Digitizing a country: The

Luxemburgish experience

A work in progress

Daniel Val Garijo, M.D.

Enterprise | Interest

This project was funded by the Fondation Cancer

Luxembourg:

2,586 square

kilometres (998 sq

mi) in size, and

measures 82 km (51

mi) long and 57 km

(35 mi) wide

Luxembourg

city

Dudelange

Laboratoire National de Santé – Luxembourg (Dudelange)

Département de Génétique

Département de Biologie Médicale

Département de Microbiologie

Département de Médecine Légal

Département de Pathologie Morphologique et Moléculaire

• Service d’Anatomie Pathologique

• Service de Cytologie Gynécologique

Département de Pathologie Morphologique et Moléculaire

-2015: Plan to integrate all the hospitals in a

telepathology network

-2016-17: Implementation in two hospitals (CHEM and

CHL)

-2018: Test phase in one hospital (CHDN)

-Validation phase (20 cases)

-Follow-up phase

- Dedicated fully equipped room in each hospital

- Staffed by one histotechnician with specific

training in macroscopic dissection and sampling

- Centralized VPN network

- Dedicated pathologist during test and validation

phase

- Tutorial for all the pathologist staff during

follow-up

- Ongoing process

Telepathology Room

Macroscopic dissection table (Workstation Bx, MILESTONE)

Integrated Macroscopic Camera (Macro Path Pro-X, MILESTONE)

Telepathology room

Cryo-embedder PrestoCHILL

Telepathology room

Cryostate (Leica CM1520)

Telepathology room

Linear Stainer (Leica ST 4020)

Telepathology room

Cassette and slide printers (Signature, PRIMERA Technology Inc.)

Telepathology room

Remotely controled digital microscope (VisionTEK Live Digital Microscope, SAKURA)

HistoTechnical staff

Core of highly trained staff with specific training in macroscopic processing

4 years degree in Pathology (3 years theoretical and practical and 1 year only

practical).(Escola Superior de Tecnologia da Saude de Lisboa)

1 year degree in Macroscopic dissection (theoretical and practical) (Faculdade

de Medicina de Lisboa)

Working experience

Training program

Personalized training (no more than 2 people at a time)

Training suited to trainees previous level of knowledge

6 months to 1 year for a person without previous knowledge in Macroscopy

1 to 3 for a person with previous knowledge and experience in Macroscopy

Bibliography followed in term of gross specimen description and sampling

protocols

- Westra, William; Surgical Pathology Dissection: An Illustrated Guide, 2nd

edition

- Rosai and Ackerman’s, Surgical Pathology

- Lester, Susan C; Manual of Surgical Pathology; 3rd edition

Telepathology Impacts and Challenges—Meyer & Paré,

Arch Pathol Lab Med—Vol 139, December 2015

Healthnet is a highly secured network to connect public health institutions. This guarantees the confidentiality and data protection of the digital information.

Telepathology network using the Healthnet VPN infrastructure.

Bandwidth of 1 Gbit/s.

Every hospital we are uses the same IT systems in order to reduce maintenance costs.

The macroscopist uses a Touchscreen computer connected to a camera on top of the macroscopy workstation. He has access to our LIMS (laboratory information management system) (DaVinci) and other services hosted by the LNS.

The digital microscope uses a direct Teamviewer connection. This allows the pathologist to remotely see and manipulate the virtual microscope from his office at LNS.

Use of virtual slide system for quick frozen intra-operative

telepathology diagnosis in Kyoto, Japan Diagnostic Pathology 2008 3 (Suppl 1) :S6

Comparison of delays prior to the use of Telepathology

showed a clear reduced time in frozen section reporting

(average of 15 and 20 minutes from CHEM and CHL

respectively).

Discrepancies between virtual and traditional frozen

section were analyzed, with no significant disadvantages

of a telepathology assessment Vs a traditional one.

-8 cases (out of 135) (5,9%) showed discrepancies

between frozen section and final diagnosis

-5 (3,7%) cases were due to sampling errors

-3 (2,2%) cases were interpretation errors

-1 (0,7%) case deferred

-Comparable to reported discrepancies in the

literature

1: Sams SB, Wisell JA. Discordance Between Intraoperative Consultation by

Frozen

Section and Final Diagnosis. Int J Surg Pathol. 2017 Feb;25(1):41-50. doi:

10.1177/1066896916662152. Epub 2016 Aug 20. PubMed PMID: 27507675.

Salivary Gland

Télépathologie (10x) LNS (10x) Histologie (10x)

Rectum

Télépathologie (10x) LNS (10x) Histologie (10x)

Lipoma

Télépathologie (10x) LNS (10x) Histologie (10x)

-The use of DP (outside the scope of Telepathology for intraoperative frozen sections) in every-day routine reporting is still very reduced (under 5%)

-Philips High-throughput Ultra Fast Scanner

-Implementation technical challenges: consistent slide identification recognition, interoperability with different bar codes and lab equipment, image storage, remote access

-Implementation “cultural” challenges: reluctance to use of DP by part of the personnel, changes in workflow.

-Upcoming incentives (adoption of IA algorithms assisting diagnostic act, prioritize use of current standardized quantitative digital tools) might increase use of DP in the routine sign out setting.

Conclusions

-A project to integrate all the hospitals in Luxembourg with a central

Pathology Laboratory is underway.

-Two of the hospitals have been already integrated and as of May 2018,

the test phase in a third one (Centre Hospitalier du Nord-CHdN) has been

completed.

-The implementation of DP in the routine requires further investment,

both economically and behavioral. New functionalities and AI based

algorithms may tip the balance towards extended use of DP.

Telepathology’s impact on patient care and surgeon satisfaction has

proved beneficial due to:

1) Dramatic reduced time in frozen section reporting

2) Improved communication regarding macroscopic assessment, allowing

the surgeon to indicate the areas of interest (live mode)

3) Optimal frozen sections due to immediate freezing and samples not

subject to drying effect in long transportations

4) Collection of fresh and frozen tissue for biobank and research projects

Conclusions (II)

Thanks to the dedicated

team:

-Prof F Schmitt

-Dr Daniel Val Garijo

-Dr Javier Alves Ferreira

-Dr Adrian Cuevas Bourdier

-Margarida Sarreira

-Paulo Miranda

-Jean-Marc Papi

-Prof. Mittelbronn

Thank you very much