Bridging the distance between Pathologists

The Progress of Digital Pathology in Egypt

Dr. Essam E. AyadProf. of Pathology & Head of Digital Pathology Unit, Faculty of Medicine, Cairo UniversityAnd Italian Hospital in Cairo

Importance of Pathology Imaging In a typical American medical center, studies have

indicated that 70% of the clinical data in the electronic medical record are from pathology, and seventy percent of requests for data from the electronic medical record are for pathology data (Becich, 2000).

Significantly, clinical decision support programs are highly dependent on pathology data. Much of the analysis performed in the pathology lab is visual, therefore pathology imaging has become an important and growing area of medical imaging environment.

Pathology Digitalization(Telepathology)

The first telepathological system was developed in the 1960’s at the Massachusetts General Hospital.

However, it was not explored and used until the late 1990’s.

Telepathology

Types of telepathology system

1) Static (store and forward). 2) Dynamic (with or without robotic

microscope). 3) Combination of Static and Dynamic, Hybrid. 4) Whole slide imaging (Virtual slide imaging).

1) Static Image telepathology

1.Non-Robotic2.Robotic:

* Both systems can be used effectively in limits situations

Dynamic Telepathology Systems

Whole slide imaging (Virtual slide imaging)

WSI

Whole slide imaging (WSI) Def.: is new technology that has brought with it

the possibility of beginning of standardization

in pathology.

In particular, WSI Scanners image entire slides

(so there is no issue of sub-sampling) and

automates the imaging process (thereby

replacing forcing specific parameters and

eliminating human factors in image capture)

ADVANTAGES OF WHOLE SLIDE IMAGING

1. Reading barcodes on slides2. Can automatically capture & compress an

image of a slide.3. WSI devices are becoming very fast, with

current devices ranging from 50 seconds to 2 minutes per slide.

4. To provide the digital view of the complete slide in context, several new technologies have emerged using Whole Slide Imaging.

ADVANTAGES OF WHOLE SLIDE IMAGING

4) The digital image allows users to view entire microscopic images at any magnificationon their monitor.

5) WSI allows pathologists to control the image during examination.

6) These digitized images can be stored as an archive to be viewed on any browser over the internet.

WSI This technique is capable to capture and

store tens to hundreds (or even thousands) of whole slide images.

This valuable scientific material can be used for:

1. Education and Training 2. Network Consultation 3. Quality Assurance

WSI Applications

Routine surgical pathologySecond opinionsExpert-to-Expert consultationsQuality assuranceDistance education- Frozen Section Study

HISTORY OF DIGITAL PATHOLOGY IN THE MIDDLE EAST

Successful Experiences

DIGITAL PATHOLOGY IN THE MIDDLE EAST

The idea of applying telemedicine programs in the Italian hospital in Cairo was born 17 years ago in the conference, organized by WHO in Cairo in Dec. 2001.

DIGITAL PATHOLOGY

IN EGYPT

Telepathology Project In The Italian Hospital“Umberto I” In Cairo

(1903-2018)

PILOT PROJECT BETWEEN ITALY AND

EGYPT

Static Telepathology In The IHC

Basic System Components

DYNAMIC TELEPATHOLOGY:

Advanced digital Camera Video camera

New participants:

Charing Cross Hospital in London Since 2004. Pathology Department in Ospedale S.

Giovanni e Paolo Hospital, Venice, ItalyVenice since 2005.

Since the beginning of our telepathology program, many cases were consulted with the

pathologists in:Palermo & Venice [Italy],

Charing Cross Hospital in London

and Pittsburgh [USA]

Better medical service. More specialization. Saving money. Saving time. Teaching and learning. Exchange knowledge.

The benefits of Telepathology:

No. of Problematic cases weekly per week

1

Fee for Transportation 150 $

Fee for consultation 250 $

No. of centers 3

Duration of the project 5 Years

Total > 250.000 $

Financial Evaluation of the Project

Whole slide imaging (Virtual slide imaging)

WSI

We have established our

Digital Pathology Unit[DPU]

in the Department of Pathology, Faculty of medicine, Cairo University

using the latest techniques of virtual slide Imaging, Whole Slide Imaging

WSI

(1821-2018)

WSI Applications1) Scanning of all our Teaching Students Slides

aimung to change the way of pathology teaching from the classic form [using the glass slides and microscopes] to the digital one.

All the teaching virtual slides were avilable for our students through our website:

http://www.kmis.medicine.cu.edu.eg/slides/pathology/The virtual slides are used for:

a) Routine Learning in the histopathology classes.b) E-learning.

E-education for medical Students

using WSI in EgyptDr. Essam E. AyadProf. of Pathology & Head of Telepathology Unit, Faculty of Medicine, Cairo UniversityConsultant Pathologist, Italian Hospital In Cairo

Digital Learning of our undergraduate students

www.kmis.cu.edu.eg/slides/path

WSI Applications2) Routine Scanning of all our interesting cases

[Recent & archive] to create a huge Digital Pathology Library which will be available on the Website of the Faculty of Medicine Cairo University. The material of this

Digital Pathology Librarycan be used for e-learning of our Post Graduate candidates.

WSI Applications*) So we succeeded to change our technique of

pathology teaching to be virtual either for Under-

& Post Graduate Students.

Even our professors became more acquainted

with the new technology dealing with the digital

file rather than the ordinary microscopes.

Changing Pathology Environment

WSI Applications3) Local Telepathology: Second opinions [Expert-to-

Expert consultations]. We have now in Egypt three centers using the slide scanners and use the WSI in telepatholgy:

* Faculty of Medicine, Cairo University* Children’s Cancer Hospital Egypt [57357]* Military International Medical CenterWe are planning to create a network between all these

centers to facilitate tele-consultation of cases.We are also planning to establish a digital network

between all the cancer centers allover Egypt.

Central Lab Jobs: Receiving the cases sent from remote labs daily. Classification of cases according to subspecialties. Examination of the cases sent from remote labs by

teams of specialized pathology consultants, signing the report and then sending it to the remote labs

For difficult cases, The center can send the VS to highly specialized centers abroad (through a commitment with these centers in USA & European countries).

Offering the Digital Quantitative Analysis needed for the cases (specially immunohistochemical studies).

Saving a copy of all VS as an archive.

Remote Labs Requirements &Jobs Classic Labs for tissue processing, … Dissection & Gross Examination of the cases (by

junior pathologist). Taking photos for the gross examination Slides Scanner An advanced Server with high storage volume ( it

will work 24/7) An internet connection with unlimited volume and

a very high speed. Sending the Gross photos & VS of the cases to

the central lab

The Advantages of this Pproject:

Offering our patients a better medical service Examining the cases by more than one consultant

pathologist. Applying pathology subspecialization. Fast Accurate diagnosis of the cases. Permanent archiving of the VS of the cases Reaching a more accurate cancer registry in Egypt. Building a huge Pathology Digital library which will

be of great teaching value to our junior (& senior Staff).

WSI Applications4) International Telepathology, Second opinions

[Expert-to-Expert consultations].

We made a provisional agreements with different

highly specialized pathology centers in developing

countries [like Italy, UK, USA] to consult our cases.

We are trying nowadays to increase the number of

centers of expertise that can cooperate with us in this

promising fields.

We usually face marked acceptance from everybody.

Telepathology Project between :* Histopathology Department,

Cairo University &* Histopathology Department,

St. James University, Leeds, UK

[2014 - Now]

WSI Applications

5) A third channel of Telepathology: Second opinions [Expert-to-Expert consultations]:

We are trying to make some agreements with different pathology centers in different surrounding Arabic countries with limited number of specialized pathologist [like Palestine, Sudan, Yemen & Libya] to consult their cases.

Applications of

WSI TECHNOLOGY

In Research & Comprehensive Image Analysis

Digital assessment of membrane staining component:

– 3+ cells = 54.7%– 2+ cells = 23.4%– 1+ cells = 21.9%

Comparative Study between Morphometric Analysis and

Fluorescence In-Situ Hybridization (FISH) in Cases of Breast Cancer Tumours with

Equivocal HER2 Score 2+

ByEssam Ayad (1), Mina Mansy (1), Dalal Elwi (1), Mostafa Salem (1),

Mohamed Salama (2) & Klau. Kayser (3)

(1) Faculty of Medicine, Cairo University, (2) University of Utah and ARUP Reference lab, USA,,

(3) Humbold University Berlin, Germany

Digital assessment of the nuclear stain:

– Index = 13.7%

Digital & Manual Analysis of Ki-67 in Invasive Breast Cancer

[Comparison between Visual & Automated Digital Assessment]

Dr. Essam E. AyadProf. of Pathology & Head of Digital Pathology Unit, Faculty of Medicine, Cairo UniversityConsultant Pathologist, Italian Hospital In Cairo

New Versions of Slides Scanners:

1. Higher Magnification [63x]2. Cytology Scanners [3Z, 5Z,7Z,9Z]3. Immuno-flourescent Scanners4. Confocal Scanners.

The Amazing Applications of Digital Pathology

Routine surgical pathologySecond opinionsExpert-to-Expert consultationsFrozen Section.Distance education.- Quantitative assessment of IHC, …etc

Bridging the Distance Between Pathologists

The first microscope was built by Zacharias Janssen, in Middleburg, Holland, around the year 1595.

400   Years

? Years