Radiology and pathology: From old friends to strategic partners

Imaging is the common lens through which radiologists and pathologists contemplate and diagnose disease. This largely shared approach has led radiology and pathology to become old friends, with mutual appreciation and understanding, although they are drawn more to relationships with others.

For a long time now, joint hospital sessions between the two specialisms have been the clearest expression of this closeness. In these sessions, radiologists and pathologists gradually uncover the diagnosis by comparing the black and white shadows of lesions with the explicit forms in surgical samples and the microscopic traces that the disease leaves imprinted on the tissue in shades of blue and pink.

It is time, however, for this limited coming together to be extended to a strategic alliance that would strengthen the position of both specialisms in our rapidly changing healthcare environment. For the good of patients, it is crucial that diagnostic practice does not disregard the clinical and morphological landscape in which new molecular findings need to be situated. Nevertheless, the ability to generate an increasingly vast amount of molecular data at ever lower prices has led some to foretell the imminent and drastic devaluation of imaging's role in diagnosis.

We are already seeing glimpses of this bright new world, where clinical symptoms and imaging will be relegated to the pages of history. For example, it is not very difficult to find sophisticated reports that, after dramatically unfurling a plethora of alphanumeric molecular results, draw disparate diagnostic conclusions that completely ignore the clinical, radiological and pathological context. The antidote to such nonsense spreading has a name: integration.

Through integration, radiology and pathology offer an indispensable framework in which to situate clinical and molecular data. The effective development of the unlimited potential of molecular medicine depends on us not allowing a divorce between the medical and molecular aspects of the new paradigm. The rich information offered by the “omics” (genomics, transcriptomics, proteomics, epigenomics, metabolomics, microbiomics, etc.) will dwindle to statistical gibberish if we throw out the clinical and imaging rule book in its interpretation. The representativeness of the sample, for example, is a key factor which cannot be controlled if the patient and their disease are reduced to merely an Eppendorf tube and a bar code. Likewise, it is impossible to adequately define the actionability of molecular data through a reductionist lens. A comprehensive diagnostic report is not therefore an option; it is a necessity.

This integration is facilitated by digitisation of images, a process that, in radiology, is already mature and widely established, but is still in its adolescence in the field of pathology. This difference can be explained in part by the greater memory requirements of complex polychromatic images of histological, cytological, immunohistochemical, immunofluorescence and in situ hybridisation preparations. For example, the digitisation of all the fields in a single histological preparation with haematoxylin and eosin staining can require three gigabytes. These challenges prose problems for agile use and storage capacity, among others.^1,2

The pathologist, used to changing microscope slides at high speed and changing the magnification without thinking about it, may feel that, on-screen, the movements of digitised histological images are slow and changes in magnification lack dynamism. Nevertheless, digitisation systems in pathology are becoming increasingly more agile and powerful in all aspects, including the capture, viewing, storage and recovery of images. Although it will not be immediate, the day will come when digitisation will be as established in pathology as it is now in radiology. This change will spur communication between the two specialisms and enhance the value of imaging, at the same time as facilitating the integrated diagnosis and multidisciplinary management of patients.

But, like any change, digitisation has advantages and disadvantages. The ease of sending digitised images over the internet aids teaching and consultation with expert colleagues. However, it also enables a radiologist in Bangalore to interpret and report, for a modest fee, images captured by a technician in Boston, where a clinician, by virtue of the different time zones, will find the radiological report on their computer when they arrive at work in the morning. This is not exactly a process that encourages diagnostic integration. The relative delay in digitisation becoming established means that this extreme form of diagnostic outsourcing is not so prevalent in pathology, but all in good time. Here, then, is a front where radiology and pathology must ally with one another and together push for regulations governing diagnostic internet traffic.

Another aspect that might benefit from an alliance between the two specialisms is quality.^3,4 In general, cases of discordance between the radiological and pathological diagnoses are not subject to systematic analysis. Implementing this, aided by the incorporation of support tools in existing IT systems, would greatly benefit quality of care and, no less importantly, the continuing education of specialists in both fields. In keeping with the above analogy of old friends who take their closeness for granted and pay more attention to other relationships, the radiological literature contains recommendations that do not include pathologists among the specialists with whom radiologists should preferentially interact.⁵ Fortunately, there are radiologists³ who, in response to the inappropriateness of this omission, are highlighting the importance of also including pathologists in this select group.

In some fields, such as bone pathology, interstitial lung diseases or neuropathology, these interactions have deep roots. For example, neuropathologists are well aware that the grade of a glioma does not depend exclusively on the microbiological study of a small sample of brain tissue obtained via stereotactic biopsy. They know that, in their report, as well as stating strictly what is observed under the microscope, they must refer to radiological findings like necrosis which, due to tumour heterogeneity, may be absent from the biopsy, but plays a decisive role in grading the tumour. Projecting these interactions towards the future, nobody can be certain that one day radiologists and pathologists will not study images together in vivo, in a multidisciplinary approach to lesions in which, without the need for invasive measures, it will be possible to observe not only anatomical details, but also, in situ, immunophenotypic and genotypic traits.

A further similarity between the two specialisms in Spain resides in their official journals of their respective scientific societies. In other words, the journal Radiología, for the Sociedad Española de Radiología Médica (Spanish Society of Medical Radiology [SERAM]), and the Revista Española de Patología for the Sociedad Española de Anatomía Patológica (Spanish Society of Anatomical Pathology [SEAP]). Both play an essential role, but, as they are published in Spanish, have serious difficulties when it comes to making an impact in international bibliometric classifications, where the use of a language other than English has strong negative repercussions.⁶

Among Spanish radiologists and pathologists, there is no lack of voices that, seeing the costs generated by these publications, recommend dispensing with them. Certainly effort is needed in order to rise in the bibliometric lists (recently the Revista Española de Patología achieved a listing on PubMed) and lower the costs associated with publication, but beyond these considerations there are reasons to keep and look after our journals. Firstly, they are an ideal medium for disseminating reviews, opinion pieces, guidelines and protocols that, in their content and form, suit and are applicable to our circumstances. Secondly, Spanish-speaking specialists and junior doctors on both sides of the Atlantic find in them a springboard to make the difficult leap into the competitive arena of scientific publications.⁷

Last but not least, to support both of these journals is to avoid our professional language, both spoken and written, becoming a poor, robotic translation of English or ending up expressing ourselves in a confusing and imprecise “Spanglish” rendering us fluent in neither language in our own specialism. As the Frenchman Yves Menu⁸ said in this very journal, “language is an essential pillar of mutual understanding and a vital factor both at the beginning of and throughout our education. Whatever our level in a foreign language, we will always better understand the nuances of communication in our native tongue”.

What doubt could there be that, with Prof. Luis Humberto Ros at the helm of Radiología, the journal's vitality will continue to grow. His tireless pursuit of the objectives highlighted will bear fruit for the publication, the specialism and, consequently, our patients. Among these objectives, it would not be amiss, nor irrelevant, to include a strategic alliance with pathologists. It is eminently reasonable that the two specialisms which have made imaging a key part of diagnostic medicine should innovate in unison.