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Digital IHC User's Guide

1. eII IlI For more detailed information on how to view slides please refer to the ImageScope User s Guide Digital IHC User s Guide Reading Slides on a Computer Monitor Please refer to the Digital IHC application guides for more details including intended use on the reading of IHC slides on a computer monitor Open On the case page scroll down to the Case Digital Slides list to see the slides associated with this case 4 To quickly open a slide in ImageScope click on the thumbnail of the Macro image To open multiple slides simultaneously select the check box next to all slides you want to open and click View Images Case Digital Slides The slide appears in the ImageScope window IR Aperio ImageScope File Edit Image View Tools Window Help caaPfre COs pt Fece AROA ORs oO mOOe Wieg 25 P10 Chapter 6 Reading Cases Step by Step Navigate To read a slide you need to navigate through the slide in much the same way you would with a microscope You can pan and zoom but do not need to focus The image of the tissue is already in focus optimum focus has been determined during the scanning of the slide You may want to start at a low power of 4x or 5x that provides you with diagnostic viewing capabilities and pan through the slide to look for invasive tumor regions When you identify an invasive tumor region you can then go to the highest power and do your quantitative assessment Then go
2. 1 if more than 10 of the cells are stained at the 1 and higher level and 0 if less than 10 of the cells are stained at the 1 or higher levels As you can see the HER2 image analysis not only provides the coarse HER2 score but also a detailed breakdown by percentages of 3 2 and 1 cells that allows you to identify border line cases easily and use our HER2 image analysis readily with the new CAP ASCO HER2 guidelines Your Spectrum administrator can set up an automatic HER2 score calculator as part of Spectrum that uses the 30 threshold for 3 cells as outlined in the CAP ASCO HER2 guidelines Please refer to the Digital IHC application guides for more details on the image analysis application you are using for HER2 Jf oD perio Chapter 6 Reading Cases Step by Step ER PR The ER PR image analysis detects the positive nuclear staining for the individual tumor cells and quantifies their staining intensity Cells Nuclei are individually classified as 0 1 2 and 3 A nucleus is classified 0 when it has no nuclear staining 1 when it has weak nuclear staining 2 when it has moderate nuclear staining and 3 when it has intense nuclear staining SOP gs a SN e ae de rae d a Tr Po a jel Cell 0 O Cell 1 ji a ws Cell 24 d ee Cell3 gt 52 3 Intensit J Based on the percentages of 0 1 2 and 3 cells 7 98 5 the percentage of positive stained cells a
3. Tools Window Help Oo x mic Q f I The analysis results provide the number of detected cells the percentage of cells per class 0 1 2 and 3 corresponding to the mark up image and the assay specific scores e g HER2 score for HER2 and Percentage and Intensity Score for ER PR The analysis results are provided for each region and accumulated for the entire slide all regions fen 2 Icicle de IHC HERZ Breast Dako tdetau iw A oo O Selected Annotation Current Screen 36 Digital IHC User s Guide Chapter 6 Reading Cases Step by Step perio Digital IHC User s Guide HER2 The HER2 image analysis detects the membrane staining for the individual tumor cells and quantifies the intensity and completeness of the membrane staining Tumor cells are individually classified as 0 1 2 and 3 A tumor cell is classified 0 when there is no membrane staining 1 when there is only partial membrane staining or weak membrane staining 2 when there is moderate and complete membrane staining and 3 when there is intense and complete membrane staining Cell 0 Cell 1 E gt 3 Cell2 Rental J on oe Based on the percentages of 0 1 2 and 3 JTE classified cell scores a HER2 assay Score of 0 1 34 7 0 2 or 3 is determined The score is 3 if more than a 10 of the cells are stained at the 3 level 2 if pz 2 0 more than 10 of the cells are stained at the 2 and higher levels
4. adobe com Personal Setup Your Spectrum administrator sets up Spectrum for your institution s Digital IHC workflow These setup steps are covered in the Digital IHC Guide to Spectrum Setup Each pathologist may also want to do a small amount of setup discussed below This setup only needs to be done once Select Your Spectrum Start Page You can set up your Spectrum start page when you log in the first time into Spectrum see Instant Access Anytime Anywhere Logging into Spectrum on The set up of page 23 for details Spectrum for your institution s Digital 1 Go to the Spectrum Administrative menu and select My Settings IHC workflow is discussed in details 2 Inthe User Details section select the startup page you want to see when in the Digital IHC Guide to Spectrum you log in by selecting the page from the Spectrum Start Page drop Saye down list We provide work lists based on case statuses that you can select as your Spectrum start page Your Spectrum administrator can set up 18 Digital IHC User s Guide Chapter 6 Reading Cases Step by Step Digital IHC User s Guide perio appropriate case statuses for your workflow Work lists are automatically created for each case status and can be accessed via the Cases menu at the top of the Spectrum page as well as assigned as your start page Pathologists may want to go directly to the cases that need their attention In our example cases th
5. and right keys 27 oD perio O Chapter 6 Reading Cases Step by Step Slide Quality Control It is up to the pathologist to verify that the slides are of sufficient quality to perform his her task whether that is a manual read of the digital slide or image analysis Note that the quality of a slide depends on the laboratory following the quality control instructions recommended in the labeling of IHC assays It is recommended that the pathologist follows the appropriate instructions in the specific IHC assay to assess the quality of the slide preparation The pathologist should review the quality of the scanning by evaluating that the entire tissue sample has been scanned and that the tissue is in focus The staining process can yield artifacts that need to be assessed properly by the pathologists Typical artifacts to consider are normal epithelium staining heterogeneous staining background staining and cytoplasmic background staining as well as edge thermal and crush artifacts Staining artifacts should be considered carefully In some cases severe staining artifacts may prevent accurate IHC image analysis Those regions should be excluded from the IHC image analysis IHC image analysis is sensitive to excessive cytoplasmic staining and tissue being out of focus It is the responsibility of the pathologist to know the limitations of the algorithm and to make sure that only good quality digital slides are used for the IHC ima
6. as soon as you log in In our example cases that need the attention from pathologists have the case status Pending Spectrum User Dr John Smith D110 Role Pathologist Cases Specimens Digital Slides Analysis Administrative Help Font Size Log off List Cases Pending Digital IHC User s Guide A O O O O O O O O O O O 0O O O O Case ID H sos 03015 H sos 03014 H s08 03013 H sos 03012 H s08 03011 H sos 03010 ff s08 03009 H sos 03008 H s08 03007 M sos 03006 ff sos 03005 H s0s 03004 H s08 03003 H sos 03002 H sos 03001 Mai Gor Shim Cheong Yamada Hanako Naima Naamalum Olga Ivanovich Maria Tade Maria Rossi Menganita de Tal Ola Nordmann Maija Meiklinen Lisa Svensson Erika Mustermann Angelique Unetelle Juanita Prez Jane Doe Patient ID MG730001 SC770001 YH610001 NN690001 01700001 MT780001 MR450001 MT820001 ON710001 MM810001 LS590001 EM670001 AU810001 JP550001 JD6 50001 Date of Birth 1973 02 27 1977 10 23 1961 05 19 1969 07 18 1970 08 20 1978 06 07 1945 08 24 1982 12 29 1971 09 01 1981 01 08 1959 12 31 1967 02 25 1981 12 03 1955 03 16 1965 04 05 Country of Birth Gender Physician Name Thailand Korea Japan India Russia Greece Italy Spain Norway Finland Sweden Germany France Mexico USA Dr Lalana Srisai Dr Chin Ho Kim Dr Keiko Watanabe Dr Maniram Gahoi Dr Viktor Panin Dr Timothy Amyntas Dr Gino Caporaso Dr Alejandro de la
7. can be selected for a slide and a report image only appears in a report if the report template used has the provision for using report images Later on you can navigate to the report image region by selecting Report Image in the Annotations window To go back to the analysis you need to reselect the appropriate image analysis algorithm that is marked default in the Annotations window 4 lt f __ gt xe Recotinage i Close Once you read the IHC slide run image analysis and designate a report image you need to save all annotations and close ImageScope 19 Click the Save Wl icon in the Annotations window 20 Click J at the top of the ImageScope window Digital IHC User s Guide 4 D perio Chapter 6 Reading Cases Step by Step Automatic Data Flow from Analysis to Reports Aperio automates the data flow from analysis to reports for you providing automatic score and interpretation calculation It is the responsibility of the pathologist to provide the final score based on his her assessment If you agree with the provided scores and interpretation you do not need to do anything If you disagree just overwrite the score or interpretation results in question Values that have been updated automatically are shown with a link icon Overwritten values are shown with a broken link icon Once a value has been overwritten it is no longer updated automatically making sure that data provided by the pathologist
8. data reside in the Spectrum database Spectrum uses the administrator user structure that restricts security sensitive actions to an authorized administrator The administrator can E Set up users with passwords Users must log into Spectrum with their username and password and be authenticated before they can access restricted data E Set up data groups that restrict access to specific data E Set users access permissions to grant them full access read only access or no access to the defined data groups E Assign users roles that limit the commands they can perform and data they can access 6 Digital IHC User s Guide Digital IHC User s Guide 2 Intended Use Aperio s Digital IHC solution is intended to be used with different applications some FDA cleared for In Vitro Diagnostic IVD use and all others for Research Use Only RUO In Vitro Diagnostic Use The following IHC applications are FDA cleared for In Vitro Diagnostic IVD use For specific information on those applications refer to the application guides E Breast HER2 Digital Read Breast PR Digital Read Breast HER2 Dako Image Analysis Breast ER Dako Image Analysis Breast PR Dako Image Analysis Research Use Only All other applications are for Research Use Only RUO Additional documentation is provided for the following applications E Membrane Image Analysis E Nuclear Image Analysis perio Chapter 2 Intended Use Caution F
9. not yet been saved are colored yellow 22 Click the Save button on the top or bottom of the Case page Digital IHC User s Guide 43 P perio Chapter 6 Reading Cases Step by Step Automatic Report Generation Automatically create error free professional reports with representative images a from the slides You can now generate professional reports yourself while For more jain information on ENTE enna ere creating reports see the 23 Go to the Case Report section and select the appropriate report template PeU SO T from the drop down list Plus Reporting User s Guide 24 Click Generate Report Case Reports Select Template Case Report IHC Report H amp E HERZ ER PR It is easy to create a new report template tailored to your institution s needs Any information in the database can be laid out in a professional report in exactly the format you desire Ask your Spectrum administrator which report template you should use As you can see with our IHC HER2 ER PR report template next page your customer or oncologist address with logo your address with logo patient information case comment specimen information and the scores interpretation comments and images of the slides are automatically pulled into a nicely laid out report If image analysis was used on an IHC slide this is clearly identified for your billing purposes Once you have reviewed the report you can use an electronic signatu
10. sections that are too thick will result in blurry images Problems with blurry slides may require the preparation of a new slide Mechanics The mechanics of the slide are important for its scan quality and ease of scanning The slides should be in clean and good condition no air pockets under cover slip no dirt no fingerprints no markings no writing no extra adhesive no broken slides no chips no scratches no overhanging cover slip etc The tissue ideally should be located in the middle of the slide a distance from the edges of the slide the label and any other markings It is helpful for the tissue to be placed consistently in the same location and orientation on the slide 08 04003 Angelique Unetelle Make sure there is no glue around the edges of a slide that would cause it to stick or catch in the ScanScope stage area Keep the glue attaching the cover slip to a minimum Excess glue makes it hard for the tissue finder to distinguish between actual tissue and the glue If a focus point lands on the glue slide focus will not be accurate Some of the mechanical problems of a slide can be resolved by cleaning the slide with a cotton rag don t use chemical cleaners or trimming the sides with a razor blade Permanent problems with a slide may require the preparation of a new slide perio Chapter 3 Slide Preparation Staining Reproducibility of the IHC stains is important for consistent and accurate scoring Make
11. A Digital Pathology Solution for Immunohistochemistry Digital IHC User s Guide Copyright 2007 2009 Aperio Technologies Inc Part Number Revision MAN 0099 Revision B Date September 4 2009 This document applies to software versions Release 10 1 and later All rights reserved This document may not be copied in whole or in part or reproduced in any other media without the express written permission of Aperio Technologies Inc Please note that under copyright law copying includes translation into another language User Resources For the latest information on Aperio Technologies products and services please visit the Aperio Technologies website at http www aperio com Disclaimers Use normal care in maintaining and using the Spectrum servers Interrupting network connections or turning off the Spectrum and DSR servers while they are processing data such as when they are analyzing digital slides or generating an audit report can result in data loss This manual is not a substitute for the detailed operator training provided by Aperio Technologies Inc or for other advanced instruction Aperio Technologies Field Representatives should be contacted immediately for assistance in the event of any instrument malfunction Installation of hardware should only be performed by a certified Aperio Technologies Service Engineer ImageServer is intended for use with the SVS file format the native format for digital sli
12. C User s Guide perio Chapter 6 Reading Cases Step by Step Set Report Image Preferences You can set up your report image preferences the first time you open a digital slide with ImageScope see Opening a Digital Slide on page 25 for details 1 Go to the ImageScope Tools menu and select Options i Aperio ImageScope Tools Options Ctrl P 2 Click the Report Image tab on the Options window You can now select the image resolution and region size setting for the report image Ask your Spectrum administrator which settings will work best with your report templates For our IHC report template we recommend that you select Full Resolution Image Fixed Sized Report Region with a Width of 320 Pixels and a Height of 240 Pixels Click OK to save your settings Options General Navigation Annotations Tracking Performance HTTP Proxy Report Image Color Manage Fixed Region Size Width 320 Pixels Height 240 Pixels Image Resolution and Region Size Settings Full Resolution Image Fixed Sized Report Region O Full Resolution Image User Drawn Report Region O Curent Image Resolution Fixed Sized Report Region O Current Image Resolution User Drawn Report Region Set these report image preferences on each computer you are going to use Digital IHC User s Guide 21 2 perio Set up Viewing Separate Stains Optional You can set up your standard stain sets for your IHC slides th
13. E EE 9 GEMINI IN e P E E AIE A E E E 10 CHAPTER A SCANNING aicemcninerasowalannaumd a 11 Reguired TW teak ah sc cay ce saeapesoa cpa cas tue e aiae ae 11 MARVIN yy SECON Sets ia cccsac A E E T 11 Calibration and Calibration Verification ccsccsscsssssssscssssssesssssssessseesseeees 11 AN SS NIN s sees ses teas ca eae cae cans cance enna a cone cond ce astacg nsseeetarsceciawesassenmaneriast 12 rol Eg 0 lt 3 1 16 9 eppeper err oerere rer er erry reer eter er rrerrerrrrery i 12 Predefined Parameter Set for Scanning THC Slides et ssceeeeeeeeeeeeeeee 12 Resolution for TC SUGGS iiss cssscscsessassinsasertncassentacsanvstansvanstinsermavivassaaleaareiasennstinss 12 Automatic One Touch Scanning eessessessesseeseesoessessesscesoessessessoesoessessessessoesse 13 Mannal SCAU ieaiaia ea aaa veces SENN S NE EEEE Aa 14 CHAPTER 3 DATA ENTRY txcrsneneagsineccusneusennmentscusstinecparcaneetvnmniaiesseeentemaese 15 CHAPTER 6 READING CASES STEP BY STEP ssssnpiscanonsavsaesasenuscaunionstininasannantininns 17 ISG EC Malni No siren E naa aE E Ea E e 17 Reading Digital Slides on a Computer Monitor s eessesseeseresesrrerrerrerrerrrrsresees 17 Required Hardware and Software eeseseesossossossossesseseeseeseesossossessesesseesessessesses 18 Persona oep ien E E E 18 Select Your Spectrum Start Pag a sssscacsecvarsaacetasaressnnssepananasseaseavweteetsansesdeasbesanteate 18 Set ImageScope Viewing Preferences eeesees
14. Pe a Dr Lars Solberg Dr Sara Sandstrom Dr Eric Bjornstjerna Prof Dr Heinrich Schmidt Dr Corina Dupont Dr Juan Garcia Dr John Cooper Physician Phone Status 210 223 1324 214 632 2363 215 541 7115 619 702 3165 408 946 3417 313 962 0326 206 726 9155 317 264 8155 617 425 1421 617 425 1474 617 425 1489 312 738 6125 213 245 7699 415 772 1473 212 556 7025 23 Papero Chapter 6 Reading Cases Step by Step View all Case Specimen and Slide Information When you open a case all case specimen and slide information including gross images and controls are conveniently at your fingertips 3 On the case list open the case to be reviewed by clicking on the open 24 Exes Case Details d Preyer CREE CRED kiki ict Coe iE ai sagopa Vihaa sued 1981 12 09 000000 France Formip Guest Dr Coma Dupont FAE MA E Case Attachments ci A ee Perey Case Reports Baieti Tertplata Case Specimens Thumimae Acai Hener data icon for the case The Case Details page opens for that case biti Tmt ACtea gion Surber ZOMOZI RO 14 ooo 1 amp 07 00 Recordin Par Paga inbrrpr riali Cental Pess aay corto PASSED KERJ Contre mutica wer Fi Central Paced Assay corre PASSED ER Control wer hea bot Corin Passei dasay control A SSE wertimalign Dapa I Terany Der Page Digital IHC User s Guide Chapter 6 Reading Cases Step by Step DB r10
15. an from 0 worst to 100 best Note that a low quality factor can be caused by poor slide preparation like folds thick tissue sections air pockets under the cover slip dirt fingerprints markings writing extra adhesive broken slide scratches etc but that the scan of the tissue still might be good therefore the operator should not rely on the quality factor alone to determine the quality of a scan he she typically uses the quality factor as a triage tool to determine which slides he she wants to review Rack Slot Quality Scan Factor Status 1 gg SUCCESS ScanScope operators should use the quality factor to triage slides for manual review and then review those slides by panning through the entire slide and verifying that the tissue sample is in focus The ScanScope operator should re scan a slide if the entire tissue sample has not been scanned or if a tissue area is out of focus 13 D perio Ne Chapter 4 Scanning Manual Scanning In some cases the quality of a digital slide can be improved by manually scanning the slide In other cases it might be necessary to prepare a new slide Manual scanning allows the ScanScope operator to designate the scan area position the calibration area place focus points and focus the focus points manually The problem that the entire tissue sample has not been scanned can be resolved by designating the scan area manually and re scanning To resolve the problem that a t
16. assessment of the protein expressions A report is generated for the oncologist IHC quantification is used to determine the appropriate treatment options for the patient HER2 is a membrane stain The pathologist assesses the intensity and completeness of the membrane staining of the tumor cells and determines a score of 0 1 2 or 3 for the slide HER2 is used specifically to assess Herceptin Trastuzumab as a treatment option and to determine the aggressiveness of breast tumors ER and PR are nuclear stains from which the pathologist assesses the staining intensity of the nuclei of the tumor cells and determines the percentage of positive stained nuclei as a percentage between 0 to 100 and the average staining intensity of the positive nuclei as a score of 0 1 2 or 3 Different labs use different scoring schemes for the nuclear stains For example some labs use only the percentage of positive nuclei as a score and use different cut off thresholds of 1 5 or 10 for the interpretation other labs use the percentage of positive nuclei and the average staining intensity of the positive nuclei to calculate a combined score like the Allred Score P10 Chapter 1 Overview Aperio s image analysis algorithms are FDA cleared for specific clinical applications and are intended for research use for other application Z Digital IHC User s Guide Chapter 1 Overview e _ Te Glass Slides Processing Cutting w Tis
17. at a 1 25 dilution for 30 minutes which was visualized with DAR The slide was then counterstained with DakoCytomation hematoxylin for 1 minute The PR slide was incubated with the PqR amp S6 monoclonal anti FPR antibody from DakoCytomation at a 1 100 dilution for 20 minutes which was visualized with DAB The slide was then counterstained with DakoCytomation hematoxylin for 1 minute While some antibodies have not been approved by the FDA clearance approval is not mandated These antibodies are well documented and clinically accepted prognostic indicators Enorn positive and negative control tissue show appropriate staining The prognostic marker results should be used in context with clinical pathological findings Angelique Unetellie Hovember 19 2008 11 39 AM Page 2 of 2 Digital IHC User s Guide 45 Papero Chapter 6 Reading Cases Step by Step After signing the report is automatically created in Adobe Acrobat format in a secure format that cannot be edited and it is stored at a secure server location 27 Go to the History section under Case Reports and click on the Report File Case Reports IHC Report H amp E HER2 ER PR Generate Report History Report File Template State User Case 53 Rev 1 2008 02 1516 37 pdf IHC Report H amp E HER2 ER PR FINAL Dr John Smith This will open the report in Adobe Reader You must have Adobe Acrobat Reader installed on your computer to view the report
18. at need the attention from pathologists have the case status Pending and you would select List Cases Pending Click Save to save your settings User Dr John Smith Role Pathologist Administrative My Settings User Details Login JSmith Full Name Dr John Smith Phone Number 1 760 634 7265 E mail Address mith labs com New Password Retype New Password Enable Auto View Images F Spectrum Start Page List Cases Pending Data Group for Scanning 19 2 perio Chapter 6 Reading Cases Step by Step Set ImageScope Viewing Preferences You can set up your ImageScope viewing preferences the first time you open a digital slide with ImageScope see Opening a Digital Slide on page 25 for details 1 Go to the ImageScope View menu and select your preferred viewing options We recommend you select the following options FA Aperio ImageScope vew y Zoom Slider w Thumbnail Ctrl T w Label Image w Annotations Crl4 y 2 Ifthe Annotations window comes up in the Detailed View click Summary to get the Annotations Summary View that is used for the Digital IHC solution You can move this window around so it is not in your way for viewing digital slides A convenient location may be the bottom left corner in ImageScope Annotations Summary View ule raf fff max i EN GE Fun Anais Selected Annotation Current Screen Set these viewing preferences on each computer you are going to use 20 Digital IH
19. back to low power and continue scanning the slide for more invasive tumor regions 5 Click 5X on the zoom slider MERER G ow OOS Tico 6 Pan through the slide by clicking on the slide holding and moving 7 Zoom in by double clicking on the invasive tumor regions 8 Zoom out by double clicking again and continue panning 26 Digital IHC User s Guide Chapter 6 Reading Cases Step by Step Digital IHC User s Guide Del 10 Here is a short list of common zooming and panning features in ImageScope commands in italic are preferred for fast single hand operation Zoom Adjust zoom level by using the controls in the zoom slider Fit Pan IX 29 20K Increase and decrease zoom by rolling the mouse wheel toward you zoom in and away from you zoom out First click anywhere on the digital slide to enable this mode If you accidentally click the wheel you start a panning mode not described here just click anywhere on the slide to return to the normal mode Go to maximum zoom level highest resolution by double clicking any location of the digital slide Go back to the previous zoom level by double clicking again Position the slide view by clicking on the rectangle current view in the slide thumbnail window holding and moving to the desired position Move the view by clicking on the slide holding and moving Move to an adjacent view by pressing the Shift and arrow up down left
20. ble processing resources Aperio provides server side processing for its image analysis so that the images are processed where they reside thereby eliminating the need for moving the images over the network and also not using the processing resources on the pathologist s computer Aperio s server side analysis also provides a scaleable processing architecture that allows easily adding computer resources to the server to meet expanding analysis needs to guarantee fast response times for a large number of users and allows the image analysis to keep up with slide scanning 35 P10 Chapter 6 Reading Cases Step by Step While analyzing a progress bar is shown in the Annotations window It should take about 6 seconds to analyze the current screen at 20x about 2 000 to 3 000 cells Once the analysis is complete a mark up image of the individual cell classifications can be seen in the ImageScope window and the numerical results of the analysis can be reviewed in the Annotations window The mark up image highlights the detected cells which are color coded according to their classification blue 0 yellow 1 orange 2 red 3 The markup image allows you to easily verify the analysis results and to gain confidence in using this new technology You can view the digital slide with or without the mark up image by clicking on the eye icon 2 without with mark up image in the Annotations window oe Jog Fie Edit Image View
21. core The interpretation can be calculated automatically based on a score 42 Digital IHC User s Guide B10 Chapter 6 Reading Cases Step by Step Generate Reports Easy Data Entry using Canned Comments The slide and case comments can be entered easily accurately and quickly using canned pre defined comments 21 Select a canned comment from the drop down list of the slide and case comment fields You can add any number of canned comments for a field edit the canned comments you used and add your own text Your Spectrum administrator can define the canned comments for your institution Specific canned comments can be defined for your different slide types e g Breast H amp E HER2 ER PR and the case comment see the Digital IHC Guide to Spectrum Setup nvasive and In Situ In Situ Onhy Mo Carcinoma Paraffin Block Comment Sections i year old female with invasive breast carcinoma year old female with invasive breast carcinoma Focus of Invasive Invasive Invasive Intraductal Invasive Ductal Invasive Ductal intraductal Invasive Ductal Lobules invasive Intraductal Lobules Invasive Intraductal invasive and intraductal carcinoma is confirmed Invasive v Scoring performed on invasive component only Heterogene Some Heterogene Very Aberrant Cytoplasm Crush Artifact Once you have entered all data you need to save it Note that all data fields that have been changed but have
22. ded but systematic change in diagnostic performance Users should be aware that their IHC categorizations may be biased when switching from conventional to digital microscopy and as such training beyond self study should be undertaken as needed to assure concordance before clinical adoption of the device The laboratory is responsible for ensuring that concordance goals are reached and maintained Digital IHC User s Guide I7 Prev Chapter 6 Reading Cases Step by Step Required Hardware and Software A good monitor is a recommended investment for any pathologist who is viewing digital slides Our minimum requirements for a computer monitor used for Digital IHC are the following Display Type Any high quality LCD Screen Resolution 1680 h x 1050 v pixels Screen Size 24 Color Depth 24 bit Brightness 300 cd m minimum Contrast Ratio 500 1 minimum Other hardware and software you need E Windows workstation with an Internet connection E Internet browser Internet Explorer Firefox or equivalent E The address URL of the Spectrum server so that you can log into Spectrum See the Spectrum administrator or your IT group for this address E Aperio s ImageScope digital slide viewer If ImageScope has not been installed on your workstation see the Spectrum administrator for assistance The version of Spectrum installed must be compatible with the version of Spectrum E Adobe Acrobat Reader free download from www
23. des created by scanning glass slides with the ScanScope scanner Educators will use Aperio software to view and modify digital slides in Composite WebSlide CWS format Aperio products are FDA cleared for specific clinical applications and are intended for research use for other applications For clearance updates visit www aperio com Trademarks and Patents ScanScope is a registered trademark and ImageServer TMALab ImageScope and Spectrum are trademarks of Aperio Technologies Inc All other trade names and trademarks are the property of their respective holders Aperio products are protected by U S Patents 6 711 283 6 917 696 7 035 478 7 116 440 7 428 324 7 457 446 7 463 761 7 502 519 7 518 652 and licensed under one or more of the following U S Patents 6 101 265 6 272 235 6 522 774 6 775 402 6 396 941 6 674 881 6 226 392 6 404 906 6 674 884 and 6 466 690 Contact Information Headquarters Europe Office Aperio Technologies Inc Aperio UK Ltd 1360 Park Center Drive The Vineyard Vista CA 92081 Axbridge United States Somerset BS26 2AN UK Asia Office Aperio Technologies KK UZ Building 5F 3 3 17 Surugadai Kanda Chiyoda ku Tokyo Japan 101 0062 United States of America Customer Service Technical Support Email Europe Customer Service amp Technical Support Email Asia Customer Service Technical Support i Tel 866 478 4111 toll free Fax 760 539 1116 Tel 866 478 4111 tol
24. e first time you open any digital slide in ImageScope see Opening a Digital Slide on page 25 for details 1 6 7 Click the IQ icon E on the ImageScope toolbar and select the Default setting Go to the ImageScope Image menu and select Quality SX Aperio ImageScope Image Quality Ctrl Q iQ Default You now see the IQ viewer toolbar HE DAB View Hematoxylin HE DAB aja a e m Click the Details button on the IQ viewer toolbar Click the Stains Applied tab and select the stains used for your IHC slides typically Hematoxylin and DAB To save this combination for future use click the Manage Sets tab and type a name like HE DAB and click Save HE DAB View Hematoxylin HE DAB HE DAB View Hematoxylin HE DAB Stains Applied Re Mix Re Color Manage Sets Manage Stains Stains Applied Re Mix Re Color Manage Sets Manage Stains Save Set Stains Applied to the Image Save the currently select applied stains mix and reconstruction colors as a named set A Hematoxylin HE HE DAB Delete Set Remove the selected set None alia a e fae a e Click the View Only button on the IQ viewer toolbar Close the IQ viewer toolbar by clicking X at the top of the window Create a stain set for each type of IHC digital slide you are going to view on each computer you are going to use to view digital slides F
25. echnician ScanScope Operator The Digital IHC Solution Aperio s complete Digital IHC solution is based on several components E ScanScope glass slide scanner Spectrum Plus Barcode LIS Integration IHC Image Analysis Reporting More Information For more details on your ScanScope scanner the Spectrum digital pathology information management system the ImageScope slide viewer and running Aperio image analysis algorithms please see m The user s guide for your ScanScope instrument Spectrum SpectrumPlus Operator s Guide Spectrum Spectrum Plus Administrator s Guide Digital IHC Guide to Spectrum Setup ImageScope User s Guide IQ Image Quality User s Guide Spectrum Plus Reporting User s Guide Digital IHC User s Guide 5 perio Chapter 1 Overview Meeting Regulatory Requirements E EEEE information on the Spectrum Plus contains several features that assist your organization in Compliance Module complying with regulatory requirements such as FDA 21 CFR Part 11 HIPAA please refer to the and GLP The optional Spectrum Compliance Module contains additional Spectrum spectrum Plus Administrator s features that address specific regulatory requirements Coude Patient Data Confidentiality Spectrum provides a full security system that ensures that users can only access data they are authorized to see thus protecting patient data from unauthorized access Digital slides and related meta
26. ed in your institution Please refer to the Digital IHC application guides for more details on the image analysis application you are using for ER PR 38 Digital IHC User s Guide Chapter 6 Reading Cases Step by Step Digital IHC User s Guide Del 10 At this point you can add regions and run analyses again The IHC image analysis works incrementally which means that as you add new regions and click Run Analysis on the Annotations window only the new regions are analyzed Any time you click Run Analysis again all slide results are updated As you add regions additional numbered buttons appear on the Annotations window You can easily navigate between regions by clicking on the numbered button corresponding to a region or use the arrow keys to step through them all The selected region is shown centered in the ImageScope window Hal a e _ gt gt fed To delete any region click the annotation on the main ImageScope window to select it and press the Delete key on your keyboard or select the numbered button for the region in the Annotations window and click the icon When you delete an analyzed region the slide results are automatically updated 39 perio Chapter 6 Reading Cases Step by Step Image Analysis Quality Control IHC image analysis is an aid to the pathologists It is the responsibility of the pathologists to verify the proper operation of the analysis It is important that the pa
27. ederal U S law restricts this device to sale by or on the order of an appropriately licensed healthcare practitioner IMPORTANT If the ScanScope is used in any manner not specified in this documentation the protection provided by the equipment may be impaired WARNING This equipment generates uses and can radiate radio frequency energy If not installed and used in accordance with the instructions in this manual it may cause interference to radio communications It has been tested and found to comply with the limits for a Class A computing device pursuant to Subpart B of Part 15 FCC Rules which are designed to provide reasonable protection against such interference when operated in a commercial environment Operation of this equipment in a residential area is likely to cause interference in which case you at your own expense will be required to take whatever measures may be required to correct the interference 8 Digital IHC User s Guide Digital IHC User s Guide 3 Slide Preparation Slide preparation has a considerable influence on how well slides can be scanned Optimizing the slide preparation for scanning is a good idea to get the most out of your digital pathology system Make sure to control the quality of your glass slides This chapter is for the lab manager who is responsible for the slide preparation Tissue Preparation The tissue preparation is important for scan quality Folds in the tissue and tissue
28. eeeereereerersrrsrrsresrerrererrsresressenes 20 Set Report Image Preferences wecisezsusscssssssenteateasesasenasaesgonaionisuaussutsuesesatevacosnoansees 21 Set up Viewing Separate Stains Optional eeeeeesesseseeseeeererreresrersrrerrsresrerseess 22 Instant Access Anytime Anywhere cscscccsssssceccsssseccessssccecssnsecccsonsecssecsooacces 23 Case Managemen i siissesscsscaccsscsszsesdesszoliaszencedceusasesestiventssacavnsttanastscensaenssessstbeessnoeness 23 View all Case Specimen and Slide Information eseessessessssessessessescescssesses 24 Reading Slides on a Computer Monitor essessessesseesoessessesseesoesoessesssessessessossse 25 e a aigs cree scorns A A E T E A A 25 iii D perio DN AVE AUC nates E E sande es E E E 26 Annotate Tumor Regions on H amp E Slides Optional 29 View H amp E and IHC Slides Side by Side Optional oes eeeeee eee 30 Use IQ to View Separate Stains O pilotia l jscssuesssnsssossunsssnovnosdnasinnssuestenedaossepetss 31 Ponia e Warel E eee ee ee ee 33 aha AEE E seeesune E E ssersshouete sua oneonun oes 37 PE ES cco ere aici gece a oases sagen ce lade ev A toners lease 38 Selec Report Ae seniiti seana aianei aio 41 E A TE O P E E E EE A E 41 Automatic Data Flow from Analysis to Reports eseesssereesseseseesereeserseserseseeseseese 42 Generate Reporte ecncnscnsesnisn nna N aN 43 Easy Data Entry using Canned Comments esseseesserserseerersresresreeesresresreseesees 43 PUTO I
29. ge analysis If slides have poor quality it might be necessary to prepare a new slide or to re scan the slide E The pathologist verifies that the entire tissue sample has been scanned and requests a re scan of the slide if the scan area does not include the entire tissue sample E The pathologist assesses the presence of any staining artifacts in particular cytoplasmic staining and requests the preparation of a new slide if excessive cytoplasmic staining is observed E The pathologist assesses the focus of the digital slide and requests a re scan of the slide if the tissue in the tumor regions is out of focus 28 Digital IHC User s Guide DB r10 Chapter 6 Reading Cases Step by Step Annotate Tumor Regions on H amp E Slides Optional You typically read the H amp E slides first to determine the need for an IHC Panel You could annotate the invasive tumor regions on the digital H amp E slides to help you find them faster and more reliably later when you are reading the IHC slides You can use the annotation tools in ImageScope to mark the invasive tumor regions 9 If you want to provide any form of annotations first select Annotation in the Annotations drop down list on the Annotations window BIBI EIB es Annotation 10 Then click on the Pen icon on the ImageScope toolbar and draw an outline of the invasive tumor region Regions can be outlined anywhere in the slide and at any zoom level Note that the drawing to
30. glass slides are optimized Lab Manager Chapter 3 Slide Preparation for Digital IHC Performing high quality slide scans and enter Lab Assistant or Chapter 4 Scanning data Technician ScanScope Chapter 5 Data Entry Operator Step by step instructions on how to read a Pathologists Chapter 6 Reading Cases Step by case everything the pathologist needs to Step know to use the system In addition several additional documents are intended for personnel responsible for setting up and administering Digital IHC Functional Area Responsible Person Where to Find Information Set up and configure Spectrum for your IHC Administrator Digital IHC Guide to Spectrum Setup workflow Additional application description set up Administrator Digital IHC Application Guides instructions and performance specifications Pathologists Breast HER2 Digital Read Medical Director E Breast PR Digital Read E Breast HER2 Dako Image Analysis Breast ER Dako Image Analysis Breast PR Dako Image Analysis Membrane Image Analysis Nuclear Image Analysis 4 Digital IHC User s Guide Papero Chapter 1 Overview The illustration below shows a quick summary of the basic steps of the Aperio Digital IHC workflow and refers to the corresponding chapters in this document Annotate tumor regions Slide Preparation on H amp E slides optional Chapter 3 Chapter 6 y Lab Assistant Pathologist Pathologist or T
31. ie Report EME Fat ON ess aai 44 Amendments and COLT ECIOMS scasisonssnncgonvsqpeantasesavonssdeasceasnpentneneponssasesnseaeaiscsabers 47 Poeh bhe CAS ea E E E 48 INDEX OE E T 49 IV Contents Digital IHC User s Guide Digital IHC User s Guide Overview Aperio provides a complete Digital Pathology Solution for Immunohistochemistry IHC Digital IHC that combines scanning management viewing and analysis of slides with reading IHC slides on a computer monitor quantitative IHC image analysis and professional reports all integrated into an efficient clinical workflow This chapter provides an overview of Aperio s Digital IHC solution and its documentation The Immunohistochemistry IHC Workflow A lab receives a specimen from a biopsy and prepares a block from which an H amp E Hematoxylin and Eosin slide is prepared The typical IHC Immunohistochemistry workflow starts with the diagnosis of cancer by a pathologist reviewing the H amp E slide Once the pathologist has determined that a patient has cancer he she orders an IHC panel An IHC panel consists of consecutively cut slides from the same specimen block that are then stained with different IHC stains A typical IHC panel for breast cancer includes the following IHC stains HER2 Human Epidermal growth factor Receptor 2 ER Estrogen Receptor and PR Progesterone Receptor The pathologist then reads the IHC slides and provides a semi quantitative
32. ion reports for any range of dates Spectrum Spectrum Plus Administrator s Guide Compression Because of the large size of whole slide images Digital Pathology applications often use lossy data compression technologies such as JPEG and JPEG2000 Aperio s ScanScopes allow users to select JPEG or JPEG2000 image compression types and quality factors between 10 and 90 The Digital IHC applications require that glass slides be scanned with JPEG2000 compression type 3 as defined in the ScanScope Console with quality factor 70 Sharpening Aperio s ScanScopes provide the capability of applying a sharpening filter while the slides are scanned CAUTION Using image filters may affect analysis of the image While sharpening filters tend to provide a more pleasing image to the human eye they may compromise analysis performed by analysis algorithms because the image has been altered The Digital IHC applications require that no sharpening filter is used Predefined Parameter Set for Scanning IHC Slides It is important that all IHC slides are scanned with the required parameter settings Aperio provides the required parameter settings for IHC slides in the ScanScope Controller XML file called the IHC parameter set The Digital IHC applications require that the IHC parameter set or equivalent be used for scanning IHC slides Resolution for IHC Slides Pathologists using a standard microscope typically view IHC
33. issue area is out of focus it helps to understand the cause of the problem it might be a fold thick tissue section air pocket under the cover slip dirt fingerprint marking writing extra adhesive broken slide scratch etc Some of the mechanical problems of a slide can be resolved by cleaning the slide with a cotton rag or trimming the sides with a razor blade General guidelines to overcome focus problems are place the focus points on the tissue and exclude the artifacts place only a small number of focus points when the tissue is flat place more focus points to adjust to a shaped tissue area and use manual focus when the auto focus fails for example in thick tissue 14 Digital IHC User s Guide For more detailed information on how to automate data entry or how to enter data manually please refer to the Spectrum Spectrum Plus Operator s Guide Digital IHC User s Guide gt Data Entry Data entry can be completely automated using barcodes and by integrating to your Laboratory Information System LIS When a glass microscope slide is scanned by a ScanScope scanner a licensed barcode on the slide label can be decoded to populate data fields in Spectrum Plus Decoding barcodes requires some custom work so contact Aperio Professional Services for assistance By integrating Spectrum with your Laboratory Information System you can automatically transfer data between Spectrum and your LIS Depending on how
34. l free Tel 866 478 3999 toll free Email support aperio com Tel 44 0 1934 733679 Fax 44 0 1934 733660 Tel 44 0 1934 733679 Email europesupport aperio com Tel 81 3 3259 5255 Fax 81 3 3259 5256 Email asiainfo aperio com Email asiasupport aperio com Digital IHC User s Guide Digital IHC User s Guide Contents CHAPTER OVERVIEW cccssatcnssteccand tootevinsn usecenienesaciceteuversadar enddencsnncesnadetauerst 1 The Immunohistochemistry THC Workflow sesesesesseseesereeseseeserseseesereesereesereeses 1 Who This Guide Is Intended For e sessessessessessescesossessossessessessssossossossesssssessssssse 4 The Dre CaN TENG SOU OD sacs cisees ca reccicaccsaseas sane sexsctsupacntevascscussudeasscentenneteaseesteeasevageiues 5 More Min EO PRA CLO sssini aean an rana anasa ai aeaii raidai aaa saadaan aeisi 5 Meeting Regulatory Requirements ssisssssssesisssesiurosusussssssssssresssssvinvosniussssssanisesensstni 6 Patient Data Confidentiality essscosadenssouesccvanectiassa sentative oni iea 6 CHAPTER Z INTENDED USE iiniisscescsaiiiivetsnsumnddesususcunsseeenneadacersmtnndeseninddbesensiit 7 ln Vitro Diagnostic USC visas cksscassseivsscratanvaasaceusssusvancannascsds sastaswiiesiavaataceanvansstauascaavent 7 Research Use ONIY ernconrosnndro na n 7 CHAPTER 3 SLIDE PREPARATION siivirensusessinestnsuwniwesvousedeeteustsausiedsewubevsseussansvas 9 Tissue Prepara O oia ir n E a E A E 9 Mechan CS seirena n E
35. l read 17 manuals 5 mark up image 36 monitor requirements 18 navigating digital slide 26 opening digital slide 25 panning 27 patient data confidentiality 6 PR stain 1 preparing slides 9 mechanics 9 staining 10 tissue 9 prerequisites 18 quality control algorithms 40 digital slide 13 28 glass slide 10 reading digital slide 25 regulatory requirements 6 reporting amending a report 47 correcting a report 47 creating reports 44 image preferences 21 report image 41 sample 45 required training pathologist 17 technician 11 resolution 12 scanning 11 automatic 13 calibration 11 compression 12 manual 14 49 D perio predefined parameter set 12 required training 11 resolution 12 scoring slides 42 overriding automatic 42 setup ImageScope 20 21 individual 18 IQ 22 50 Index slide preparation 9 smart synchronization 30 Spectrum logging in 23 start page 18 updating analyses 39 updating case status 48 viewing case information 24 zooming 27 Digital IHC User s Guide Index Digital IHC User s Guide 5 perio Digital IHC User s Guide MAN 0099 Revision B
36. m ONS Mi g Zoom WA GA y De a po ar hs Note that when you want to outline regions for analysis that the appropriate algorithm name needs to be selected in the annotations window not Annotations Annotations are for general annotations of the slide The default setting for the analysis of Current Screen is automatically changed to Selected Annotation when you outline regions for analysis You can outline as many regions as you like and then run analyses on them 17b Click Run Analysis on the Annotations Summary View window If the Annotations window is not shown go to the View menu in ImageScope and select Annotations or press the Ctrl and N keys IHC HERS Breast Dako default w Selected Annotation Curent Screen 34 Digital IHC User s Guide Chapter 6 Reading Cases Step by Step D perio Digital IHC User s Guide You can also analyze the entire invasive tumor by using an algorithm with automatic tumor cell detection and running it on a coarse outline of the invasive tumor regions Processing those large regions may take some time and a different workflow is recommended to save you time where the lab pre runs image analysis for you based on the tumor regions you outlined on the H amp E slide R Aperio ImageScope m o X File Edit Image View Tools Window Help ox Safro OOs Ma FRQAa Digital slides consist of large images and the analysis of large images requires considera
37. ols are not persistent for each region to be outlined you must select the drawing tool again and then outline the region To delete any region click the annotation on the main ImageScope window to select it and press the Delete key on your keyboard 11 You can easily navigate from one annotation to the next by clicking on the corresponding region numbers in the Annotations window Hal 4 5 5 7 9 gt mi x 209 Annotation o When you outline the tumor regions on the H amp E slides your lab could provide a service where it pre identifies the tumor regions on the IHC slides and pre runs image analysis for you based on the tumor regions you outlined Digital IHC User s Guide 29 D010 Chapter 6 Reading Cases Step by Step View H amp E and IHC Slides Side by Side Optional Something you cannot do on a microscope is to view multiple slides side by side You know how difficult it can be to identify invasive tumor regions on a negative IHC slide Being able to view the H amp E and IHC slides side by side can help you to identify the tumor regions faster and more reliably Using advanced computer technologies multiple slides can be automatically synchronized so that when you navigate through one of the slides you see the same region at the same magnification in all slides 12 Click the smart synchronization icon on the ImageScope toolbar to automatically synchronize all open slides Note tha
38. our Spectrum administrator can set up appropriate case statuses for your workflow In our example when a final report has been generated for a case the new case status is Approved Now you can go to your next case 29 Click Next Case Alternatively you can go back to your work list of cases that require your attention by clicking Case List Case Details Previous Case Case List Next Case gt When you stop working log out of Spectrum 30 Click Log Off in the Spectrum toolbar and close the Internet browser User Dr John Smith Role Pathologist 48 Digital IHC User s Guide Digital IHC User s Guide analysis ER PR 38 HER2 37 mark up image 36 quality control 40 results 36 running 33 automatic data flow 42 bar codes 15 calibration 11 canned comments 43 data entry 15 deleting regions 39 Digital IHC illustration 5 digital slide navigating 26 opening 25 quality control 13 28 reading on computer monitor 17 25 ER stain 1 FDA clearances 7 generating reports 44 H amp E slide 29 annotating 29 HER2 stain 1 IHC workflow 1 image compression 12 sharpening 12 image analysis See analysis ImageScope Annotations summary view 33 34 drawing tumor regions 34 manual synchronization 30 navigating regions 39 report image preferences 21 smart synchronization 30 tools 26 viewing preferences 20 Index intended use 7 IQ 22 setup 22 using 31 logging in 23 manua
39. re to sign it 25 Click Sign Please provide your password to sign this report 26 Enter your Password the password you used to log into Spectrum and click Sign 44 Digital IHC User s Guide Chapter 6 Reading Cases Step by Step FINAL Report THC REPORT Report ra Ap 15 THE Lab Santa Maria Hospital 1360 Park Center Dr 1 Main Street Vista CA 92081 Los Angeles CA 90001 Phone 666 478 4111 Phone 213 245 7656 Fax 760 539 1116 Fax 212 245 7600 naea ue ID 1981 12 03 Unetelle AU810001 00 00 00 CASE COMMENTS 26 year old female with invasive breast carcinoma SPECIMEN ACCESSION NUMBER SMHO8000299 508 03003 2008 02 13 2008 02 1 09 01 00 16 07 00 Invasive and intraductal carcinoma 1s confirmed HER2 POSITIVE Score 3 Scoring performed on invasive component only Used computer assisted image analysis ER Score 91 9801 Scoring performed on invasive component only Used computer assisted image analysis PR POSITIVE Score f Scoring performed on invasive component only Used computer assisted image analysis February 15 2008 Page lor2 This test was performed by IHC in conjunction with computer assisted image analysis where specified The specimen is a section of formalin fixed and paraffin embedded tissue The HERZ neu slide was stained with the HercepIlest from DakoCytomation The ER slide was incubated with the 105 monoclonal anti ER antibody from DakoCytomation
40. rom now on when using IQ to view separate stains you will be able to easily select the appropriate stain set for the digital slide you are viewing 22 Chapter 6 Reading Cases Step by Step Digital IHC User s Guide Papero Chapter 6 Reading Cases Step by Step Instant Access Anytime Anywhere All digital pathology data is accessed via Aperio s web based information management system Spectrum You can log into Spectrum securely anytime anywhere and read your cases as soon as they have been scanned Ask your Spectrum administrator for the Spectrum web address URL and for your username and password 1 Open Microsoft Internet Explorer or any other standard web viewer like Firefox and enter the Spectrum web address Spectrum displays the login page You may want to bookmark this web page for convenience 2 Log into Spectrum by entering your username and password and clicking the User Login button You may be asked to change the password before continuing depending on the security settings your Spectrum administrator has chosen for your account Login Required Username jemith Password wes User Login Case Management We provide work lists based on case statuses so that every user of the system can manage his work efficiently If you have set up your start page see Select Your Spectrum Start Page on page 18 to be the list of cases that need your attention you will see this list
41. s a 2 21 3 percentage of 0 to 100 and the average staining lez a5 0 47 7 intensity of the positive nuclei as a score of 0 1 2 or 3 is determined Cytoplasmic or background staining can create problems for the correct quantization of the staining because it increases the overall staining intensity of the slide Cytoplasmic or background staining can also create problems for image analysis algorithms because segmentation of the nuclei becomes more difficult Slides that exhibit high cytoplasmic or background staining due to the staining process vs biological cause should be caught by the laboratory s quality control process In any case our ER PR image analysis is able to deal with a certain degree of cytoplasmic or background staining The ER PR image analysis detects cytoplasmic staining and corrects for it in the staining intensities and in the segmentation of the nuclei An interesting point about ER and PR scoring is that many labs use different scoring schemes some use the percentage of positive cells with a 1 5 or 10 cut off some use the Allred score and others have their own scoring scheme combining intensity and percentage to derive a meaningful score Our ER PR image analysis provides the percentage of positive cells and the intensity score on which all those scoring schemes are based Your Spectrum administrator can set up an automatic score calculator as part of Spectrum that implements the scoring scheme establish
42. s always takes precedence Stain Analysis Interpretation 80 53 0 3704 HERZ Score 3 e POSITIVE 19 07 a 0 02058 Cells 460 Percent 91 9801 Intensity 3 ot 81 1947 2 8 40708 sil a a 5A 1 2 4832 0 6 01991 Cells 1808 Percent 18 0694 Intensity 3 Allred Score 12 604 3 51878 Percent 1 9496 Intensity 61 9306 Cells 7103 Spectrum shows for each slide the Report image the Analysis results as well as the Score and the Interpretation results Your Spectrum administrator can set up the slide specific processing for each slide defining the appropriate image analysis algorithm and the specific score and interpretation schemes that are used in your institution The analysis results here are the same as the slide results in the Annotations window in ImageScope Note that only the results from the specified image analysis algorithm default are reported here making sure that the right analysis always is used When the analysis results are updated in ImageScope the results in Spectrum are also updated at the same time Scores can be copied over directly from the analysis results and or a new calculated score can be defined Our automatic score calculator can be used to create any scoring scheme you want such as a score that follows the new CAP ASCO guidelines for HER2 the Allred Score or for that matter any score that is based on the percentage of positive cells and the intensity score for ER PR or the H S
43. slides with a 20x objective which is required to view all relevant cell features for their IHC scoring Aperio ScanScopes provide slide scanning at 20x and 40x Although scanning at 40x provides more detail it also requires unnecessarily longer scan times and larger file sizes The Digital IHC applications require that IHC slides be scanned at 20x 12 Digital IHC User s Guide Chapter 5 Data Entry Digital IHC User s Guide D perio Automatic One Touch Scanning Aperio s ScanScopes can scan slides automatically using one touch operation Digital Slide Quality Control Ultimately it is up to the pathologist to look at digital slides to verify they are of sufficient quality to perform his her task In addition ScanScope operators should verify digital slide quality after scanning The quality criteria that are important for the IHC image analysis system and that should be verified by the ScanScope operators are 1 that the entire tissue sample has been scanned and 2 that the tissue is in focus Entire Tissue Sample Scanned The ScanScopes provide a Macro Image a low resolution image of the entire slide that also provides a green outline of the scanned area The Digital IHC applications require that the ScanScope operators look at the Macro Images of all the digital IHC slides and verify that the entire tissue sample was scanned Tissue in Focus The ScanScopes provide a quality factor for each sc
44. sue Section Blocks Sections Surgery Accessioning Specimen H amp E Order IHC Panel i a g ta x j lt 2 am Sas ce Oe Primary Diagnosis H amp E Staining Collate amp Deliver Read Slides IHC provided by Digital IHC Solution Archive Blocks Diagnosis amp Treatment Planning Here is an overview of the traditional clinical workflow We highlight in blue where our Digital IHC Solution affects the traditional clinical workflow Aperio s digital pathology system provides easy access to all case specimen and slide information from the current and all previous biopsies including the gross images H amp E slides IHC slides and controls Our Digital IHC solution provides a new all digital workflow for IHC from glass slides to reports Digital IHC User s Guide 3 Papero Chapter 1 Overview Who This Guide Is Intended For This guide is a reference document that covers all aspects of using Aperio s Digital IHC solution Different steps of your IHC workflow may involve different people with different skills and responsibilities Therefore the chapters in this guide are organized by function so that a particular reader can go directly to the section of interest to him or her Functional Area Responsible Person Where to Find Information Overview All readers Chapter 1 Overview Compliance Medical Director Chapter 2 Intended Use Ensuring that your
45. sure that the variations of the staining process are controlled and eliminated to the greatest extent possible Employ appropriate morphological studies and controls as specified in the reagent manufacturers instructions Glass Slide Quality Control It is the responsibility of the lab to verify the quality of the tissue preparation the mechanics of a slide and the staining 10 Digital IHC User s Guide eee For more detailed information on how to scan slides please refer to the ScanScope User s Guide Digital IHC User s Guide 4 Scanning The imaging system and its calibration as well as the scanning parameters are critical to transforming a glass Slide into a high quality digital slide Aperio s ScanScope instruments allow slides to be scanned automatically Make sure to control the quality of the digital slides This chapter is for the lab assistant or technician who scans the glass slides on the ScanScope Required Training A ScanScope operator should be able to scan slides properly for the Digital IHC applications after self study of the ScanScope User s Guide for information on the general use of the ScanScope instrument and this chapter for specific information and requirements for the Digital IHC applications Imaging System The most important property of any imaging system is its image quality Aperio s ScanScope systems are based on Aperio s patented line scanning technology which provides s
46. t this icon is similar to the manual synchronization icon except that it is yellow instead of white QB ALAA Mae mOO e MWe g Anerio Im ss eS elena File Edit Image View Tools Window Help oo ee 1 O O sei ra a FELA If smart synchronization is not effective because of special tissue characteristics such as torn or missing tissue then you can use manual synchronization Set all slides to the same magnification align them manually and then click the manual synchronization icon 30 Digital IHC User s Guide Chapter 6 Reading Cases Step by Step IQ offers many more features than simply viewing separate Stains such as adjusting stain colors to your preference or Standards measuring your stains and so on see the Q Image Quality User s Guide for details Digital IHC User s Guide DB r10 Use IQ to View Separate Stains Optional With nuclear stains like ER or PR it may be challenging to identify faint DAB staining on the nuclei as Hematoxylin the background staining and DAB colocalize on the nuclei Using advanced computer technologies the stains can be properly separated and you can look at the individual stains This way you can easily identify faint DAB stained nuclei as well as any positive stained region on the slide hot spots 13 Click the IQ icon E on the ImageScope toolbar to select the appropriate stain set such as HE DAB from the IQ drop down list Make sure
47. the integration is implemented data from a slide s barcode that automatically goes into the Spectrum database can also automatically go into your LIS or new or modified data in your LIS can automatically be copied into Spectrum The integration requires custom work and your participation in deciding what information you want to share between the systems contact Aperio Professional Services for assistance 15 16 Chapter 5 Data Entry Digital IHC User s Guide 6 Reading Cases Step by Step Aperio provides a complete solution for IHC that includes reading slides on a computer monitor quantitative image analysis and professional reports This chapter provides step by step instructions on how a pathologist reads a case using Aperio s Digital IHC solution Aperio provides a new approach to IHC with an all digital solution Pathologists can now use quantitative image analysis conveniently with a click of a button while reading slides on a computer monitor Required Training A pathologist should be able to use Aperio s Digital IHC solution and its applications after self study of this chapter and after referring to the information in the application guides Reading Digital Slides on a Computer Monitor As with any change in diagnostic methodology and especially one that relies on visual interpretation of complex images a transition from conventional microscopy to digital microscopy presents the possibility of uninten
48. thologists feel comfortable with the IHC image analysis but identify when it might have failed quality control Aperio s IHC image analysis makes it easy for the pathologists to follow what the analysis is doing and how scores were determined The analysis provides meaningful outputs of the different processing steps to which the pathologist can relate intuitively the same cell features and the same scoring scheme as used for manual scoring E The pathologist reviews the mark up image for each of the tumor regions and makes sure that the analysis properly detected and classified the tumor cells If there are regions where the analysis did not perform properly then those regions need to be excluded from the analysis Deleting regions may require adding new regions to make sure that the tumor regions used for the analysis are representative for the tumor If it is impossible to analyze a representative set of tumor regions where the algorithm performs properly then the IHC image analysis should not be used for this particular slide 40 Digital IHC User s Guide perio Chapter 6 Reading Cases Step by Step Select Report Image With a simple click of a button you can designate a representative region of the slide that will be automatically included in your report 18 Click the Report Region Tool E icon on the ImageScope toolbar and then click the area of the image that you want to appear in your report Only one report image
49. to set up the stain sets for your IHC slides see Set up Viewing Separate Stains Optional on page 22 14 Go to the ImageScope Image menu and select Quality Image Quality crl Q iQ You see the IQ viewer toolbar HE DAB View Hematoxylin HE DAB aja a 0 15 Use the IQ viewer toolbar to view separate stain channels AB to see both stains at the same time EEE 2 Olat snom Mi o OT d g a Ae IQ HE DAB 31 Papero Chapter 6 Reading Cases Step by Step A to see the first stain only in this example Hematoxylin Ei File Edit Image View Tools Window Help 8 X ou ON E mig Nes Fl File Edit Image View Tools Window Help x 16 Click at the top of the IQ viewer toolbar to turn off IQ 32 Digital IHC User s Guide oD D erlo Chapter 6 Reading Cases Step by Step Run Image Analysis Aperio provides a new approach to IHC with an all digital solution While reading slides on a computer monitor you can now use quantitative image analysis efficiently with a simple click of a button Image analysis classifies and counts thousands of cells for you accurately and consistently in just seconds The entire slide is important for assessing the tumor and Aperio s Digital IHC solution makes the entire digital slide available to you for image analysis When identifying tumor regions for analysis make sure to properly identify invasive cancer
50. uact th compu ute slsted limage analyals section of res malin ized end paraffin embedded IHC REPORT THE Lab Santa Maria Hospital T i2 neu slide was stalned with the HercepTest fros DakoCytomatica 1360 Park Center Dr i Main Street Vista CA 92061 Los Angeles CA 0001 The ER alide was incubated with the 105 monselo ati ER antib from Dako ytomatlon Phone 866 478 4111 Phone 213 245 7656 at 1 25 dilution pe 30 misutes which a viseua sed with DAR the slide was thes Fax 760 539 1116 Fax 212 245 7600 counterstained with DakoCytamt lin l minute prende cei The PR slide was incubated with the Pgh636 monoclonal antl PR antibody fros 191712 Deore DIN 5 Datocytamst tor ath 25108 Gidekion fee 30 Samten SAd wma SENLIGA With Di price ag auetc001 7699 he sosht alned with DakoCyt on be lin for iaute CASE COMMENTS iile an ot y the vo A cle approval la aot 26 year old female with invasive breast carcinoma wandated These 1 doc asd cl ES cept ves p rogne tie a ne coats sue show appropria oie sho oe ko used i context with lt liaic y pa ne eats SPECIMEN RUNDER DATE srenoeo0ess9 08 03003 09 01 00 Score 3 Scoring performed on invasive component only Used computer assisted image analysis Score s1 3501 Scoring performed on invasive component only Used computer Scoring performed on invasive component only Used competer assisted image analysis From within Adobe Reader
51. umor cells but also lymphocyte stroma and normal cells Consult the Digital IHC application guides to learn more about the capabilities of the algorithms you are using Digital IHC User s Guide 33 perio Chapter 6 Reading Cases Step by Step Other algorithms provide only a limited capability to identify tumor cells and you are required to identify the tumor cell only regions excluding lymphocyte stroma and normal cells for the analysis 17a Click on the Pen icon on the ImageScope toolbar or simply press F2 and draw an outline of the invasive tumor region Alternatively you can use the rectangle drawing tool by clicking on the U Rectangle icon or pressing F5 Regions can be outlined anywhere in the slide and at any magnification images are always analyzed at the maximum resolution of 20x Note that the drawing tools are not persistent for each region to be outlined you must select the drawing tool again and then outline the region Note as well that if you interrupt the drawing of a region ImageScope will close the region by connecting the end points not visible If this is not what you want then you should delete the current outlined region by pressing the Delete key and starting over again with this region Once you draw a region a numbered button that corresponds to the region you have drawn shows up the Annotations window A Aperio ImageScope Jog Fie Edit Image View Tools Window Help Apak Safro OOsAl reaa AVAA i
52. uperior high quality high resolution digital slides Calibration and Calibration Verification Color and intensity reproducibility are important for the consistent and accurate scoring of IHC slides The ScanScope systems provide a high degree of color and intensity reproducibility scan after scan and also from one ScanScope to another Professional color management using ICC International Color Consortium profiles ensures that you always see the same true color calibrated image of a slide wherever and whenever you view it The ScanScope automatically calibrates each slide when it is scanned The calibration at scan time is optimal as it takes into account the characteristics of each slide and the system at the exact moment of the scan and not at the moment in time when a daily or factory calibration was performed The ScanScope automatically assures proper operation of the ScanScope for each scan by performing a test of each calibration that determines if there is a problem In case of a problem the scan is aborted A calibration problem can have different causes including problems with the light source camera gains id D perio Chapter 4 Scanning macro camera offsets location of the slide on the tray optical misalignment etc please see the troubleshooting section in the ScanScope User s Guide for more For information on details printing calibration reports see the The Spectrum administrator can print calibrat
53. versus carcinoma in situ and not to include regions with staining artifacts If the staining is heterogonous ensure that your choice of tumor regions for analysis is representative for the heterogeneity of the tumor When you have identified an invasive tumor region you want to use for quantitative image analysis the easiest way is to run analysis on the current screen Make sure to zoom in to the highest magnification when running analysis to keep the processing time short 17 Click Run Analysis on the Annotations window If the Annotations window is not shown go to the View menu in ImageScope and select Annotations or press the Ctrl and N keys Annotations Summary View ae Wa TA IHC HER Breast Dako default i Selected Annotation Current Screen Slide Region Cells The appropriate algorithm for the analysis identified as default is automatically selected for you For advanced users You may run any other analysis algorithm available to you as well but only the results from the default algorithm will be available in Spectrum for further reporting Some of our algorithms provide an automatic tumor cell detection capability that identifies tumor cells versus lymphocyte stroma and normal cells and only includes those tumor cells in the analysis This capability provides robust analysis results when the analysis is run on the entire screen or on coarse tumor regions that not only include t
54. you can then print save or email the report 46 Digital IHC User s Guide Papero Chapter 6 Reading Cases Step by Step Amendments and Corrections Once a report has been signed you have to amend or correct it if you need to modify it First make your changes and then generate the report again Now before you can sign the report you need to specify if you want to do an Amendment or Correction by choosing from the Select Update Type drop down list Then you need to sign the report again using the electronic signature Select Update Type Sign Select Update Type Amendment Correction A new report is automatically created and can be found in the History section under Case Reports Case Reports IHC Report H amp E HER2 ER PR Generate Report History Report File Template State User Case 53 Rev 2 2008 11 19 13 44 pdf IHC Report H amp E HER2 ER PR FINAL AMENDED Dr John Smith Dr John Smith Case 53 Rev 1 2008 02 15 16 37 pdf IHC Report H amp E HER2 ER PR FINAL Digital IHC User s Guide DP r10 Chapter 6 Reading Cases Step by Step Finish the Case When you are finished with the case select the case status that your organization uses to identify reviewed cases 28 Go to the Case Details section and select the new case status from the Status drop down list Status App aor RTT TTEE Eee ECeECeeeeCReeRTETETETeee Incomplete Pending Complete Approved Y

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