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Background
If one pathologist were able to send the microscopic images they are viewing to another expert, in real time, the benefits for the patient and medicine may be immense. This is the promise that telepathology seeks to fulfill. With the growth of the interent and world wide web, browser based systems are now in place. In addition, digital images can be emailed for future group discussions.
Regulation of this nascent field is beginning. The following article records the experience of pathologists in Minnesota.
CAP Pursues Telemedicine Issue in Minnesota
The College has asked the Minnesota Medical Association to help secure legislation that would require state medical licensure for out-of-state pathologists who practice medicine, including telepathology, on Minnesota patients.
The College's request for legislation follows a Nov. 22 interpretation by the Minnesota Board of Medical Practice that out-of-state pathologists practicing telepathology on Minnesota patients are not required to either be registered or licensed in the state when the pathologist is reporting the results to an attending Minnesota physician.
That interpretation effectively reverses the board's 1995 policy guidance that out-of-state physicians are required to have Minnesota medical licenses if they practice medicine on Minnesota patients. The 1995 guidance stated that it is "the location of the patient which makes the license necessary."
The board's interpretation is based on a Minnesota law enacted this year that creates a registration system, in lieu of medical licensure, for out-of-state physicians practicing telemedicine on Minnesota patients. But the law exempts from the registration requirement out-of-state physicians who provide consultative services for patients under the care of Minnesota physicians. The Medical Board's Nov. 22 interpretation defines telepathology as a consultative service.
It is the position of the College and the Minnesota Society of Pathologists, both of which opposed enactment of the law, that "telemedicine is tantamount to the practice of medicine" and, as such, out-of-state pathologists providing services for Minnesota patients should be licensed in Minnesota, the CAP said in a Dec. 10 letter to the state medical association. "We believe that a state licensure requirement serves the best interests of the patient, of the state and the practice of medicine," the College wrote.
Source: CAP STATLINE--Dec. 18, 2002 (Volume 18, Number 24)OUTLINE
General Information Clinical Applications Dermatopathology
Frozen section
Mohs Surgery
TeleconferenceCommonly Used Terms Internet Links
GENERAL INFORMATION
CHARACTERIZATION
Diagnostic accuracy of second-opinion diagnoses based on still images.
Nordrum I, Johansen M, Amin A, Isaksen V, Ludvigsen JA.
Hum Pathol. 2004 Jan;35(1):129-35 Abstract quote.
Second opinion of histological specimens is an important part of the daily routine in anatomic pathology practices. Today, extramural second opinion can be easily obtained by sending still images via an electronic network.
The aim of this study was to examine the diagnostic accuracy of second opinion diagnosis based on still images selected from glass slides of 90 archived cases originally referred for extramural second opinion. Two pathologists together diagnosed first the still images (phase 1) and then the glass slides (phase 2). Phase 1 and phase 2 diagnoses were compared with the original second opinion diagnoses (OSODs). The pathologists achieved the same diagnostic results in phase 1 and in phase 2 measured against the OSOD, 67.8% (n = 61) and 68.9% (n = 62) complete agreement, respectively. In 29 cases in phase 1, the diagnoses were discordant with the OSOD. Three cases had incorrect benign diagnoses and 8 cases had incorrect malignant diagnoses. There were 8 false-negative diagnoses regarding malignancy, 6 false-positive diagnoses regarding malignancy, and 4 other discordant diagnoses. Eleven of the 29 discordant diagnoses could have had clinical implications.
In interpreting these results, it is important to acknowledge the observer variability in diagnostic histopathology in general. In conclusion, the results support the concept of using still images to obtain second opinion diagnosis.
Image quality issues in a static image-based telepathology consultation practice.
Williams BH, Hong IS, Mullick FG, Butler DR, Herring RF, O'Leary TJ.
Department of Telepathology, Armed Forces Institute of Pathology, Washington, DC 20306-6000, USA.
Hum Pathol. 2003 Dec;34(12):1228-34 Abstract quote.
Field selection and image quality have often been identified as impediments in the successful employment of static-image telepathology. One thousand seven hundred fifty-three electronic consultations using static images were performed at the Department of Telemedicine, Armed Forces Institute of Pathology (AFIP) between November 1994 and September 2001, with 98.3% receiving a telepathology diagnosis.
In 47.9% of cases, imagery was considered good by AFIP consultants, 38.5% were considered adequate, and 14.6% of cases were considered to have poor-quality imagery. Deficiencies in image quality were recorded for each case. Cases with imagery rated as good averaged significantly fewer deficiencies per case (0.45, range: 0 to 3) than cases with imagery rated adequate (0.95, range: 0 to 6) or poor (2.4, range: 0 to 7).
Deficiencies in focus were most commonly identified in this series of cases (28.1%), followed by improper white balancing of the capture device (14.1%) and inadequate resolution (10%). Cases in which images were of inadequate resolution showed an increased likelihood for discordance between the telepathology diagnosis and the diagnosis rendered on follow-up material ("truth diagnosis"). Inadequate field selection, although only cited in 6.7% of cases overall, was seen with a significantly higher frequency in cases in which there was discordance between the telepathology and truth diagnosis.
A review of common image deficiencies in static-image telepathology and possible causes is presented.
Telepathology: current status and future prospects in diagnostic histopathology.Cross SS, Dennis T, Start RD.
Digital Pathology Research Group, Academic Unit of Pathology, Section of Oncology and Pathology, Division of Genomic Medicine, School of Medicine and Bioscience, University of Sheffield, South Yorkshire, UK.
Histopathology 2002 Aug;41(2):91-109 Abstract quote Telepathology is the process of diagnostic histopathology performed on digital images viewed on a display screen rather than by conventional glass slide light microscopy. The technology of telepathology has radically improved over the past 5 years so that it is no longer the limiting factor in the diagnostic process.
This review looks at the resources needed for dynamic and static telepathology, including image quality, computers and software interfaces, means of transmission and human resources. It critically analyses 32 published trials of telepathology, including some large prospective studies, in all areas of diagnostic histopathology including intraoperative frozen sections, routine and referral cases. New developments, including internet solutions and virtual microscopy, are described and there is analysis of the economics of telepathology within health care systems.
The review concludes that all the necessary technology for telepathology is available, there is strong published evidence for a diagnostic accuracy comparable with glass slide diagnosis, in many contexts there is a clear-cut economic argument in favour of telepathology, and that the technique should now be integrated into mainstream diagnostic histopathology.
The image pyramid system--an unbiased, inexpensive and broadly accessible method of telepathology.Gombas P, Skepper JN, Hegyi L.
MI Central Hospital, Division of Pathology Varosligeti Fasor 9-11, Budapest, H-1071, Hungary.
Pathol Oncol Res 2002;8(1):68-73 Abstract quote Although computerised information technology, including the Internet is broadly used and globally accessible it is still not a significant form of professional communications in diagnostic histopathology.
The high cost of interactive dynamic telepathology systems makes their use limited outside the richest economies. In contrast static telepathology systems are relatively cheap but in practice their information content can be heavily biased by the choice of images sent by the consulting pathologist. The degree of this bias may be regarded simply as the amount of information transferred to a remote location expressed as a percentage of the total information present in the histological sample.
We refer to this as the percentage of explicit versus implicit information. Another major source of bias may be found in the information transmitted in written or verbal discussion with a remote consultant.
We have developed a system of static telepathology, the image pyramid, which attempts to minimise bias by transferring all of the information in a section to the consultant. It is inexpensive and should prove to be widely accessible.
Storage and distribution of pathology digital images using integrated web-based viewing systems.Marchevsky AM, Dulbandzhyan R, Seely K, Carey S, Duncan RG.
Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
Arch Pathol Lab Med 2002 May;126(5):533-9 Abstract quote CONTEXT: Health care providers have expressed increasing interest in incorporating digital images of gross pathology specimens and photomicrographs in routine pathology reports.
OBJECTIVE: To describe the multiple technical and logistical challenges involved in the integration of the various components needed for the development of a system for integrated Web-based viewing, storage, and distribution of digital images in a large health system.
DESIGN: An Oracle version 8.1.6 database was developed to store, index, and deploy pathology digital photographs via our Intranet. The database allows for retrieval of images by patient demographics or by SNOMED code information.
SETTING: The Intranet of a large health system accessible from multiple computers located within the medical center and at distant private physician offices.
RESULTS: The images can be viewed using any of the workstations of the health system that have authorized access to our Intranet, using a standard browser or a browser configured with an external viewer or inexpensive plug-in software, such as Prizm 2.0. The images can be printed on paper or transferred to film using a digital film recorder. Digital images can also be displayed at pathology conferences by using wireless local area network (LAN) and secure remote technologies.
CONCLUSIONS: The standardization of technologies and the adoption of a Web interface for all our computer systems allows us to distribute digital images from a pathology database to a potentially large group of users distributed in multiple locations throughout a large medical center.
Practical applications of Internet resources for cost-effective telepathology practice.Leong FJ.
Nuffield Department of Clinical Laboratory Sciences, University of Oxford, John Radcliffe Hospital, Headington, UK.
Pathology 2001 Nov;33(4):498-503 Abstract quote Telepathology is the interpretation of digital microscopy images on a computer monitor at a significant distance from the location of original histology slides. Its use has proliferated globally and is part of routine practice in many laboratories. Even so, many perceive telepathology as requiring heavy initial capital expenditure. However, telepathology may be implemented in a wide variety of ways, some inexpensive. The limiting factor is often the technical knowledge and skill of the pathologist, not the technology or economics.
The Internet is a versatile medium that may act as a repository of information in telepathology or as a communication conduit for either real-time (dynamic or robotic) or store-and-forward (static) methods. PubMed is an excellent starting point for literature research, with many journals providing full versions of their articles online to subscribers. However, these are largely in other fields of medicine and good online resources dedicated to telepathology techniques and information are less easily found.
As a conduit for communication, the Internet can be the most economical option. Nearly every form of telepathology may use the Internet, provided there is sufficient bandwidth. Several techniques applied to general imaging may be used in store-and-forward telepathology. This article outlines some examples and discusses their relative merits.
Clinical evaluation of an international static image-based telepathology service.Williams BH, Mullick FG, Butler DR, Herring RF, O'leary TJ.
Department of Telepathology, The Armed Forces Institute of Pathology, Washington, DC 20306-6000, USA.
Hum Pathol 2001 Dec;32(12):1309-17 Abstract quote Telepathology is the use of telecommunications technology as a means to facilitate transfer of image-rich pathology data between remote locations for the purposes of diagnosis, education, and research.
Although varying levels of technology exist to accomplish this task, static image--based systems are currently the most widely used around the world. Field selection and image quality have often been identified as major impediments to the successful use of static images for diagnostic telepathology. Between November 1994 and July 1999, the Armed Forces Institute of Pathology (AFIP) performed electronic consultation on over 1,250 static image--based cases, recording a clinically significant concordance rate of 97.3% between telepathology and final diagnosis (in cases in which follow-up material was available). For the same subset of cases, an absolute concordance rate of 73.7% was attained.
A review of the case flow and construction of the AFIP telepathology system is presented, as well as factors that have an impact on the diagnostic accuracy of static image-based telepathology sytems in general.
CLINICAL APPLICATIONS CHARACTERIZATION DERMATOPATHOLOGY
From the Departments of *Dermatology; double daggerGynaecology, Medical University of Graz; section signInstitute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria; and daggerHokkaido University Graduate School of Medicine, Sapporo, Japan.
Telepathology is the practice of diagnostic histopathology performed on digital pictures. In this study, we focused on the technical requirements for achievement of a correct diagnosis on digital histopathologic images.
A collection of 560 melanocytic lesions was selected from the files of the Department of Dermatology, Medical University of Graz, Austria. From each lesion one histologic slide was completely digitally scanned with a robotic microscope. Digital pictures were reviewed by 4 dermatopathologists using a presentation program, which recorded the number of image calls, applied magnifications, overall time needed, and amount of transmitted bits during the digital sign-out. One month later, the 4 microscopists had to review the corresponding slides and render a direct diagnosis on each case.
Telepathologic diagnoses corresponded with the original diagnoses in a range from 90.4% to 96.4% of cases (kappa 0.80 to 0.93; P < 0.001). The median time needed for achievement of a diagnosis was 22 seconds and was significantly higher for melanomas compared with nevi. The median transmission effort for each diagnosis was 510 kilobytes after JPEG compression. Using an ISDN line with a transmission capacity of 64 kilobits/ second, this correlates to a transmission time of about 1 minute.
Our results demonstrate that correct reporting on digital histopathologic images is possible with only a little time exposure. For an adequately fast transmission ISDN lines are suffcient after JPEG compression.Comparison of skin biopsy triage decisions in 49 patients with pigmented lesions and skin neoplasms: store-and-forward teledermatology vs face-to-face dermatology.
Shapiro M, James WD, Kessler R, Lazorik FC, Katz KA, Tam J, Nieves DS, Miller JJ.
Departments of Dermatology, University of Pennsylvania, Penn State Milton S. Hershey Medical Center, Philadelphia, PA 19104, USA
Arch Dermatol. 2004 May;140(5):525-8. Abstract quote
OBJECTIVE: To determine the relative efficacy of store-and-forward teledermatology vs face-to-face dermatology consultations in triage decisions about the need for a biopsy of neoplastic skin changes.
DESIGN: Prospective study of consecutive patients judged by an internist to require dermatologic consultation for a skin growth.
SETTING: Private primary care and dermatology practices and an academic dermatology practice.
PATIENTS: Patients requiring dermatology consultation for evaluation of skin growths. Patients were seen by a single primary care physician between July 10, 1998, and August 4, 2000.
INTERVENTION: Digital photographs of skin growths were obtained by the primary care physician and evaluated by a teledermatologist. The patient was then seen face-to-face by a dermatologist. A biopsy was performed if either dermatologist favored biopsy.
MAIN OUTCOME MEASURES: Decisions to perform a biopsy. Agreement between the dermatologists was assessed.
RESULTS: Of the 49 patients with evaluable photographs, the face-to-face dermatologist and teledermatologist recommended a biopsy for the same 26 patients, yielding a sensitivity of the teledermatologist of 1.00 (95% confidence interval [CI], 0.87-1.00) and a specificity of 1.00 (95% CI, 0.85-1.00). The agreement between the dermatologists (kappa) was 1.00 (95% CI, 0.72-1.00).
CONCLUSION: Store-and-forward teledermatology may provide an accurate and cost-effective method of determining whether skin growths in patients presenting to primary care physicians should undergo biopsy.
Telepathology in the diagnosis of routine dermatopathologic entities.Morgan MB, Tannenbaum M, Smoller BR.
Departments of Pathology, University of South Florida College of Medicine and the Bay Pines, James Haley Veterans Hospitals, Tampa, Fla.
Arch Dermatol 2003 May;139(5):637-40 Abstract quote BACKGROUND: Telepathology involves the use of video technology to facilitate remote-site diagnosis. To our knowledge, no studies have compared the reproducibility of real-time telepathology between dermatopathologists with that of traditional 2-headed microscopy in the diagnoses of routine dermatopathologic entities.
OBSERVATIONS: The kappa statistic for both techniques was favorable: 0.76 (telepathology) vs 0.93 (conventional 2-headed microscopy); P =.04. The time taken per case was 42 seconds (telepathology) vs19 seconds (conventional 2 -headed microscopy); P =.003.
CONCLUSIONS: Telepathology between 2 remote diagnostic centers offers a feasible means of facilitating the remote-site diagnosis of routine dermatopathologic entities. Although diagnostic accuracy and time taken per case were acceptable with video-assisted diagnosis, conventional microscopy had significantly higher accuracy and shorter time per diagnosis.
Concordance between telepathologic diagnosis and conventional histopathologic diagnosis: a multiobserver store-and-forward study on 20 skin specimens.Piccolo D, Soyer HP, Burgdorf W, Talamini R, Peris K, Bugatti L, Canzonieri V, Cerroni L, Chimenti S, De Rosa G, Filosa G, Hoffmann R, Julis I, Kutzner H, Manente L, Misciali C, Schaeppi H, Tanaka M, Tyler W, Zelger B, Kerl H.
Department of Dermatology, University of L'Aquila, Italy.
Arch Dermatol 2002 Jan;138(1):53-8 Abstract quote OBJECTIVE: To study the validity and feasibility of transferring images of cutaneous biopsy specimens via e-mail to remote physicians active in dermatopathology for teleconsultation.
DESIGN: Twenty skin specimens previously diagnosed at the Department of Dermatology, University of Graz, Austria, were subsequently sent for teleconsultation using the store-and-forward method. For each case, 3 or 4 images at different magnifications were sent by e-mail to 16 colleagues (11 dermatopathologists and 5 pathologists) in 15 centers in 6 different countries. Six weeks later each observer received the hematoxylin-eosin-stained specimens to render a conventional diagnosis.
SETTING: Dermatopathology and pathology units within institutional and private settings.
MATERIAL: Twenty small skin biopsy specimens of cutaneous diseases were selected randomly from a study set of 80.
MAIN OUTCOME MEASURE: Concordance between telepathologic diagnoses and conventional histopathologic diagnoses of 20 skin specimens.
RESULTS: On average, 78% of the telediagnoses were correct (range, 60%-95%), whereas 85% of the conventional diagnoses were correct (range, 60%-95%). A perfect diagnostic concordance was obtained in 7 (35%) of 20 cases, and a significant difference was identified in only 1 case.
CONCLUSIONS: Results suggest that telepathology performed by physicians active in dermatopathology may serve as a reliable technique for the diagnosis of cutaneous diseases when experts in dermatopathology are not available locally. Furthermore, teledermatopathology is attractive because it provides an opportunity to obtain timely consultation on difficult cases.
FROZEN SECTIONS
Department of Pathology, University of Virginia Medical Center, Box 800214, Charlottesville, VA 22908, USA.
Residents in anatomic pathology are allowed increased diagnostic responsibility including the initial interpretation of intraoperative frozen-section consultations during their years of training. This frozen-section responsibility requires staff faculty backup for diagnostic confirmation and consultation.
In this study, we tested a telepathology system using an ultra portable computer with a 4.5-in diagonal screen (scrolled image size of 2.5 x 1.75 in, width x height) and both wireless Local Area Network (LAN) final connection from a DSL and wireless Wide Area Network (WAN) telecommunications. The diagnostic agreement for a chief resident/faculty staff duo using telepathology for 100 consecutive frozen-section cases (50 with wireless LAN final connection and 50 with wireless WAN) with limited clinical information was compared with the original frozen-section diagnosis rendered by other staff pathologists.
There was diagnostic agreement for 95 of the 100 cases. For the 5 that were discordant, 2 were deemed to be errors in the original frozen-section diagnosis; 1 was not clinically important; and 2 were believed to have potential clinical implications. For the 2 having potential clinical importance, the absence of knowledge of the gross findings in each case and the preoperative biopsy results for one specimen contributed to the misinterpretation of the frozen sections. The median time between transmission of image(s) from the chief resident to the faculty consultant until diagnosis by the latter was 1 minute 42 seconds for wireless WAN and 51 seconds for the wireless LAN final connection to the display device.
We conclude that a telepathology system using an ultra portable computer and wireless telecommunications is useful for frozen-section consultation between an experienced resident and a faculty member in pathology.Telepathology for Routine Light Microscopic and Frozen Section Diagnosis
Katherine Chorneyko, MD,1 Ronald Giesler, ART,1 Deborah Sabatino,3 Catherine Ross, MD,1 Francesca Lobo, MD,1 Hafez Shuhaibar, MD,1 Vicky Chen, MD,1 Leela Elavathil, MD,1 Franco Denardi, MD,1 Saira Ansari, MD,1 Samih Salama, MD,1 Victoria LeBlanc, PhD,2 Geoff Norman, PhD,2 Brian Sheridan, MD,3 and Robert Riddell, MDAm J Clin Pathol 2002;117:783-790 Abstract quote
Telepathology (TP) uses telecommunication linkages to electronically capture, store, retrieve, and transmit images to distant sites.We assessed the feasibility of a dynamic real-time TP system for light microscopic (LM) diagnosis of anatomic pathology specimens, including frozen sections. Six pathologists, in 2 separate periods, read a set of 160 retrospectively retrieved slides (80 of which were frozen sections) by TP and LM. Reading times were recorded. Diagnoses were compared with the reference diagnosis (established by a group of 5 independent pathologists) and graded on a scale of 0 to 2 (2, correct; 1, incorrect but no clinical impact; 0, incorrect with clinical impact).
Overall, LM was more accurate than TP compared with the reference diagnosis (score, 1.68 vs 1.54). There was no difference in accuracy between frozen section and paraffin-embedded tissue. Intraobserver agreement ranged from 82.5% to 88.2%. The average reading time was 6.0 minutes for TP and 1.4 minutes for LM. During the study, reading time decreased for TP but not for LM.
These results show that despite marginally lower accuracy and longer reading times, TP is feasible for routine light microscopic diagnosis, including frozen sections.
Use of robotic telepathology for frozen-section diagnosis: a retrospective trial of a telepathology system for intraoperative consultation.Kaplan KJ, Burgess JR, Sandberg GD, Myers CP, Bigott TR, Greenspan RB.
Department of Pathology (KJK, JRB, RBG) and Telemedicine Directorate (TRB), Walter Reed Army Medical Center, Washington, DC.
Mod Pathol 2002 Nov;15(11):1197-204 Abstract quote Telepathology is the practice of digitizing histological or macroscopic images for transmission along telecommunication pathways for diagnosis, consultation, or continuing medical education. Previous studies have addressed static versus dynamic imaging in several specimen types with a wide variety of systems and communication pathways.
The goal of this paper was to assess the validity of a Web-based telepathology system for frozen section consultation within the Army Medical Department. The system provides real-time, dynamic remote control of a robotic microscope over standard Internet connections. Oftentimes, a solo pathologist is called on to provide diagnostic services without the support of immediate second or expert consultation during an intraoperative consultation. The use of telepathology is attractive because it provides an opportunity for pathologists to obtain immediate consultation.
For purposes of the study, 120 consecutive frozen section cases were diagnosed at a distance using the system. Intraobserver agreement between the telepathology diagnosis and glass slide diagnosis was observed. Diagnostic agreement was 100% for a wide variety of specimens. This study suggests that such a system will help support pathologists located at distant sites.
Store-and-forward diagnostic telepathology of small biopsies by e-mail attachment: a feasibility pilot study with a view for future application in Thailand diagnostic pathology services.Settakorn J, Kuakpaetoon T, Leong FJ, Thamprasert K, Ichijima K.
Chiang Mai University, Department of Pathology, Faculty of Medicine, Chiang Mai 50200, Thailand.
Telemed J E Health 2002 Fall;8(3):333-41 Abstract quote Diagnostic telepathology by electronic mail (e-mail) attachment is relatively simple and incurs minimal cost.
We assessed its accuracy and practical aspects in routine diagnostic pathology. Using 100 small biopsy specimens, a total of 1,488 images were digitized by one pathologist and sent as e-mail attachments from Nara Medical University, Japan, to a pathologist at Rajavithi Hospital, Thailand. His diagnoses were compared with his conventional light microscopy interpretation at a later date. The average total turnaround time spent on each case was 215 minutes, far less than the several days required by conventional post. There were two clinically significant errors. One was a diagnostically difficult case of colonic dysplasia, which was called carcinoma with telepathology. The other was a signet ring cell carcinoma of the stomach which was undetected with telepathology.
Microscopy objective magnification and digital image quality may have played a role in impairing interpretation in both cases. Store-and-forward telepathology provides acceptable efficacy, a comparatively faster turnaround time than post and could be applied in routine work within Thai pathology services.
MOHS SURGERY
Use of dynamic telepathology in Mohs surgery: a feasibility study.Nehal KS, Busam KJ, Halpern AC.
Dermatology Service and Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
Dermatol Surg 2002 May;28(5):422-6 Abstract quote BACKGROUND: Telepathology is an emerging technology for remote pathology consultation and diagnosis.
OBJECTIVE: To assess the diagnostic accuracy and utility of a dynamic telepathology system in the setting of Mohs surgery.
METHODS: Using a dynamic telepathology system, a single dermatopathologist at a remote site assessed the following cases: (1) 50 fixed-tissue slides of basal and squamous cell carcinomas for pathologic diagnosis; (2) 40 frozen-section slides from Mohs surgery for the presence or absence of tumor; (3) 20 frozen-section slides from Mohs surgery for intraoperative consultation with the Mohs surgeon. All 110 slides were then randomly reviewed by the same dermatopathologist by conventional light microscopy. Telepathology and conventional light microscopy diagnoses were then compared.
RESULTS: There was complete agreement between telepathology and conventional light microscopy diagnoses.
CONCLUSION: Dynamic telepathology is a convenient, useful, and accurate system for remote diagnosis and consultation in the setting of Mohs surgery.
TELECONFERENCE
Internet teleconferencing method for telepathology consultations from lung and heart transplant patients.Marchevsky AM, Lau SK, Khanafshar E, Lockhart C, Phan A, Michaels PJ, Fishbein MC.
Departments of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California; and UCLA School of Medicine, Los Angeles, California.
Hum Pathol 2002 Apr;33(4):410-4 Abstract quote Current Internet-based teleconferencing techniques allow a referring pathologist to transmit real-time images from a microscope to a consultant, while maintaining a verbal conversation using Internet telephony.
In our study, 50 randomly selected transbronchial biopsies from lung allograft recipients and 58 randomly selected endomyocardial biopsies from heart transplant patients were diagnosed by consultant pathologists using Internet-based teleconferencing methods. The referring pathologists acquired the real-time video images from the biopsies using a light microscope equipped with a phototube adapter and a video camera. The consultant pathologists viewed the processed images on a video monitor at 800 x 600 resolution, using a standard microcomputer equipped with Netmeeting software, and directed the referring pathologist to move the slide under the microscopy and/or change image magnification. The validity of telepathology diagnoses was assessed with kappa coefficients.
Consultations were completed in 5 to 15 minutes per case. Sound transmission was unreliable, and in approximately 25% of consultations the referring pathologist needed to "call back" to reestablish verbal communication. In all but 2 transbronchial biopsies there was agreement between the original diagnosis and the diagnosis by telepathology (kappa = 0.92). In 48 of 58 endomyocardial biopsies there was concordance between the 2 diagnoses (kappa = 0.692). Only 3 out of 10 of these discrepancies were clinically significant (kappa = 0.897).
Internet-based teleconferencing techniques provide effective and relatively inexpensive tools for real time telepathology consultations. The technology is probably best suited for the study of small specimens from patients that require rapid diagnosis by a consultant.
Offline telepathology diagnosis of colorectal polyps: a study of interobserver agreement and comparison with glass slide diagnoses.Cross SS, Burton JL, Dube AK, Feeley KM, Lumb PD, Stephenson TJ, Start RD.
Academic Unit of Pathology, Section of Oncology and Pathology, Division of Genomic Medicine, School of Medicine and Biological Science, University of Sheffield, Beech Hill Road, South Yorkshire S10 2RX, UK.
J Clin Pathol 2002 Apr;55(4):305-8 Abstract quote BACKGROUND/AIMS: Technological advances have produced telepathology systems with high quality colour images and reasonable transmission times. Most applications of telepathology have centred on the remote diagnosis of frozen sections or remote real time expert opinions. This study investigates the reproducibility and accuracy of offline telepathology as a primary diagnostic medium for routine histopathology specimens.
METHODS: One hundred colorectal polyps (50 hyperplastic, 50 adenomatous) were presented in a randomised order to five histopathologists as offline images on a telepathology workstation. Six images of each case were used: the slide label, a low power scan of all material on the slide, and four higher magnification views. The times taken to prepare the images, and to make the diagnoses, were recorded. Interobserver agreement was measured with kappa statistics and compared with the glass slide diagnoses.
RESULTS: The kappa statistics for the interobserver agreement on the telepathology images lay in the range of 0.90-1.00, which is interpreted as excellent agreement, and were significantly higher than those for the glass slide diagnoses (range, 0.84-0.98; p = 0.001). The median time taken to capture the images for a case was 210 seconds. The median time taken to make a diagnosis from the telepathology images was five seconds, which was significantly shorter than for the glass slide diagnoses (median, 13 seconds; p < 0.0005).
CONCLUSIONS: Offline telepathology has the potential to be a primary diagnostic medium for routine histopathology with a high degree of reproducibility and short diagnosis times. Further studies are required to validate offline telepathology for different types of specimens and different operators of the image capture system.
Interobserver variability in the diagnosis of ulcerative colitis-associated dysplasia by telepathology.Odze RD, Goldblum J, Noffsinger A, Alsaigh N, Rybicki LA, Fogt F.
Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
Mod Pathol 2002 Apr;15(4):379-86 Abstract quote Telepathology (TP) is the practice of remote diagnostic consultation of electronically transmitted, static, digitalized images. The diagnostic efficacy of TP-based consultation services has not been widely tested. Dysplasia that arises in association with chronic ulcerative colitis (CUC) is, at present, the most important marker of an increased risk of malignancy in patients with this disease. Unfortunately, dysplasia is difficult to diagnose histologically and, as a result, suffers from a significant degree of intra- and interobserver variability. Furthermore, it is often necessary to obtain expert consultation of potential CUC-associated dysplasia cases before treatment.
Therefore, the aim of this study was to evaluate the utility and interobserver variability of diagnosing dysplasia in CUC with the use of TP. Static, electronically transmitted, digitalized images of 38 CUC cases with areas considered negative, indefinite, or positive for dysplasia (low or high grade) were evaluated independently by four gastrointestinal pathologists. All cases were then graded by each of the pathologists by light-microscopic examination of the hematoxylin and eosin-stained glass slides. The degree of interobserver variability was determined by kappa statistics.
Overall, there was a fair degree of agreement (kappa = 0.4) among the four reviewing pathologists after analysis of the digitalized images. The poorest level of agreement was in the indefinite and low-grade dysplasia categories. Grouping together several diagnostic categories (for instance, indefinite and low-grade dysplasia, or low-grade dysplasia and high-grade dysplasia) had no effect on the overall level of agreement. The degree of variability in interpretation of glass slides was slightly better (kappa = 0.43) but still remained fair. After reviewing all cases by glass slide analysis, the diagnosis was changed in 38% of the slides; in the majority of these, the grade of dysplasia was increased.
Use of TP for consultation in CUC-associated dysplasia has a moderate level of interobserver agreement. Because of a variety of technical reasons, diagnoses rendered by evaluation of digitalized images tended to be of a lower grade than that observed after a review of the glass slides.
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