Leveraging technology to transform Anatomic Pathology

Eye on Innovation

In January, as part of Mayo Clinic’s Digital Pathology Program, the Division of Anatomic Pathology in Mayo’s Department of Laboratory Medicine and Pathology in Rochester, Minnesota, transitioned a significant portion of its clinical practice, including both surgical and biopsy cases, into digital workflows.

The transition means all surgical — or frozen section — biopsy slides will be scanned into digital images prior to a pathologist’s review. Historically, patient tissue has been evaluated by generating glass slides, applying stains, and evaluating them with a microscope. Scanning slides digitally allows pathologists to take action that previously required a series of physical handoffs within analog workflows before it could be completed.

While converting glass slides into digital images means adding about one hour to each case, Joaquin Garcia, M.D., medical director of the Digital Pathology Program, believes the overarching gains are worth that investment. “In exchange for time, we get a digital format that we can share frictionlessly between medical secretaries, residents and fellows, and multiple consultants,” he says.

Joaquin Garcia, M.D.

“Also, if a consultant needs a specialty opinion, he or she can seek that from another colleague down the hall, or by leveraging digital image access to Mayo Clinic consultants in Arizona, Florida, Rochester, and the Mayo Clinic Health System. Once the slides are scanned, we can share these digital images and really bring exponential expertise to that case within seconds.”      

Enhancing consultation

The successful transition from glass slides to digital has taken enormous collaboration, and has included staff in the Histology Lab, Immunostains Lab, and the new Anatomic Pathology Digital Scanning Labs, as well as pathology reporting specialists. And pathologists now are adapting to and incorporating the new equipment and system into their practices.

But again, the effort is worth the investment. For example, Gary Keeney, M.D., co-director of the Anatomic Pathology Frozen Section Laboratory, is already seeing promise from digital scanning in what he calls the “curbside consult” practice. “Fifty percent of our work is consultative, and we have one practice in Wisconsin with which we’re piloting a consult service line in a digital environment,” he says. “It’s been a lot of fun because, when I get a notification that I have a consult, I can usually look at that case really quickly.”

Gary Keeney, M.D.

The digital images often provide him with all the information he needs for the consult.

“If you’re operating with that kind of efficiency, you’re cutting almost two days off the turnaround time on a consult case,” Dr. Keeney says. “In this way, we’re able to handle the case without waiting for the slides or repeating special studies.”

Improving learning

In the analog world, pathology trainees previously had to wait for pathology reporting specialists to hand them cardboard folders full of glass slides called “flats.” Next, they marked areas of interest on the glass slides and wrote notes and questions on a paper printout. They would then hand the flats and paperwork off to the consulting pathologist. Now, residents and fellows are working totally within the digital system, which allows for more precise annotation. If a trainee has specific comments on a digital slide, they can mark that area on the image and annotate it.

“It’s really efficient from a teaching perspective for our trainees to know exactly what they are looking at, which helps them dial in their questions,” Dr. Keeney says. “In the past, we would dot an area in the slide. You could never get the dot exactly where it was supposed to be, and it can be time consuming. But with a digital image, you can pinpoint it, which makes it really nice. Because sometimes the trainees will miss things. Now, I can circle a positive margin, for example, and say, ‘Hey take another look at this.’ It really enriches the back-and-forth between consultant and trainee.”

Another bonus of digital images? They don’t deteriorate over time, unlike glass slides in which hematoxylin and eosin are used to stain tissue samples. The deterioration of glass slide specimens means they are viewable only for a limited time. After that, the sample needs to be recut and stained, which requires more time and effort from laboratory staff.

Playing the long game

Anatomic Pathology processes several hundred biopsies a day from patients at Mayo Clinic’s hospitals. After a patient undergoes a biopsy, diagnostic and treatment decisions are often made by the clinical team within 24 to 48 hours. Some of these are Frozen Section Laboratory (surgical) cases, where patient organs and tissues are evaluated during an operation. This allows the pathologist to communicate with the surgical team in real time, addressing issues such as disease classification and surgical margin status. The following day, the pathologist confirms the intraoperative interpretations using glass slides — or digital images.

For these biopsy and surgical cases, the full benefits of the digital transformation will come to fruition over time, as the image archive becomes more robust.

“To benefit from the longer-term big wins, we must transition to a digital ecosystem, including workflows, that will allow us to deploy AI into our pathology practice,” Dr. Garcia says.

Artificial intelligence algorithms can identify and recognize lesional cells and tissue, aiding the pathologist in the classification of disease and crafting a report.

Dr. Garcia continues: “For example, we can incorporate an algorithm into practice that prescreens prostate biopsy slides, identifying and quantifying cancer cells when present. Installing this algorithm into the clinical workflow empowers specialists to work more efficiently and generate more accurate reports. The roles of the pathologist will not be supplanted by AI. He or she will still make ultimate determinations on histopathologic parameters, such as perineural invasion, lymphovascular invasion, and Gleason grade.”

And old-school analog may never completely disappear from pathology practice. “I think it’s going to be highly individualized as to how people approach this,” Dr. Keeney says. “I suspect there will always be a case here and there where the pathologist still wants to look at a glass slide. But I can see where artificial intelligence will come in down the road.”

He offers an example of 20 glass slides of lymph nodes that are negative for tumor, with a pathologist attempting to find just a few tumor cells in one of those nodes.

“In the digital environment, you could have an algorithm that has already looked at those 20 slides and shows you the five most likely micrometastases,” Dr. Keeney says. “It will take you right to those five possibilities, so you can view the digital images. Clearly, AI is going to assist pathologists in some of these diagnostic problems that we face.”

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Chris Bahnsen

Chris J. Bahnsen covers emerging research and discovery for Mayo Clinic Laboratories. His writing has also appeared in The New York Times, Los Angeles Times, and Smithsonian Air & Space. He divides his time between Southern California and Northwest Ohio.