Digital Pathology, The Heart of the Lab, The Birmingham Heartlands Experience. Dr Bruce Tanchel Heart of England NHS Foundation Trust, Birmingham, UK

Transcription

1 Digital Pathology, The Heart of the Lab, The Birmingham Heartlands Experience Dr Bruce Tanchel Heart of England NHS Foundation Trust, Birmingham, UK

2 Disclaimer This project is a collaboration with Roche I am an average histopathologist in an average NHS laboratory I am not an IT expert

3 Take a few moments to think of how our world has been taken over by binary

4 Music

5 Dictation

6 Books, Newspapers, Magazines

7 Art

8 Photography

9 Television

10 Films

11 Presentations

12 Mail

13 Radiology

14 Introduction We live in the digital age It is time cellular pathology joined in

15 Introduction This is not a scientific presentation I want to share my experience of trying to implement Digital Pathology in my Trust I know the way we have tried to introduce this new technology is not perfect I am sure most, if not all of the difficulties we have encountered will not be unique

16 Digital Pathology at Heartlands Working in collaboration with Roche Objective was to see how a digital pathology system would integrate into a working NHS Cellular Pathology laboratory No defined budget but resources have been put in by both parties to keep the project moving along

17 The Laboratory Our laboratory is situated at Birmingham Heartlands Hospital Part of Heart of England NHS Foundation Trust The Trust covers 3 hospital sites, Heartlands, Solihull and Good Hope and the Birmingham Chest Clinic.

18 The Laboratory 13 consultants with a post for a 14 th 60 laboratory staff including BMS s and MLA s 6 secretarial staff 3 trainee pathologists and 1 FY2 doctor

19 The Laboratory We receive about histology cases, 5000 non gynae cytology and gynae cytology cases per year slides including immunohistochemistry Essentially a big district general hospital with skin, breast, gastrointestinal and uropathology dominating the workload. Also offer some molecular tests including HER2, lymphoma and ALK FISH.

20 Early Days In collaboration with Roche we were loaned a iscan Coreo slide scanner in early 2012 Well loved instrument Delivered good quality images 160 slide capacity

21 Early Days Quickly noted that scan times were a bit slow 2 minutes a slide for 20X 2-3 times longer for 40X It didn t like variation in slide size Data entry interface too cumbersome Too slow for routine use in our laboratory

22 Early Days The iscan Coreo did have many redeeming features Images good Measurement excellent Produce great photos for presentation and publication Excellent for presenting cases such e.g for MDT and teaching

23 Current Situation Replaced with VENTANA iscan HT in early 2013 High throughput scanner Faster scanning time 360 slide capacity Improved features

24 Current Usage MDT meetings Microscopic measurement of tumours and margins Teaching Photography Validation of different tissue types

25 Our Experience Some successes Many difficulties

26 Successes Demonstration / Teaching / Photography Clinicians and pathologists have enjoyed the improved quality of the images when compared with the old video camera images Produce excellent photos with no significant extra work needed, especially low power You can electronically dot the slide to speed up presentation We have had increasing requests to have teaching material scanned in

27 Successes Measurement Much easier to do than hand held micrometer or microscope vernier scale, especially in very small measurements (less than 1mm) Actual record of what was measured May lead to improved measurement consistency between pathologists

28 Successes Measurement

29 Successes Renal MDT Used digital pathology for one renal MDT Outcry at next MDT when it was not available. Clinicians demanded we use digital for their MDT The clinicians subsequently have asked for access to images so they could show the pathology slides to their patients and use it during consultations We are working on a way to try make this a reality

30 Difficulties IT Environment Large Trust with large number of PCs all with variable specifications IT within the Trust lagging way behind what is available in the real world PCs in the Trust still use Internet Explorer 8 and Windows XP Our IT only support PCs from 1 manufacturer

31 Difficulties IT Environment After one software upgrade, we could not access slides at MDT due to outdated internet browsers Restricted access on the PC so we could not upgrade the programmes when needed Trust IT and other IT providers can be slow to respond e.g. interfacing with LIMS IT environment not set up for the demands of DP Despite all working for the NHS access between Trusts is very difficult

32 Difficulties IT Environment Noticed the DP system was slower on my desktop than at the Education Centre Slide took about 8 seconds to open at MDT but sometimes over 30 seconds on my desktop Thought the network was the issue Turned out to be my computer rather than the network

33 Difficulties Local IT Environment Also has hardware composed of a mixture of specifications usually very low Software outdated too Cabinets chock full Network struggles cope with peak times Need to optimise the network as well as hardware. Has a cost implication.

34 Difficulties Capacity Extra step in the specimen pathway It does add extra time and complexity to the process One instrument could not service our needs. We would need 2 or 3. It is easy to underestimate the time it takes to allocate the slides and enter the data

35 Difficulties Reluctant Pathologists Pathologists reluctant to consider using any modality other than a microscope for reporting Most have had bad experiences of early systems which cloud their thinking Complain that it is slower Field size is small Image not as clear Will blame the technology for any error

36 Difficulties Reluctant Pathologists On the other hand, pathologists happy to embrace digital pathology where they feel it adds value Photography, especially low power Teaching and demonstration Measurement Much less happy and confident to use it for routine reporting

37 Difficulties Slide Storage Whole slide images are large Our laboratory workload is large We would need many terabytes to store each years work Our current glass slide storage is relatively cheap Slides need to be stored for a long time Deleting images seems inefficient to me We need a storage solution

38 Difficulties Slide Types Not all aspects of our work are covered Can scan in cytology but results have been variable. Recent upgrade to scanner may solve this. No macroblock scanning. A large proportion of our prostate and colon cancer cases and some breast cancer use macroblocks. Immunofluorescence scanning

39 Difficulties Validation I found information on this difficult to find initially No clear guidance from Royal College of Pathologists their document focuses mainly on telepathology UKAS/CPA laboratory accreditation requires new instruments to be validated Liron Pantanowitz, John H. Sinard, Walter H. Henricks, Lisa A. Fatheree, Alexis B. Carter, Lydia Contis, Bruce A. Beckwith, Andrew J. Evans, Avtar Lal, and Anil V. Parwani (2013) Validating Whole Slide Imaging for Diagnostic Purposes in Pathology: Guideline from the College of American Pathologists Pathology and Laboratory Quality Center. Archives of Pathology & Laboratory Medicine: December 2013, Vol. 137, No. 12, pp

40 Difficulties Reliability We have had a few episodes of down time Some are fixed by a reboot Others needed specialist intervention We even had a host of images corrupted, which has delayed my validation study Not a major issue at the moment but would have been catastrophic if we were reliant on the system for reporting

41 Difficulties Image Analysis Good for some immunohistochemical stains such as HER2 and ER Interpretation less subjective and with improved quality But I find it is very time consuming Can pick up cells that are not relevant Will improve and become an important part of digital pathology

42 Difficulties Slide Sharing Slides move to other NHS Trusts quite frequently for 2 nd opinion and review Slides for teaching need regional distribution If you can t access our Trust network, you can t access the images Need a Trust PC with a dongle

43 Difficulties Sharing across Trusts Arranged to scan in slides for a regional gynaecology pathology seminar Sent slides to Roche HQ to be scanned and stored on their server Sent out web address link for participants Web link would not work from within NHS Trusts Web linked worked from private homes unless you tried to use Safari Not yet had a coherent explanation of the problem. Presume it has to do with firewalls.

44 Next Steps Software and scanner updates. Completed last week. Validate an organ system/s Optimise the environment Role out routine reporting of that system Assuming that all goes well, work towards converting colleagues to using digital pathology

45 My Thoughts I think Digital pathology is inevitable, but when? Will improve work flow through the lab with major benefits in getting slide to pathologists, off site working, collecting slides for MDT s and retrieval of old cases It adds value especially in work flow, measurement, image analysis, quality assurance Benefits only accrue if all cases are scanned The whole slide images are excellent but high power is still not quite as good as under the microscope I am not convinced using a digital microscope is faster and I don t think reporting speed will change

46 My Thoughts There are still some problems to solve: Slide storage issues Do you keep the glass slides or the images Better integration of digital pathology into the specimen pathway and the LIMS. The LIMS has both reporting and business function. The digital pathology systems are just for reporting. Eradicate duplication in the pathway

47 My Thoughts We need to work hard to engage pathologists to become involved and embrace the benefits it will bring Any irritations result in withdrawal by pathologists. There are still irritations. Perhaps introduce DP it via MDT s. Once pathologists see the benefits acceptance may improve Increase DP usage in EQA The older pathologists are less likely to let go of their microscopes

48 My Thoughts Not a perfect project Some of the issues were predictable e.g. poor IT environment, lack of hardware Some issues unexpected e.g. unable to share slides despite using outside server Some issues still need resolution e.g. storage of images, ability to scan whole workload Both Roche and ourselves have learned a lot

49 Concerns (2010) Cost Function of such a system in the NHS IT infrastructure Adoption by pathologists Time taken to scan Macroblocks, Fluorescence, Cytology Storage of digital slides Ability to send cases to other trusts Work lost to cheaper sources of labour

50 Concerns (end 2014) Cost Function of such a system in the NHS IT infrastructure Adoption by pathologists Time taken to scan Macroblocks, Fluorescence, Cytology Storage of digital slides Ability to send cases to other trusts Work lost to cheaper sources of labour

51 Conclusion Implementing DP has been much slower than originally anticipated We are on the cusp of moving forward and testing it out for routine cases Installing and using DP in a routine NHS pathology laboratory has not been easy Hopefully our experience will make it easier for others We still need to iron out some of the issues and work within the Trust and with manufacturers to solve these

52 Thank you To Roche for the collaboration and allowing me the freedom to openly discuss our project My colleagues at Heartlands Hospital who have taken an interest and helped with the project