while the benefits of digital pathology in routine clinical use continue to inspire initiatives around the world , some european countries are arguably ahead of the curve .
there are now a number of sites using digital pathology for primary diagnostic review , for example , in sweden , the netherlands , finland , lithuania , and denmark .
the nordic symposium on digital pathology ( ndp ) was created in 2013 to promote exchange of state - of - the - art knowledge .
the pioneering experiences in sweden have been a sounding board for the care providers moving in the same direction .
in contrast to research use of digital techniques , ndp specifically targets the clinical adoption of whole - slide imaging ( wsi ) and other digital technologies . while there appears to be broad consensus on the opportunities that lie ahead ,
a foundational motivation for the symposium is that effective progress is dependent on tight collaboration between health care , industry , and academia .
judging from the attendees evaluations from this and previous years , this type of venue with ample room for interactive discussions is highly appreciated and much needed . here
, we provide a summary of the ndp 2016 , in the form of a meeting overview , results from the symposium 's integrated diagnostics workshop , speaker contributions , and finally brief conclusions .
the 2016 ndp symposium took place on november 89 , 2016 , in linkping , sweden .
a total of 170 attendees gathered , of which 47% listed health care as the primary affiliation , 35% industry , and 18% academia .
pathologists constituted the lion share of health care representatives , with managers , laboratory technologists , and information technology ( it ) staff also being well - represented categories .
the participants represented 13 different countries across europe , asia , and north america , with the nordic attendees being a large majority ( 88% ) .
a large part of the program was devoted to invited talks and a workshop on integrated diagnostics .
the contents of these sessions will be outlined in the sections below . in the science and innovation session ,
12 posters were presented , with contributions from groups in linkping , bremen , tampere , uppsala , lund , and norrkping .
the ndp also included an industrial exhibition with 12 vendors , showing a wide range of digital pathology products and services .
figure 1 shows a snapshot from the symposium and the program details are available at the ndp website www.ndp2016.se .
a central component of this year 's ndp was a workshop discussing collaboration between radiology and pathology and how digital tools relate to developments in this area .
it is important to note that the survey respondents represent a biased selection among the pathology community .
since only ndp participants were asked , this means that respondents are likely to be among the most positive to digital pathology and also among the most experienced .
there is also strong geographical dominance from the nordics and , in particular , sweden .
it is likely that the questions that require deep knowledge of clinical practice were dominated by pathologists as those questions to a substantial extent were skipped or received 
role distribution of survey respondents the survey first asked ,  today , to what degree do you use digital images of histology slides in your practice ? ( in percentage of all histology cases ) . 
the results are shown in figure 3 , for instance that a majority of respondents report substantial use of digital imaging in primary diagnostics (
another bias to note for these questions is that several people from the same institution may have responded ) .
current use of digital pathology among survey respondents the main theme of the survey was integrated diagnostics , i.e. , the idea of closer collaborative work practices between pathology and radiology .
such proposals have been voiced over the years and appear to be gaining traction in the respective communities , likely fueled by the increasing possibilities arising when pathologists also work in a primarily digital environment . to the end of forming a baseline , the survey asked pathologists ,  how often do you have direct interaction with a radiologist regarding a patient case ?
 figure 4 shows the results , painting the picture that multidisciplinary team meetings are where the interaction primarily happens but also that the direct interaction overall is low .
one could argue that computer chat would be a very convenient and efficient way of interdisciplinary communication as it has proven to be within radiology settings .
the low use may , however , merely be a sign that appropriate it tools are currently missing . interaction frequency between pathologist and radiologist , across different communication types
the respondents were also asked to imagine well - crafted future collaboration support in the form of new it tools and workflows , and in that environment assess the potential :  what impact will pathology - radiology collaboration have ?  the impact within different areas is presented in figure 5 .
overall , the ndp attendees were very positive about the potential , in particular , about the possibility for deeper discussion on diagnosis discordance .
assessed impact of deepened pathology - radiology collaboration of different types , assuming well - crafted information technology tools and workflows are available .
what impact will pathology - radiology collaboration have , in the area of   the survey results were presented as a segway into a panel discussion .
jeroen van der laak ( radboud university , nijmegen , the netherlands ) , and prof .
some of the main points brought forward were as follows : the underlying technology is there , now we need to focus on integrating them into workflows and good user experiences ( prof .
hamilton ) ; it is important to step out of the  back office  mindset and actively contribute to shaping the best possible care chain for the patient ( dr .
devlin ) ; integrated diagnostics should also be seen in the broader perspective of regional / national integration ( prof .
farstad ) ; it is vital to avoid misdirected diagnostic activities  the diagnosticians should challenge any request they believe to be unnecessary ( dr .
devlin ) ; an attractive concept is to have a  matre d  for diagnostics , a new role guiding diagnostic paths and providing effective single - point communication to referrers ( prof .
the overall conclusion from the panel and the discussion with the ndp attendees is that closer collaboration between pathology and radiology is a positive and important development track going forward .
levenson presented the latest achievements with slide - free microscopy technology based on ultraviolet ( uv ) excitation .
the technology , dubbed microscopy with uv surface excitation , allows direct depiction of unsectioned specimens at full microscopic resolution .
levenson demonstrated many case examples also including image features not represented in traditional staining and microscopy , including three - dimensional tissue information , features whose diagnostic value is now being explored . along another vein , levenson shared insights on using trained pigeons as unbiased proxies for human visual pattern recognition in pathology , work which was both humorous and thought - provoking . the second keynote speaker , associate prof .
jeroen van der laak , radboud university , provided ample insight into state of the art in image analysis for wsi . among other topics ,
van der laak shared result details from the recent grand challenge , called camelyon16 , in lymph node metastasis detection .
the research challenge encompassed a whole - slide task , in this sense closer to the clinical reality than previous challenges , and leading results demonstrated levels of accuracy in line with human assessment . of interest , however , was that machines were being compared with the ultimate human effort ( i.e. , the painstaking detailed microscopic review of every part of the lymph node , something not always feasible in clinical practice ) . in tandem with those promising results , van der laak emphasized the demanding efforts still needed to bring the algorithms into the everyday clinical context .
johan hartman , karolinska institutet , presented work concluding that computational analysis outperformed manual assessment for breast cancer subtyping .
for example , the image analysis algorithm showed higher sensitivity and specificity for the luminal b subtype , being considered a very challenging distinction .
arvydas laurinavicius , vilnius university , spoke to the distinct prognostic value of bimodality of ki67 expression - an analysis requiring computational methods . instead of restricting proliferation measures to a hotspot , laurinavicius showed results where heterogeneity across the slide proved to be a more powerful survival indicator in breast cancer .
he also shared his group 's experiences on running routine primary review using telepathology , with several colleagues reporting routine clinical work remotely .
peter van ooijen , university medical center groningen , described the challenges an informatician will meet , ranging from overarching strategic efforts to mundane pragmatic problem - solving .
a key takeaway was the importance of adopting and enforcing standards when building an effective and robust digital system .
devlin , altnagelvin hospital , presented the journey to a fully digitized national radiology system in northern ireland .
apart from advice on handling technology and workflow change , devlin emphasized the need to establish direct support from stakeholders in top leadership layers .
bethany williams , leeds university , contributed to the ongoing efforts in wsi validation by presenting a systematic analysis of the type of cases where discordance with microscopic review has occurred and what can be learned from them . among the most challenging areas were diagnosis of dysplasia and finding small objects ( e.g. , micrometastases ) .
tieto sweden had invited theo papaioannou from the vstra gtaland region , sweden , to present their ongoing large - scale digitization project . from philips , dr .
hamilton presented computational imaging solutions and insights on remaining challenges for digital pathology in the context of workforce shortages and the need to collaborate .
jesper molin from sectra presented key takeaways from his phd thesis , devoted to new opportunities for pathologist interaction in digital image review .
finally , dr . per hertz from eizo nordic discussed the importance of high and controlled display performance in the context of diagnostic quality .
finally , a seminar on implementing digital microscopy in medical education was hosted by clinicum , linkping university .
the topics covered have evolved from entry - level concerns about how to scan slides properly , or whether complete digitization is possible , to mature discussions on how to design systems and workflows to accomplish quality and productivity gains  gains that are undisputed . as in previous years
, the attendees expressed the great value of this experience sharing across organizations , disciplines , and sectors .
darren treanor is a member of the aperio / leica advisory board and the sectra advisory board .
darren treanor is a member of the aperio / leica advisory board and the sectra advisory board .
 the nordic symposium on digital pathology ( ndp ) was created to promote knowledge exchange across stakeholders in health care , industry , and academia . in 2016 , 
 the 4th ndp installment took place in linkping , sweden , promoting development and collaboration in digital pathology for the benefit of routine care advances . 
 this article summarizes the symposium , gathering 170 attendees from 13 countries . 
 this summary also contains results from a survey on integrated diagnostics aspects , in particular radiology - pathology collaboration . 
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