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.
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