Digital Pathology Blog

Anatomic Pathology has been experiencing a major paradigm shift over the past several years as digital technology provides new ways of performing the daily work. Changes in workflow are affecting all aspects of pathology, whether clinical, research or education.

The early years of whole-slide-scanning offered academic institutions a way to provide teaching sets, resident collections and publication images without requiring technical staff to perform additional recuts, staining procedures and handling of blocks and slides. While there was indeed clinical utilization of telepathology techniques as far back as 1968¹, widespread use was limited. Over time, however, the use of telepathology became a way to perform intra-operative consultations, share cases, collaborate and seek clinical opinions from colleagues and outside experts.

As a first-year pathology resident, one of both the most daunting and exhilarating experiences of your training was presenting at tumor boards. The preparation to do so as a junior resident, meticulously reviewing every slide and picking the best ones to show the pertinent findings, was in and of itself a laborious task. Reviewing them again with your attending to confirm the slide(s) you chose showed the pertinent features also took time. Thinking about what to read in the report during the course of the tumor board was another task, planning for when the moderator says, “Can we review the pathology?” and what your spiel was going to be.

My maternal grandfather was a glazier. He was orphaned at a young age and raised in an orphanage on the West side of Chicago with 2 brothers. One of those brothers died during adolescence. My grandfather and his oldest brother fought in World War II and became part of America’s Greatest Generation. He and his brother started Chicago Glass which became the largest glazier company in the city. For over 30 years, my grandfather hung glass on some of the tallest buildings in the world at the time. Sears Tower, John Hancock, Lake Point Tower, Standard Oil, you name it, he worked on it. Buildings downtown had to be “glassed in” by November 15 if the electricians, plumbers, elevator, drywall and carpet guys were to have a chance to work through the winter for spring occupancy on a residential or commercial high rise. In the winters, my grandfather drove a cab between “indoor” jobs such as hanging mirrors, repairing windows or building storm windows. He would drive me around in his large Checker cab and point out what buildings he worked on and what he did, what worked and what didn’t, if he got injured, or one of his men did, and when they “glassed” it in.

We were privileged to present at the Digital Pathology and AI forum hosted by The Pathologist. In our portion of the forum, Dr. Wilbur focused on how the use cases and workflow solutions of digital pathology compare to those in the clinical environment. Dr. Wilbur focuses on how the use cases and workflow solutions of digital pathology compare to those in the clinical environment. While both of these are well established in the clinical setting, image management systems need some additional features to satisfy the requirements for research. Use cases and workflows are similar in how the user interacts with the digital environment but can be quite different in how they relate to the ultimate task and output.

A radiologist, an internist, a surgeon and a pathologist go duck hunting. The radiologist is up first and a flock of ducks fly overhead. He raises his shotgun but does not shoot. The surgeon asked him why he didn’t shoot to which the radiologist replied, “They had the outline of ducks, their contrast looked like ducks, but I wasn’t sure they were ducks.” The internist is up next. When the next flock flies overhead, he raises his shotgun in the air but does not shoot. The surgeon, getting irate at what is happening, asked the internist why he did not shoot to which the internist replied, “They looked like ducks and quacked like ducks, but I wasn’t sure they were ducks.”

The strains of the last two plus years have forced us to make many changes to our daily routines, both on a personal and a professional level. Remote interactions have become the norm, with families “zooming” for the holidays and family events, elbow bumps instead of hand-shakes, and remote work conferences and meetings in all walks of life. We are all looking forward to the return to many of our previous lifestyles, but the old adage remains true, out of adversity comes opportunity.

There is a joke among surgeons and oncologists -- the pathologist at a tumor board is like the guy whose funeral that you are attending; you can't do it without him, but you don't want him saying too much. 

Nearly 2 years ago, our tumor boards went "virtual". Like billions around the world, we scrambled to get Zoom, GoToMeeting, WebEx and other applications up and running to hear each other’s voices and share screens to show radiology and pathology images. We anticipated that by the Summer or Fall we would be back to "normal".

Don’t get me wrong based on the title; I am not advocating for proficiency testing (PT). After Medical Boards, Resident In-Service and Board exams, I never thought I would be thinking about any more testing at all. There are better ways to test for ongoing real proficiency. Exercises that test “real-world” skills, such as focused review of signed out cases or concurrent reviews - with feedback – not only lead to better outcomes (patient safety) but also improve practice (constructive feedback). But testing is an unfortunate part of modern life. It’s a metric, and regulators like metrics. For years we dealt with the specter of impending gynecologic cytology PT. Based on the complexity of the federally mandated glass slide testing format, the organizations capable of producing such a monumental effort appeared to reach a détente with CMS, and no testing took place for many years after the federal regulation went into effect. However, when one organization came up with a program, the seeming détente was at an end, and CAP and ASCP were essentially forced to enter the fray.

Recently I received a call from an oncologist. After giving me the patient’s name, she asked “What does the gene panel show?”

I responded we didn’t have the patient’s biopsy yet, that he was scheduled to undergo a CT-guided needle core biopsy, and we would process it overnight and review tomorrow as we normally do.

The oncologist acknowledged the patient was undergoing the biopsy in the afternoon, and we hadn’t even yet done an immediate fine needle aspiration rapid on-site assessment prior to the core biopsy.

Digital pathology, in one form or another, has been with us for several decades supporting clinical, research and academic applications world-wide. Early use cases for pathology focused primarily on research and teaching. Today, however, whole slide images are playing a larger role in the clinical realm offering remote support for intra-operative procedures, consultations with subspecialty experts and, most recently, primary diagnosis reporting.