1. Digital Frozen Section
Pathology:
Validation and Implementation
at The Royal Brompton &
Harefield Hospital s
Dr Brian Mitchelson
Histology Supervisor -Harefield Hospital
The Royal Brompton & Harefield NHS
Foundation Trust

2. Our problems!
► Firstly the two hospital sites are 20 miles apart.
► Harefield currently has 1 resident Associate
Specialist Histopathologist.
► The Royal Brompton has 3 Consultant
Histopathologists, one of whom shares her time
between the Brompton and Harefield sites.
► This could cause potential problems for frozen
section diagnosis if no Consultant was available
for difficult cases at the Harefield site.
The Royal Brompton & Harefield NHS
Foundation Trust

3. Our Solution
►The Aperio Scanscope system
was purchased in 2009 with a
view to overcoming this problem
by utilising Digital Microscopy to
view the frozen section slides
remotely.
The Royal Brompton & Harefield NHS
Foundation Trust

4. The Harefield Laboratory
The Royal Brompton & Harefield NHS
Foundation Trust

5. Validation Methodology
► Frozen sections were prepared and reported as
usual at Harefield Hospital.
► Once the slides had been reviewed by a Harefield
pathologist and the result phoned to the surgeon
in theatre, the slides were scanned at x20
magnification on the ScanScope machine.
► The reporting pathologist on duty at the Royal
Brompton Hospital (RBH) was informed a frozen
section was being scanned.
► Once scanning was complete, he/she logged onto
the remote server and blindly reviewed and
reported the scanned images.
The Royal Brompton & Harefield
NHS Foundation Trust

6. Methodology (cont’d)
► The pathologists then entered their frozen
section report onto separate databases to
ensure impartiality.
► The time taken to scan the slides and to remotely
report the frozen section slides was also noted.
► Once approx. 50 frozen sections had been
reported: the concordance in diagnosis, average
time for scanning and average reporting times
were assessed.
The Royal Brompton &
Harefield
NHS Foundation Trust

7. Recording the data
RBH
Time arrived in Time scan time to
FS Case the Time reported completed report
Test Date type No. laboratory HH HH (seconds)
1 ######## LN 09P1552 12:00:00 12:15:00 12:20:00 30
2 ######## Lung 09P1576 16:15:00 16:40:00 16:45:00 90
3 ######## LN 09P1601 10:30:00 10:45:00 10:55:00 90
09P1616
4 ######## LN A 09:15:00 9:35:00 09:55:00 60
The Royal Brompton & Harefield
NHS Foundation Trust

8. Our Findings
► The initial results were very encouraging
and show an almost 100% concordance of
diagnosis within minutes of being available.
► To date we have scanned several hundred
cases 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 & Harefield
NHS Foundation Trust

9. Results.
Results
Between November 2009 and October 2010, 49 cases were scanned
and reported.
These 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 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 histological section and of the digitised image.
The Royal Brompton & Harefield
NHS Foundation Trust

10. Our one discrepancy
Only one case showed a minor discrepancy
between the two reports, which had no effect on
patient treatment.
This case was a lung nodule removed from a patient
with known CLL. Both pathologists reported the
presence of necrosis with granulomatous
inflammation and a small lymphocytic infiltrate.
The possibility of lymphoma was raised by the
Harefield pathologist (to whom the history of CLL
was known), but not by the Brompton pathologist
(who was not aware of the history of CLL).
The Royal Brompton & Harefield
NHS Foundation Trust

11. Validation Process
► All the data we recorded was tabulated and presented to
the Trust 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 formally requested that in view of the data submitted
that approval be granted to use this technique for reporting
frozen section pathology when the need arises.
► Approval of the technique was then given for surgical
pathology use in frozen section reporting, when required.
The Royal Brompton & Harefield
NHS Foundation Trust

12. Case A - 79 year old male
Frozen Section Specimen - Jugular LN
► Right lung base
lesion with
supraclavicular
lymph nodes on the
right side
► FS Diagnosis –
Hodgkin's
Lymphoma
The Royal Brompton & Harefield NHS Foundation Trust

13. 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 & Harefield NHS Foundation Trust

14. Case B - 73 year old male
Frozen Section Specimen- Apical segment of
RLL
► RLL mass, ?
Malignancy, previous
bowel cancer2007,
► chemotherapy
► FS Diagnosis –
adenocarcinoma
The Royal Brompton & Harefield NHS Foundation Trust

15. The paraffin processed block
► Final diagnosis :
RLL apical
segmentectomy:
metastatic colorectal
carcinoma
The Royal Brompton & Harefield NHS Foundation Trust

16. Case C - 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
The Royal Brompton & Harefield NHS Foundation Trust

17. The paraffin processed block
► Final diagnosis : malignant
epitheliod tumour,
► OR, 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 & Harefield NHS Foundation Trust

18. 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 and in many cases was made
easier due to the large screen image and
zoom magnification.
► Other potential benefits include second
opinions, referrals and teaching.
The Royal Brompton & Harefield NHS Foundation Trust

19. In Summary
► The image quality is excellent
► The accessibility is rapid and simple
► Real time image handling is a benefit
► The more we use the system the more uses and
benefits we are finding for this instrument:
Cross-site referrals: this saves transferring slides
from one hospital to the other
MDT meetings: allowing real time image handling
and auditing cases on either site.
The Royal Brompton & Harefield NHS
Foundation Trust

20. The End
Thank you for your attention
Brian
The Royal Brompton & Harefield NHS
Foundation Trust