Better Breast Cancer Care: Radiology & Pathology Converge Across the Digital Divide

	Ossama W. Tawfik, MD, PhD, director of anatomic and surgical pathology, can view his pathology slides and radiology images via web-conferencing to assist in determining the proper surgical or treatment plan for a patient.

When at first you don’t succeed, try, try again. That old adage was put to work when physicians from the radiology and pathology departments at the University of Kansas Medical Center wanted to work more closely in caring for breast cancer patients. A pathology information system, radiology PACS and video-conferencing system were the enablers for the two specialties to reach across the digital divide and hold weekly virtual conferences to discuss breast cancer biopsy findings vs. images. What did they learn? Better diagnosis and patient care arise from communication, correlation and consensus of concordancy between radiology and pathology findings.

Pathology has been one of the slower disciplines to come into the digital age, transitioning from the glass slide and microscope to a digital slide and pathology system in much the way radiology transitioned from the film and light box to PACS. As pathology catches up to radiology in terms of clinical information systems, radiologists and pathologists are still faced with discordance between histological findings and imaging findings—and wondering if they are truly reviewing the same biopsy tissue specimens? Are there more lesions than could be seen via imaging but were biopsied? Until IT vendors find the key to true integration—when pathology and radiology images can be shared via one software application—many clinicians are turning to a blend of purchased and homegrown technology solutions to solve the problem.

The image disconnect

In the last three decades, improvements in imaging and biopsy technologies have resulted in a significant decrease in the size of suspicious lesions detected on imaging studies, a shift from open surgical to percutaneous image-guided biopsy as well as a decrease in biopsy specimen size.

Video-conferencing Requirements
Radiology and pathology images must be available in an interactive, full-fidelity/high-resolution digital format Simultaneous real-time visualization of both radiology and histological images Interactive capability which allows any participant to take control of the conference and direction attention to a particular finding Video- and audio-conferencing capabilities

While these advancements are significant, there is room for improvement. Currently, the interaction between a radiologist and pathologist is this: radiologist performs the biopsy of suspicious breast lesion(s); pathologist reviews tissue specimens and written radiology report to generate a diagnosis. The radiologist then reads the pathology report and determines results to be concordant or discordant based on image appearance alone and recommends appropriate patient management based on histological diagnosis and concordancy. The missing link in the chain is the communication, correlation and consensus of concordancy.

The disconnect is primarily due to a lack of understanding, according to Mark L. Redick, MD, PhD, assistant professor of radiology, section of breast imaging at the University of Kansas Medical Center (UKMC) in Kansas City, Kan. “The disconnect is really a lack of education as to what the other discipline is up against, what they need and how [we] can help each other.”

Pathologists are unfamiliar with radiologists’ work and what information they need to make the next decision, such as whether a truly benign lesion is clear enough so the patient can be put to follow-up or whether the pathologic diagnosis not concordant with what a pre-operative impression was and the patient needs another procedure or surgery.

“Many benign lesions require a change in patient management not because they have a chance of increased risk but because we need to be very clear about specific information regarding the lesions that we biopsy,” says Redick. “And while pathologists do a good job of understanding their end, they are not always aware of the information we need back to make decisions. And on the flip side, radiologists don’t always have a good idea of what pathologists go through to get the diagnosis.”

“As long as we are working in a paper world, shooting reports back to each other or to a third-party referring physician, these problems don’t really get worked out,” he adds.

Building a telemedicine bridge

In an effort to work out such problems, improve the radiology/pathology correlation—and ultimately, improve patient care—Redick and his colleague Ossama W. Tawfik, MD, PhD, director of anatomic and surgical pathology at UKMC, embarked last September on a multidisciplinary approach to review imaging studies and tissue slides. The objective: to ensure a more reliable benign diagnosis and provide a more thorough consideration of the cases of patients with a high-risk lesion or malignant diagnosis.

Components of the Telemedicine Bridge
Radiology PACS from GE Healthcare Server with high-speed internet connection PC with a web camera Digital pathology system (Aperio ScanScope XT) Spectrum Plus digital pathology information management software Web conferencing system (PolyCom PVX)

Because of the disconnect and lack of understanding of the respective needs, the only practical solution became a regularly scheduled, live video conference to ensure adequate sampling, reduce errors, reach a proper diagnosis and determine the proper surgical/treatment. A telemedicine conference offered the answer.

“So we had to set up a formal, productive, efficient way of doing that and we turned to telemedicine, specifically videoconferencing,” Redick says, adding that it solves the problem of time and geography since it is done remotely from their respective offices, which are about 1.5 miles away from each other.

What started out as just a virtual collaboration between Redick and Tawfik once a week on Fridays, has evolved to include other breast radiologists and pathologists who come together to resolve cases from the prior week. Redick says the biggest challenge has been in making sure that the referring physicians’ and patients’ expectations are still met with no delays in the final sign-off on a case.

Using Aperio’s ScanScope system on the pathology side, a PACS from GE Healthcare and PolyCom PVX video conferencing system, Redick and Tawfik are able to show each other, as well as breast surgeons, their respective desktops during the live video conference. “We are watching each other’s discussion live and have the histology, the imaging and the videoconferencing up on the screens at one time.”

Changes in patient management

In looking at the changes in concordancy decisions, Redick and Tawfik were able to track changes that would have gone unsuspected if they had just gone with the written pathology report. In an initial study, they looked at the results of 106 patients with 122 biopsies. They cited 14 cases in which breast cancer was found that perhaps could have been missed if pathology and radiology weren’t working together. Of these 14 cases, there were four excised lesions, three re-biopsies and nine follow-up radiologic studies. In 28 cases, Redick and Tawfik found a minor impact on concordance, the majority of which (22) were x-ray tissue blocks/deeper sections. In 80 cases, no change was made in patient management. Redick says once they achieve 500 cases, they will revisit the data to see how the collaboration has affected changes in patient management.

Tawfik and Redick say they have learned two things from the collaboration. First, that there have been a few changes in the diagnostic aspect of the cases being reviewed. Second, that on the treatment side, pathology/radiology integration is driving significant changes in how the patient receives treatment and what therapies are recommended.

Looking to the future

Institutions like UKMC tackling the disconnect between radiology and pathology would clearly benefit from the development of one software application that could enable similar communication and collaboration, albeit in a more robust manner, with no delays, and fast, full-fidelity viewing. 

The ideal solution would have histology or significant images from histology sent to radiology PACS and tagged to the biopsy procedure, and likewise for the pathologist, says Redick. However, in this economy it would be challenging to get funding to purchase such an application simply because it doesn’t generate any revenue to justify the purchase, he notes.

“What we need is not a new product coming from a new vendor but an application from our current vendors that takes us to the next digital level without having to do it on our own,” Redick concludes.