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SPECI AL:DIGITALPATHO LOGY EUROPEAN HOSPITAL  Vol 24 Issue 6/15 10 DIGITAL PATHOLOGY Digital pathology algorithms will be in the lab in the next five years Scaling the barriers to precise diagnoses Report: Mark Nicholls Whilst digital pathology has the potential to deliver more precise diagnostics, there remain a number of barriers to its widespread imple- mentation. Cost, as with any new technology, remains an issue particularly against the backdrop of financial constraints experienced within, for example, the UK’s National Health Service (NHS). Doubts remain over whether digi- tal methods are as good as tradi- tional ones and there are also IT challenges in sharing data across national and international bounda- ries. One of the UK’s leading digital pathology experts, Dr David Snead, focused on these challenges when he addressed the international Global Engage 2nd Digital Pathology Congress in London (3-7 D e c e m b e r 2015). In his presentation, Overcoming Barriers in Adoption of Digital Pathology, the consultant outlined the challenges, opportuni- ties and potential that digital pathol- ogy offers for a new era of diagnos- tics and healthcare. As Consultant Cellular Pathologist with University Hospitals Coventry & Warwick (UHCW) NHS Trust, Snead believes research, conducted by his team and others, is demon- strating that digital pathology is as good as traditional methods. ‘We’ve answered these doubts with our validation study where we demon- strated that we can do 90% of the job on a digital platform that you can with a microscope.’ Cost remains an issue, but indi- cations are that, as more manufac- turers enter the market over the next 4-5 years, competition will drive down price and see greater implementation of digital pathology systems. An issue, particularly facing the NHS, is that of sharing data with regulations and a lack of clarity, agreements and protocols on data sharing rules, security and confiden- tiality, he suggested. What remains clear to Snead, who also heads the UHCW Centre of Excellence for Digital Pathology, is the potential of the technique. ‘It’s clear to me as a pathologist that digital pathology offers an increase in quality which we do not have yet,’ he said. ‘But, within a couple of years, authorities will accept there is a need to acquire and pay for this increase in quality that it offers.’ The Coventry centre, as an early adopter of digital pathology, is championing the case within the UK and with support and funding from the trust management is ‘geared to providing pathologists with the tools they need to make digital pathology work for them’. Snead: ‘These will be tools which grade cancer more accurately and grade intensity staining in biomark- ers in an entirely quantitative, repro- ducible and robust way, which we cannot do at present. What is done by the pathologist’s eye and judge- ment at the moment is not good enough for today’s treatment. Breast cancers are still being reported with varying degrees of their grade and patients require much more robust analysis, particularly in cancer treat- ment of the tumours they have. ‘That’s what excites us about digi- tal pathology, about really improv- ing pathology because we can now measure things we could not meas- ure before.’ The Centre of Excellence has seven PhD students, two post docs and a computer scientist, working on digital pathology algorithms with the trust’s partner, the University of Warwick. ‘In the next five years we will see those algorithms in the lab, Snead predicts, ‘deliver- ing better assessments of pathology slides than we get at the moment and, I think, when we get to that point will be when digital pathol- ogy is really going to take off.’ He recognises that, in Europe, health systems are not necessarily facing similar issues as the NHS, in part due to the different configuration of healthcare in comparison with that of the UK. Sweden, Spain and Holland are making strong progress as individual hospitals, institutions and heath organisations introduce their own initiatives. However, Snead is confident that digital pathology will overcome barriers against its implementation. ‘Everybody will be using this tech- nology in 10 years because they will have to,’ he said. ‘There will not be any other way of doing it.’ Dr David Snead is Consultant Cellular Pathologist with University Hospitals Coventry & Warwick NHS Trust and Director of the Digital Pathology Centre of Excellence. His main research interests are digital pathology as applied to routine diagnostic histopathology and lung cancer research. I n c r e a s i n g r e q u i r e m e n t s for specialisation and diagnostic qual- ity in pathology, on the one hand, and the importance of pathology findings for treatment planning, on the other, call for new solutions in pathomorphological diagnostics. One important starting point is the fast-paced opportunity for digitisation along with communi- cation systems that can facilitate the storage and transfer of very large data volumes. These open up new opportuni- ties in pathology summarised by the term digital pathology. ‘The term stands for procedures which facilitate improvements in quality and improved exchange with col- leagues in the same field who may have a different or special exper- tise in certain areas. It also serves the improvement of communica- tion with hospitals, both internally and across larger distances,’ explains Professor Hans-Peter Sinn MD, who works at the Institute of Pathology at Heidelberg University Hospital. Telemedicine in pathology used to be termed ‘telepathology’. But this only means that a diagnosis is carried out over a certain distance for conventional preparations. It has a historical background, as there were efforts in the 1990s to trans- mit diagnostic images via bundled ISDN lines or similar, i.e. using out- dated means that have long been abandoned due to the unsatisfac- tory technology and limited validity. Pathology and, in particular, tumour pathology, is increasingly integrating non-morphological procedures such as NGS (next generation sequenc- ing) on which classifications are dependent. Histological prepara- tions are now primarily digitised and made available by the server via virtual microscopy. ‘The term ‘digital pathology’ not only comprises the transmission of images but also their metadata and additional informa- tion concerning the case, which the pathologist can use to gain a more complex understanding than with a microscopic image alone,’ Professor Sinn explains. Digitisation in pathology facilitates improved standardisation, transpar- ency and digital archiving of micros- copy. However, there is also another important factor. ‘Telemedicine in pathology allows the networking of pathologists with one another in an uncomplicated way, particu- larly with regards to specialist areas of expertise. There are networks for haematopathology and gynaeo- copathology where content about histological preparations, research concepts or molecular procedures can be exchanged,’ Sinn reports. Telemedicine not only concerns patients and individual cases but also includes continued education, quality circles, lecture series, tumour registers and reference centres. Is everything positive, then? By no means! ‘The process of digitisation is unstoppable, but in the case of rou- tine pathology has only just begun and poses particular challenges to this field. This concerns, for instance, the lack of standardisation of platforms, image formats and interfaces of vir- tual microscopy with pathology- and hospital information systems. Currently, there is also a lack of non-proprietary solutions for the networking of subsystems for molec- ular pathology as well as immuno- histochemistry.’ Furthermore, financial aspects also play an important role. It would be misleading to assume that digi- talisation and electronic provision of histological preparations and results definitely lowers costs per se by, for example, assuring that duplicate examinations are avoided. ‘This is not actually the case with digital pathology,’ says the expert, and sub- stantiates this. ‘Digitising histological prepara- tions, or other pathological findings and making them available electron- ically for transmission if necessary, involves higher costs. We depend on the conventional histological, immu- nohistological and molecular meth- ods and then we have to digitise them in a secondary procedure. Therefore, digitisation is a sec- ondary, expensive step. These days it is still easier and cheaper to put samples into envelopes and send them off. The costs of digital pathol- ogy are in the high six-figure range and therefore significantly higher than exchanging preparations in the conventional way.’ The amounts of data that need processing are a further problem: ‘Due to the micro- scopic resolution needed, the image data takes up a lot more storage space than data stored in radiology, for instance. A single histological preparation, once digitised, converts into around one gigabyte of data. If we want to digitise our entire microscopic diagnostics we would generate several hundred terabytes of data a year and, over a period of several years for routine image docu- mentation in microscopy for just one institute, would end up in the peta- byte range. This is another reason why digitisation in pathology is still a lot less common and standardised than in other areas of medicine,’ the expert points out. Sinn is essentially in favour of further digitisation, which, as said, he believes to be unstoppable. However, he warns against being naïve about this: ‘The introduction of telemedicine on a broader scale pri- marily improves the quality of care, and only secondarily the efficiency. ‘In the future this is going to result in the opportunity to work more objectively and in a more networked manner through the increased digiti- sation of medical results. Therefore, the patient has the potential advan- tage of improved care, but higher costs and significantly increased expenditure regarding time and resources are limiting factors, par- ticularly for pathology.’ Higher costs and increased expenditure on time and resources are limiting factors Telemedicine in pathology Telepathological depiction of a breast tumour in virtual microscopy Professor Hans-Peter Sinn MD, from the Division of Gynaecopathology, Heidelberg University Hospital

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