The Royal Brompton & Harefield Hospitals’ Experience Dr Brian Mitchelson THE VALIDATION AND INTRODUCTION OF A REMOTE FROZEN SECTION REPORTING SERVICE The Royal Brompton & Harefield Hospitals’ Experience Dr Brian Mitchelson Cadiz 2013 The Royal Brompton and Harefield Hospitals NHS Foundation Trust 1 1

The Harefield Laboratory The Royal Brompton & Harefield NHS Foundation Trust

The Royal Brompton and Harefield Hospitals NHS Foundation Trust OUR PROBLEMS! The trust consists of two Specialist Cardio-thoracic hospital sites which are 20 miles apart. On the retirement of the Harefield Hospital Consultant pathologist we were left with one resident Associate Specialist Histopathologist. The Royal Brompton Hospital has 4 Consultant Histopathologists, one of whom now shares her time 1 or 2 days per week between the Royal Brompton and Harefield sites. The Royal Brompton and Harefield Hospitals NHS Foundation Trust

The Royal Brompton and Harefield Hospitals NHS Foundation Trust It was also decided to centre the majority of the workload at the Royal Brompton Hospital. This would leave the Harefield Hospital with either the shared consultant or the Associate Specialist with one junior scientist to provide a rapid biopsy and frozen section service. This plan meant the Harefield site has no Consultant cover for several days per week. The Royal Brompton and Harefield Hospitals NHS Foundation Trust

The Royal Brompton and Harefield Hospitals NHS Foundation Trust OUR SOLUTION The decision was made to use Digital Microscopy to provide a cross-site reporting service After looking at the various options and availability, the Aperio Scanscope system was purchased. We felt Aperio offered a “Gold Standard” in the ease of use, speed of scanning and most importantly the scanned image quality. The Royal Brompton and Harefield Hospitals NHS Foundation Trust

The Royal Brompton and Harefield Hospitals NHS Foundation Trust INITIAL TRIALS As an initial test of our technique we monitored the system by scanning the frozen section slides immediately after initial diagnosis, at Harefield, then informed the Royal Brompton pathologists that a frozen section was ready for a second opinion. This was a blind trial, the reviewing Pathologist at the Brompton Hospital had no information of the initial diagnosis made at Harefield Hospital. All the scan times, times to report, diagnosis and reviewed diagnosis were recorded. The Royal Brompton and Harefield Hospitals NHS Foundation Trust

The Royal Brompton and Harefield Hospitals NHS Foundation Trust VALIDATION PROCESS All the initial trial data we recorded was tabulated and presented to the Hospital Clinical Practice Committee. All the procedures were carried out in accordance with the Guidelines set out by the Royal College of Pathologists in 2005. We requested that, in view of the data submitted, approval be granted to use this technique for reporting frozen section pathology when the need arises. Clinical approval of the technique was then given for reporting intra-operative frozen sections; when required. The Royal Brompton and Harefield Hospitals NHS Foundation Trust

The Royal Brompton and Harefield Hospitals NHS Foundation Trust OUR PROTOCOL The slide is routinely scanned at x20 magnification using either the “One Touch” scanning, or “Manual Scan" on the Aperio Scanscope. The specimen details are entered on the case file. The Royal Brompton pathologists are informed that a frozen section is ready for reporting. Should the pathologist require a x40 scan they will telephone the request through to the Harefield laboratory and discuss the area of the section to be re-scanned. The Royal Brompton and Harefield Hospitals NHS Foundation Trust

The Royal Brompton and Harefield Hospitals NHS Foundation Trust OUR FINDINGS The initial results were very encouraging and showed an almost 100% concordance of diagnosis within minutes of being available. To date we have scanned several hundred slides with an average time for the x20 scan being 4 minutes. The average time from completion of the scan to reporting at the Royal Brompton is approximately 90 seconds. The Royal Brompton and Harefield Hospitals NHS Foundation Trust

OUR VALIDATION RESULTS. The validation trial included single and multiple frozen sections, totalling 73 frozen section slides. The specimen type was as follows; Lymph node = 19, Lung = 32, Pleura = 6, chest wall = 3. The average time from end of reporting, at Harefield, to completion of scan and second opinion was 6.3 minutes. The average time to review the slides was 64 secs. There was 98% complete concordance in diagnosis made on review of the wax processed histological section and of the frozen section digitised image. The Royal Brompton and Harefield Hospitals NHS Foundation Trust

CASE-1 79 YEAR OLD MALE FROZEN SECTION SPECIMEN – RLL JUGULAR LN Right lung base lesion with supraclavicular lymph nodes on the right side FS Diagnosis – Hodgkin's Lymphoma Right lung base lesion with supraclavicular lymph nodes on the right side. Final diagnosis: Nodular Hodgkin's Lymphoma, nodular lymphocyte predominant type, with prominent T-cell/hystiocyte rich B-cell lymphoma like areas The Royal Brompton and Harefield Hospitals NHS Foundation Trust

THE PARAFFIN PROCESSED BLOCK Final diagnosis: Nodular Hodgkin's Lymphoma, nodular lymphocyte predominant type, with prominent T-cell/hystiocyte rich B-cell lymphoma like areas The Royal Brompton and Harefield Hospitals NHS Foundation Trust

The Royal Brompton and Harefield Hospitals NHS Foundation Trust CASE- 2 73 YEAR OLD MALE FROZEN SECTION SPECIMEN- APICAL SEGMENT OF RLL RLL mass, ? Malignancy, previous bowel cancer 2007,chemotherapy RLL FS Diagnosis – adenocarcinoma RLL mass, ? Malignancy, previous bowel cancer 2007,chemotherapy RLL Final diagnosis: RLL apical segmentectomy: metastatic colorectal carcinoma The Royal Brompton and Harefield Hospitals NHS Foundation Trust

THE PARAFFIN PROCESSED BLOCK Final diagnosis: RLL apical segmentectomy: metastatic colorectal carcinoma The Royal Brompton and Harefield Hospitals NHS Foundation Trust

The Royal Brompton and Harefield Hospitals NHS Foundation Trust CASE- 3 60 YEAR OLD FEMALE FROZEN SECTION SPECIMEN- RIGHT PARIETAL PLEURA Pleura coated with talc, shortness of breath, right pleural effusion, pleural thickening, previous lump excision of breast FS Diagnosis – malignant epithelioid tumour Pleura coated with talc, shortness of breath, right pleural effusion, pleural thickening, previous lump excision of breast Final diagnosis: malignant epitheliod tumour, ER, PR, calretinin, and CK5/6 negative, BerEP4, CEA and TTF-1 positive, the profile is in keeping with metastatic adenocarcinoma from a lung primary The Royal Brompton and Harefield Hospitals NHS Foundation Trust

THE PARAFFIN PROCESSED BLOCK Final diagnosis: malignant epithelioid tumour, ER, PR, Calretinin, and CK5/6 negative, BerEP4, CEA and TTF-1 positive. The profile is in keeping with metastatic adenocarcinoma from a lung primary The Royal Brompton and Harefield Hospitals NHS Foundation Trust

The Royal Brompton and Harefield Hospitals NHS Foundation Trust CONCLUSIONS The current data suggests this is a clinically useful system; with only a minimal time delay in reporting the frozen section diagnosis. Diagnosis was found to be no more problematic than using a conventional microscope. In many cases diagnosis was made easier due to the Whole Slide Image (WMI) of the section and the ability to zoom in on relevant areas remotely from the pathologists PC. Other potential benefits include second opinions, referrals and teaching. The Royal Brompton and Harefield Hospitals NHS Foundation Trust

The Royal Brompton and Harefield Hospitals NHS Foundation Trust THE FUTURE We are currently evaluating remote tissue dissection. The scientific staff will carry out the dissection of the submitted frozen section tissue under the remote guidance of a consultant pathologist using an audio-visual link between the two centres. The selected area of tissue will be cut, stained and scanned for remote reporting using our current protocol. The scanning speed and quality of the final digital image is an essential part of this process. We feel this type of work lays the foundations for the future use of digital microscopy. The Royal Brompton and Harefield Hospitals NHS Foundation Trust

Ladies and Gentlemen thank you for your attention I would like to thank the Aperio staff for their co-operation and invaluable help when we set up this technique. Brian. The Royal Brompton and Harefield Hospitals NHS Foundation Trust