title: Working toward consensus among professionals in the identification of classical cervical cytomorphological characteristics in whole slide images.
abstract: BACKGROUND
  Cervical cancer is one of the most common causes of death in women worldwide.([1]) The introduction of cervical cytology in screening programs is an effective way for early detection and treatment of cervical precancerous lesions. Conventional screening of cervical cytology slides is still considered the current "gold standard" for the assessment of proficiency in becoming a cytotechnician, but diagnosis using digital whole slide images (WSI) may offer many advantages.
  
  
  METHODS
  In this study, we have used a selection of WSI from thin-layer specimens of the most common cervical infections and (pre) neoplastic lesions, and hypothesized that weekly WSI based case-meetings would help to obtain optimal acceptance of the new digital workflow in daily pathology practice. A questionnaire, before and after the test period was used to study the effect of our approach.
  
  
  RESULTS
  The participants clearly had to go through a learning curve to get accustomed to viewing WSI. In the beginning, there was a little self-confidence in recognizing classical cervical cytomorphological features in the WSI, and there were complaints about the speed of viewing and insufficient Z-resolution for cell groups. Adjusting the Z-stack settings resulted in better three-dimensional information due to better focusing options. Weekly meetings appeared to be instrumental in the implementation process, as participants had to select and present WSI from thematic cases themselves, and thereby, got used to viewing WSI. Some WSI were replaced by better ones until a final set of 45 representatives WSI remained. Eventually, the consensus was reached among all participants that cytomorphological features in WSI from thin-layers cervical specimens could comparably be appreciated in WSI as by conventional microscopy. The selection of 45 WSI was now used to create a digital WSI based reference atlas to support further studies.
  
  
  CONCLUSIONS
  We have obtained consensus between professionals that WSI from cervical cytology can be used to identify cytomorphological features, necessary for diagnosis. In addition, we observed that active participation of professionals had a positive effect on the overall acceptance of WSI and was important in the change management.
authors.affiliation: Department of Pathology, Atrium Medical Center, Parkstad, Heerlen, The Netherlands.
authors.forename: Odille
authors.initials: O
authors.lastname: Bongaerts
authors.affiliation: Department of Pathology, University Medical Center, Heidelberglaan, Utrecht, The Netherlands.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: van Diest
authors.affiliation: Fertility Unit, Division Mother and Child, University Medical Center, Heidelberglaan, Utrecht, The Netherlands.
authors.forename: Math
authors.initials: M
authors.lastname: Pieters
authors.affiliation: Department of Pathology, Atrium Medical Center, Parkstad, Heerlen, The Netherlands.
authors.forename: Marius
authors.initials: M
authors.lastname: Nap
keywords: Cervical cytology; digital pathology reference atlas; education; implementation; whole slide images