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La cytologie digitalisée: avantages et limites.
R. Dina, MD, FIAC, FRCPathImperial College London, UK
COI
▪Declaration d’interet
• Je suis un simple cytopathologiste qui essaie de
comprendre les developments en pathologie digitale
et moleculaire
• Ma femme ne crois pas que j’aille une qualilification
medicale
• En effet, même si instruit je ne trouve rien dans le
frigidaire.
• Je n’ai acun interêt commercial
Avantages▪ (1) Diagnostic primaire (télécytologie)
▪ (2) Consultation specialiste à distance
▪ (3) Activité éducative dans la même institution ou à distance
▪ (4) Archivage des cas intéressants et medico-légaux (réplication de lames de cytologienumérique)
▪ (5) assurance de la qualité
▪ (6) Conférences éducatives telles que des panneaux de tumeur (localement ou àdistance)
▪ (7) Test de compétence cytologique
▪ (8) Examen ou certification à distance
▪ (9) Analyse d'image détaillée et cytomorphométrie
▪ (10) Annotation électronique de diverses entités sur les lames à des fins d'enseignement
▪ (11) Acquisition facile d'images statiques à partir d'images de la lame entière
▪ (12) Fournir des services de cytopathologie aux hôpitaux sans cytopathologie
▪ (13) Accèder à l'expertise en cytologie à distance
▪ (14) Évaluation et triage à distance des lames (ROSE)
▪ (15) consultation synchrone
Limitations
▪ (1) Coûteux: configuration initiale et memoire▪ (2) Fonctions de mise au feu limitée au moment▪ (3) temps de digitalisation▪ (4) Stockage: grande taille de fichier▪ (5) Exigences de formation▪ (6) études de validation limitées▪ (7) Absence de normalisation: fournisseurs multiples,
logiciels et manque d'interopérabilité▪ (8) Soutien à l'infrastructure informatique (limitation
de la bande passante des réseaux)▪ (9) réticence des professionnels à adopter
Patholog Res Int. 2011; 2011: 264683.
Walid E. Khalbuss, 1, 2 * Liron Pantanowitz, 1, 2 and Anil V. Parwani 1
1Division of Pathology Informatics, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh,
PA 15232, USA2Division of Cytology, UPMC Shadyside Hospital, 5150 Centre Avenue, POB2, Suite 201, Pittsburgh, PA 15232,
USA
Review Article:Screening for Cervical Cancer Using Automated Analysis of PAP-SmearsEwert Bengtsson and Patrik Malm
Division of Visual Information and Interaction, Department of Information Technology, Centre for Image Analysis,Uppsala University, Box 337, 751 05 Uppsala, SwedenComputational and Mathematical Methods in MedicineVolume 2014
Development of automated screening devices
Type Tools Issues
Cytoanalyzer 1956 2D histograms of nuclear size vs density
Too many false positives
CYBEST 1974 Nuclear area, density, cytoplasmic area, N/C ratio
Could not measure nuclearshape and chromatin pattern
PAPNET (NSI) 1994 first to introduce interaction into automated screening first by an algorithmic classifier and then by a neural network classifier
centralization of scanning, litigation issues,
LBC (Cytic,AutoCyte) early90s
Liquid based cytology samples facilitate digital scanning
More expensive
Development of automated screening devices
Tools Issues
AutoPap 300-Tripath-BDFirst FDA approved 1998
25% of the slides as normal for no further review;theother 75% are ranked into five categories at risk forabnormality.
Very expensive; could also allow review of fieldsMedico-legal issues
Cytyc- ThinPrep Imaging System 2003 -from 2007 Hologic
Increasing detectionof abnormalities by improved specimen preparation andscreening both visually and bymachine
Expensive- Not clearly shown to improve detection in a screening setting
Use of Digital Imaging
At Imperial College we have been using in the past digital images for
▪ cytology tests during our MSc in Cytopathology▪ Cytology mock exams during our Advanced Courses
which prepare for the MRCPath examination ▪ WSI for research purposes and testing.▪ We currently informally review WSI of cases but we
do not issue a formal report on them. This is because although technology on the different platforms available on the market has markedly improved we do not feel that there is an agreed standardised practice for it.
Conclusions
▪ WSI is here to stay and is fast improving and getting cheaper
▪ It is an important teaching and training tool
▪ It is used for EQA schemes and Quality Assurance
▪ It is used in MDT meetings (Tumour Boards)
▪ It helps retaining a screening component to all assessment tests
▪ BUT…… it is one of the many tools!
1) The research has used the Google search engine: www.google.com;
2) Searched nouns as keyword: nouns had to be the most concise as possible. The used keywords are: cytology web sites, cytology atlas, cytology and cytopathology journal, and cytology societies;
How many web sites use digital cytology?
1) Sponsor, scientific society, personal web page, academic institution or commercial site: whether a website is sponsored by a Society, a particular product or interest group, the owner of the web site. Personal web page web sites can list the author of the information and biographical information.
2) Society: the name of the involved Society.
3) Purpose: to provide educational information, professional advice, promoting the profession of cytologists, encouraging the science of cytology. Many web sites provide information on topics of interest to the owner, as well as tutorials or opinions.
4) Topic: FNA, gynaecologic or non-gynaecology cytology.
5) Target groups: whether the web site is recommended to cytologists, cytotechnologists, cytology trainees or students, laboratory personnel.
Criteria
6) Access: public, only registered members, any payment fees required.
7) Educational resources: each web site has been checked whether with or without educational purpose or to improve academic success.
8) Imaging: static or dynamic as virtual slides.
9) Passive or interactive: some web sites have just slides to look but no possibility to have an interactive approach. Other web sites allow the visitors to take quizzes or view solutions previously hidden, in order to test trainees or students.
Criteria
▪ The number of web sites is about 671,000 results for each keyword. Sites with only histopathology have been excluded.
▪ Based on the above mentioned criteria, the number of web sites considered adequate is 31.
Results
▪ There are numerous web sites available
▪ Aims are different
▪ Few are available in multiple languages
▪ Cytology is notoriously more difficult to comprehensively scan
▪ Too few web sites are completely free to use
▪ Few offer interactive e-training
▪ However it is getting better all the time!
Conclusions
Average monthly traffic 2009-14
0
10000
20000
30000
40000
50000
60000
year 2009 year 2010 year 2011 year 2012 year 2013 year 2014
average visits
average page downloads
Observations after 5 years of use▪ The platform is used more during the
academic months
▪ Page download is higher in the academic months
▪ After 5 years the content and IT architecture is obsolete
▪ This is reflected by the decrease in page downloads
Eurocytology 2013-15
▪ Successful in applying for another EU grant▪ Move platform from static to dynamic architecture
▪ EFCS is a partner (already linked to website)▪ Linked to IAC website▪ Translate into Turkish, Czech, Portuguese and German
▪ Incorporate translations and adaptations into national curricula (Turkey, Czech Republic)
▪ Increase interactivity by devising online assessment and testing tools
▪ Maintain an editorial committee
▪ Validate it as a European Accreditation Scheme Platform Through QUATE
What is peculiar to this project?
▪ Transnationality
▪ Validation through a European Network
▪ Dinamic tests through the use of a specific software and image database
▪ Use of virtual slides
▪ Translated in several languages
AnalyticsEurocytology 2.0
All Web SiteDataGo to report
Audience Overview
Mar 1, 2018 - Feb 28,2019
Overview
2
50,000
Users
100,000
… May
Users
018 July 2018 September 2018 November 2018 January 2019
New Visitor Returning Visitor
New Users Sessions
771,338 756,828 919,524 11%
Number ofSessions per User
1.19
Pageviews
1,254,510
Pages / Session
1.36
89%
Avg. Session Duration
00:01:07
Bounce Rate
85.94%
Language Users %Users
1. pt-br 126,478 16.56%
2. es-es 98,820 12.94%
3. en-us 93,158 12.20%
4. es-419 69,146 9.05%
5. es 30,262 3.96%
6. el-gr 29,190 3.82%
7. tr-tr 26,793 3.51%
8. it-it 26,700 3.50%
9. en-gb 25,437 3.33%
10. es-us 22,556 2.95%
© 2019 Google
All Users100.00%Users
AnalyticsEurocytology 2.0
All Web SiteDataGo to report
Rows 1 -10 of212
Location
Mar 1, 2018 - Feb 28,2019
Map Overlay
Summary
Country
Acquisition Behavior Conversions
Users New Users Sessions Bounce Rate Pages / Session Avg. Session Duration Goal Conversion Rate GoalCompletions GoalValue
771,338
% of Total:
100.00%
(771,338)
757,234
% of Total:
100.05%
(756,828)
919,524
% of Total:
100.00%
(919,524)
85.94%
Avg forView:
85.94%
(0.00%)
1.36
Avg forView:
1.36
(0.00%)
00:01:07
Avg forView:
00:01:07
(0.00%)
0.00%
Avg forView:
0.00%
(0.00%)
0
% of Total:
0.00%
(0)
$0.00
% of Total:
0.00%
($0.00)
1. Brazil 134,803
(17.69%)
134,619
(17.78%)
159,697
(17.37%)
87.35% 1.22 00:01:03 0.00% 0
(0.00%)
$0.00
(0.00%)
2. Mexico 68,192
(8.95%)
67,615
(8.93%)
79,743
(8.67%)
88.06% 1.24 00:00:58 0.00% 0
(0.00%)
$0.00
(0.00%)
3. Greece 49,675
(6.52%)
49,352
(6.52%)
61,564
(6.70%)
80.90% 1.40 00:01:22 0.00% 0
(0.00%)
$0.00
(0.00%)
4. Colombia 46,083
(6.05%)
45,799
(6.05%)
53,007
(5.76%)
89.64% 1.18 00:00:46 0.00% 0
(0.00%)
$0.00
(0.00%)
5. Italy 43,123
(5.66%)
43,032
(5.68%)
53,323
(5.80%)
86.56% 1.39 00:01:06 0.00% 0
(0.00%)
$0.00
(0.00%)
6. Turkey 40,455
(5.31%)
40,235
(5.31%)
46,076
(5.01%)
88.58% 1.20 00:00:41 0.00% 0
(0.00%)
$0.00
(0.00%)
7. Spain 38,050
(4.99%)
37,773
(4.99%)
48,677
(5.29%)
84.01% 1.60 00:01:23 0.00% 0
(0.00%)
$0.00
(0.00%)
8. Romania 31,471
(4.13%)
31,267
(4.13%)
40,468
(4.40%)
86.94% 1.27 00:01:06 0.00% 0
(0.00%)
$0.00
(0.00%)
9. United States 27,833
(3.65%)
27,349
(3.61%)
30,718
(3.34%)
88.02% 1.37 00:00:46 0.00% 0
(0.00%)
$0.00
(0.00%)
10. Poland 27,548
(3.62%)
27,154
(3.59%)
32,348
(3.52%)
86.27% 1.39 00:00:49 0.00% 0
(0.00%)
$0.00
(0.00%)
1 134,803
© 2019 Google
All Users100.00%Users
Digital Histology vs digital Cytology
▪ Digital Histology and digital Cytology need a different technical approach for many reasons
Digital Histology vs digital Cytology▪ Dimension:
Digital Histology vs digital Cytology▪ Dimension:
Digital Histology vs digital Cytology▪ The nature of the material is different:
Histology
Cytology
Digital Histology vs digital Cytology▪ The scanning technique is different:
If the scanner autofocus works well, a single layer virtual slide allows a high quality screen of a histological preparation.
A multi level scanning is compulsory to get an acceptable cytological virtual slide.
Digital Cytology: a 3D problemApparently it is like a short blanket:
Low number of levels = not acceptable focusing wideness.
Short distance between levels = increased number of levels.
Many levels with short distance between them = very big files.
In any case: sensibly longer scanning time.
Digital Cytology: a 3D problemThere are at least 3 possible ways
to try to find a solution.
Digital Cytology: a 3D problemThe first is the one used in the virtual slides library of some teaching web sites.
For example:
www.eurocytology.eu
www.cytology.cloud/gk
Digital Cytology: a 3D problemThis technique consists 3 steps:
1. dividing in small areas (tiles) the image resulting from the scanning of each level
1. taking the best-focused tile from each layer
1. building a new virtual slide where all the objects result in focus
Leve
l 1
Leve
l 2
Leve
l 3
New single level
image
Digital Cytology: a 3D problemThe final result is a single level virtual slides where all the tiles are perfectly in focus.
Pros: - small dimension of the file
- good “visual” results
Cons: - long processing time
- a lot of unnecessary data generated
Digital Cytology: a 3D problem
Digital Cytology: a 3D problem
A second interesting method is proposed in
Digital Cytology: a 3D problem
A specific software generates during the scanning a three
dimensional focus map of the cells in the slide.
Following this map the scanner takes only the images of the cells
avoiding the generation of unnecessary and unwanted data.
Digital Cytology: a 3D problem
A third interesting solution is based on the
“tilted focus plane” and/or “tilted lens”.
Digital Cytology: a 3D problemThe idea to tilt the camera lens or the focus plane is quite old
Digital Cytology: a 3D problem
The idea to tilt the camera lens or the focus plane is quite old
Digital Cytology: a 3D problem
Tilting of the focus plane or the lens
this kind of camera can take sharp pictures
of objects located at different distances
from the camera without the need to close
the camera iris to increase the depth of focus
Digital Cytology: a 3D problem
Digital Cytology: a 3D problem
Digital Cytology: a 3D problem
By means of a scanner equipped with tilted lens or focus plane it is possible to scan with a single pass all the cells in the thickness of the smear saving time and disk space (with the appropriate software)
Summarizing
If time and disk space are not a problem any
method suits well.
This is true for teaching, research, documentation
and second opinion.
For real primary diagnostic purposes new
technologies must be developed.
Thank you!
