The Usefulness of Incorporating Non-pathomorphological

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The Usefulness of Incorporating
Non-pathomorphological Data Recorded in the
Hospital Information System into the Pathology
Report Form and a Standardized Method of Viewing
Digital Pathology Images Keizo Furuya, Toshiharu
Maeda, Takanori Kikuchi Department of Pathology
and Radiology, Ehime Prefectural Central
Hospital ???? Oct. 25, 2010 Pathology
Vision 2010 (San Diego)
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Hospital information system of Ehime Prefectural
Central Hospital (2010)
(2013)
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Constitution 1. Background 2. Aim 3. Materials
and methods 3a. Pathology report form 3b.
Seamlessly viewing images 3c. Medical
library 4. Result 5. Conclusion
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Changes in the filed of pathology over the past
several decades Pathologists have confined
themselves within a static microscopic world. On
the other hand, medical fields other than
pathology, including imaging diagnosis and
molecular and genomic medicine, have developed
remarkably. The work of clinicians is
comprehensive and dynamic because of constant
changes in patient states.
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Medical record description by POMR (problem
oriented medical record) First medical
examination 1. Data base 1) Patient
information patient profile, chief complaint,
history of present illness, past history, family
history, social history, system review,
etc. 2) Physical examination findings general
status (external appearance, mental state, skin
condition) specific status 3) Test
findings 2. Problem listdisease name, signs and
symptoms, patients condition or findings, etc.
1) 1 title, 2 title, 3 title--- 2)
Distinguish active title from inactive title 3.
Initial plan 1) Diagnostic plan to select the
diagnostic tests and plan a schedule for
enforcement, e.g. urine tests, blood tests,
blood biochemistry tests, immunoserum tests,
chest and abdominal plain X-rays, ECG, urine
culture and blood culture tests and abdominal US
etc 2) Therapeutic plan 3) Education
plan Second medical examination or since the
second day after admission 4. Progress note 1)
Narrative note S subjective data (patient
complaint) O objective data (physical
findings and test findings) A
assessment (each problem is analyzed on the basis
of the information available about the disease
and a hypothesis is established on what
happens and why) P plan (make plans to prove
the correctness of the hypothesis and describe
it) Imaging examinations (CT scan, MRI
scan, etc.) and pathological examination 2)
Flow chart Record at discharge 5. Discharge
summary Provide a brief description, so it is
understood easily by all who read it.
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Clinicians As for the daily duties, clinicians
collect all kinds of clinical information and
summarize important data in progress notes to
see patients. Radiologists Imaging diagnosis in
radiology has converted from screen-film to
digital monitor diagnosis. Radiologists read
digital images by Paging as they give clinical
signs and symptoms, and laboratory data in
mind. Pathologists Why do pathologists not move
out from their static narrow minded
patho- morphological world and include factors
other than pathomorphological findings into
pathological diagnosis reports at least from the
standpoint of medical education?
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FDG PET-positive lung cancers with a high SUV
have been considered to represent a more
malignant disease process, resulting in a
significantly worse survival rate. Park CM, Goo
FM, Lee HF, et al. Tumors in the
tracheobronchial tree CT and FDG PET features.
RadioGraphics 2009 29(1) 55-71. Downey RJ,
Akhurt T, Gonen M, et al. Preoperative F-18
fluorodeoxyglucose-positron emission tomography
maximal standardized uptake value predicts
survival after lung cancer resection. J Clin
Oncol 2004 22 3255-3260. ---most
pheochromocytomas accumulate FDG, uptake is found
in a greater percentage of malignant than benign
pheochromo- cytomas, and FDG PET is especially
useful in defining the distribution of those
---. Blake MA, Cronin CG, Broland GW. Adrenal
imaging. JR 2010 1941450-1459 FDG, METO
(11C-metomidate a marker of 11-beta-hydroxylase),
FETO, MIBG (metaiodobenzylguanidine), HED
(11C-hydroxyephedorine), F-DOPA
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Constitution 1. Background 2. Aim 3. Materials
and methods 3a. Pathology report form 3b.
Seamlessly viewing images 3c. Medical
library 4. Result 5. Conclusion
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Aim To examine the usefulness of incorporating
non-pathomorphological data recorded in the HIS
(hospital information system) into the pathology
report form and the applicability of a
standardized method for viewing digital
pathology images.
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Constitution 1. Background 2. Aim 3. Materials
and methods 3a. Pathology report form 3b.
Seamlessly viewing images 3c. Medical
library 4. Result 5. Conclusion
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Materials and Methods 3a Information was
acquired from the HIS, including the electronic
patient record and findings of radiology,
pathology, and laboratory tests. The pathology
report form has the diagnosis and findings
sections, as before, but are structured like
research papers.
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Structured pathology report in the environment of
HIS One case is considered as one research paper
Diagnosis (abstract including the clinicians
requirements) Findings 1) Handling of
specimens (materials and methods) 2)
Patho(morpho)logical description (results)
Incorporation of non-pathomorphological data such
as radiological data (glucose uptake in
PET-CT scans), results of laboratory tests
(tumor markers), etc, with the date of each
test. 3) Comment (discussion) Incorporation of
substantial comments by utilizing our
medical library containing research papers on the
cases in our hospital.
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Structured pathology report surgically resected
cases Case 1 73-year-old man Chief complaint
liver tumor detected at the follow-up CT imaging
after gastrectomy for gastric cancer Clinical
diagnosis liver cancer suggestive of a combined
type HCC (hepatocellular carcinoma), CCC
(cholangiocellular carcinoma), or metastatic
carcinoma
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Diagnosis Liver, partial hepatectomy
hepatocellualr carcinoma, Lo S7/8, size 4.03.1
cm, necrosis 10, egig, fc, fc-inf, sf-, s,
vp, vv-, b-, im, p-, tw0.3 cm Findings 1)
Materials The resected liver was cut into 15
slices and slices 7, 8, and 11 with the main
tumor and slice 2 with a metastatic nodule were
examined microscopically. 2) Findings Grossly,
the tumor is basically of the nodular type but of
the partly confluent multinodular type.
Microscopically, the tumor consisted of 2
different patterns of HCC the trabecular type
with a thickness of 5-10 cells and the combined
trabecular and pseudoglandular types consisting
of stronger cellular atypia. Hence this tumor is
a moderately to poorly differentiated HCC. The
tumor invades the liver surface exposed in the
abdominal cavity. (Aug. 18, 2010) AFP 33.7H,
PIVKA ?2180H, DUPAN-2 ?25, SPAN-2 13.8, CA19-9
177.8H, CEA 1.3 (Aug. 25, 2010) GLU 152H, HbA1c
6.0H (Aug. 19, 2010) PET-CT FDG-SUVmax 4.8
(background liver 2.2) The tumor in segment 8
exhibits similar microscopic findings as the main
tumor, so it is identified as metastatic. Liver
mild fatty change (non-B, non-C) 3) Comment
Contrast-enhanced MRI shows peripheral dominance
in the early phase and a low signal in the
heptatocyte phase. The DWI (diffusion- weighted
image) shows a high signal. The imaging pattern
and relatively high value of FDG SUVmax are not
analogous to typical HCC however, the tumor is
microscopically an HCC with moderate to poorly
differentiated cell components. These phenomena
seem to be related to the microscopic findings
of 2 different patterns of HCC and the
macroscopic findings of 2 gross types.
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Structured pathology report ESD (endoscopic
submucosal dissection) case Case 2 63-year-old
man Clinical diagnosis Early gastric
cancer Chief complaint gastric polyp (introduced
from an other hospital)
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Diagnosis Stomach, ESD Early gastric cancer,
type 0-??a, sm1, adenocarcinoma (por1tub1),
INFß, 3.33.81.9 cm, location M Gre, ly2,
v0, lm- 0.3 cm, vm C16.9/ICD-O
814031 Findings 1) Materials The size of the
excised specimen was 5.03.9 cm2, cut along the
short axis into 11 slices, and all slices were
examined microscopically. 2) Findings Grossly,
the tumor is type 0-??a and its size is
3.33.81.9 cm3 (see reference
images). Microscopically, the tumor is an
adenocarcinoma (por1tub1) and invades into the
submucosa (sm1). The vertical margin is in
contact with the portion of exhibiting lymphatic
permeation. The lateral margin is tumor free.
(Sep. 01, 2010) H. pylori antibody () 66.2
U/ml CA19-9 3.9 U/ml CEA 0.8 ng/ml 3)
Comment The tumor is an adenocarcinoma of the
gastric type, and foveolar hyperplasia is
observed in the background. Although it is
difficult to clearly differentiate between
hyperplasia and neoplasia, the portion with
structural atypia in the hyperplastic epithelium
is a very well differentiated adenocarcinoma of
the gastric type. Partial gastrectomy is
recommended because of a large poorly
differentiated adenocarcinoma, ly2, and vm.
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Constitution 1. Background 2. Aim 3. Materials
and methods 3a. Pathology report form 3b.
Seamlessly viewing images 3c. Medical
library 4. Result 5. Conclusion
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Every day clinicians observe various types of
images including radiological and gross
pathological images using the HIS.
Hospital information system of Ehime Prefectural
Central Hospital (2010)
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1
1
1
Reference CT and MRI images in the electronic
patient record are arranged in the following
order from head to foot, left to right, and top
to bottom.
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Materials and Methods 3b All kinds of images
including radiological, gross pathological and
histopathological images are arranged to be
viewed seamlessly as follows. 1) The resected
gross specimens were sliced in the same planes as
the radiological axial images. 2) The slices
were then placed on a photography table in the
same order as in the radiological images and
were photographed. 3) All the gross slices and
histology slides were assigned corresponding
numbers and 4) the glass histology slides were
digitized by virtual microscopy.
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HCC case Gross pathology specimen
1
1)The resected gross specimens were sliced in
the same planes as the radiological axial
images.
2)The slices were then placed on a photo- graphy
table in the same order as in the Radiological
images and were photographed.
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Gross pathology images are arranged in the
following order from head to foot, left to
right, and top to bottom.
3) All the gross slices and histology slides
were assigned corresponding numbers
3
4
1
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A gross pathology slice, unicassettes for tissue
embedding, and VS
10A
Slice 10
10A
4) the glass histology slides were digitized by
virtual microscopy.
Virtual slide 10A
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Gross pathology slice
CT image
Virtual slide
All kinds of images can be viewed seamlessly.
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A resected case of HCC macroscopically, this
case is basically nodular type, but some parts
are the confluent multinodular type.
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Figure (CT images)
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CT imaging Radiologists observe several hundreds
of images by paging as shown in this movie.
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Movie on the gross pathological images Just like
radiologists, pathologists, too, can observe
gross pathological imaging by paging.
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Movie of the gross pathological images from
arbitrary direction
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Constitution 1. Background 2. Aim 3. Materials
and methods 3a. Pathology report form 3b.
Seamlessly viewing images 3c. Medical
library 4. Result 5. Conclusion

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Materials and Methods 3c Using the HIS, a
medical library was set up containing research
papers about the cases in our hospital. Lib 11
Blood vessels Lib 12 Heart Lib 13 Diseases of
blood cells, lymph nodes, spleen, and thymus Lib
14 The lung Lib 15 Head and neck Lib 16 The
gastrointestinal tract Incidence of lymph node
metastasis in cases of early gastric carcinoma
(Treatment of early gastric carcinoma by ESD)
Gastric carcinoma and lymph node dissection level
Risk level of GIST and FDG-PET Lib 17 Liver and
biliary tract HCC and FDG-PET Lib 18 The
pancreas Lib 19 The kidney Lib 20 The lower
urinary tract and male genital system Lib 21 The
female genital tract Lib 22 The breast Lib 23 The
endocrine system Lib 24 The skin Lib 25 Bones,
joints, and soft tissue tumors Lib 26 Peripheral
nerve and skeletal muscle Lib 27 The central
nervous system Lib 28 The eye
link
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Constitution 1. Background 2. Aim 3. Materials
and methods 3a. Pathology report form 3b.
Seamlessly viewing images 3c. Medical
library 4. Result 5. Conclusion

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Result The inclusion of a wide range of
information in the pathological report form and
the use of a standardized method for viewing
digital images facilitated the understanding of
each case and helped easy comparison of
radiological and pathological images. The
incorporation of non-pathomorphological data, in
connection with evidence from our library,
helped improve the reliability of the comments
in the pathology reports. The methods presented
here facilitate the research of radiology and
pathology. We show the result of HCC study
obtained by the present methods.
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HCC and glucose metabolism (FDG-PET)
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Figure. Gross types of HCC type 1, 2x, 2a, 2b,
3, and 4
Type 1
Type 2x
Type 2a
Type 2b
Type 3
Type 4
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Figure 3. Morphogenetic changes in the gross
types of HCC Relation between the 4 gross
types--type 1 (replacing growth type), type 2a
(macro-subnodular type), type 2b
(micro-subnodular type), type 3
(confluent multinodular type), and type 4(massive
type) deep color pure form, light color mixed
form of pure form
Type 4
57.1
8
Type 3
40.9
9
6
11
2
3
9
Type 2a
71
84.2
Type 2x
8
2
9
3
Type 1
72.7
Type 2b
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Table 4 Relation between HCC gross type, size,
and necrosis in HCC cases with TAE
Gross type No. of cases () Tumor size (cm) Tumor necrosis ()
1 2 (2.0) 2.40.5 15.021.24) 2a 44 (44.9) 3.32.2 87.817.55) 2b 23 (23.5) 3.92.1 69.824.76) 2x 5 (5.1) 2.31.7 88.013.07) 3 15 (15.3) 3.52.3 59.332.1 4 9 (9.2) 10.63.7 43.920.68)

• HCC Hepatocellular carcinoma, 2) TAE
  transcatherter arterial embolization, 3) Gross
• type 1 replacing growth type, 2a
  macro-subnodular type, 2b micro-subnodular type,
  
• 3 confluent multinodular type, 4 massive type
• 5) vs. 6) P0.0009, 4) vs. 6) p0.0059, 4) vs. 7)
  p0.0059, 6) vs. 8) p0.0092

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Table 5 Relation between HCC gross type,
DD-score, DD-G, and FDG uptake in HCC cases
without TAE (same cases in Table 3)
Gross type DD-score DD-G FDG uptake (No. of cases)
1 7.71.7 4.21.7 1.20.2 (3)12) 2a 10.52.58) 2.61.010) 1.70.7 (17)13) 2b 14.03.29) 4.42.311) 2.61.0 (13)14) 2x 8.50.7 4.33.0 - (0) 3 13.72.2 4.22.6 1.90.6 (7) 4 15.41.9 1.40.8 5.42.1 (4)
HCC Hepatocellular carcinoma, 2) DD-score
dedifferentiation score, 3) DD- G
dedifferentiation gradient, 4) FDG
18F-fluorodeoxyglucose, 5) FDG ratio FDG-SUVmax
of HCC per background FDG value, 6) TAE
transcatherter arterial embolization, 7) Gross
type 1 replacing growth type, 2a
macro-subnodular type, 2b micro-subnodular type,
3 confluent multinodular type, 4 massive
type 8) vs. 9) plt0.001, 10) vs. 11) p0.0004, 13)
vs. 14) p0.0071, 12) vs. 13) p0.0305
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Constitution 1. Background 2. Aim 3. Materials
and methods 3a. Pathology report form 3b.
Seamlessly viewing images 3c. Medical
library 4. Result 5. Conclusion
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Conclusion The format of the pathology report
form with seamless image viewing described in
this study is expected to promote deeper
integration of comprehensive information in
evolving HIS and contribute positively to
education, research, and patient care.
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Thank you very much for your attention ??????????
??????
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New information system in Our New Hospital
(2013) to utilize accumulated data in HIS
Todays presentation Structured pathology
report Seamless viewing images Medical
library
Lab. system
??Data Warehouse
Statistical data
Search engine
RISPACS
Data optimization
Data base
Pathology system
Case data
Electronic patient record