May 2009
Feature Story

Anne Paxton

They’re a mile and a half apart, they had no extra time, and exchanging written reports had always been standard procedure. Nevertheless, an anatomic pathologist and a radiologist at Kansas University Medical Center have been holding a weekly, online, head-to-head meeting for a year now to correlate tissue and imaging findings for their breast cancer patients.

The special teleconferences, one hour at 8 AM on Fridays, are a pilot project the two specialists launched because of a paradox of breast cancer diagnosis. In any particular case, says Ossama Tawfik, MD, PhD, vice chairman and director of anatomic and surgical pathology, there may be a discordance in findings that somehow has to be resolved. “What the radiologist is seeing is correct; what I’m reporting is correct. But that doesn’t mean they are both correct.”

“Mammography has done a wonderful job in identifying cancers very early, and now we can cure cancer if we find it. The issue is, Are we finding every cancer? Are we doing our best to find that cancer?”

In a presentation in February at the Molecular Summit, sponsored by The Dark Report, Dr. Tawfik and Mark Redick, MD, PhD, assistant professor of radiology in the medical center’s Section of Breast Imaging, described how their pilot project got underway and how it fared. Part of a trend toward more integration of pathology and radiology, the project required sophisticated but readily available technology and a strong desire to see if closer interaction between radiologists and pathologists can bring about more accurate diagnosis and better treatment.

Did it work? Drs. Tawfik and Redick have the numbers, and they show that tele-consultations are having a dramatic impact on how breast cancer patients are managed at KUMC.

In early 2008, Dr. Redick told the Molecular Summit audience, he had become increasingly concerned about the problems in resolving discordances between images and diagnoses of breast cancer patients. “We felt we may be re-biopsying too many patients, and possibly we could do better if we spent more time sitting down and correlating things with the pathologist,” he said.

On the anatomic pathology side, Dr. Tawfik and his partners were also frustrated at not being able to correlate the imaging appearances and characteristics of the lesions they were biopsying, which are often small, with the tissue samples they were reviewing.

The advancing technology in screening mammography of the past three decades has brought about what is sometimes called a “new era” in breast cancer diagnosis, Dr. Redick said.

“Today we are finding and biopsying very small lesions, almost all less than 1.5 cm and often less than 1 cm. The significant decrease in size has caused us to shift from open surgical biopsies to percutaneous image-guided needle biopsies, with corresponding decreases in biopsy specimen size. Most of these small and impalpable cancers are not evident to the surgeon or pathologist, even looking at the gross specimen.”

“We used to take out big pieces of tissue and hand them over to the pathologist, and say, ‘What is it?’” Dr. Redick said. “Today we’re taking very small core biopsy specimens from an area of a mass, or multiple areas of a mass, and submitting those for histopathological evaluation.”

The change is a positive one because the cost and morbidity of needlessly taking patients with benign diagnoses into the OR are reduced. “In instances of patients with malignant disease as well, we can also offer better subsequent care by having a preoperative diagnosis of cancer from a needle biopsy,” he said.

Tissue samples ranging from 2 to 3 mm in diameter and 10 to 20 mm in length are increasingly excised, “particularly in the case of suspicious calcifications that we think might represent early ductal carcinoma in situ,” he said. Histologic sampling of these core specimens must be done in a very exhaustive, complete way, because “we’re really looking for very small lesions inside these tissue specimens, and it’s generally accepted at least six step levels are required to adequately screen a 3-mm core.”

But that creates a kind of nightmare for the pathologist, he said: a needle-in-a-haystack search mission. “We may have a very small cluster of microcalcifications contained in this one portion of this one core, and we hand it to the pathologist as a whole group of cores.”

“To make it worse, the surrounding tissue may contain any of the myriad benign pathologies that often exist with benign or malignant lesions—and these, too, may have calcifications within them that may confuse the issue, leading the pathologist to actually think they’re looking at our targeted lesion.”

These aren’t the only risks that keep radiologists awake at night, he added. “Assessing tumor size, determining the status of tumor markings, and recognizing high-risk precursor lesions that may indicate unsuspected multiple foci or even bilateral cancers require that both pathology and radiology tools come to bear on diagnosis and treatment of patients.” Failing to use this integrated approach increases the odds of misdiagnosis, he said.

Both groups of specialists, in practice, tend to review the others’ written reports rather than look at the radiographs (in the case of the pathologist), or at the tissue slides (in the case of the radiologist), and from those reports make their recommendations for further management. “From our viewpoint, what was missing in the process at our institution was communication, correlation, and consensus on concordance,” Dr. Redick said. In fact, it appeared anecdotally that when patholo­gists and radiologists by happenstance met and discussed a case, “a lot better information came out and better management of patients resulted.”

The pathology and radiology departments decided how they would proceed. “We determined we would need all the images in digital format in a high-resolution, full-fidelity format, they needed to be simultaneously interactive, and we needed the ability for any participant in the conference, anywhere on campus, to take control and direct attention to any particular finding on imaging or histology. And obviously that meant video conferencing capability.”

There’s nothing new about video conferencing and the technology is available in off-the-shelf form, “but it hasn’t been applied in our region to attack this particular kind of problem,” Dr. Redick said.

The chief obstacle, as Dr. Tawfik saw it at first, was finding the time to add teleconferences to the weekly workload. Radiology wasn’t the first to push for closer consultation with pathology. “The liver people want this, the GI people, the kidney, the sarcoma—how do we come up with the time to do it?” he said.

Still, Dr. Tawfik knew it was a project whose time had come. “The Institute of Medicine has mandated a 50 percent reduction in medical error in five years. It is important, and if we can come up with a better way of communicating and improving our service, it is very, very relevant indeed.”

Moreover, medical practice is shifting away from academic centers to community settings such as surgicenters, and more procedures are being done in small offices. “So we needed to find a way to communicate with each other—not just in our institution but across town, across the state, even across the ocean.”

“We decided to have a real-time, multidisciplinary approach and use a high level of technology to make all radiology and pathology images done in the last week available for review by the pathologist and radiologist.”

Using the Aperio ScanScope XT system, a PolyCom PVX video conferencing system, GE Healthcare’s Radiology PACS, and a Spectrum Plus digital pathology information system, the two specialists set up their personal computers with webcams and started their teleconferencing project: a Web-based pre-diagnostic workup conference in which the pathology slides and mammograms could be analyzed together.

“We relied on a Web-based type of diagnosis for benign lesions,” Dr. Tawfik explained. “I want to stress ‘benign lesion diagnoses’ because if a patient has cancer, in reality it’s the end of one dilemma and the beginning of another dilemma. Yes, you start treatment, but what if it is not cancer? If the diagnosis is ‘not cancer,’ does it mean it’s really not cancer? Does it mean we need to do something else? Did the radiologist or pathologist misdiagnose? Did they hit the right lesion? We really don’t know.”

Unfortunately, the radiologist and pathologist are often not speaking the same language. “Currently we’re working in silos,” Dr. Tawfik said in an interview with CAP TODAY. “I’m relying on his report, he’s relying on my report, but we’re not really relying on the facts we’re considering in our hand.”

In addition, pathologists do not see their “customers,” Dr. Tawfik notes. “Our colleagues tell them what we saw about the patients, so we’re leaving the door open for assumptions that might be wrong.”

The Aperio ScanScope system became part of the solution somewhat accidentally. “We currently have one used in medical student education, and it was literally collecting dust after we scanned all the slides for the medical school histology and pathology courses. Every time I passed it I would say I wished I could have it to use on the clinical side.”

Dr. Tawfik did get what he wished for, and he was also able to get the telemedicine department to install in his and Dr. Redick’s offices the same PolyCom PVX conferencing system the hospital used. In some conferencing technology the ability to talk and see each other is missing, and it’s a failing, he said. “There is an element of trust and reliability in our business. If you don’t have that added experience of watching body language, your ability to communicate and advise is limited.” So in their weekly consultations, they now see each other’s faces as well as desktops.

After the first year, to test whether the pilot project is making a difference in managing patients, they decided to study the concordance between the radiology and pathology diagnoses about which there had been conferencing.

“We looked at the quality of the digital slides, the efficiency of the process, the concordance between the glass and digital slides and the images, the comfort level of people running the show, and most importantly, a comparison of the actions taken based on the digital consultation,” Dr. Tawfik said.

In reviewing 122 biopsies done for 106 patients, they found a potpourri of diagnoses, “the kind you normally see in your practice.” The easiest cases to agree on were fibroadenomas. Overall, in 80 biopsies, the pathologist and radiologist agreed on the diagno­sis and took no further action.

But as a result of the teleconference, they also found there were 42 cases in which they had to do something extra—and they classified that something as “major” 14 times {see Cases (PDF, 3.3 MB)}. They excised the lesion in four cases, re-biopsied the patient in three cases, and did followup radiologic studies in nine cases. The “minor impacts,” as they were called, were ­x-ray of tissue blocks or deeper sections, and findings of mislabeling, no calcification, benign cyst, papillomas, and diabetic changes.

“That was very, very amazing to me that we could find such a difference,” Dr. Tawfik said. “Quite a few cases required work on my end; quite a few cases required work on his end. But we talked. And that in itself made a tremendous difference in the care of the patient.”

Just as fibroadenomas are quickly agreed on, “the cases that give us lots of anxiety and grief are clustered microcalcifications,” he said. In one example, Dr. Redick said he had a core biopsy and that Dr. Tawfik should look for microcalcifications for that patient. “I said sure, I have that. End of discussion,” Dr. Tawfik said. And Dr. Redick assumed that Dr. Tawfik saw what he saw in the patient or in the x-rayed tissue block. “But in reality, I saw something he never saw,” Dr. Tawfik said, “because there is a size limit: He’s not going to be able to see anything less than 100 microns.”

In one case of discordancy, Dr. Tawfik analyzed a core biopsy and found only a bit of hyperplasia at the outset. “We discussed it, and he said, ‘I’m worried. I’m not convinced I sampled the entire area.’ I said, ‘Well, I’m sorry, but I don’t have cancer.’ And he said, ‘Despite the diagnosis being not cancer, whatever I’m seeing is worrisome. I’m going to refer this patient to the surgeon who will excise the lesions.’ And lo and behold after excision of the lesion, we found ductal carcinoma very close by the previously sampled area.” So it’s obvious that cross-talking and communication is important, if not essential, Dr. Tawfik said.

As part of the project’s evaluation, Dr. Tawfik plotted the change in the number of minutes it took to retrieve, scan, and review a slide over the course of several months. “Scanning started at about 10 to 15 minutes. Now it’s down to four and sometimes three. So there was a learning curve, but it didn’t take long. We educated each other, and once we realized how we talked to each other, it became much more efficient.”

The collaboration has done two things to improve patient care, Dr. Redick noted. It has ensured a more reliable benign diagnosis, and it has given physicians the opportunity to examine more carefully the cases of patients with high-risk lesions or malignant diagnoses. “By participating in this conferencing, each specialty has also achieved the goal of educating the other department to its needs. We continue to work on ways to make each other’s jobs easier.”

Soon, the pathology department will start a similar project with endoscopy, says Dr. Tawfik, who is also in the early stages of a pilot study using Aperio with a medical center in Egypt. He says caution is called for anytime advanced technology is used. “You have to be very careful you’re leveraging it to solve problems and not create problems. It’s never one size fits all. It depends on the question you’re asking and the answer you want to get. It’s there to help you, not for you to become a slave to it.

“And if it’s not working,” he adds, “you have to do something else.”

Related Links

• Cases (PDF, 3.3 MB)