Accuracy and perceptions of virtual microscopy compared with glass slide microscopy in cervical cytology

A. Evered and N. Dudding Accuracy and perceptions of virtual microscopy compared with glass slide microscopy in cervical cytology Objective: To evaluate virtual microscopy in terms of diagnostic performance and acceptability among practising cytologists. Methods: Twenty‐four experienced cytologists were recruited to examine 20 SurePath® cervical cytology slides by virtual microscopy. Diagnostic accuracy was compared with glass slide microscopy using an unbiased crossover experimental design. Responses were allocated a score of one for a correct identification of normal or abnormal (borderline/atypical changes in squamous or glandular cells or worse) and a score of zero for an incorrect response (a normal slide reported as abnormal or vice versa). Perceptions of virtual microscopy were assessed by questionnaire analysis. Results: Participants yielded a total of 285 responses for the virtual slide set and 300 for the glass slide set. The approximate time to screen a virtual slide was 18 minutes, compared with 8 minutes or less for a glass slide. Overall there was no significant difference between virtual microscopy and glass slide microscopy in terms of diagnostic accuracy (P = 0.22). Virtual microscopy under‐performed when images were captured over a narrow focal range (P = 0.01). Diagnostic accuracy of virtual microscopy equalled that of glass slide microscopy when participants were able to focus through the full thickness of the slide images (P = 0.07). The most common difficulties experienced by participants with virtual microscopy were freezing of the computer screen during image download, slow response of the computer during slide movement and, in some instances, ‘fuzzy’ images. Cytologists have a strong preference for glass slides over virtual microscopy despite the overall equal diagnostic performance of the two viewing modalities. Conclusions: Diagnostic accuracy of virtual microscopy can equal that of glass slide microscopy. However, without good computer network connections, wide focal range and software that permits effortless navigation across virtual slides, cytologists are unlikely to be convinced of the utility of this technology for cytology screening and diagnosis.     

Learning regions of interest from low level maps in virtual microscopy

Virtual microscopy can improve the workflow of modern pathology laboratories, a goal limited by the large size of the virtual slides (VS). Lately, determination of the Regions of Interest has shown to be useful in navigation and compression tasks. This work presents a novel method for establishing RoIs in VS, based on a relevance score calculated from example images selected by pathologist. The process starts by splitting the Virtual Slide (VS) into a grid of blocks, each represented by a set of low level features which aim to capture the very basic visual properties, namely, color, intensity, orientation and texture. The expert selects then two blocks i.e. A typical relevant (irrelevant) instance. Different similarity (disimilarity) maps are then constructed, using these positive (negative) examples. The obtained maps are then integrated by a normalization process that promotes maps with a similarity global maxima that largely exceeds the average local maxima. Each image region is thus entailed with an associated score, established by the number of closest positive (negative) blocks, whereby any block has also an associated score. Evaluation was carried out using 8 VS from different tissues, upon which a group of three pathologists had navigated. Precision-recall measurements were calculated at each step of any actual navigation, obtaining an average precision of 55% and a recall of about 38% when using the available set of navigations.     

Organizational model for a telepathology system

The technological development of telemedicine has performed important progress, assuming a diagnostic relief role inside of the processes. Among the fields in fast evolution, telepathology is placed among those of greater interest. Up to some years ago, telepathology allowed us to observe at a distance and in real time, histological or cytological slides through the Internet, using a motorized microscope (dynamic telepathology). Currently, telepathology has completed an important step in ahead being possible to digitize completely a slide and to store it. This allows observation of the whole surface of histological or cytological slides remotely with a customary PC, without human intervention (virtual slide). The described systems have exclusive characteristics, so that a "hybrid system" supporting both technologies, turns out to be the best solution applicable in a wide range program. In order to realize the theoretical aspects previously described, we report an organizational model practicable and applicable to a territory in which three hospitals operate. An essential prerequisite in order to arrange an efficient telepathology system turns out to be one structured data transmission network, equipped with elevated guaranteed bandwidth, and one consolidated experience in the registration and management of digital images.     

Quality evaluation of virtual slides using methods based on comparing common image areas

Background

There are many scanners of glass slides on the market now. Quality of digital images produced by them may be different and pathologists who examine virtual slides on a monitor may subjectively evaluate it. However, objective comparison of quality of digital slides captured by various devices requires assessment algorithms, which will be automatically executed.

Methods

In this work such an algorithm is proposed and implemented. It is dedicated for comparing quality of virtual slides which show the same glass slide captured by two or more scanners. In the first step this method looks for the largest corresponding areas in the slides. This task is realized by defining boundaries of tissues and providing the relative scale factor. Then, a certain number of smaller areas, which show the same fragments of both slides, is selected. The chosen fragments are analyzed using Gray Level Co-occurrence Matrix (GLCM). For GLCM matrices some of the Haralick features are calculated, like contrast or entropy. Basing on results for some sample images, features appropriate for quality assessment are chosen. Aggregation of values from all selected fragments allows to compare the quality of images captured by tested devices.

Results

Described method was tested on two sets of ten virtual slides, acquired by scanning the same set of ten glass slides by two different devices. First set was scanned and digitized using the robotic microscope Axioscope2 (Zeiss) equipped with AxioCam Hrc CCD camera. Second set was scanned by DeskScan (Zeiss) with standard equipment. Before analyzing captured virtual slides, images were stitched and converted using software which utilizes advances in aerial and satellite imaging.The results of the experiment show that calculated quality factors are higher for virtual slides acquired using first mentioned device (Axioscope2 with AxioCam).

Conclusions

Results of the tests are consistent with opinion of the pathologists who assessed quality of virtual slides captured by these devices. This shows that the method has potential in automatic evaluation of virtual slides’ quality.

     

Utility of 2-D and 3-D virtual microscopy in cervical cytology education and testing

OBJECTIVE: To evaluate the effectiveness of 3-D vs. 2-D virtual microscopy as adjuncts to education and assessment in cervical cytology. STUDY DESIGN: Five cervical cytology slides were acquired in 2-D; then the identical area of the slide was acquired in 3-D, resulting in 2 sets of virtual slides for comparison with the original glass slide. Seventy-nine paid volunteer cytologists and cytotechnology students participated. Approximately half were sent the 2-D set of slides via the Web, and the others a 3-D set of slides on a DVD. Evaluators examined the virtual slides and committed to an interpretation. After receipt of the original glass slides, a second interpretation was made, if different from the virtual slide interpretation. RESULTS: Diagnostic accuracy using virtual cytology slides was similar to that for glass slides (94% vs. 96%). There was no difference in diagnostic accuracy between 2-D and 3-D slides (p = 0.28); however, the ability to focus 3-D slides in the z-axis was strongly endorsed by the participants because of the uncertainty and frustration of having some cells out of focus on 2-D virtual slides. CONCLUSION: There was consensus that virtual cervical cytology slides would be a useful augmentation to education and testing.     

How could static telepathology improve diagnosis in neuropathology?

The present paper reports our experience with, and our opinion of static telepathology as applied to neuropathology by means of the PHAROS acquisition system and conventional telephone data transmission (modem). The classical procedure of expert consultation based on surface mailing of histological slides is routinely performed, especially in highly specialized fields of pathology. Telepathology is an easy means of sharing scientific expertise at international level and could thus improve diagnosis particularly in neuropathology, where certain tumor types are very rare and complex to diagnose. Dynamic telepathology allows the referring pathologist to capture by himself images supporting their diagnosis. Using static telepathology the pathologist could be limited in diagnosis by problems in fields selection. We devoted a whole year to collecting all the technical parameters characterizing the use of digitized neuropathological data files in order to investigate the feasibility of telepathology and the extent to which its use could improve diagnoses. Our results on a series of 38 histological brain examinations illustrate how we successfully established an international connection between two departments of pathology in Belgium and the USA. The referring pathologists gave diagnoses in 35 cases and deferred only 3. Despite a time-consuming procedure for the telepathology session of a few cases, this tool provides easy access to expert diagnosis and real-time discussion, both of which are of considerable interest and offer significant improvements in neuropathology.     

Virtual nanoscopy: Generation of ultra-large high resolution electron microscopy maps

A key obstacle in uncovering the orchestration between molecular and cellular events is the vastly different length scales on which they occur. We describe here a methodology for ultrastructurally mapping regions of cells and tissue as large as 1 mm(2) at nanometer resolution. Our approach employs standard transmission electron microscopy, rapid automated data collection, and stitching to create large virtual slides. It greatly facilitates correlative light-electron microscopy studies to relate structure and function and provides a genuine representation of ultrastructural events. The method is scalable as illustrated by slides up to 281 gigapixels in size. Here, we applied virtual nanoscopy in a correlative light-electron microscopy study to address the role of the endothelial glycocalyx in protein leakage over the glomerular filtration barrier, in an immunogold labeling study of internalization of oncolytic reovirus in human dendritic cells, in a cryo-electron microscopy study of intact vitrified mouse embryonic cells, and in an ultrastructural mapping of a complete zebrafish embryo slice.     

“Proof-Of-Concept” Evaluation of an Automated Sputum Smear Microscopy System for Tuberculosis Diagnosis

Background

“TBDx” is an innovative smear microscopy system that automatically loads slides onto a microscope, focuses and digitally captures images and then classifies smears as positive or negative using computerised algorithms.

Objectives

To determine the diagnostic accuracy of TBDx, using culture as the gold standard, and compare this to a microscopist''s diagnostic performance.

Methods

This study is nested within a cross-sectional study of tuberculosis suspects from South African gold mines. All tuberculosis suspects had one sputum sample collected, which was decontaminated prior to smear microscopy, liquid culture and organism identification. All slides were auramine-stained and then read by both a research microscopist and by TBDx using fluorescence microscopes, classifying slides based on the WHO classification standard of 100 fields of view (FoV) at 400× magnification.

Results

Of 981 specimens, 269 were culture positive for Mycobacterium tuberculosis (27.4%). TBDx had higher sensitivity than the microscopist (75.8% versus 52.8%, respectively), but markedly lower specificity (43.5% versus 98.6%, respectively). TBDx classified 520/981 smears (53.0%) as scanty positive. Hence, a proposed hybrid software/human approach that combined TBDx examination of all smears with microscopist re-examination of TBDx scanty smears was explored by replacing the “positive” result of slides with 1–9 AFB detected on TBDx with the microscopist''s original reading. Compared to using the microscopist''s original results for all 981 slides, this hybrid approach resulted in equivalent specificity, a slight reduction in sensitivity from 52.8% to 49.4% (difference of 3.3%; 95% confidence interval: 0.2%, 6.5%), and a reduction in the number of slides to be read by the microscopist by 47.0%.

Discussion

Compared to a research microscopist, the hybrid software/human approach had similar specificity and positive predictive value, but sensitivity requires further improvement. Automated microscopy has the potential to substantially reduce the number of slides read by microscopists.     

Correlative microscopy: bridging the gap between fluorescence light microscopy and cryo-electron tomography

Cryo-electron tomography of frozen-hydrated biological samples offers a means of studying large and complex cellular structures in three-dimensions and with nanometer-scale resolution. The low contrast of unstained biological material embedded in amorphous ice and the need to minimise the exposure of these radiation-sensitive samples to the electron beam result in a poor signal-to-noise ratio. This poses problems not only in the visualisation and interpretation of such tomograms, it is also a problem in surveying the sample and in finding regions which contain the features of interest and which are suitable for recording tomograms. To address this problem, we have developed a correlative fluorescence light microscopy-electron microscopy approach, which guides the search for the structures of interest and allows electron microscopy to zoom in on them. With our approach, the total dose spent on locating regions of interest is negligible. A newly designed cryo-holder allows imaging of fluorescently labelled samples after vitrification. The absolute coordinates of structures identified and located by cryo-light microscopy are transferred to the electron microscope via a Matlab-based user interface. We have successfully tested the experimental setup and the whole procedure with two types of adherent fluorescently labelled cells, a neuronal cell line and keratinocytes, both grown directly on EM grids.     

Clustering methods applied in the detection of Ki67 hot-spots in whole tumor slide images: An efficient way to characterize heterogeneous tissue-based biomarkers

Whole-slide scanners allow the digitization of an entire histological slide at very high resolution. This new acquisition technique opens a wide range of possibilities for addressing challenging image analysis problems, including the identification of tissue-based biomarkers. In this study, we use whole-slide scanner technology for imaging the proliferating activity patterns in tumor slides based on Ki67 immunohistochemistry. Faced with large images, pathologists require tools that can help them identify tumor regions that exhibit high proliferating activity, called "hot-spots" (HSs). Pathologists need tools that can quantitatively characterize these HS patterns. To respond to this clinical need, the present study investigates various clustering methods with the aim of identifying Ki67 HSs in whole tumor slide images. This task requires a method capable of identifying an unknown number of clusters, which may be highly variable in terms of shape, size, and density. We developed a hybrid clustering method, referred to as Seedlink. Compared to manual HS selections by three pathologists, we show that Seedlink provides an efficient way of detecting Ki67 HSs and improves the agreement among pathologists when identifying HSs. ? 2012 International Society for Advancement of Cytometry.     

Robust automated tumour segmentation on histological and immunohistochemical tissue images

Tissue microarray (TMA) is a high throughput analysis tool to identify new diagnostic and prognostic markers in human cancers. However, standard automated method in tumour detection on both routine histochemical and immunohistochemistry (IHC) images is under developed. This paper presents a robust automated tumour cell segmentation model which can be applied to both routine histochemical tissue slides and IHC slides and deal with finer pixel-based segmentation in comparison with blob or area based segmentation by existing approaches. The presented technique greatly improves the process of TMA construction and plays an important role in automated IHC quantification in biomarker analysis where excluding stroma areas is critical. With the finest pixel-based evaluation (instead of area-based or object-based), the experimental results show that the proposed method is able to achieve 80% accuracy and 78% accuracy in two different types of pathological virtual slides, i.e., routine histochemical H&E and IHC images, respectively. The presented technique greatly reduces labor-intensive workloads for pathologists and highly speeds up the process of TMA construction and provides a possibility for fully automated IHC quantification.     

Plastic-embedded semi-thin sections of fine needle aspiration biopsies with dibasic staining. Diagnostic and didactic applications

The diagnostic and didactic utility of plastic-embedded semi-thin sections of fine needle aspiration biopsies is presented using a case-study approach. The Spurr epoxy semi-thin sections were stained with a newly developed sequential basic fuchsin-methylene blue stain, which gives hematoxylin-and-eosin-like staining and simultaneously substitutes for a wide variety of special stains. The informational content of the sections can approach that of electron microscopy. The use of a direct off-the-slide "pop-off" technique in preparing the plastic-embedded sections allows for a direct comparison between similar groups of cells embedded in plastic and present on the routine aspiration slides; retrospective analysis can discern subtle, previously unrecognized morphologic features in the alcohol-fixed, Papanicolaou-stained slides. The limitations of this comparative approach, however, become manifest when the effects of alcohol fixation on cells are directly compared in plastic and at the ultrastructural level to aldehyde fixation.     

A red knot as a black swan: how a single bird shows navigational abilities during repeat crossings of the Greenland Icecap

Despite the wealth of studies on seasonal movements of birds between southern nonbreeding locations and High Arctic breeding locations, the key mechanisms of navigation during these migrations remain elusive. A flight along the shortest possible route between pairs of points on a sphere (‘orthodrome’) requires a bird to be able to assess its current location in relation to its migration goal and to make continuous adjustment of heading to reach that goal. Alternatively, birds may navigate along a vector with a fixed orientation (‘loxodrome’) based on magnetic and/or celestial compass mechanisms. Compass navigation is considered especially challenging for summer migrations in Polar regions, as continuous daylight and complexity in the geomagnetic field may complicate the use of both celestial and magnetic compasses here. We examine the possible use of orientation mechanisms during migratory flights across the Greenland Icecap. Using a novel 2 g solar-powered satellite transmitter, we documented the flight paths travelled by a female red knot Calidris canutus islandica during two northward and two southward migrations. The geometry of the paths suggests that red knots can migrate across the Greenland Icecap along the shortest-, orthodrome-like, path instead of the previously suggested loxodrome path. This particular bird's ability to return to locations visited in a previous year, together with its sudden course changes (which would be appropriate responses to ambient wind fields), suggest a map sense that enables red knots to determine location, so that they can tailor their route depending on local conditions.     

Grid computing in image analysis

Diagnostic surgical pathology or tissue–based diagnosis still remains the most reliable and specific diagnostic medical procedure. The development of whole slide scanners permits the creation of virtual slides and to work on so-called virtual microscopes. In addition to interactive work on virtual slides approaches have been reported that introduce automated virtual microscopy, which is composed of several tools focusing on quite different tasks. These include evaluation of image quality and image standardization, analysis of potential useful thresholds for object detection and identification (segmentation), dynamic segmentation procedures, adjustable magnification to optimize feature extraction, and texture analysis including image transformation and evaluation of elementary primitives. Grid technology seems to possess all features to efficiently target and control the specific tasks of image information and detection in order to obtain a detailed and accurate diagnosis. Grid technology is based upon so-called nodes that are linked together and share certain communication rules in using open standards. Their number and functionality can vary according to the needs of a specific user at a given point in time. When implementing automated virtual microscopy with Grid technology, all of the five different Grid functions have to be taken into account, namely 1) computation services, 2) data services, 3) application services, 4) information services, and 5) knowledge services. Although all mandatory tools of automated virtual microscopy can be implemented in a closed or standardized open system, Grid technology offers a new dimension to acquire, detect, classify, and distribute medical image information, and to assure quality in tissue–based diagnosis.     

iPathology cockpit diagnostic station: validation according to College of American Pathologists Pathology and Laboratory Quality Center recommendation at the Hospital Trust and University of Verona

Background

Validation of digital whole slide images is crucial to ensure that diagnostic performance is at least equivalent to that of glass slides and light microscopy. The College of American Pathologists Pathology and Laboratory Quality Center recently developed recommendations for internal digital pathology system validation. Following these guidelines we sought to validate the performance of a digital approach for routine diagnosis by using an iPad and digital control widescreen-assisted workstation through a pilot study.

Methods

From January 2014, 61 histopathological slides were scanned by ScanScope Digital Slides Scanner (Aperio, Vista, CA). Two independent pathologists performed diagnosis on virtual slides in front of a widescreen by using two computer devices (ImageScope viewing software) located to different Health Institutions (AOUI Verona) connected by local network and a remote image server using an iPad tablet (Aperio, Vista, CA), after uploading the Citrix receiver for iPad. Quality indicators related to image characters and work-flow of the e-health cockpit enterprise system were scored based on subjective (high vs poor) perception. The images were re-evaluated two weeks apart.

Results

The whole glass slides encountered 10 liver: hepatocarcinoma, 10 renal carcinoma, 10 gastric carcinoma and 10 prostate biopsies: adenocarcinoma, 5 excisional skin biopsies: melanoma, 5 lymph-nodes: lymphoma. 6 immuno- and 5 special stains were available for intra- and internet remote viewing. Scan times averaged two minutes and 54 seconds per slide (standard deviation 2 minutes 34 seconds). Megabytes ranged from 256 to 680 (mean 390) per slide storage. Reliance on glass slide, image quality (resolution and color fidelity), slide navigation time, simultaneous viewers in geographically remote locations were considered of high performance score. Side by side comparisons between diagnosis performed on tissue glass slides versus widescreen were excellent showing an almost perfect concordance (0.81, kappa index).

Conclusions

We validated our institutional digital pathology system for routine diagnostic facing with whole slide images in a cockpit enterprise digital system or iPad tablet. Computer widescreens are better for diagnosing scanned glass slide that iPad. For urgent requests, iPad may be used. Legal aspects have to be soon faced with to permit the clinical use of this technology in a manner that does not compromise patient care.

     

Telepathology and continuous education: important tools for pathologists of developing countries

Education shows that active participation allows the best development of skills to acquire, and the results are better when the information is well documented. Now, with digital images and the Internet, in the case of the Static Telepathology (ST), it is easy to share macroscopic and microscopic photographs. The progress of the technologies enabled a form of Dynamic Telepathology (DT) named "virtual slides", with navigation tools, and can be moved around changing powers as desired, making any personal computer into a digital microscope. The use of these tools in continuous education leads to optimal development of knowledge. We reported the experience of a Latin-American Pathologist from La Rioja, a small Province of Argentina, and we also mentioned the electronic publications in Virtual Hispano-American Congresses of Pathology (VHACP) since 1997(18 reports in the case of ST) and in two Virtual Slide Congress (VSC). In the 1st (2005) and 2nd (2007) Internet VSCs two of our cases were digitized in Spain (case 1 and 3 respectively). In these Virtual Slides, the microscopic images can be moved remotely from any computer connected to the Internet, we should recognize that it will become a valuable continuing Medical Education tool in microscopy, probably related to the phrase "a picture is worth more than a thousand words", then we might add; "what about thousands of images?" Similarly, the autoevaluation test is very important. ST and DT, in support of Virtual Congresses allows learning, teaching and sharing of diseases in scientific presentations and the exchange of views in the forums, these are the optimum material for distance education. In addition we received CDs or DVDs and certificates as authors, recognized by European Institutions. The active participation and the autoevaluation test are the best tools for continuous medical education in telepathology, not only for pathologists in developing countries but for the entire world.     

Field Trial of a Microcolony Method for Testing the Antibiotic Sensitivity of Bacteria

The sensitivity of bacteria to antibiotics may be measured by a rapid method in which the criterion of sensitivity is inhibition of microcolony formation on agar which contains antibiotic. As this method allows a report on the antibiotic sensitivity of a pathogenic bacterium four hours after the test is set up, a trial of the method was carried out in a diagnostic laboratory. Two thousand five hundred and four strains of fast-growing bacteria were tested against 10 antibiotics. The overall correlation rate between the four-hour microscopic readings and the subsequent overnight readings on the same cultures was 98.1%. Seven per cent of the microscopical readings attempted gave indeterminate results, and reports on these tests were withheld until the following day.The time spent in making microscopical readings was considered fully justified by the fact that results of a high proportion of antibiotic sensitivity tests were available one day earlier than is usual with established methods.     

Optimized quality of histologic images allows the use of neural network scanning in diagnosis of fungal infection of abnormal nails

OBJECTIVE: The neural network scanning (NNS) system, formerly known as Papnet, is capable of selecting fungi in cervical smears. The objective of this study was to investigate whether the optimized quality of histologic images created using a combination of coagulant fixation and microwave histoprocessing allows the application of this computer-assisted microscopy in the diagnostic process. STUDY DESIGN: In a prospective study, 117 abnormal nails clinically suspect for fungal disease werefixed in a coagulant fixative, BoonFix, processed in a microwave histoprocessor to obtain optimal paraffin sections and stained with the periodic acid-Schiff (PAS) method. The stained paraffin sections were randomly numbered and screened by two independent pathologists for diagnosis of fungal hyphae and spores. The same sections were subsequently scanned by a neural network, and a maximum of 128 digital images produced by the system were screened and diagnosed by pathologists. Using light microscopy as the gold standard for diagnosis of fungi, the usefulness of NNS was then assessed. RESULTS: The fungi and spores were clearly demonstrated in the paraffin sections, and the NNS system detected and recorded them efficiently. The hyphae and spores could be identified in these pixilated images with relative ease. Of the 117 examined cases, 50 were positive and 47 negative by both methods. In the 20 remaining cases, NNS did not present images of fungi that were present in the histologic sections. In practice, this implies that only 67 out of 117 cases (57%) must be screened by light microscopy. NNS recorded not only fungi and spores in the 128 digital images but also artifacts, such as round, deeply PAS-positive granules of talcum powder, which by light microscopy might be mistaken for fungal spores. CONCLUSION: NNS proves applicable for the selection of spores and fungi if the histologic sections are of sufficiently high quality. As a result, the number of slides to be screened by light microscopy can be reduced substantially. In a throughput diagnostic laboratory handling a large number of such cases this technology can be highly valuable.     

An update on the validation of whole slide imaging systems following FDA approval of a system for a routine pathology diagnostic service in the United States

Pathologists have used light microscopes and glass slides to interpret the histologic appearance of normal and diseased tissues for more than 150 years. The quality of both microtomes used to cut tissue sections and microscopes has improved significantly during the past few decades, but the process of rendering diagnoses has changed little. By contrast, major advances in digital technology have occurred since the introduction of hand held electronic devices, including the development of whole slide imaging (WSI) systems with software packages that can convert microscope images into virtual (digital) slides that can be viewed on computer monitors and via the internet. To date, however, these technological developments have had minimal impact on the way pathologists perform their daily work, with the exception of using computers to access electronic medical records and scholarly web sites for pertinent information to assist interpretation of cases. Traditional practice is likely to change significantly during the next decade, especially since the Federal Drug Administration in the USA has approved the first WSI system for routine diagnostic practice. I review here the development and slow acceptance of WSI by pathology departments. I focus on recent advances in validation of WSI systems that is required for routine diagnostic reporting of pathology cases using this technology.