In an increasingly digital world, will glass slides and microscopes grow obsolete? The short answer is probably—but we’re not there yet. With the emergence of digital pathology, whole slide imaging (WSI) and assistive technologies that help pathologists work more efficiently, we are inching closer to going fully digital in everyday practice. Vektra Casler, M.D., director of our new Informatics division, is leading the effort to gradually incorporate WSI into certain subspecialties at URMC.
Whole slide imaging is a method in which glass slides are placed under a camera microscope that captures images that can then be viewed on a computer screen. From there, the images can be easily saved and shared virtually for diagnosis, and virtual consultation, as well as teaching purposes. This not only alleviates the burden of transporting slides back and forth between institutions (or even across the hall) but has potential to change how pathologists do their jobs. The end goal of becoming all-digital is still years away, she explains.
“The goal of diagnostic medicine overall is to have all the puzzle pieces at your fingertips so you can render a diagnosis quickly and as best and efficiently as you can,” said Casler. “We want to digitize as many aspects as possible so the pathologist and the slides don’t have to be in the same room.”
The benefits of WSI are two-fold. In addition to providing greater portability, going digital allows the user to apply artificial intelligence (AI) to the scanned image. While computers aren’t going to make them obsolete, this kind of AI can help set the stage for the pathologist to make a final diagnosis.
“AI is never going to be completely in the driver seat,” said Casler, who compares the pathologist to a pilot flying a plane with help from a GPS and radar. “You have a very real responsibility and if you misdiagnose a case, somebody could die or have their life change forever.”
Because a computer is very fast at doing mundane things, AI can identify visual hotspots and immediately pinpoint potential areas of concern on the scanned image so the pathologist can zero in on those areas. The result is a nice pairing of detection software, which is highly sensitive, with an expert pathologist, who is highly specific. Both can help the latter work more efficiently by saving time and tedium that comes with traditional microscope-based practice.
We as an institution are just getting into the game when it comes to WSI, and becoming fully digital will take time. One challenge is available equipment. URMC currently has some microscope scanners that can scan a few dozen slides at a time. The next step will be purchasing a scanner that can scan 10 times the number of slides.
Perhaps the greatest challenge, however, is the sheer size of the data. For example, one scanned slide is 1.5 gigabytes – which is as large as a full movie, Casler explained. Like other outside institutions that have hundreds of terabytes of storage, we hope to follow suit by getting a central server to host the files so they are not only easily accessible from anywhere but stored securely for years to come. Digital pathology will not only strengthen and streamline patient care, but teaching opportunities as well.
“This foray into WSI and getting our feet wet into digitizing is going to open a door to teaching sets and research so we can do our job better in the future,” said Casler.
John Plavnicky, chief supervisor of Cytology, recently gave a quick tutorial on a new digital scanning instrument called the Hologic Genius. The instrument performs whole slide imaging on gynecologic specimens, and though it’s currently being used in Europe, it’s still awaiting FDA approval in the U.S. Plavnicky’s team is working in conjunction with the vendor to use it for research in the meantime, making URMC one of the first institutions in the country to experiment with the Genius.
To start, they are running about 500 previously-tested samples on the Genius and re-screening slides to compare results to microscope-based diagnoses – very much like a “double blind” study. In future studies, they will likely simplify the process and compare the instrument’s findings to the known diagnoses.
The Genius works after samples are loaded into the machine, which then captures a scanned image of each slide and saves it to a server. The image is then viewable on a separate computer monitor from virtually anywhere. The software program then applies rapid detection to certain fields of view on the image, highlighting areas that could contain cells of interest.
“If it works, it’ll increase the flexibility in when and where screening is done,” said Plavnicky. Right now, the process of slide examination is laborious. Each slide has to be physically moved from a prep area to a cytotech, then to a pathologist and finally placed in a storage area. Going digital removes some of these (literal) moving parts.
“Now we’re limited to where we can sign these out because the scope has to be connected to the imager,” he said. “That would go away with this system because it’s linked to a server accessible anywhere.”
As a longtime cytotech who spends many hours at the scope, he said the prospect of going digital is a big shift. But it’s not as big of a leap as you’d think.
“It feels strange in field that revolves around microscopy. Not that it’s going away,” he said, pointing directly at the microscope within the machine itself. “The technology is not necessarily removing it. It’s removing the way it’s utilized.”
When asked what pointed her to the field of pathology, Grace Choung, M.D. responded with a single profound truth: It explains how human suffering translates into science. “Pathologists are explaining someone’s experience, and that’s why I like it,” she said.
Choung is a renal pathologist who joined the URMC faculty in January 2020. Her sharp skill and insight are rooted in a deep desire to help people – the driving force in a winding path of a career.
Her family moved from South Korea to New Jersey when she was young and in college, she majored in sociology – hoping to one day become a social worker. She used the time before getting her master’s in biomedical science at Rutgers to explore different opportunities in the medical field.
She worked full-time at Cornell Weill Medical College’s Department of Psychiatry where they studied trauma in Sept. 11 attack survivors, interned for a community-based program that made drug and health care services available to low-income residents without health insurance and in 2006, she interned at the medical examiner’s office.
These “real-world” experiences were eye opening, Choung says. While spending the summer working alongside the ME isn’t every young person’s idea of a joy ride, she saw it as an opportunity to learn. “There were a lot of aspects of public health and community life that autopsy explores,” she said. “You see drug overdoses, suicide and mental health issues that are germane to a lot of our experiences.” She was hooked.
The next year, Choung entered Medical School at Tulane, where she was surrounded by the vibrant culture of New Orleans for the next four years. She returned to the Northeast to do her residency back at Yale New Haven followed by a renal pathology fellowship at Columbia in 2018.
But why renal? In her first year of medical school, she emailed the entire pathology faculty at Tulane looking for help with a project, and the renal pathologist was the only person who responded, a fact that still makes Choung laugh.
Her work combines her interest in the link between health and socioeconomic factors by looking at the mechanisms on a cellular level. It means interacting with nephrologists and internists to identify mechanistic reasons for how disease is expressed in a patient’s kidney biopsy.
This “detective work” is a way she is making a real difference. On the research end, she and nephrology fellows are now working on two collaborative research studies on autoimmune related kidney disease.
“My interest in renal is understanding human experience, human suffering and being able to explain it. With anything in pathology, we are truth seekers and speakers and that’s what I want to do in the renal arena,” Choung said.
She lives in Brighton with her mother (who followed her from New Jersey) and her hobbies include Zoom tea parties with her friends – which include decadent scones, sandwiches and tea. Like many during the pandemic, she already has plans to travel when she’s able.“The dream is to go to England someday and get real tea.”
This story appeared in the October 2021 issue of the Pathways to Excellence newsletter.
The third phase of the Bailey Road project, which will relocate many of URMC's anatomic pathology (AP) services offsite to our central lab, officially kicked off in September. Design is being led by HDR Architects, the same firm that designed the building where the majority of our clinical pathology testing moved in 2019.
HDR is meeting with all AP groups to determine what services will permanently move out of Strong Memorial Hospital. The goal of these meetings is to collect input from faculty, staff and stakeholders to best determine the scope of this next phase of the project. Once this is established, the work of designing space can begin to pave the way for construction at Bailey Road, expected to begin next summer (2022).
Vice Chair for AP, Christa Whitney-Miller, M.D., said the move offers an opportunity for Surgical Pathology to grow into its already booming service. “We have experienced record growth in AP volumes across the board due to growing partnerships with our affiliates, which is exciting," she said. "Our current space at URMC does not allow us to keep up with this growth, so devising how to best maximize our service lines offsite will allow us to advance care into the future."
As with prior moves, our AP teams will retain a footprint at Strong that will include some faculty and essential operations for acute patient care needs: Accessioning, frozen sections and cytology, to name a few. Histology and immunohistochemistry are among the service lines that are earmarked to move to Bailey.
Others, like Point of Care Testing (POCT), Flow Cytometry/HLA, and Education may move to different space within the hospital. Because we are in the early phase of planning, the plan for some labs is still undecided.
The plans will also address new ways to gain efficiencies, and solutions for much needed storage for paraffin blocks that have resulted from growing volume. The current timeline is for all relocating groups to move in late 2023 with all operations commencing at Bailey Road in January 2024.
Summer marks the beginning of a new academic year as we welcome a new class of residents taking the first step in their professional exploration.
In many ways, relationships – with peers, mentors, and even subspecialties – are what truly fuel the experience for our department’s residency program.
Notably, our training opportunities reflect the same growth we see in daily clinical workload; there are 20 total spots and opportunities to customize one’s training to AP, CP, or research. Our department also offers an impressive slate of 10 post-residency fellowships.
This sort of growth, both of the program and opportunities for our pathologists-in-training, does not happen in a vacuum. Linda Schiffhauer, who has served as program director since 2019 after five years as associate director, says being actively involved in the process is extremely rewarding.
“My favorite part of the job is seeing them come and develop their passion throughout those years,” Schiffhauer said. “Being a part of that process as a mentor, and watching them grow is so satisfying.”
We have been able to accommodate more trainees thanks to an explosion in surgical volumes and successful administrative lobbying. In 1992, the ACGME gave our department the green light to host 21 residents, but URMC consistently capped this around 16 for many years. That changed in 2020, when the department’s request to expand that number to 20 over four years was approved.
More people in the program means more access to expert training alongside faculty who are leaders in their area of interest. Residency is a time of exploration, and the program is structured to maximize their exposure to different specialties. Making that experience customizable is crucial in steering trainees toward a fulfilling career, Schiffhauer explains.
“Our mission is not to create academic pathologists out of everybody,” she said. “Our whole philosophy is that we want a personalized experience to usher them along in any path they choose.”
One recent addition to the training experience is a boot camp rotation for all incoming PGY-1’s that includes eight weeks of immersive experiences in both AP and CP before they begin their regular rotations. This kind of early exposure is one way residents can learn what captures their interest before choosing something specific to pursue later on.
Bahadir Yildiz is a second-year resident who says he came into the program with an open mind. After finishing his first year, he’s set on doing forensics after residency with the goal of working in a medical examiner’s office someday.
He was drawn to URMC because of the specimen volume, abundance of PA’s and supportive environment. “The thing that made it shine for me was seeing the close relationship between the residents, attendings and other staff,” said Yildiz. “They really looked like family and I felt like I could easily get along with the people here.”
Others who have come through the program echo these sentiments years later. Diana Agostini-Vulaj was chief resident (2015-16) and joined our GI faculty after staying to complete her fellowship at URMC. For her, staying in Rochester was an exciting next step as she joined the ranks alongside her longtime teachers and mentors.
She noted several facets of training that made URMC attractive – including robust clinical service and ample research opportunities – but was impressed with the emphasis on the individual resident’s needs instead of the other way around. As a result, our graduates come out of the program feeling energized about their work, and do remarkably well wherever they land.
“I think our education program really puts the emphasis on what the trainees need and ensuring these needs are met,” said Agostini-Vulaj. “They allow a particular trainee’s curriculum to be tailored to their specific interests and career goals, with a very successful mentoring program.”
Taking Wellness to Heart
Earlier this year, the program was pleased to open the doors to a new resident room in the 2-2100 suite at Strong Hospital. The newly renovated space has a mixture of individual and group space where trainees can work or simply socialize during their downtime.
The new room was designed after obtaining survey input – not only from our own residents, but more than 30 residency programs across the U.S. Their findings pointed to the need for a space that mixed individual and group space. Then chief resident, Anna-Karoline Israel, was successful in publishing an abstract on this topic, co-authored with several faculty, that was accepted to USCAP 2020.
This data-driven decision to create a workspace comes as we prepare to move certain AP services offsite to the central laboratory on Bailey Road in the next few years, and it made sense to create a space at URMC while plans continue to take shape. The space not only helps residents get work done, but gives them an informal setting to enjoy each other’s company along the way.
“It’s about wellness,” said Schiffhauer. “For them to just relax from the pressures of work and build bonds that will last after they leave the program not only helps them, but ultimately impacts their care of patients,” she said. “We are deeply invested in both of those things.”
Congratulations to our Graduates!
Outgoing Residents: Where They're Headed
Bennett Wilson Buffalo VA, faculty
Anna-Karoline Israel Cleveland Clinic, H&N fellowship
Chelsea Milito ME – Philadelphia, Forensic fellow
Numbereye Numbere URMC, Surgical Pathology fellow
Michael Karasick NYC Blood Bank Center, TM fellow
Outgoing Fellows: Where They're Headed
Hani Katerji: URMC, Breast faculty
Roula Katerji URMC, GI faculty
Alexandra Danakas URMC Breast fellow, then URMC faculty
Cynthia Reyes Barron Dermatopathology faculty, El Paso, TX
Andrew Cameron URMC, Microbiology faculty
Nivedita Suresh General pathologist at Cancer Institution Hospital, India
Meet our New Residents
Hometown: Hyderabad, India
Medical school: Deccan College of Medical Sciences
Fun fact about you? I know five different languages.
Hometown: Burlington, Ontario, Canada
Medical school: American University of the Caribbean
Fun fact about you? In the four years of medical school I lived in four countries (Saint Martin, England, Canada, U.S.) and four states (NY, TX, MD, AZ).
Hometown: Grand Rapids, MI
Medical school: Oakland University William Beaumont School of Medicine
Fun fact about you? My most memorable summer is the one I spent studying abroad in Santiago de Compostela.
Hometown: Ridgefield, WA
Medical school: UR School of Medicine and Dentistry
Fun fact about you? Ran a 100-miler during my time as post-sophomore fellow at URMC Pathology.
Hometown: Izmir, Turkey
Medical school: Ege University School of Medicine
Fun fact about you? I have a goal to start a URMC Pathology basketball team and start an informal tournament! I’m always up for sports or activities and love any kind of physical challenge.
Hometown: Delran, NJ
Medical school: Rowan University School of Osteopathic Medicine
Fun fact about you? I have been skydiving three times and recently became certified in technical scuba diving and cavern diving. I love adventures and nurturing my inner child!
Members of Pathology & Laboratory Medicine gathered to celebrate and recognize the accomplishments of the 2020-21 academic year. View a photo gallery from the event on June 14.
Chair's Recognition Award
Dr. Jerome Jean-Gilles
Eric Schenk Award for Excellence in Teaching
Dr. Bruce Smoller
Outstanding AP Didactics/Unknowns Award
Dr. Ellen Giampoli
Outstanding CP Didactics Award
Dr. Helene McMurray
Outstanding Faculty Grand Rounds Award
Dr. John Bennett
Outstanding Resident Grand Rounds Award
Dr. Betul Zengin
Outstanding CP Seminar Award
Dr. Anthony Cardillo
Most Interesting Case Conference Award
Dr. Numbereye Numbere
Outstanding Faculty Mentor Award
- Dr. Linda Schiffhauer
- Dr. Jennifer Findeis-Hosey
Outstanding Resident Mentor Award
Dr. Anna-Karoline Israel
Outstanding Technical Staff Award
- Sierra Kovar
- Hannah McRae
Outstanding Administrative/Clerical/Support Staff Award
Outstanding PA Educator Award
Most Helpful the Gross Room Award
Resident Helping Hand Award
Dr. Tatsiana Pukhalskaya
Faculty Helping Hand Award
Dr. Xiaoyan Liao
Stormy Weather Award
- Dr. Dongwei Zhang
- Dr. Irene Chen
Dr. W. Richard Burack
Outstanding resident oral scientific presentation:
Dr. Bennett Wilson: Negative urine cytology and the rate of diagnostic agreement between cytotechnologist and cytopathologist: Why not let cytotechnologists sign-out negative urines?
Photo contest winners
- Jill Brockman: Interstitial (cornual) ectopic pregnancy with fetus, less than 8.5 weeks
- Dr. Chauncey Syposs: En Caul Hysterectomy at Week 20
- Dr. Bahadir Yildiz: COVID Decedent Lung
- Dr. Cynthia Reyes Barron: Coccidiomycosis Endospores and Spherules
- Dr. Numbereye Numbere: Molluscum X400
Dennis Denning: Glow Worm
Dr. Hasimran Kaur: My Rural Village
Dr. Bahadir Yildiz: Glasses Mask Combo Problems