Setting Up an ePathology Service at Cleveland Clinic Abu Dhabi: Joint Collaboration With Cleveland Clinic, United States.

CONTEXT.­: The production of whole slide images is the most advanced form of digital pathology, in which a high-resolution digital scanner is used to rapidly scan glass microscope slides and produce a computer-generated whole slide image that can be saved, stored in a network-attached storage device, and accessed through slide management software within the hospital domain and remotely by authorized users. Digital transformation of glass slides has revolutionized the practice of anatomic pathology by facilitating and expediting consultative services, improving clinical workflow, and becoming an indispensable tool in education and research. OBJECTIVE.­: To highlight the institutional need of Cleveland Clinic Abu Dhabi (Abu Dhabi, United Arab Emirates) and the cultural background for obtaining the United Arab Emirates' first comprehensive digital pathology program; to describe a multiphase road map for achieving full implementation of this platform; and to describe the system's clinical applications and its future potential growth. DATA SOURCES.­: At Cleveland Clinic Abu Dhabi, we prioritized our efforts to initiate digital consultations (eConsultations) and digital immunohistochemistry services (eIHC) with Cleveland Clinic Laboratories (Cleveland, Ohio). After this, we established an internal archiving system together with a subspecialty-based, organ-specific digital library of pathologic diseases. CONCLUSIONS.­: We describe the strategic adoption and implementation of digital pathology into the clinical workflow of the pathology and laboratory medicine institute of Cleveland Clinic Abu Dhabi, and we highlight its impact on clinical operations, educational activities, and patient care.

Validation of whole slide imaging for frozen section diagnosis in surgical pathology.

BACKGROUND: Whole slide imaging (WSI) using high-resolution scanners is gaining acceptance as a platform for consultation as well as for frozen section (FS) evaluation in surgical pathology. We report results of an intra-observer concordance study comparing evaluation of WSI of scanned FS microscope slides with the original interpretation of the same microscope slides after an average lag time of approximately 1-year. METHODS: A total of 70 FS cases (148 microscope slides) originally interpreted by 2 pathologists were scanned at ×20 using Aperio CS2 scanner (Leica Biosystems, San Diego, CA, USA). Reports were redacted such that the study pathologists reviewed images using eSlide Manager Healthcare Network application (Leica Biosystems) accompanied by the same clinical information available at the time of original FS evaluation. Discrepancies between the original FS diagnosis and WSI diagnosis were categorized as major (impacted patient care) or minor (no impact on patient care). RESULTS: Lymph nodes, margins for head and neck cancer resections, and arthroplasty specimens to exclude infection, were the most common FS specimens. The average wash-out interval was 380 days (range: 303-466 days). There was one major discrepancy (1.4% of 70 cases) where the original FS was interpreted as severe squamous dysplasia, and the WSI FS diagnosis was mild dysplasia. There were two minor discrepancies; one where the original FS was called focal moderate squamous dysplasia and WSI FS diagnosis was negative for dysplasia. The second case was an endometrial adenocarcinoma that was originally interpreted as Federation of Gynecology and Obstetrics (FIGO) Grade I, while the WSI FS diagnosis was FIGO Grade II. CONCLUSIONS: These findings validate and support the use of WSI to provide interpretation of FS in our network of affiliated hospitals and ambulatory surgery centers.

Validating whole-slide imaging for consultation diagnoses in surgical pathology.

CONTEXT: The interpretation of scanned whole-slide images (WSI) offers some theoretical advantages for long-distance, consultative diagnosis in surgical pathology. Few WSI validation studies have focused on difficult consultation cases. OBJECTIVE: To test intraobserver variability of WSI interpretations in cases that had been submitted for consultation using the same hardware and software configuration selected by a client. DESIGN: The 217 cases (approximately 20 nearly consecutive cases received in consultation for each of 11 subspecialty groups) were scanned, uploaded to an image-distribution application, and interpreted by 26 pathologists who had reviewed the microscope slides an average of 47 days earlier. Independent pathologists identified and classified discrepancies between microscope slide and WSI diagnoses. RESULTS: There were 2 major discrepancies (0.92%) and 8 minor discrepancies (3.7%). One major discrepancy reflected atypical versus nonatypical endometrial hyperplasia; the other related to reactive squamous changes versus carcinoma. Strengths of the study include the large sample size, the many pathologists involved, the degree of difficulty of the cases, and the duplication of scanning and software configuration projected to be used by a client. Although the average 43-day washout exceeds the 2-week interval recommended by an expert panel of the College of American Pathologists, an important limitation in this study was that pathologists commonly remember consultation cases for a long time. CONCLUSION: Our results help support the safety and efficacy of WSI for surgical pathology diagnoses.

Validation of whole slide imaging for primary diagnosis in surgical pathology.

CONTEXT: High-resolution scanning technology provides an opportunity for pathologists to make diagnoses directly from whole slide images (WSIs), but few studies have attempted to validate the diagnoses so obtained. OBJECTIVE: To compare WSI versus microscope slide diagnoses of previously interpreted cases after a 1-year delayed re-review ("wash-out") period. DESIGN: An a priori power study estimated that 450 cases might be needed to demonstrate noninferiority, based on a null hypothesis: "The true difference in major discrepancies between WSI and microscope slide review is greater than 4%." Slides of consecutive cases interpreted by 2 pathologists 1 year prior were retrieved from files, and alternate cases were scanned at original magnification of ×20. Each pathologist reviewed his or her cases using either a microscope or imaging application. Independent pathologists identified and classified discrepancies; an independent statistician calculated major and minor discrepancy rates for both WSI and microscope slide review of the previously interpreted cases. RESULTS: The 607 cases reviewed reflected the subspecialty interests of the 2 pathologists. Study limitations include the lack of cytopathology, hematopathology, or lymphoid cases; the case mix was not enriched with difficult cases; and both pathologists had interpreted several hundred WSI cases before the study to minimize the learning curve. The major and minor discrepancy rates for WSI were 1.65% and 2.31%, whereas rates for microscope slide reviews were 0.99% and 4.93%. CONCLUSIONS: Based on our assumptions and study design, diagnostic review by WSI was not inferior to microscope slide review (P < .001).