Real-Time Telepathology for Subspecialty Consultation

Nikolaj Lagwinski, MD

September 10th, 2007

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

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

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)

System installation• Remote site (Main

campus)– Staff computer

running a Java-enabled web browser

– No specific software requirements

– High-speed internet access

Study design

Diagnostic Question

Telepathology Consult

Courier case or bring it in person

Case signed out with consult

Diagnostic Question

Courier case or bring it in person

Case signed out with consult

1. Subspecialty pathologist contacted

2. TP impression

3. Light microscopy

4. Final diagnosis

Telepathology algorithm

Case shown

TP Impression Deferral

Concordant Discordant

Major

Case complexity Image/technical

Minor

LM diagnosis

Data analyzed

• Reasons for deferring TP impression

• Concordance rates

• Dates– Telepathology consult– Final signout

Results

• 50 cases

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

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%)

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

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

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 >2 days

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

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

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

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

Thank you

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

The end