Navigating the Shift to Digital Pathology
By David Muirhead for tissuepathology.com
The undeniable wave of the future is steadily moving labs and organizations from analog into
the realm of digital pathology solutions, and although the rewards are great, the adoption of
these new products and processes does present some unique challenges.
Routine workflow in most AP departments across the country, and indeed throughout the
world, has traditionally consisted of a pathologist using a basic compound microscope to
examine slides from the histology lab and issuing a diagnostic report. Digital technology
streamlines the pre-analytic process by converting standard glass slides into high-definition
digital files that can be quickly and conveniently accessed, manipulated, stored and shared.
Simply put, the benefits of conversion to digital pathology translate to an ability to efficiently
process more slides in less time, along with better quality control and, ultimately, faster access
to care for patients.
However, a successful implementation of digital pathology solutions can require considerable
logistical planning, support from organizational leadership and financial outlay. The shift toward
digital pathology (DP) is also encountering resistance from some laboratorians who fear the
new technology may render their roles obsolete.
The decision to go digital
City of Hope (COH) is a specialized 225-bed oncology-focused facility with service lines that
include hematology, soft tissue tumors, breast cancer, T-cell immunotherapies and diabetes
research. My current responsibilities include overseeing clinical pathology, which consists of
microbiology, the core chemistry and hematology lab, hematopathology and all of the AP labs.
We have 22 pathologists on staff, and they interact and collaborate closely with our surgeons.
About six months ago, our hospital leadership began to express greater interest in exploring
digital pathology, due in large part to the influence of a new president who brought a great
depth of knowledge and experience in the field. In-depth discussions about how digital
pathology fits into the landscape of precision medicine and the integration of multiple
modalities led to the decision to expand the digital line for our existing digital modality, which is
used by a few pathologists but has gained a wider use in the research efforts of COH. That
initiative is still taking shape, but when our digital pathology implementation is complete, we
anticipate having a fully state-of-the-art AP department.
Challenges and obstacles
Resistance from staff pathologists has perhaps been the biggest impediment to digital
pathology adoption in many organizations, and ours was no exception. We fielded questions
about who would do the actual scanning and QE/QEC, and what kinds of training would be
required. Some clinicians were worried that scanning slides into the digital format would slow
the overall workflow and increase time for sign out, but after going through the initial learning
curve, they will discover that the benefits of high-definition viewing, ease of image
manipulation, image analysis and electronic file-sharing capability actually help them do their
jobs more efficiently. Our younger pathologists are really becoming the true champions of
digital technology, and their enthusiasm is helping bring their peers into the fold more quickly
as well.
Digital pathology solutions can also represent a fairly significant capital investment. Prior to
purchase, organizations should determine exactly how they plan to use the technology to find
the best cost/benefit balance and the appropriate entry point. One of our primary
considerations was selecting a solution that was optimal for histopathology and cytopathology,
where it’s essential to produce high resolution and good color rendition for frozen sections and
microscope slides in general. We originally selected a high-throughput scanner (VENTANA iScan
HT, Roche Diagnostics, Indianapolis), but with management’s new focus on DP, we eventually
added an efficient small capacity scanner (VENTANA DP 200, Roche Diagnostics) that met our
workflow requirements and offered features that were valuable to us in the areas of image
quality and speed of operation. We are currently using the new DP system in a research
capacity (per its regulatory approval status) to validate its use for tumor boards, consults and
some international consults, with the main focus being on clinical trials and research projects.
Over the last several months we have had requests from COH clinicians within the hospital
setting and our community practice physicians asking for digital pathology support. It is very
encouraging from our perspective that the demands are now coming from outside a laboratory
setting within our facility, e.g., intervention radiology and the surgical suites. It is not unusual
during corridor conversation with COH leadership members and senior physicians to discuss
where we are in our digital pathology journey and how soon COH will see an impact.
We have found it interesting that our researchers are more willing to adopt and embrace digital
pathology than their clinical counterparts. We’ve already begun receiving requests from tech-
savvy researchers who want us to perform whole-slide digital imaging for them, and we’re in
the process of conducting several clinical trials and studies. Additionally, we’re finding digital
pathology to be a useful tool for international consults, especially in countries that forbid the
shipping and mailing of actual DNA slide samples.
One of the areas where we have noticed the most significant difference from using digital
technology is our tumor boards. Incorporating digital files has begun to win over naysayers by
demonstrating how easy is it to scan slides for electronic presentation, eliminating the need to
physically transport bulky files to conference rooms for meetings across campus. We’re not
quite ready to incorporate digital pathology for bone marrow biopsies and lymph nodes,
although we are currently performing a study using lymphoma images to prove a positive
correlation between normal sign out and digital sign out.
Advice to colleagues considering a DP transition
If your organization is thinking about making the shift to digital pathology, there are several
crucial factors worth considering. First, clearly define your expectations and limitations for
instrumentation and implementation. For example, what do you want to achieve through the
use of digital technology, and what resources can you commit to implementation and training?
What departments will realize the most measurable benefit? What kind of staff training will be
required to get the new system up and running? Then, carefully weigh the costs and the
prospective impacts of the technology to assess your potential return on investment. Will the
benefits of a streamlined AP workflow or better quality control offset the time and expense
you’ll need to outlay for installation, implementation and staff training?
Be patient, shop several vendors and test out the products to see which best deliver the
benefits you need. Don’t underestimate the value of support you’ll require before, during and
after implementation to assure a smooth transition, and make sure any vendor you’re
considering can deliver to meet your expectations.
Finally, if you make the decision to proceed, try to find early adopters who believe in the power
and benefits of digital pathology. Their support can help pave the way among staff who might
be a little slower in warming to the idea of a changeover.
Where do we go from here?
At City of Hope, the digital pathology future looks bright. We meet on a weekly basis to fine-
tune our DP strategy and goals, and our leadership strongly supports the direction to eventually
adopt digital technology for both research and clinical applications. One of our more immediate
aims includes faster development of new algorithms for image analysis. If every picture tells a
story, every degree of clarity we can add to an image provides additional details.
Europe is already embracing digital pathology solutions, but the United States hasn’t been as
keen on adoption, in part due to lagging approvals from regulatory bodies. The recent CE-IVD
approval of digital pathology instruments as a first-read diagnostic tool for frozen sections is an
important step in moving the technology forward into more widespread applications.
I believe we’re still in the early stages of the paradigm shift into digital pathology, and as the
wave continues to crest, I think we’ll see exciting advances that simultaneously improve our
anatomic pathology workflows and the level of patient care we can provide.
David Muirhead is the Administrative Director of Pathology Services at City of Hope National
Medical Center in Duarte, CA
