Digital pathology for intraoperative frozen section diagnosis of thoracic specimens: an evaluation of a system using remote sampling and whole slide imaging diagnosis

BackgroundDigital pathology is now used for primary diagnostic work as well as teaching, research and consultation. In our multisite institution service reorganisation led to histopathology being located in a separate hospital from some surgical specialities. We implemented remotely supervised specimen sampling and frozen section diagnosis using digital pathology. In this study we assessed the concordance of glass and digital slide diagnosis using this system.MethodsWe reviewed cases from the first 2 years of digital frozen section reporting at our institution. Cases with potential digital to glass slide discordance were reviewed by three experienced thoracic histopathologists. The reasons for discordance were determined and common themes identified. We also reviewed critical incidents relating to digital pathology during the study period.ResultsThe study population comprised 211 cases. Frozen section to final diagnosis concordance between digital and glass slide diagnosis was found in 196 (92.6%) cases. The 15 potentially discordant cases were reviewed. Intraobserver concordance between glass and digital slide review ranged from 9/15 to 12/15 cases across the three pathologists. Glass slide review diagnosis showed better concordance with ground truth in two cases; digital slide review was more accurate in two cases. One relevant critical incident was identified during the study period.DiscussionThis is the largest study to examine digital pathology for thoracic frozen section diagnosis and shows that this is a safe and feasible alternative to glass slide diagnosis. Discordance between digital and glass slide diagnoses were unrelated to the processes of whole slide imaging and digital microscopy.

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Clinical digital neuropathology: experience and observations from a departmental digital pathology training programme, validation and deployment

Journal of Clinical Pathology ◽

10.1136/jclinpath-2019-206343 ◽

2020 ◽

pp. jclinpath-2019-206343 ◽

Cited By ~ 1

Author(s):

Bethany Jill Williams ◽

Azzam Ismail ◽

Arundhati Chakrabarty ◽

Darren Treanor

Keyword(s):

Frozen Section ◽

Digital Pathology ◽

Ground Truth ◽

Training Programme ◽

Primary Diagnosis ◽

Glass Slide ◽

Digital Slide ◽

Neuropathological Diagnosis ◽

Pathology Training ◽

Diagnostic Pitfalls

AimTo train and individually validate the neuropathologists in digital primary diagnosis and frozen section reporting using a novel protocol endorsed by the Royal College of Pathologists. The protocol allows early exposure to live digital reporting in a risk mitigated environment.MethodsTwo specialist neuropathologists completed training in the use of a digital microscopy system for primary neuropathological diagnosis and frozen section assessment. Participants were exposed to training sets of 20 histology cases and 10 frozen sections designed to help them identify their personal digital diagnostic pitfalls. Following this, the pathologists viewed 340 live, complete neuropathology cases. All primary diagnoses were made on digital slides with immediate glass slide reconciliation before final case sign-out.ResultsThere was 100% clinical concordance between the digital slide and glass slide assessment of frozen section cases for each pathologist, and these assessments corresponded with the ground truth diagnoses obtained from examination of definitive histology. For primary diagnosis, there was complete clinical concordance between digital slide and glass slide diagnosis in 98.1% of cases. The majority of discordances were related to grading differences attributable to mitotic count differences.ConclusionNeuropathologists can develop the ability to make primary digital diagnosis competently and confidently following a course of individual training and validation.

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Experience with a Dynamic Inexpensive Video-Conferencing System for Frozen Section Telepathology

Analytical Cellular Pathology ◽

10.1155/2000/908426 ◽

2000 ◽

Vol 21 (3-4) ◽

pp. 169-175 ◽

Cited By ~ 18

Author(s):

J. P. A. Baak ◽

P. J. van Diest ◽

G. A. Meijer

Keyword(s):

Image Quality ◽

Frozen Section ◽

Video Conferencing ◽

Final Diagnosis ◽

Complete Agreement ◽

Frozen Sections ◽

Predictive Values ◽

Video Conferencing System ◽

Frozen Section Diagnosis ◽

Conferencing System

Aim: To evaluate the feasibility of an inexpensive, generally applicable video‐conferencing system for frozen section telepathology (TP).Methods: A commercially widely available PC‐based dynamic video‐conferencing system (PictureTel LIVE, model PCS 100) has been evaluated, using two, four and six ISDN channels (128–384 kilobits per second (kbs)) bandwidths. 129 frozen sections have been analyzed which were classified by TP as benign, uncertain (the remark probably benign, or probably malignant was allowed), malignant, or not acceptable image quality. The TP results were compared with the original frozen section diagnosis and final paraffin diagnosis.Results: Only 384 kbs (3 ISDN‐2 lines) resulted in acceptable speed and quality of microscope images, and synchronous image/speech transfer. In one of the frozen section cases (0.7%), TP image quality was classified as not acceptable, leaving 128 frozen sections for the analysis. Five of these cases were uncertain by TP, and also deferred by frozen section procedure (FS). One more benign and three malignant FS cases were classified as uncertain by TP. Three additional cases were uncertain by FS, but benign according to TP (in agreement with the final diagnosis). In one case, FS diagnosis was uncertain but TP was malignant (in agreement with the final diagnosis). Thus, test efficiency (i.e., cases with complete agreement) was 120/128 (93.8%, Kappa = 0.88) between FS and TP. Sensitivity was 93.5%, specificity 98.6%, positive and negative predictive values were 97.7% and 96.0%. Between TP and final diagnosis agreement was even higher. More importantly, there was not a single discrepancy as to benign‐malignant. Moreover, there was a clear learning effect: 5 of the 8 FS/TP discrepancies occurred in the first 42 cases (5/42=11.9%), the remaining 3 in the following 86 cases (3/86=3.5%).Discussion: The results are encouraging. However, TP evaluation is time‐consuming (5–15 min for one case instead of 2–4 min although speed went up with more experience) and is more tiring. The system has the following technical drawbacks: no possibility to point at objects or areas of interest in the life image at the other end, resolution (rarely) may become suboptimal (blocky), storage of images evaluated (which is essential for legal reasons) is not easy and no direct control of a remote motorized microscope. Yet, all users were positive about the system both for telepathology and personal contact by video‐conferencing. Conclusion: With a relatively simple videoconferencing system, accurate dynamic telepathology frozen section diagnosis can be obtained without false positive or negative results, although a limited number of uncertain cases will have to be accepted.

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Analysis of frozen section in correlation with surgical pathology diagnosis

International Journal of Research in Medical Sciences ◽

10.18203/2320-6012.ijrms20192519 ◽

2019 ◽

Vol 7 (6) ◽

pp. 2312

Author(s):

Ashwini Tangde ◽

Vaidik Shrivastava ◽

Anil Joshi

Keyword(s):

Frozen Section ◽

Final Diagnosis ◽

Surgical Pathology ◽

Histopathological Diagnosis ◽

Pathology Laboratory ◽

Medical College ◽

Incorrect Diagnosis ◽

Frozen Section Diagnosis ◽

Sensitivity Specificity ◽

Suspected Lesion

Background: Frozen section (FS) is a rapid diagnostic procedure performed on tissues obtained intraoperatively. This method serves useful purposes, such as determining the malignancy or benignancy of a suspected lesion, determining the adequacy of a biopsy of a suspected lesion, confirming the presence or absence of metastasis, and identifying small structures. But it bears many disadvantages and limitations, the most of which is the danger of incorrect diagnosis. Therefore, it is critical to determine efficiency of frozen section performance periodically. This study was performed to determine accuracy of frozen section by correlating the intra-operative frozen section diagnosis with final diagnosis on permanent sections.Methods: In this retrospective study, authors compared the results of frozen section with their final permanent section diagnosis in Government Medical College and Hospital, Aurangabad, Maharashtra, India during January 2017 to December 2018.Results: Study comprises 83 patients, of which 73 were female and 10 were male. Out of 83 cases, the diagnosis of 76 cases was concordant with conventional histopathology diagnosis while seven were discordant. This gave overall accuracy rate of 91.57% and discordant rate of 8.43%. The overall sensitivity was 85.71% and specificity was 97.92%. The positive predictive and negative predictive value was 96.77% and 90.38% respectively.Conclusions: The accuracy, sensitivity, specificity of frozen section diagnosis in this study are comparable with most international quality control statistics for frozen sections. The results suggest that the correlation of intra-operative frozen section diagnosis with the final histopathological diagnosis on permanent sections forms an integral part of quality assurance activities in the surgical pathology laboratory and specific measures should be taken to reduce the number of discrepancies.

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Borderline ovarian tumor frozen section diagnoses with features suspicious of invasive cancer: a retrospective study

Journal of Ovarian Research ◽

10.1186/s13048-021-00897-8 ◽

2021 ◽

Vol 14 (1) ◽

Author(s):

Koen De Decker ◽

Karina H. Jaroch ◽

Joost Bart ◽

Loes F. S. Kooreman ◽

Roy F. P. M. Kruitwagen ◽

...

Keyword(s):

Ovarian Tumor ◽

Invasive Carcinoma ◽

Frozen Section ◽

Paraffin Section ◽

Final Diagnosis ◽

Borderline Ovarian Tumor ◽

Histopathological Diagnosis ◽

Frozen Section Diagnosis ◽

Histologic Subtypes ◽

Section Evaluation

Abstract Background A frozen section diagnosis of a borderline ovarian tumor with suspicious features of invasive carcinoma (“at least borderline” or synonymous descriptions) presents us with the dilemma of whether or not to perform a full ovarian cancer staging procedure. Quantification of this dilemma may help us with the issue of this clinical decision. The present study assessed and compared both the prevalence of straightforward borderline and “at least borderline” frozen section diagnoses and the proportion of these women with a final histopathological diagnosis of invasive carcinoma, with a special interest in histologic subtypes. Methods A retrospective cohort study was performed in three hospitals in The Netherlands. All women that underwent ovarian surgery with perioperative frozen section evaluation in one of these hospitals between January 2007 and July 2018 were identified and included in case of a borderline or “at least borderline” frozen section diagnosis and a borderline ovarian tumor or invasive carcinoma as a final diagnosis. Results A total of 223 women were included, of which 41 women (18.4%) were diagnosed with “at least borderline” at frozen section. Thirteen of forty-one women (31.7%) following “at least borderline” frozen section diagnosis and 14 of 182 women (7.7%) following a straightforward borderline frozen section diagnosis were diagnosed with invasive carcinoma at paraffin section evaluation (p < 0.001). When compared to straightforward borderline frozen section diagnoses, the proportion of women diagnosed with invasive carcinoma increased from 3.1 to 35.7% for serous tumors (p = 0.001), 10.0 to 21.7% for mucinous tumors (p = 0.129) and 50.0 to 75.0% (p = 0.452) in case of other histologic subtypes following an “at least borderline” frozen section diagnosis. Conclusions Overall, when compared to women with a decisive borderline frozen section diagnosis, women diagnosed with “at least borderline” frozen section diagnoses were found to have a higher chance of carcinoma upon final diagnosis (7.7% vs 31.7%). Especially in the serous subtype, full staging during initial surgery might be considered after preoperative consent to prevent a second surgical procedure or chemotherapy in unstaged women. Further studies are needed to evaluate whether additional sampling in case of an “at least borderline” diagnosis may decrease the risk of surgical over-treatment.

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Digital pathology is a practical alternative to on‐site intraoperative frozen section diagnosis in thoracic surgery

Histopathology ◽

10.1111/his.13804 ◽

2019 ◽

Vol 74 (6) ◽

pp. 902-907 ◽

Cited By ~ 4

Author(s):

Jonathan M R French ◽

Daniel T Betney ◽

Udo Abah ◽

Nidhi Bhatt ◽

Eveline Internullo ◽

...

Keyword(s):

Thoracic Surgery ◽

Frozen Section ◽

Digital Pathology ◽

Intraoperative Frozen Section ◽

Frozen Section Diagnosis

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Implementation of Whole Slide Imaging for Clinical Purposes: Issues to Consider From the Perspective of Early Adopters

Archives of Pathology & Laboratory Medicine ◽

10.5858/arpa.2016-0074-oa ◽

2017 ◽

Vol 141 (7) ◽

pp. 944-959 ◽

Cited By ~ 44

Author(s):

Andrew J. Evans ◽

Mohamed E. Salama ◽

Walter H. Henricks ◽

Liron Pantanowitz

Keyword(s):

Transition Period ◽

Clinical Laboratory ◽

Panel Discussion ◽

Digital Pathology ◽

Primary Diagnosis ◽

Glass Slide ◽

Whole Slide Imaging ◽

Early Adopters ◽

Implementation Team ◽

Intended Use

Context.— There is growing interest in the use of digital pathology, especially whole slide imaging, for diagnostic purposes. Many issues need to be considered when incorporating this technology into a clinical laboratory. The College of American Pathologists (CAP) established a Digital Pathology Committee to support the development of CAP programs related to digital pathology. One of its many initiatives was a panel discussion entitled “Implementing Whole-Slide Imaging for Clinical Use: What to Do and What to Avoid,” given for 3 years at the CAP annual meetings starting in 2014. Objectives.— To review major issues to consider when implementing whole slide imaging for clinical purposes as covered during the panel discussion. Design.— The views expressed and recommendations given are based primarily on the personal experience of the authors as early adopters of this technology. It is not intended to be an exhaustive review of digital pathology. Results.— Implementation is best approached in phases. Early efforts are directed toward identifying initial clinical applications and assembling an implementation team. Scanner selection should be based on intended use and budget. Recognizing pathologist concerns over the use of digital pathology for diagnostic purposes, ensuring adequate training, and performing appropriate validation studies will enhance adoption. Once implemented, the transition period from glass slide to image-based diagnostics will be associated with challenges, especially those related to a hybrid glass slide–digital slide workflow. Conclusions.— With appropriate preparation, planning, and stepwise implementation, whole slide imaging can be used safely and reliably for frozen sections, consultation, quality assurance, and primary diagnosis.

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Diagnostic accuracy value of intraoperative frozen section for ovarian neoplasms

10.21203/rs.3.rs-19106/v1 ◽

2020 ◽

Author(s):

Farinaz Shahmoradi ◽

Maliheh Arab

Keyword(s):

Diagnostic Accuracy ◽

Medical Records ◽

Ovarian Neoplasms ◽

Frozen Section ◽

Final Diagnosis ◽

Intraoperative Frozen Section ◽

Frozen Section Diagnosis ◽

Accuracy Study ◽

Extent Of Surgery ◽

Histopathology Examination

Abstract Background Accuracy of intraoperative frozen section diagnosis is extremely important in the evaluation of ovarian tumors so that suitable surgical procedures can be chosen. Methods This retrospective diagnostic accuracy study was conducted in the Department of Obstetrics and Gynecology, Emam Hossein Hospital. The case records of patients with ovarian mass who underwent surgery and intraoperatively frozen section assessments between September 2006 and December 2014 were analyzed. Demographic and clinical data, operative details, frozen section and final histopathology Examination (HPE) were reviewed from the medical records. Results one hundred and ninety three patients with ovarian masses undergoing surgery and frozen section were included. The frozen section diagnoses were benign in 155 (80.31%), borderline in 10 (5.18%), and malignant in 28 (14.51%), whereas the final diagnosis was benign in 154 (79.80%), borderline in 9 (4.66%), and malignant in 30 (15.54%). The overall accuracy of intra-operative frozen section diagnosis was 98.9%. The sensitivity for frozen section diagnosis was 100% for benign, 89% for borderline and 93.3% for malignant category, whereas the specificity was 97%, 99%, and 100%, respectively. There were 3 cases with discordance between the frozen section diagnoses and the final diagnoses, all of which were under diagnosed by frozen section. Conclusion Frozen section was found to be accurate and useful in the intraoperative assessment of patients with ovarian neoplasm. The results may help to determine the type and extent of surgery.

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Frozen Section Diagnosis: Accuracy and Errors; with Emphasis on Reasons for Discordance

Annals of Pathology and Laboratory Medicine ◽

10.21276/apalm.2932 ◽

2021 ◽

Vol 8 (2) ◽

pp. A33-38

Author(s):

Roopam Kishore Gidwani ◽

Falguni Jay Goswami ◽

Arpan Mehta ◽

Nirali V Shah ◽

Shobhana Ashok Prajapati ◽

...

Keyword(s):

Sampling Error ◽

Frozen Section ◽

False Positive Rate ◽

False Negative ◽

False Negative Rate ◽

Paraffin Section ◽

Cost Effective ◽

Final Diagnosis ◽

Frozen Section Diagnosis ◽

Final Histological Diagnosis

Background: Frozen section is a multistep process involving surgical resection, intraoperative preparation of slides and their microscopic examination. It is important to assess concordant, discordant and deferred diagnosis rates from intra-operative frozen section diagnosis with final diagnosis on paraffin section and to determine the reasons for discordance. An integral part of quality assurance in surgical pathology entails the correlation of intra-operative frozen section diagnosis with final diagnosis on permanent section. Methods: A retrospective analysis of 117 cases of frozen section biopsy was carried out which were reported in the Histopathology department between July 2007 to June 2012. The correlation between the frozen section diagnosis with final histological diagnosis was performed in order to check the accuracy of the technique. The number and type of discrepancies were compared, causes for the discrepancies were analyzed in order to decrease the avoidable errors and improve on the frozen section diagnoses. Results: The overall accuracy of frozen section diagnoses over 5years was 90.60% with false positive rate of 0.85%, false negative rate of 6.84% and 1.71% of deferred diagnosis. Sensitivity was 87.69% and Specificity was 98%. The discrepancies were mainly due to the interpretation error, sampling error and technical artefacts. Conclusions: Gross inspection, sampling by pathologist, frozen section complemented with cytological and histological review and cooperation between consultants can avoid certain limitations and provide rapid, reliable, cost effective information necessary for optimum patient care.

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Development of Whole Slide Imaging on Smartphones and Evaluation With ThinPrep Cytology Test Samples: Follow-Up Study (Preprint)

10.2196/preprints.9518 ◽

2017 ◽

Author(s):

Yu-Ning Huang ◽

Xing-Chun Peng ◽

Shuoxin Ma ◽

Hong Yu ◽

Yu-Biao Jin ◽

...

Keyword(s):

Optical Microscopy ◽

Clinical Evaluation ◽

Processing Speed ◽

Frozen Section ◽

Ground Truth ◽

Central Processing Unit ◽

Processing Unit ◽

Whole Slide Imaging ◽

Central Processing ◽

Virtual Slides

BACKGROUND The smartphone-based whole slide imaging (WSI) system represents a low-cost and effective alternative to automatic scanners for telepathology. In a previous study, the development of one such solution, named scalable whole slide imaging (sWSI), was presented and analyzed. A clinical evaluation of its iOS version with 100 frozen section samples verified the diagnosis-readiness of the produced virtual slides. OBJECTIVE The first aim of this study was to delve into the quantifying issues encountered in the development of an Android version. It should also provide insights into future high-resolution real-time feedback medical imaging apps on Android and invoke the awareness of smartphone manufacturers for collaboration. The second aim of this study was to further verify the clinical value of sWSI with cytology samples. This type is different from the frozen section samples in that they require finer detail on the cellular level. METHODS During sWSI development on Android, it was discovered that many models do not support uncompressed camera pixel data with sufficient resolution and full field of view. The proportion of models supporting the optimal format was estimated in a test on 200 mainstream Android models. Other factors, including slower processing speed and camera preview freezing, also led to inferior performance of sWSI on Android compared with the iOS version. The processing speed was mostly determined by the central processing unit frequency in theory, and the relationship was investigated in the 200-model simulation experiment with physical devices. The camera preview freezing was caused by the lag between triggering photo capture and resuming preview. In the clinical evaluation, 100 ThinPrep cytology test samples covering 6 diseases were scanned with sWSI and compared against the ground truth of optical microscopy. RESULTS Among the tested Android models, only 3.0% (6/200) provided an optimal data format, meeting all criteria of quality and efficiency. The image-processing speed demonstrated a positive relationship with the central processing unit frequency but to a smaller degree than expected and was highly model-dependent. The virtual slides produced by sWSI on Android and iOS of ThinPrep cytology test samples achieved similar high quality. Using optical microscopy as the ground truth, pathologists made a correct diagnosis on 87.5% (175/200) of the cases with sWSI virtual slides. Depending on the sWSI version and the pathologist in charge, the kappa value varied between .70 and .82. All participating pathologists considered the quality of the sWSI virtual slides in the experiment to be adequate for routine usage. CONCLUSIONS Limited by hardware and operating system support, the performance of sWSI on mainstream Android smartphones did not fully match the iOS version. However, in practice, this difference was not significant, and both were adequate for digitizing most of the sample types for telepathology consultation.

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The Application, Challenges, and Advancement Toward Regulatory Acceptance of Digital Toxicologic Pathology: Results of the 7th ESTP International Expert Workshop (September 20-21, 2019)

Toxicologic Pathology ◽

10.1177/0192623320975841 ◽

2020 ◽

pp. 019262332097584

Author(s):

Vanessa L. Schumacher ◽

Famke Aeffner ◽

Erio Barale-Thomas ◽

Catherine Botteron ◽

Jonathan Carter ◽

...

Keyword(s):

European Society ◽

International Workshop ◽

Digital Pathology ◽

Remote Access ◽

Whole Slide Imaging ◽

International Expert ◽

Digital Slide ◽

Regulatory Acceptance ◽

Expert Workshop ◽

Whole Slide Images

With advancements in whole slide imaging technology and improved understanding of the features of pathologist workstations required for digital slide evaluation, many institutions are investigating broad digital pathology adoption. The benefits of digital pathology evaluation include remote access to study or diagnostic case materials and integration of analysis and reporting tools. Diagnosis based on whole slide images is established in human medical pathology, and the use of digital pathology in toxicologic pathology is increasing. However, there has not been broad adoption in toxicologic pathology, particularly in the context of regulatory studies, due to lack of precedence. To address this topic, as well as practical aspects, the European Society of Toxicologic Pathology coordinated an expert international workshop to assess current applications and challenges and outline a set of minimal requirements needed to gain future regulatory acceptance for the use of digital toxicologic pathology workflows in research and development, so that toxicologic pathologists can benefit from digital slide technology.

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