digital frozen section pathology acp manchester 2012

Digital Frozen Section Digital Frozen Section Pathology:Pathology:

Validation and Validation and Implementation at The Royal Implementation at The Royal

Brompton & Harefield Brompton & Harefield HospitalHospitalss

Dr Brian MitchelsonDr Brian Mitchelson

Histology Supervisor -Harefield HospitalHistology Supervisor -Harefield Hospital

The Royal Brompton & Harefield NHS The Royal Brompton & Harefield NHS Foundation TrustFoundation Trust

Our problems!Our problems!► Firstly the two hospital sites are 20 miles apart.Firstly the two hospital sites are 20 miles apart.► Harefield currently has 1 resident Associate Harefield currently has 1 resident Associate

Specialist Histopathologist.Specialist Histopathologist.► The Royal Brompton has 3 Consultant The Royal Brompton has 3 Consultant

Histopathologists, one of whom shares her time Histopathologists, one of whom shares her time between the Brompton and Harefield sites.between the Brompton and Harefield sites.

► This could cause potential problems for frozen This could cause potential problems for frozen section diagnosis if no Consultant was available section diagnosis if no Consultant was available for difficult cases at the Harefield site.for difficult cases at the Harefield site.


Our SolutionOur Solution

►The Aperio Scanscope system The Aperio Scanscope system was purchased in 2009 with a was purchased in 2009 with a view to overcoming this view to overcoming this problem by utilising Digital problem by utilising Digital Microscopy to view the frozen Microscopy to view the frozen section slides remotely.section slides remotely.


The Harefield LaboratoryThe Harefield Laboratory


Validation MethodologyValidation Methodology

► Frozen sections were prepared and reported as Frozen sections were prepared and reported as usual at Harefield Hospital. usual at Harefield Hospital.

► Once the slides had been reviewed by a Once the slides had been reviewed by a Harefield pathologist and the result phoned to Harefield pathologist and the result phoned to the surgeon in theatre, the slides were scanned the surgeon in theatre, the slides were scanned at x20 magnification on the ScanScope at x20 magnification on the ScanScope machine. machine.

► The reporting pathologist on duty at the Royal The reporting pathologist on duty at the Royal Brompton Hospital (RBH) was informed a Brompton Hospital (RBH) was informed a frozen section was being scanned. frozen section was being scanned.

► Once scanning was complete, he/she logged Once scanning was complete, he/she logged onto the remote server and blindly reviewed onto the remote server and blindly reviewed and reported the scanned images. and reported the scanned images.

The Royal Brompton & HarefieldThe Royal Brompton & Harefield NHS Foundation TrustNHS Foundation Trust

Methodology (cont’d)Methodology (cont’d)

►The pathologists then entered their The pathologists then entered their frozen section report onto separate frozen section report onto separate databases to ensure impartiality.databases to ensure impartiality.

► The time taken to scan the slides and to The time taken to scan the slides and to remotely report the frozen section slides was remotely report the frozen section slides was also noted. also noted.

► Once approx. 50 frozen sections had been Once approx. 50 frozen sections had been reported: the concordance in diagnosis, reported: the concordance in diagnosis, average time for scanning and average average time for scanning and average reporting times were assessed. reporting times were assessed.

The Royal Brompton & The Royal Brompton & HarefieldHarefield

NHS Foundation TrustNHS Foundation Trust

Recording the dataRecording the data

Test DateFS type

Case No.

Time arrived inthe

laboratoryTime reported

HH

Time scancompleted

HH

RBH time to report

(seconds)

1 ######## LN 09P1552 12:00:00 12:15:00 12:20:00 30

2 ######## Lung 09P1576 16:15:00 16:40:00 16:45:00 90

3 ######## LN 09P1601 10:30:00 10:45:00 10:55:00 90

4 ######## LN09P1616

A 09:15:00 9:35:00 09:55:00 60


Our FindingsOur Findings

►The initial results were very encouraging The initial results were very encouraging and show an almost 100% concordance and show an almost 100% concordance of diagnosis within minutes of being of diagnosis within minutes of being available.available.

►To date we have scanned several To date we have scanned several hundred cases with an average time for hundred cases with an average time for the x20 scan being 4 minutes.the x20 scan being 4 minutes.

►The average time from completion of The average time from completion of the scan to reporting at the Royal the scan to reporting at the Royal Brompton is approximately 90 seconds.Brompton is approximately 90 seconds.


ResultsResults.Between November 2009 and October 2010, 49 cases were scanned and reported.

These included single and multiple frozen sections, totalling 73 frozen section slides.

The specimen type was as follows;

Lymph node = 19, Lung = 32, Pleura = 6, chest wall = 3.

The average time from end of reporting, at Harefield, to completion of scan was 6.3 minutes.

The average time to review the slides was 64 secs.

There was 98% complete concordance in diagnosis made on review of the histological section and of the digitised image.


Our one discrepancyOur one discrepancyOnly one case showed a minor discrepancy between the two reports, which had no effect on patient treatment. This case was a lung nodule removed from a patient with known CLL. Both pathologists reported the presence of necrosis with granulomatous inflammation and a small lymphocytic infiltrate.The possibility of lymphoma was raised by the Harefield pathologist (to whom the history of CLL was known), but not by the Brompton pathologist (who was not aware of the history of CLL). The Royal Brompton & HarefieldThe Royal Brompton & Harefield


Validation ProcessValidation Process► All the data we recorded was tabulated and presented All the data we recorded was tabulated and presented

to the Trust Clinical Practice Committee.to the Trust Clinical Practice Committee.

► All the procedures were carried out in accordance with All the procedures were carried out in accordance with the Guidelines set out by the Royal College of the Guidelines set out by the Royal College of Pathologists in 2005.Pathologists in 2005.

► We formally requested that in view of the data We formally requested that in view of the data submitted that approval be granted to use this submitted that approval be granted to use this technique for reporting frozen section pathology when technique for reporting frozen section pathology when the need arises.the need arises.

► Approval of the technique was then given for surgical Approval of the technique was then given for surgical pathology use in frozen section reporting, when pathology use in frozen section reporting, when required.required. The Royal Brompton & HarefieldThe Royal Brompton & Harefield


Case A - 79 year old maleCase A - 79 year old maleFrozen Section Specimen - Jugular LNFrozen Section Specimen - Jugular LN

►Right lung base Right lung base lesion with lesion with supraclavicular supraclavicular lymph nodes on lymph nodes on the right sidethe right side

►FS DiagnosisFS Diagnosis – – Hodgkin's Hodgkin's LymphomaLymphoma

The Royal Brompton & Harefield NHS Foundation TrustThe Royal Brompton & Harefield NHS Foundation Trust

The paraffin processed blockThe paraffin processed block

►Final diagnosisFinal diagnosis: : Nodular Hodgkin's Nodular Hodgkin's Lymphoma, Lymphoma, nodular lymphocyte nodular lymphocyte predominant type, predominant type, with prominent T-with prominent T-cell/hystiocyte rich cell/hystiocyte rich B-cell lymphoma B-cell lymphoma like areaslike areas


Case B - 73 year old maleCase B - 73 year old male Frozen Section Specimen- Apical segment of Frozen Section Specimen- Apical segment of

RLLRLL►RLL mass, ? RLL mass, ?

Malignancy, Malignancy, previous bowel previous bowel cancer2007,cancer2007,

►chemotherapychemotherapy

►FS DiagnosisFS Diagnosis – – adenocarcinomaadenocarcinoma



►Final diagnosisFinal diagnosis: : RLL apical RLL apical segmentectomy: segmentectomy: metastatic metastatic colorectal colorectal carcinomacarcinoma


Case C - 60 year old femaleCase C - 60 year old female Frozen Section Specimen- Right Parietal Frozen Section Specimen- Right Parietal

PleuraPleura►Pleura coated with Pleura coated with

talc, shortness of talc, shortness of breath, right pleural breath, right pleural effusion, pleural effusion, pleural thickening, previous thickening, previous lump excision of lump excision of breastbreast

►FS DiagnosisFS Diagnosis – – malignant epithelioid malignant epithelioid tumourtumour



► Final diagnosisFinal diagnosis: : malignant epitheliod malignant epitheliod tumour, tumour,

► OR, PR, Calretinin, and OR, PR, Calretinin, and CK5/6 negative, CK5/6 negative,

► BerEP4, CEA and TTF-1 BerEP4, CEA and TTF-1 positive. positive.

► The profile is in keeping The profile is in keeping with metastatic with metastatic adenocarcinoma from a adenocarcinoma from a lung primarylung primary


ConclusionsConclusions

►The current data suggests this is a The current data suggests this is a clinically useful system; with only a clinically useful system; with only a minimal time delay in reporting the frozen minimal time delay in reporting the frozen section diagnosis.section diagnosis.

►Diagnosis was found to be no more Diagnosis was found to be no more problematic than using a conventional problematic than using a conventional microscope and in many cases was made microscope and in many cases was made easier due to the large screen image and easier due to the large screen image and zoom magnification.zoom magnification.

►Other potential benefits include second Other potential benefits include second opinions, referrals and teaching.opinions, referrals and teaching.


In SummaryIn Summary

► The image quality is excellentThe image quality is excellent► The accessibility is rapid and simpleThe accessibility is rapid and simple► Real time image handling is a benefitReal time image handling is a benefit► The more we use the system the more uses The more we use the system the more uses

and benefits we are finding for this and benefits we are finding for this instrument: instrument:

Cross-site referrals: this saves transferring Cross-site referrals: this saves transferring slides from one hospital to the otherslides from one hospital to the other

MDT meetings: allowing real time image MDT meetings: allowing real time image handling and auditing cases on either site.handling and auditing cases on either site.


The Royal Brompton & Harefield NHS Foundation Trust

The EndThe EndThank you for your attentionThank you for your attention

BrianBrian

digital frozen section pathology acp manchester 2012

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brompton pathologistwho

frozen section slides

average time

frozen section reporting

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multiple frozen sections

average reporting timeswere