent years, numerous platforms for the storage and sharing of digital pathology images have arisen, established by universities, non-academic organizations, and even individuals. Although useful educational and reference tools, these platforms nonetheless have downsides. For instance, they are usually limited to findings from specific sub-fields of pathology, or from specific diagnoses, or even specific regions. As such, they don’t fully reflect the diversity of either the potential content, or of pathology itself. In many cases, they are often driven by a particular person or group within the organization – meaning that, if the budget (or the enthusiasm) for the project is not maintained, the database also won’t be. Even commercially developed solutions, which sidestep these difficulties, have issues: they often require a fee for access, and usually focus heavily on WSI at the cost of other material. As a result, many pathologists and laboratories are either unable to access the content, or fail to find material that meets their needs.

Of course, no man is an island – and that is especially true of image database developers. No one pathologist can be expected to assemble a broadly useful collection of pathology images alone; he or she must involve colleagues, convincing them to undertake the same level of effort and dedication to providing images and growing the database. And if one pathologist wishes to use an image-sharing platform to upload a case and request assistance from colleagues, then those pathologists must also have access to the platform – which may require an investment of money, effort, or both. Collaboration should be as easy as possible; the more barriers stand in its way, the less likely it is to take place – and most pathologists would rather find a different platform than risk a valuable consultation with a colleague.

Remote Resources

By Yasmine Lahoubi

Digital pathology has had a tremendous rise in the last few years, and has proven that it can be a viable alternative to working with conventional slides. Thus far, it has mostly been used in education, meetings and consultations – but now, with the first FDA-approved solution, we will see digital pathology’s potential for primary diagnosis begin to unfold. Working digitally – sharing images and discussing them online – can be exceedingly helpful, especially in remote regions where young pathologists are often forced to work alone, with no experts in direct reach. It’s a particularly significant issue in cytopathology, where pathologists frequently have access to limited tissue but must still conduct technically demanding examinations. Remote consultation allows young pathologists to discuss cases with experts, enabling them to confidently proceed with diagnosis, prognosis and treatment recommendations.

In many cases, though, smaller laboratories lack the sophisticated hardware (like virtual slide scanners) and software they need to truly take full advantage of telepathology. Pathologists working without those resources welcome any way of sharing and discussing images easily – especially if they can do so using just a standard web browser, or even via mobile phone (so that they can share snapshots taken directly with the phone’s camera). For these pathologists – just as for those working with extensive resources – digital pathology is a huge advance that can only bring benefits.

Yasmine Lahoubi is a fourth-year pathology resident at Mustapha Bacha University Hospital, Algiers, Algeria, and a USCAP ambassador.

To social media… and beyond

Some solutions are easier than others – and social media has proven a good starting point. Pathologists have discovered that social media platforms, in particular Facebook and Twitter Twitter (see Figure 1), are effective places to exchange and discuss images among themselves. Some even take matters one step further, working with patient groups in ways that benefit both sides. Interestingly, such collaboration tends to take place outside working hours; social media’s accessibility and ease-of-use make it a simple, low-cost tool that pathologists can use at any time – all that’s needed is the smartphone every person already carries.

Social media makes an especially significant difference in regions of the world where pathologist expertise is wildly scattered and resources are limited. Laboratories without the money or equipment to safely transport patient samples can use digital images and their associated commentary to share the details of complex cases. Those that can’t afford a dedicated specialist platform for image sharing can create a Facebook or Twitter account and gain access to thousands of experts with the ability to provide assistance. And those that can’t afford expensive imaging equipment can post photographs taken with regular digital cameras, or even smartphones. Conversations can be as public or as private as desired, and hashtags and groups can help target questions to the patients and professionals most likely to be able to help.

But as convenient a solution as social media is, it still has limitations. When it comes to direct collaboration with colleagues, image sharing can still be complicated and cumbersome – because diagnostic second opinion consultations necessitate secure, private channels, and often require the sharing of whole-slide images (far too large and detailed for social media). To fulfill these professional needs, most pathologists use a suite of purpose-built software tools: scanning programs, image editors, annotation tools, cloud storage solutions and more. It stands to reason that they also need dedicated image-sharing platforms – services that can be used from any location or device and that combine affordability, security and easy collaboration. The wide range of laboratory setups available today should facilitate answers for patients – not present an obstacle to them.

Designing the ideal platform

What features does such an image-sharing platform need?

  • The ability to browse, search and share. Pathologists should be able to look up images of particular conditions or features to use as educational references, or to compare with slides currently being used for diagnosis. They should also be able to upload their own images, whether as reference cases or to share with other professionals for informal assistance or a formal second opinion.
  • Ease of use. All services should be accessible in one place, and from anywhere. For instance, a web portal that can be accessed via browser from a smartphone, tablet, laptop or desktop computer is ideal. Optional apps for smaller devices might enhance accessibility further. And as these types of tools are already familiar to most, the “intimidation factor” is significantly reduced, meaning staff are more confident and willing to engage with the technology.
  • Affordable and immediate. Many labs cite startup costs as a major obstacle to digital pathology, whereas others have difficulty convincing IT and computing departments to assist with installation. A web portal that can be used without the need to install or integrate with existing technology removes those hurdles – and making it available low-cost or free of charge means there’s no need to convince administrators or funders to provide a hefty budget.
  • The ability to serve as a hub. All involved parties should be able to not only access the platform, but also participate in sharing, annotating, and discussing the images. Thoughtfully designing such a tool for group interaction means that it can be used effectively for education, expert exchange, research, and more.

So what can pathologists do to make the switch to digital images not only smooth, but useful? First, establish the parameters of your transition. What equipment do you have, or will you be acquiring? What hardware and software will you be using? What aspects of your workflow will become digitally based, and which – if any – will remain as they are? What resources are available to you?

No two laboratories have the same needs, so no two changeovers are the same – but regardless of how your own transition works, an image-sharing platform that is device-, location- and format-agnostic is a key part of making digital pathology a practical part of your daily work.

A Case Study in Digital Nephropathology

By Helen Liapis

By Helen Liapis

Nephropathologists are not new to the world of digital pathology. Digital electron microscopy images are used for routine primary diagnosis in many nephropathology laboratories around the world. Static (“store-and-forward”) digital images are used in teaching and training, to share interesting cases over social media, and for numerous telepathology purposes, including quality assurance, conferencing, consultations and collaborative studies. Simultaneous remote access by multiple pathologists is currently the preferred method for collaboration in my specialty because of its ease, the speed of communication, and the complete absence of travel costs. Some hospitals with low case volumes have even implemented digital imaging for the interpretation of transplant renal biopsies, which means they no longer need to send out samples, or – even more costly – bring an expert in to examine the biopsies in person.

Whole-slide imaging (WSI), an extension of static images, allows for dynamic interpretation of the pathology on renal biopsies. One major benefit is that WSI is unbiased; whereas static images are subjective to the person taking the image, WSI allows for independent viewing and evaluation of all of the structures or findings on a given slide. Once scanned, whole-slide images can easily be stored, revisited or distributed – and, with the use of appropriate software, digitized images can even be used for morphometric analysis. WSI on scanned slides is increasingly used for clinical trials, allowing pathologists to review renal biopsies remotely. Even in-house biopsy review uses WSI; renal pathologists receive digital images from remote, affiliated hospitals to examine. User-friendly, web-based digital pathology consultation portals are excellent tools because of their ability to handle large image files, and because they bring together information from many different sources and present it in a user-friendly manner.

In short, innovations in digital pathology are transforming the pathology workplace from a strictly on-site, lab-based environment into one that can be accessed anytime, anywhere.

In the near future, I expect to see the digitization of renal biopsies in many more hospitals, universities and private laboratories. The advantages are many, and the cost relatively low in the long run. Of course, the necessary infrastructure is a significant expenditure – but the potential return on investment is great! Institutions can set up permanent libraries and databases for future use. Digital renal biopsy repositories will one day be used to standardize histopathological interpretations, scoring systems and protocols for material collection and data mining. Research will be performed from shared resources, yielding increased transparency, reproducibility and accuracy. Of course, there are still unanswered questions regarding the practical use of digital technologies in routine diagnosis – defining new standards, establishing reimbursement, licensing, credentialing, legal issues and more – but such questions are inevitable with any new way of working.

In nephropathology in particular, the use of diagnostic digital pathology is likely to increase. Why? Because of the complexity of renal biopsy interpretation, the acute shortage of expert renal pathologists worldwide, the high processing costs, and the demand for short turnaround times for final diagnoses. Nephropathology is a high-maintenance service that requires high volumes to be cost-effective. As technologies improve, scanning times decrease, and viewing becomes more efficient, digital nephropathology is likely to allow for lower operational costs and better use of expertise across countries and even continents. In my opinion, this is one of the biggest changes to occur in the practice of pathology in this century, and one that I expect to continue.

Helen Liapis earned her medical degree in Greece, was trained in pathology in the United States, and spent over 20 years as a faculty member at Washington University in Saint Louis, USA. The author of more than 140 peer reviewed scientific articles, books, and book chapters, she received the Renal Pathology Society’s Jacob Churg Award in 2011 and Washington University’s Distinguished Clinician Award in 2012. She was elected president of the Renal Pathology Society in 2014.

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  1. U.S. Food and Drug Administration, “FDA allows marketing of first whole slide imaging system for digital pathology” (2017). Available at: Accessed October 27, 2017.
About the Author
Michael Schubert

While obtaining degrees in biology from the University of Alberta and biochemistry from Penn State College of Medicine, I worked as a freelance science and medical writer. I was able to hone my skills in research, presentation and scientific writing by assembling grants and journal articles, speaking at international conferences, and consulting on topics ranging from medical education to comic book science. As much as I’ve enjoyed designing new bacteria and plausible superheroes, though, I’m more pleased than ever to be at Texere, using my writing and editing skills to create great content for a professional audience.

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