An Overview of Digital Slides, hardware and software

Dražen JukiĆ M.D., Ph.D.

Who are we

• 150 pathology faculty• 21 hospitals• 3 flagship hospitals• 250,000 specimens per year• Residency program• Medical school • Histotechnology school

Programs

• UPMC IMITS– Collaboration with DOD– Help implementation of digital pathology

in Air Force • Vendor study challenge• Multiple other studies• APIII

Histopathology

Typical High-End Optical Microscope

Pathology Terms

• H&E – hematoxylin and eosin• S/O – sign-out; the process of reading slides and

creating the report and finalizing the report• IHC – immunohistochemistry• Grossing – the process of cutting a specimen in

preparation for histologic processing• Turnaround time – the time elapsed between

specimen reception and final reporting; a measure of pathology department’s efficiency

Pathologic Examination Today

• Hematoxylin and Eosin (H&E) is the core– DNA (nucleus) = Purple– Protein (cytoplasm) = pink– All decisions based on this: focus here

• Immunohistochemistry (IHC)– Application of stains to the tissue that turn different colors based on

chromogen– “black and white”, positive or negative– Some exceptions (Her2, Ki-67%)

• ‘Special’ Studies– Largely +/- as well– Special needs: polarized light

• Amyloid• Foreign bodies• crystals

H/E scanning magnification (20-40X)

H/E high power magnification (400X)

H&E examination with an optical microscope

• 1X – gross exam• 20X scanning magnification

– Examine overall architecture of lesion• 40X, 100X, 200X,• 400X

– Examine fine cytologic details (5-6 µm) – High power examination typically requires use

of a condenser– Most digital imaging systems fail here

Immunostain Special stain

Imaging

• Multiple imaging areas in medicine:– Radiology;– Pathology;– Dermatology;– Colonoscopy, esophagoscopy, etc …– Nuclear medicine;– Etc.

Imaging

• How do we image?– Proprietary hardware;– Proprietary software;– Off-the shelf hardware;– Off-the shelf software;– No software;– Home-brewed software.

How we use images today• Static images – field of view snap shots (jpeg,

tiff)– Gross images to aid in 3D reconstruction– Selected diagnostic fields archived and stored in

APLIS for future reference – avoid slide pulls – Attached to S/O reports which are distributed to our

customers (gimmick but now being used as a competitive market tool to some extent)

– Q/A conferencing (Neuropathology @ UPMC)– Shuffled around on web for UNOFFICIAL

consultations– EDUCATIONAL TOOL

Nationwide

• CAP has awoken from a long slumber– Initiative to integrate molecular medicine;

– Initiative to integrate digital pathology;• Whole slide imaging, for education and QA• Radiologic or quasi-radiologic methods to help

image bodies for (or before) autopsy procedures;– Issue of reimbursement

Process of Image acquisition (ie workflow integration)

• Field is selected by pathologist• Image entry function is opened on APLIS

– Image acquisition GUI is started with real time image monitoring on screen

– Image is ‘focused on the screen’– Image acquired and saved in APLIS with

generic name• Too many keystrokes

– Image is manually annotated if needed

Implementing a Field of View Capture Strategy

• 3rd party camera and software navigated through APLIS (TWAIN)

• Images stored and managed in APLIS as part of patient profile

• Possibly images exported to PACS wrapped in DICOM as directed by APLIS – no extra data entry by user

Opportunities for Field of View Image Taking within an APLIS

• Creation of a Q/A module – Avoid massive amounts of slide pulls and

transportation of slides• Creation of a Conferencing module

– Avoid exporting images • Creation of Consultation module

– Avoid shuffling around slides to colleagues

AP - LIS

How we use images today

• Dynamic images (whole slide imaging systems, any navigable image)– EDUCATIONAL TOOL** (Trestle/Zeiss, Aperio)– Remote telepathology (Nikon or Trestle robot over the

web)• Real time intra-operative consultation

– US Labs ‘Model’• Reference Lab in southern CA posting reports including

graphical data and images for referring pathologists to review and make additional orders over the web

Implementing a Whole Slide Imaging (WSI) Strategy - Challenges and Opportunities

• MUST be able to reproduce the H&E experience– Quality of image: granularity, depth, quality of eosin

(all the shades of pink)– Usability of Interface

• Touch screen?• Voice navigation?• Google maps style model in use today

– 2.5GB per square cm of digital tissue (uncompressed), 115MB compressed

• 80,000 surgical cases per year with 2-20 slides each

WSI - Opportunities

• Digital Enhancements– Digital polarization (foreign bodies, crystals)– Detection and Quantification of Abnormal

elements (AI)• Counting mitoses• Counting lymphocytes• Pleomorphism index?

– Enhancements of elements that don’t stain well with H&E

• Fungal forms

WSI - Challenges • H&E staining is NOT standardized

– Different quantities and qualities of H and E in different labs• ‘Easy’ diagnoses tend to be easy to image

– Low power exam (skin lesions)• ‘Hard’ diagnoses tend to be hard to image

– Reactive vs. neoplastic ( Is this an abscess or am I missing something [real case])

– Giant cell lesions, reactive bone vs. neoplasm– Atypical melanocytic neoplasms

• Maybe one approach is to triage and do extra imaging on ‘hard’ cases – ie one imaging approach may not work for all lesions - retain flexibility

WITH CONDENSER

NO CONDENSER

‘Easy’ diagnoses, low power

‘Hard’ diagnoses – patterns look similar on low power (architecture)high power exam may reveal subtle differences

Foreign body granuloma - REACTIVEGiant cell tumor - NEOPLASM

Robots …

More robots

40

Founded in 1999; HQ in Vista (CA); Staff of 100+

“Technology & Market Share Leader” ~ 300 systems in multiple countries 8 large pharnmaceutical companies Multiple systems at largest reference labs

Provide Systems and Services for Digital Pathology• ScanScope® Slide Scanners• Spectrum™ Digital Pathology Information Management Software• Services

30+ issued and pending patents

Aperio

Aperio Continued

OLYMPUS / BACUS LABS

Digital Slide Scanner

– High throughput rapid scanning– 210 slide loading capacity– Whole Slide or Region of Interest (ROI)– Batch scanning begins 20x and 40x always available

• Manual, Semi Automatic & Automatic

– Scans each slide at 20x in less than 4 minutes, 40x scans in 8 mins (20mm x 20mm size sample)

• We have experienced some scans 6+ minutes at 20 x – depends on the tissue size

– Scans using 3 CCD 4096 x 64 pixel TDI sensors– 1 x 3 glass slides only– Barcode capable both 1D and 2D – Fluorescence scanning – tested in UPMC

• 3 Filters available (FITC, TxRed, Triple)– Z-Stack Capture now available

• Did not test it yet.

Hamamatsu NanoZoomer

Virtual Slide ViewersActiveX based• Single Pane• Works with Internet Explorer• Many options for changing objectives

including right click, drop down menu, and the mouse wheel

• Open multiple WebSlide windows simultaneously

WebSlide Finder•Utilizes ActiveX•Two modes: Workflow and Education•WebSlide Conferencing•Detailed metadata and descriptions are included or can be added using SlideTray•Keyword and multiple keyword searches•Simple window navigation with F keys•Save snapshots using CTRL+C

Virtual Slide ViewersJava

•For Mac/Linux users•Right click to change magnification (apple key + mouse click)•Outline for high power only in thumbnail•Thumbnail is static

WebSlide Browser•WebSlide Synchronization & Chat Room•Annotation Tools including arrows, lines, boxes, and text•Exporting feature for Area and Tape measurements•WebSlide Link Creator- for emailing WebSlides•ActiveX & Applet Creator for Web Pages & PowerPoint Presentations

ZEISS / TRESTLE

• Small footprint

• 20x Plan-Apo objective with 0.8 NA

• Image capture from barcode area w/ barcode identification

• Optional 40x Plan-Apo objective with 0.95 NA

• Choice of different camera adaptors (1x or 0.63x)

• Optovar option (1.25x and 1.6x)

• Fluorescence option

Resolution range from 0.11 µm/pixel ... 0.52 µm/pixel

MIRAX Scanner

• Robotic Telepathology functionality, including focal control, condenser settings

• Scalable to Digital Whole Slide Acquisition with user selectable Objective (4, 10, 20, 40, 60)

• Multi-focal plane imaging and robust focus technology ensures for robust imaging capability.

• Automated Slide Handling of 1, 4, 50 slides

• Fluorescence Multi-Channel Capable

MIRAX Micro Robotic Scanner

BIOIMAGENE

BioImagene, Inc. Founded in Jan 2003, HQ in Silicon Valley,

software development and research center in Pune, India

Acquired Scimagix Inc, leader in Image Management in Nov 2004

Acquired TissueInformatics Inc, leader in toxicological image analysis provider in June 2006.

1000+ users

Total Digital Pathology Solution

Breast Panel Analysis

Prostate Panel Analysis

Colon Panel Analysis

IHC Membrane Quantification

IHC Cytoplasmic Quantification

IHC Nuclear Quantification

Pathiam™/TissueMine™

Digital Pathology Application

On board the iScan

Summary• Where do I envision imaging in MY practice

tomorrow?– In creation of image-based based educational

modules;– In creation of image-based QA tool;– In creation of image-based consult backup database;

• Today– Five major trials completed.– We are NOT trying to replace a microscope!