Image standards in Tissue-Based Diagnosis (Diagnostic Surgical Pathology)

| May 20, 2008

Diagnostic Pathology 2008, 3:17doi:10.1186/1746-1596-3-17
Image standards in Tissue-Based Diagnosis (Diagnostic Surgical Pathology)
Klaus Kayser1 , Jürgen Görtler2 , Torsten Goldmann3 , Ekkehard Vollmer3 , Peter Hufnagl4  and Gian Kayser5

1UICC-TPCC, Institute of Pathology, Charite, Berlin, Germany

2IBM DeepComputing, Brussels, Belgium

3Institute of Pathology, Research Center Borstel, Borstel, Germany

4Department of Telemedicine, Institute of Pathology, Charite, Berlin, Germany

5Institute of Pathology, University Freiburg, Freiburg, Germany

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© 2008 Kayser et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Progress in automated image analysis, virtual microscopy, hospital information systems, and interdisciplinary data exchange require image standards to be applied in tissue-based diagnosis.

To describe the theoretical background, practical experiences and comparable solutions in other medical fields to promote image standards applicable for diagnostic pathology.

Theory and experiences
Images used in tissue-based diagnosis present with pathology – specific characteristics. It seems appropriate to discuss their characteristics and potential standardization in relation to the levels of hierarchy in which they appear. All levels can be divided into legal, medical, and technological properties. Standards applied to the first level include regulations or aims to be fulfilled. In legal properties, they have to regulate features of privacy, image documentation, transmission, and presentation; in medical properties, features of disease – image combination, human – diagnostics, automated information extraction, archive retrieval and access; and in technological properties features of image acquisition, display, formats, transfer speed, safety, and system dynamics. The next lower second level has to implement the prescriptions of the upper one, i.e. describe how they are implemented. Legal aspects should demand secure encryption for privacy of all patient related data, image archives that include all images used for diagnostics for a period of 10 years at minimum, accurate annotations of dates and viewing, and precise hardware and software information. Medical aspects should demand standardized patients’ files such as DICOM 3 or HL 7 including history and previous examinations, information of image display hardware and software, of image resolution and fields of view, of relation between sizes of biological objects and image sizes, and of access to archives and retrieval. Technological aspects should deal with image acquisition systems (resolution, colour temperature, focus, brightness, and quality evaluation procedures), display resolution data, implemented image formats, storage, cycle frequency, backup procedures, operation system, and external system accessibility. The lowest third level describes the permitted limits and threshold in detail. At present, an applicable standard including all mentioned features does not exist to our knowledge; some aspects can be taken from radiological standards (PACS, DICOM 3); others require specific solutions or are not covered yet.

The progress in virtual microscopy and application of artificial intelligence (AI) in tissue-based diagnosis demands fast preparation and implementation of an internationally acceptable standard. The described hierarchic order as well as analytic investigation in all potentially necessary aspects and details offers an appropriate tool to specifically determine standardized requirements.

Tissue-based diagnosis is considered to be the most accurate and, in addition, inexpensive diagnostic technique in medicine. It is subject to considerable changes in respect to implementation of newly developed technologies. These comprise two main fields, namely molecular biology tools including molecular genetics, as well as digital information acquisition and distribution [1-4]. Telepathology, which is the transfer and viewing of macroscopic and microscopic images at a distance, served as the main promoter in developing the digitalization of histological glass slides and viewing microscopic images on a TV screen [5-10]. It was fully established in the early 1990s and was followed by the construction of specific telemedicine systems such as the iPATH or UICC-TPCC at the beginning of this century [11,12]. At present digitalization of a complete glass slide is commercially available as well as internet – accessible automated measurement systems such as EAMUS™ [13,14].

Diagnosis of radiological images obtained from computerized tomography (CT) or magnetic nuclear resonance (MR) underwent comparable changes too: the viewing of radiological films has been replaced by viewing completely digitized radiological images. These changes have been remarkably promoted by its expense savings over conventional film, its development, and environmental considerations in reducing the pollution induced by film development by-products [15-18]. The technology has been matured, and spatially completely distributed diagnostics are offered that separate the diagnostic work with the patient (CT, MR imaging, etc.) at the hardware localization from viewing the images by radiologists and, in addition, from typing the radiologists’ dictations at a different, third, location by secretaries [19,17,20,18]. Adequate standards of image acquisition, interaction with the hospital information system and data documentation have been implemented contemporarily with this development [21]. Picture Archiving and Computation System (PACS) and the DICOM standard have to be mentioned herein [19]. These regulations and internationally accepted standards are nearly missing in diagnostic pathology to our knowledge. There exist recommendations and regulations of laboratory practice which are included in the Code of Federal Regulations (CFR) of the United States of America as well as those mentioned in Good Laboratory Practice (GLP), and veterinary pathologists have stated a toxicologic pathology position paper on pathology image data (regulatory forum). Whether these recommendations can be transferred into human diagnostic pathology still remains an open question.

The same consideration holds true when taking a closer look at the working conditions of radiology and diagnostic pathology: Digital images acquired from histological slides are in use for medical diagnosis in a similar manner compared to radiological images; however, the specific conditions differ at least in image nature (black and white versus colour) and clinical environment (radiological images have to be viewed by clinicians working in different disciplines too, for example by surgeons, whereas the judgement of microscopic images completely remains a domain of surgical pathologists).

In this article we analyze the theoretical background and recent developments of microscopic image analysis and preposition to work out appropriate standards. A basic scheme of three different levels in a hierarchic order each consisting of three different "columns" (legal, medical, technological) is suggested. In addition, we want to provide tools that can serve to successfully implement such standards in the daily practice of virtual microscopy in terms of distributed and interdisciplinary medical information transfer.

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