RealTime Telepathology for Subspecialty Consultation

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Real-Time Telepathology for Subspecialty
Consultation

• Nikolaj Lagwinski, MD
• September 10th, 2007

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Literature review

• Usage of telepathology for routine frozen section
  or permanent cases is well-documented
• Limited focus on cases that are selected for
  subspecialty consults in general practice

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Objective

• To evaluate prospectively the use of a dynamic
  telepathology system for cases that a general
  pathologist would select for subspecialty consult
• Link a general pathologist at an ambulatory
  surgery center (ASC) with subspecialists at the
  main institution

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System installation

• Host site (ASC)
• Olympus (Olympus America, Melville, NY) BX-41
  scope with fluorite objectives
• Olympus DP70 digital camera

• Host site (ASC)
• PC (P4 2.8 GHZ, 512 MB RAM, 64 MB video card,
  Windows XP SP2)
• Web-enabling software (Olympus Microsuite Basic
  with Netcam)

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System installation

• Remote site (Main campus)
• Staff computer running a Java-enabled web browser
• No specific software requirements
• High-speed internet access

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Study design

• Subspecialty pathologist contacted
• TP impression
• Light microscopy
• Final diagnosis

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Telepathology algorithm
Case shown
Deferral
TP Impression
Case complexity
Image/technical
LM diagnosis
Discordant
Concordant
Major
Minor
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Data analyzed

• Reasons for deferring TP impression
• Concordance rates
• Dates
• Telepathology consult
• Final signout

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Results

• 50 cases
• 10 subspecialty pathologists
• 2 GI
• 3 GYN
• 2 ENT
• 1 Breast
• 2 GU

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Results

• 12/50 (24) cases deferred
• Additional levels needed (2)
• Special stains needed (7)
• Additional consults needed (3)
• By subspecialty
• Breast (1/1, 100)
• GU (3/7, 42.9)
• ENT (4/10, 40)
• GYN (3/18, 16.7)
• GI (1/14, 7.1)

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Results

• Of remaining 38 cases
• Major discordance in 2 (5.3)
• GYN Complex atypical hyperplasia with no atypia
  on TP atypia on LM
• GI Gastric ulcer with no atypia on TP atypia
  suggestive of dysplasia on LM
• Minor discordance in 2 (5.3)
• ENT Squamous epithelium with reactive changes
  on TP mild dysplasia on LM
• GI Rectal biopsy suspicious for invasive CA on
  TP invasive CA on LM

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Results

• 34/38 cases (89.5) concordant
• By subspecialty
• GU (4/4, 100)
• GYN (14/15, 93.3)
• GI (11/13, 84.6)
• ENT (5/6, 83.3)
• A case showed minor discordance

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Results

• Average time of TP consult was 2 minutes (Range
  1-5 min)
• Potential turnaround time saved by TP
• 17 (44.7) cases with difference of 0-1 days
• 21 (55.3) cases with difference of gt2 days

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Results summary

• High overall rate of concordance between TP and
  LM
• Deferral rates varied among different
  subspecialties
• Over half the cases could have potentially saved
  2 or more days of turnaround time

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Discussion

• Design limitations
• Sample size
• 6 month study
• Multiple subspecialty pathologists
• Variation in opinion and familiarity with setup
• Effect on deferral rates
• Preselected Cases
• Selection bias

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Discussion

• System requires a working relationship between
  consultant and consultee
• Special stains / immunohistochemistry were not
  tested
• Cases were inherently more complex
• Workup of deferred cases was expedited

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Conclusions

• Remote, real-time web-based telemicroscopy is an
  acceptable approach to subspecialty consultation
  in surgical pathology
• Although certain subspecialty types may be more
  amenable to consultation, cases may still be
  worked up more efficiently via telemicroscopy

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Thank you

• This study was made possible by a grant from the
  CAP Foundation underwritten by Olympus of
  America, Inc

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