Telepathology: current status and future prospects in diagnostic histopathology

Deep learning for necrosis detection using canine perivascular wall tumour whole slide images

Necrosis seen in histopathology Whole Slide Images is a major criterion that contributes towards scoring tumour grade which then determines treatment options. However conventional manual assessment suffers from inter-operator reproducibility impacting grading precision. To address this, automatic necrosis detection using AI may be used to assess necrosis for final scoring that contributes towards the final clinical grade. Using deep learning AI, we describe a novel approach for automating necrosis detection in Whole Slide Images, tested on a canine Soft Tissue Sarcoma (cSTS) data set consisting of canine Perivascular Wall Tumours (cPWTs). A patch-based deep learning approach was developed where different variations of training a DenseNet-161 Convolutional Neural Network architecture were investigated as well as a stacking ensemble. An optimised DenseNet-161 with post-processing produced a hold-out test F1-score of 0.708 demonstrating state-of-the-art performance. This represents a novel first-time automated necrosis detection method in the cSTS domain as well specifically in detecting necrosis in cPWTs demonstrating a significant step forward in reproducible and reliable necrosis assessment for improving the precision of tumour grading.

Establishment of a whole slide imaging-based frozen section service at a cancer center

Background

In recent years, there has been a surge of interest in clinical digital pathology (DP). Hardware and software platforms have matured and become more affordable, and advances in artificial intelligence promise to transform the practice of pathology. At our institution, we are launching a stepwise process of DP adoption which will eventually encompass our entire workflow. Out of necessity, we began by establishing a whole slide imaging (WSI)-based frozen section service.

Methods

We proceeded in a systematic manner by first assembling a team of key stakeholders. We carefully evaluated the various options for digitizing frozen sections before deciding that a WSI-based solution made the most sense for us. We used a formalized evaluation system to quantify performance metrics that were relevant to us. After deciding on a WSI-based system, we likewise carefully considered the various whole slide scanners and digital slide management systems available before making decisions.

Results

During formal evaluation by pathologists, the WSI-based system outperformed competing platforms. Although implementation was relatively complex, we have been happy with the results and have noticed significant improvements in our frozen section turnaround time. Our users have been happy with the slide management system, which we plan on utilizing in future DP efforts.

Conclusions

There are various options for digitizing frozen section slides. Although WSI-based systems are more complex and expensive than some alternatives, they perform well and may make sense for institutions with a pre-existing or planned larger DP infrastructure.

Videoconference microscopy is a reliable alternative to conventional microscopy in the evaluation of Barrett's esophagus: Zooming into a new era

Telepathology, practicing pathology from a distance, allows experts to review cases without the need to transfer glass slides. Due to significant intra- and inter-observer variabilities in the histological evaluation of Barrett's esophagus (BE), current guidelines recommend expert consultation in cases of dysplasia. We aimed to determine whether telepathology using microscope videoconferencing can be reliably used for evaluation of BE. Biopsies from 62 patients with endoscopic findings of salmon colored mucosa extending ≥1 cm proximal to the gastroesophageal junction were randomly selected to represent benign esophagus, non-dysplastic BE, low-grade dysplasia, high-grade dysplasia, and adenocarcinoma. Three gastrointestinal-trained pathologists reviewed the cases via videoconference microscopy followed by conventional microscopy. Intra-observer and pairwise inter-observer agreements between the conventional microscopy and videoconference methodologies were calculated for each of the three pathologists using Fleiss-Cohen weighted kappa (K) analysis. The intra-observer agreement for each pathologist's assessment of videoconference microscopy and glass slide readings showed very good reliability (K = 0.94, 95% confidence interval = 0.89-0.99; 0.88, 95% confidence interval = 0.79-0.98; 0.93, 95% confidence interval = 0.90-0.97). Mean pairwise inter-observer agreement was 0.90 for videoconference and 0.91 for conventional microscopy. Diagnosis and grading of BE using videoconference microscopy show similar reliability as conventional microscopy. Based on our findings, we propose that videoconferencing pathology is a valid instrument for evaluating BE.

Artificial intelligence driven next-generation renal histomorphometry

PURPOSE OF REVIEW

Successful integration of artificial intelligence into extant clinical workflows is contingent upon a number of factors including clinician comprehension and interpretation of computer vision. This article discusses how image analysis and machine learning have enabled comprehensive characterization of kidney morphology for development of automated diagnostic and prognostic renal pathology applications.

RECENT FINDINGS

The primordial digital pathology informatics work employed classical image analysis and machine learning to prognosticate renal disease. Although this classical approach demonstrated tremendous potential, subsequent advancements in hardware technology rendered artificial neural networks '(ANNs) the method of choice for machine vision in computational pathology'. Offering rapid and reproducible detection, characterization and classification of kidney morphology, ANNs have facilitated the development of diagnostic and prognostic applications. In addition, modern machine learning with ANNs has revealed novel biomarkers in kidney disease, demonstrating the potential for machine vision to elucidate novel pathologic mechanisms beyond extant clinical knowledge.

SUMMARY

Despite the revolutionary developments potentiated by modern machine learning, several challenges remain, including data quality control and curation, image annotation and ontology, integration of multimodal data and interpretation of machine vision or 'opening the black box'. Resolution of these challenges will not only revolutionize diagnostic pathology but also pave the way for precision medicine and integration of artificial intelligence in the process of care.

Photomicrograph-Based Neuropathology Consultation in Tanzania

OBJECTIVES

Since neuropathologic diagnosis in the developing world is hampered by limitations in technical infrastructure, trained laboratory personnel, and subspecialty-trained pathologists, the use of telepathology for diagnostic support, second-opinion consultations, and ongoing training holds promise as a means of addressing these challenges. This study aims to assess the utility of static teleneuropathology in improving neuropathologic diagnoses in low- and middle-income countries.

METHODS

Consecutive neurosurgical biopsy and resection specimens obtained at Muhimbili National Hospital in Tanzania between July 1, 2018, and June 30, 2019, were selected for retrospective, blinded static-image neuropathologic review followed by on-site review by an expert neuropathologist.

RESULTS

A total of 75 neuropathologic cases were reviewed. The agreement of static images and on-site glass diagnosis was 71% with strict criteria and 88% with less stringent criteria. This represents an overall improvement in diagnostic accuracy from 36% by general pathologists to 71% by a neuropathologist using static telepathology (or from 76% to 88% with less stringent criteria).

CONCLUSIONS

Telepathology offers a promising means of providing diagnostic support, second-opinion consultations, and ongoing training to pathologists practicing in resource-limited countries. Moreover, static digital teleneuropathology is an uncomplicated, cost-effective, and reliable way to achieve these goals.

Designing a novel hybrid healthcare teleconsultation network: a benchtop study of telepathology in Iran and a systematic review

BACKGROUND

Growing demand for medical services has increased patient waiting time due to the limited number or unbalanced distribution of healthcare centers. Healthcare teleconsultation networks are one of the potentially powerful systems to overcome this problem. Medical pathology can hugely benefit from teleconsultation networks because having second opinions is precious for many cases; however, resource planning (i.e., assignment and distribution of pathology consultation requests) is challenging due to bulky medical images of patients. This results in high setup and operational costs. The aim of this study is to design an optimal teleconsultation network for pathology labs under the supervision of medical sciences universities in Tehran, Iran.

METHODS

To avoid the setup cost, we first propose a modified hybrid peer-to-peer (P2P) overlay architecture for our telepathology network, using Iran's National Healthcare Information Network (SHAMS) as the underlying infrastructure. Then we apply optimization techniques to solve the request assignment and distribution problems in the network. Finally, we present a novel mathematical model with the objective of minimizing the variable operational costs of the system.

RESULTS

The efficiency of the proposed method was evaluated by a set of practical-sized network instances simulated based on the characteristics of SHAMS. The results show that the presented model and architecture can obtain optimal solutions for network instances up to 350 nodes, which covers our target network.

CONCLUSIONS

We believe that the proposed method can be beneficial for designing large-scale medical teleconsultation networks by adjusting the constraints according to the rules and conditions of each country. Our findings showed that teleconsultation networks in countries with strong information technology (IT) infrastructures are under the influence of consultation fees, while in countries with weak IT infrastructure, the transmission costs are more critical. To the best of our knowledge, no research has so far addressed resource planning in medical teleconsultation networks using optimization techniques. Besides, the target network, i.e., pathology labs under the supervision of medical sciences universities in Tehran and the SHAMS network, are discussed for the first time in this work.

Efficiency of Mobile Video Sharing Application (WhatsApp®) in Live Field Image Transmission for Telepathology

Telepathology is in its nascent stages in India. Video calling applications in mobile phones can be efficiently used to transmit static and live field microscopic images hastening low cost telepathology. To evaluate the efficiency of WhatsApp® Video Calling for dynamic microscopy in distant diagnosis. Thirty haematoxylin and eosin stained slides of common pathologies were retrieved from the archives of Department of Oral Pathology and Microbiology, coded with relevant history and given to three untrained investigators. The investigators then connected a mobile phone with VOIP facility to a microscope using a custom adaptor. Dynamic fields were transferred to three independent pathologists via WhatsApp® video call. The pathologists attempted to diagnose the lesion based on the live field video over their display screen (phone). Audio quality was found to be better than that of video. In 70% of the cases, pathologists could render a diagnosis (13% gave a confirmed diagnosis, 57.7% gave a probable diagnosis). The average time taken for connecting the adaptor, connecting the call to the pathologist and then receiving the diagnosis was 9:30 min. In addition, proper history taking and staining of the tissue slides were critical to arrive at the diagnosis. WhatsApp® free VOIP facility helped untrained investigators to send the live-field pathologic fields to a specialist rendering histopathological diagnosis. The factors affecting the diagnosis included network stability, clarity of images transmitted, staining quality and contrast of nuclear details of the stain. The history, clinico-pathologic correlation, transmission of static images, training of the person transmitting the images plays a vital role in rendering accurate diagnosis. Telepathology over WhatsApp® video calling could be used as an efficient screening tool to identify suspicious lesions and follow-up critical cases.

Invention and Early History of Telepathology (1985-2000)

This narrative-based paper provides a first-person account of the early history of telepathology (1985–2000) by the field's inventor, Ronald S. Weinstein, M. D. During the 1980s, Dr. Weinstein, a Massachusetts General Hospital-trained pathologist, was director of the Central Pathology Laboratory (CPL) for the National Cancer Institute-funded National Bladder Cancer Project, located at Rush Medical College in Chicago, IL. The CPL did post therapy revalidations of surgical pathology and cytopathology diagnoses before outcomes of the completed clinical trials were published. The CPL reported that interobserver variability was invalidating inclusion of dozens of treated bladder cancer patients in published reports on treatment outcomes. This problem seemed ripe for a technology-assisted solution. In an effort to solve the interobserver variability problem, Dr. Weinstein devised a novel solution, dynamic-robotic telepathology, that would potentially enable CPL uropathologists to consult on distant uropathology cases in real-time before their assignment to urinary bladder cancer, tumor stage, and grade-specific clinical trials. During the same period, universities were ramping up their support for faculty entrepreneurism and creating in-house technology transfer organizations. Dr. Weinstein recognized telepathology as a potential growth industry. He and his sister, Beth Newburger, were a successful brother–sister entrepreneur team. Their PC-based education software business, OWLCAT™, had just been acquired by Digital Research Inc., a leading software company, located in California. With funding from the COMSAT Corporation, a publically traded satellite communications company, the Weinstein-Newburger team brought the earliest dynamic-robotic telepathology systems to market. Dynamic-robotic telepathology became a dominant telepathology technology in the late 1990s. Dr. Weinstein, a serial entrepreneur, continued to innovate and, with a team of optical scientists at The University of Arizona's College of Optical Sciences, developed the first sub-1-min whole-slide imaging system, the DMetrix DX-40 scanner, in the early 2000s.

Emerging paradigm of virtual-microscopy for histopathology diagnosis: survey of US and Canadian oral pathology trainees

Objectives/Aims:

The application of virtual microscopy (VM) to research, pre-doctoral medical and dental educational training, and diagnostic surgical and anatomic pathology is well-documented but its application to the field of oral and maxillofacial pathology has not been explored. This is the first study to evaluate the enthusiasm and readiness of US-/Canada-based oral and maxillofacial pathology (OMFP) residents toward employing VM use over conventional microscopy (CM) for diagnostic purposes.

Materials and Methods:

All 46 current US-/Canada-based OMFP residents were invited to participate in an anonymous electronic survey via ‘Survey Monkey’ in 2015. The survey comprised sixteen multiple choice questions and two ‘free text’ questions.

Results:

14% of respondents of the 22 (48%) respondents who completed the survey indicated a willingness to substitute CM with VM in <5 years, and 33% within 10 years. 52% reported they would never substitute CM with VM. Approximately 10 and 57% of respondents thought VM will become an acceptable sole diagnostic tool in most centers within 5 and 10 years, respectively. These findings are irrespective of the fact that overall, 90% of respondents reported being familiar with VM use.

Discussion:

VM technology is unlikely to substitute CM in diagnostic oral and maxillofacial histopathology practice among future OMFP practitioners in the foreseeable future.

Pathological and Molecular Aspects to Improve Endoscopic Ultrasonography-Guided Fine-Needle Aspiration From Solid Pancreatic Lesions

Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has been applied to pancreatic lesions since the 1990s, and its use is now widespread. Improvements in endoscopic devices and sampling techniques have resulted in excellent diagnostic ability for solid pancreatic lesions. However, clinical improvements alone are not responsible for it; pathological aspects have also played important roles. Rapid on-site evaluation minimizes endoscopic procedures, although its value at improving the diagnostic ratio is still debated. Diagnostic efficacy differs by sample preparations (direct smear, cytospin, liquid-based cytology, cell block, and biopsy) and by staining methods (Papanicoloau, Diff-Quik, hematoxylin-eosin, and Giemsa). Several immunocytochemistry protocols aid in diagnosing epithelial components with cytological atypia and in differentiating various tumor types. One cytopathology diagnostic system is telecytology, which uses transmitted digital images and enables real-time diagnosis of EUS-FNA samples by expert cytologists at remote locations. However, EUS-FNA samples are useful for more than just diagnoses, as molecular analysis of these samples allows the identification of prognostic markers, such as genetic alterations in K-ras and EGFR. Expression of drug-metabolizing enzymes, human equilibrative nucleoside transporter 1, correlates with the response to gemcitabine-based chemotherapy. These pathology efforts have enhanced the diagnostic efficacy of EUS-FNA, thereby leading to better outcomes for patients with pancreatic diseases.

Digital pathology access and usage in the UK: results from a national survey on behalf of the National Cancer Research Institute's CM-Path initiative

Aim

To canvass the UK pathology community to ascertain current levels of digital pathology usage in clinical and academic histopathology departments, and prevalent attitudes to digital pathology.

Methods

A 15-item survey was circulated to National Health Service and academic pathology departments across the UK using the SurveyMonkey online survey tool. Responses were sought at a departmental or institutional level. Where possible, departmental heads were approached and asked to complete the survey, or forward it to the most relevant individual in their department. Data were collected over a 6-month period from February to July 2017.

Results

41 institutes from across the UK responded to the survey. 60% (23/39) of institutions had access to a digital pathology scanner, and 60% (24/40) had access to a digital pathology workstation. The most popular applications of digital pathology in current use were undergraduate and postgraduate teaching, research and quality assurance. Investigating the deployment of digital pathology in their department was identified as a high or highest priority by 58.5% of institutions, with improvements in efficiency, turnaround times, reporting times and collaboration in their institution anticipated by the respondents. Access to funding for initial hardware, software and staff outlay, pathologist training and guidance from the Royal College of Pathologists were identified as factors that could enable respondent institutions to increase their digital pathology usage.

Conclusion

Interest in digital pathology adoption in the UK is high, with usage likely to increase in the coming years. In light of this, pathologists are seeking more guidance on safe usage.

Freeze artifact on full-field optical coherence tomography skin imaging

BACKGROUND/PURPOSE

Full-field optical coherence tomography (FFOCT) is an emerging imaging technique for rapid histological analysis. As FFOCT is introduced into the Mohs workflow, it is important to document the effect of tissue freezing on FFOCT images and any effect FFOCT has on frozen sections. Our study aimed to evaluate the changes on FFOCT images after tissue freezing as well as FFOCT imaging effects on frozen sectioning.

METHODS

Six normal skin specimens were imaged using FFOCT and subsequently frozen using a cryostat. The specimens were then reimaged using FFOCT and compared for any differences. To evaluate the effect of FFOCT imaging on frozen sections, five normal skin specimens were bisected and one half was imaged using FFOCT. Both halves underwent frozen sectioning and analysis.

RESULTS

Significant changes in the fat, sebaceous glands, eccrine glands, and dermal collage and minimal changes in the epidermis were seen after freezing. No effect on frozen sectioning was seen after FFOCT imaging.

CONCLUSION

As FFOCT is studied for use in Mohs, clinicians should be aware that freezing prior to imaging introduces significant artifact in the FFOCT image. If possible, specimens should undergo imaging prior to being frozen.

The Empirical Foundations of Telepathology: Evidence of Feasibility and Intermediate Effects

INTRODUCTION

Telepathology evolved from video microscopy (i.e., "television microscopy") research in the early 1950s to video microscopy used in basic research in the biological sciences to a basic diagnostic tool in telemedicine clinical applications. Its genesis can be traced to pioneering feasibility studies regarding the importance of color and other image-based parameters for rendering diagnoses and a series of studies assessing concordance of virtual slide and light microscopy diagnoses. This article documents the empirical foundations of telepathology.

METHODS

A selective review of the research literature during the past decade (2005-2016) was conducted using robust research design and adequate sample size as criteria for inclusion.

CONCLUSIONS

The evidence regarding feasibility/acceptance of telepathology and related information technology applications has been well documented for several decades. The majority of evidentiary studies focused on intermediate outcomes, as indicated by comparability between telepathology and conventional light microscopy. A consistent trend of concordance between the two modalities was observed in terms of diagnostic accuracy and reliability. Additional benefits include use of telepathology and whole slide imaging for teaching, research, and outreach to resource-limited countries. Challenges still exist, however, in terms of use of telepathology as an effective diagnostic modality in clinical practice.

Telepathology Impacts and Implementation Challenges: A Scoping Review

CONTEXT

Telepathology is a particular form of telemedicine that fundamentally alters the way pathology services are delivered. Prior reviews in this area have mostly focused on 2 themes, namely technical feasibility issues and diagnosis accuracy.

OBJECTIVES

To synthesize the literature on telepathology implementation challenges and broader organizational and societal impacts and to propose a research agenda to guide future efforts in this domain.

DATA SOURCES

Two complementary databases were systematically searched: MEDLINE (PubMed) and ABI/INFORM (ProQuest). Peer-reviewed articles and conference proceedings were considered. The final sample consisted of 159 papers published between 1992 and 2013.

CONCLUSIONS

This review highlights the diversity of telepathology networks and the importance of considering these distinctions when interpreting research findings. Various network structures are associated with different benefits. Although the dominant rationale in single-site projects is financial, larger centralized and decentralized telepathology networks are targeting a more diverse set of benefits, including extending access to pathology to a whole region, achieving substantial economies of scale in workforce and equipment, and improving quality by standardizing care. Importantly, our synthesis reveals that the nature and scale of encountered implementation challenges also varies depending on the network structure. In smaller telepathology networks, organizational concerns are less prominent, and implementers are more focused on usability issues. As the network scope widens, organizational and legal issues gain prominence.

Current status and future trends in telepathology and digital pathology

OBJECTIVE

The purpose of this study was to assess the current status and future trends in telepathology (TP) and digital pathology (DP) in central India.

MATERIALS AND METHODS

A self-constructed questionnaire including 12 questions was designed with five specialists, to improve the design ambiguity. The study was conducted through postal and online survey consisting of 12 questions and sent to 300 histopathologists.

RESULTS

A total of 247 histopathologists answered the survey. The overall response rate was 81%. 98% pathologists felt the need for TP and DP. 34% pathologists used digital photomicrographic images in routine practice. Utilization of DP in most efficient way was observed by 48% pathologists mainly for the purpose of teaching in academic institutions. 82% believed that TP is helpful to take an expert opinion whereas only26% believed that a second opinion has to be taken. With respect to limitations, 67% pathologists believed that its cost-effective whereas 51% revealed high use of TP in next 5 years.

CONCLUSIONS

Our survey shows that as the field evolves, pathologists are more towards welcoming TP and DP, provided frequent workshops and training programs are conducted. The results of this survey indicates that pathology staff across central India currently utilize gross digital images for educational or academic purposes. They also revealed that technology will be required in near future applications in academics, consultation and for medico-legal purposes.

Validation of Whole-Slide Imaging for Histolopathogical Diagnosis: Current State

Rapid advances in informatics and technological improvements have led to the development of high-throughput whole-slide imaging (WSI) scanners able to produce high-quality digital images, which allow achieving a correct diagnosis of the biopsies using virtual viewers. This technology is currently prepared to be introduced in the departments of pathology for routine diagnosis. The aim of this review is to analyze the current evidence regarding the use of WSI in primary or routine diagnosis in the different subspecialties of pathology. An increasing number of studies have shown almost perfect inter- and intraobserver agreement between the diagnoses obtained with WSI and the classical diagnoses based on conventional light microscopy. The only exception seems to be cytology, which still requires some technological development. Although validation studies are needed in some areas of pathology, growing evidence indicates that WSI is a reliable tool for routine diagnosis. Pathologists have a positive perception of the ergonomics of the workstations, the low magnification of WSI and the possibility of making annotations and measurements. WSI can be used from any device and anywhere, thereby providing great opportunities for teleconsultation. New technologies such as the recognition of histopathology patterns using image analysis may facilitate diagnosis and improve the reproducibility among pathologists in the future.

Performance of residents using digital images versus glass slides on certification examination in anatomical pathology: a mixed methods pilot study

BACKGROUND

It is anticipated that many licensing examination centres for pathology will begin fully digitizing the certification examinations. The objective of our study was to test the feasibility of a fully digital examination and to assess the needs, concerns and expectations of pathology residents in moving from a glass slide-based examination to a fully digital examination.

METHODS

We conducted a mixed methods study that compared, after randomization, the performance of senior residents (postgraduate years 4 and 5) in 7 accredited anatomical pathology training programs across Canada on a pathology examination using either glass slides or digital whole-slide scanned images of the slides. The pilot examination was followed by a post-test survey. In addition, pathology residents from all levels of training were invited to participate in an online survey.

RESULTS

A total of 100 residents participated in the pilot examination; 49 were given glass slides instead of digital images. We found no significant difference in examination results between the 2 groups of residents (estimated marginal mean 8.23/12, 95% confidence interval [CI] 7.72-8.87, for glass slides; 7.84/12, 95% CI 7.28-8.41, for digital slides). In the post-test survey, most of the respondents expressed concerns with the digital examination, including slowly functioning software, blurring and poor detail of images, particularly nuclear features. All of the respondents of the general survey (n = 179) agreed that additional training was required if the examination were to become fully digital.

INTERPRETATION

Although the performance of residents completing pathology examinations with glass slides was comparable to that of residents using digital images, our study showed that residents were not comfortable with the digital technology, especially given their current level of exposure to it. Additional training may be needed before implementing a fully digital examination, with consideration for a gradual transition.

Mapping telemedicine efforts: surveying regional initiatives in Denmark

OBJECTIVES

The aim of this study is to survey telemedicine services currently in operation across Denmark. The study specifically seeks to answer the following questions: What initiatives are deployed within the different regions? What are the motivations behind the projects? What technologies are being utilized? What medical disciplines are being supported using telemedicine systems?

MATERIALS AND METHODS

All data were surveyed from the Telemedicinsk Landkort, a newly created database designed to provide a comprehensive and systematic overview of all telemedicine technologies in Denmark.

RESULTS

The results of this study suggest that a growing numbers of telemedicine initiatives are currently in operation across Denmark but that considerable variations exist in terms of regional efforts as the number of operational telemedicine projects varied from region to region.

CONCLUSIONS

The results of this study provide a timely picture of the factors that are shaping the telemedicine landscape of Denmark and suggest potential strategies to help policymakers increase and improve national telemedicine deployment.

Imaging of Mohs micrographic surgery sections using full-field optical coherence tomography: a pilot study

BACKGROUND

Full-field optical coherence tomography (FF-OCT) is a new noninvasive imaging technique that can see down to the cellular level without tissue preparation or contrast agents.

OBJECTIVE

To use FF-OCT to image Mohs micrographic surgery specimens and verify the ability of a dermatopathologist to identify or exclude malignancy.

MATERIALS AND METHODS

Two Mohs surgeons supplied 18 Mohs sections from 11 patients. Each section was scanned using the FF-OCT, and a dermatopathologist blinded to the diagnosis examined the images for malignancy. The FF-OCT images were then compared with the intraoperative hematoxylin and eosin (H&E)-stained frozen sections for concordance.

RESULTS

All 9 FF-OCT images interpreted as negative for malignancy were in agreement with the H&E frozen sections. Six of the remaining FF-OCT images were correctly interpreted as positive for malignancy, and three were deferred because malignancy could not be confirmed or excluded.

CONCLUSION

Malignancy in Mohs sections can correctly be identified or excluded using FF-OCT. Although not ready for clinical use in its current state, FF-OCT has the potential to be incorporated into the Mohs workflow in the future.

Current usage and future trends in gross digital photography in Canada

BACKGROUND

The purpose of this study was to assess the current usage, utilization and future direction of digital photography of gross surgical specimens in pathology laboratories across Canada.

METHODS

An online survey consisting of 23 multiple choice and free-text questions regarding gross digital photography was sent out to via email to laboratory staff across Canada involved in gross dissection of surgical specimens.

RESULTS

Sixty surveys were returned with representation from most of the provinces. Results showed that gross digital photography is utilized at most institutions (90.0%) and the primary users of the technology are Pathologists (88.0%), Pathologists' Assistants (54.0%) and Pathology residents (50.0%). Most respondents felt that there is a definite need for routine digital imaging of gross surgical specimens in their practice (80.0%). The top two applications for gross digital photography are for documentation of interesting/ complex cases (98.0%) and for teaching purposes (84.0%). The main limitations identified by the survey group are storage space (42.5%) and security issues (40.0%). Respondents indicated that future applications of gross digital photography mostly include teaching (96.6%), presentation at tumour boards/ clinical rounds (89.8%), medico-legal documentation (72.9%) and usage for consultation purposes (69.5%).

CONCLUSIONS

The results of this survey indicate that pathology staff across Canada currently utilizes gross digital images for regular documentation and educational reasons. They also show that the technology will be needed for future applications in teaching, consultation and medico-legal purposes.

Feasibility of telecytopathology for rapid preliminary diagnosis of ultrasound-guided fine needle aspiration of axillary lymph nodes in a remote breast care center

Background:

In the recent years, the advances in digital methods in pathology have resulted in the use of telecytology in the immediate assessment of fine needle aspiration (FNA) specimens. However, there is a need for organ-based and body site-specific studies on the use of telecytology for the immediate assessment of FNA to evaluate its pitfalls and limitations. We present our experience with the use of telecytology for on-site evaluation of ultrasound-guided FNA (USG-FNA) of axillary lymph nodes in a remote breast care center.

Materials and Methods:

Real-time images of Diff-Quik-stained cytology smears were obtained with an Olympus digital camera attached to an Olympus CX41 microscope and transmitted via ethernet by a cytotechnologist to a pathologist who rendered preliminary diagnosis while communicating with the on-site cytotechnologist over the Vocera system. The accuracy of the preliminary diagnosis was compared with the final diagnosis, retrospectively.

Results:

A total of 39 female patients (mean age: 50.5 years) seen at the breast care center underwent USG-FNA of 44 axillary nodes. Preliminary diagnoses of benign, suspicious/malignant, and unsatisfactory were 41, 52, and 7%, respectively. Only one of the 23 cases that were initially interpreted as benign was reclassified as suspicious on final cytologic diagnosis. Seventeen of 18 suspicious/malignant cases on initial cytology corresponded with a malignant diagnosis on final cytology. One suspicious case was reclassified as benign on final cytologic diagnosis. All unsatisfactory cases remained inadequate for final cytologic interpretation. The presence of additional material in the cell block and interpretative error were the main reasons for discrepancy, accounting for the two discrepant cases.

Conclusions:

This retrospective study demonstrates that the on-site telecytology evaluation of USG-FNA of axillary lymph nodes in patients at a remote breast care center was highly accurate compared with the final cytologic evaluation. It allows pathologists to use their time more efficiently and makes on-site evaluation at a remote site possible.

Remote care by telemedicine in the ICU: many models of care can be effective

PURPOSE OF REVIEW

Telemedicine, by the use of audiovisual technologies, is increasingly being used to assist in patient care by ICUs unable to be staffed by consultant intensivists. This review discusses the recent evaluation of these services and their potential role in managing intensive care patients.

RECENT FINDINGS

Models of care range from complete remote 24 h surveillance requiring direct video observation to a consultation liaison service only requiring conventional telephone links. There has been a rapid adoption of such services especially in North America where access to on-site intensive care specialists is limited for the volume of intensive care being undertaken. Early work suggests savings in terms of cost and length of stay with an improvement in compliance with care protocols. However, later work is not as supportive of such services, possibly related to differing care infrastructures and the organization of individual units. The key task is to ascertain the most appropriate service requirements that would assist in care for a given patient circumstance.

SUMMARY

Clear benefits of ICU-telemedicine systems remain unclear but at least the systems appear safe. Formal reviews of the impacts and contribution of ICU telemedicine to processes of care, the effects on unit staffing, hospital organization, and the healthcare region are needed. However, ICU-telemedicine is available and being embraced by some, especially to deal with the tyranny of distance.

Telepathology for effective healthcare in developing nations

Telepathology has grown immensely due to rapid advances in information and technology. It has a wide variety of applications especially in the developing world, namely for remote primary diagnosis, specialist referrals, secondary opinions, remote teachings and in research. Basic infrastructure and skilled and experienced staff are the prerequisites for its successful implementation.Socio-economic differences in developing nations result in a chaotic scenario so that, the advanced areas have expertise, while rural and remote areas remain deprived. Telepathology has the potential to bridge this gap.This article discusses how successful use of the internet for telepathology is bridging this gap in developing nations and thereby contributing positively to effective healthcare. Possible constraints to telepathology and some solutions to overcome them are also discussed.

Attitude of korean primary care family physicians towards telehealth

Background

Recently, a revised telehealth legislation that allows direct doctor to patient teleconsultation was proposed in Korea. However, there have been some debates. This study aimed to examine the attitude of primary care physicians towards telehealth.

Methods

A questionnaire asking attitude towards telehealth and revised telehealth legislation was self-administered to 1,988 registered members of Practitioners Council of Korean Academy of Family Medicine. A total of 218 complete responses by family physicians were included in the study.

Results

Large proportion (60.6%) of participants disagreed to the main clause of revised telehealth legislation, which allowed doctor to patient teleconsultation. Participants tended to expect that negative outcomes are more likely to occur than positive outcomes after the enforcement of the revised telehealth legislation. Around 50% of participants had an intention to adopt telehealth just as soon (4.6%) or afterwards (45.4%). The majority of participants suggested that; primary care clinic as the most appropriate telehealth facility (75.4%); patients with low accessibility to medical care (74.3%) as the best target of telehealth service; and tele-radiology (61.9%) or tele-pathology (41.3%) as the most applicable medical field for telehealh service. Around 89% of participants suggested telehealth service fee to be similar or higher than current medical consultation fee.

Conclusion

The majority of family physicians participating in this study were not in favor of the revised telehealth legislation. However, the majority of the participants had an intention to adopt telehealth to their practice and held clear opinion about practical aspects of telehealth.

Feasibility and diagnostic accuracy of Internet-based dynamic telepathology between Uganda and Germany

We assessed the feasibility and diagnostic accuracy of Internet-based telepathology compared with conventional microscopic examination. A total of 96 cases from the routine workload of the Department of Pathology at the Mulago Hospital in Uganda were examined by robotic telemicroscopy via the Internet at the Fuerth Hospital in Germany. The telepathology diagnoses were compared with those of conventional microscopy. Email and Skype telephony were used to exchange clinical and diagnostic information. The reference diagnosis (gold standard) was established by consensus between two or more experienced pathologists using both conventional microscopy and telemicroscopy; immunohistochemistry was used whenever it was necessary. It took approximately 30 min for a pathologist to learn to use the telepathology system and 4–25 min to read a case remotely. Internet speed was the main limiting factor. The images were of good quality and the pathologist at the remote site was able to navigate through the slide and change the magnification as necessary. In 92 of the specimens (97%), the pathologists at the two hospitals agreed exactly about the diagnosis. Agreement overall was moderate (kappa = 0.39). The discordant diagnoses were attributed to factors related to diseases morphologically difficult to diagnose, such as soft tissue sarcomas and primitive tumours. Internet-based conferencing systems offer an inexpensive method of obtaining a primary diagnosis by telepathology and consulting on cases that require subspecialty expertise.

Transnational telepathology consultations using a basic digital microscope: experience in the Italy-Slovenjia INTERREG project "patient without borders"

Background

In recent years, a number of technological advancements started to modify the long standing appearance and functionalities of traditional optical microscopes used in Pathology and other medical fields. In fact, at present many new tools for microscopical visualization exist that are based on digital imaging, robotization, and remote communication. Such tools are typically adopted in activities ranging from education to telediagnosis to remote consultation.

Present paper describes the features of a basic digital microscope that has been tested to verify its performance for occasional remote consultation inside an international project between Italy and Slovenija, funded by Interreg initiative of the European Regional Development Fund.

Methods

The system is composed by a pair of digital microscopes (Leica DMD108, Leitz Microsystems, Wetzlar, Germany) associated to a high resolution videoconferencing systems (Tandberg 990, Lysaker, Norway). The systems are connected through the Internet. Sixty histology and cytology cases have been collaboratively diagnosed between two Pathology Institutes to verify the diagnostic performance of the system, regarding the image quality point of view as well as time needed for diagnosis. The system has also been tested for compatibility with standard videoconferencing software.

Results

No discrepancies between local and remote diagnoses have been identified, with diagnosis time reasonably close to typical microscope observation times. Time needed for most operations is not far from that needed on a traditional microscope, except for startup.

Conclusions

The system can be considered usable as a standard microscope, and also for occasional remote consultations.

Virtual surgical pathology in underdeveloped countries: The Zambia Project

Only 1 surgical pathology laboratory is available in Zambia, a country with a population of 12 million people. Since 2004 the Italian association of pathologists Patologi Oltre Frontiera has been working to create a virtual laboratory through the use of telemedicine. The project has involved staining histologic preparations on site, with the interpretation of imaged slides performed abroad through telepathology. Starting in April 2007, all surgical specimens obtained in Mtendere Mission Hospital, Chirundu, Zambia, were submitted for microscopic examination through whole-slide scans. Two independent Italian pathologists evaluated the cases by means of satellite connection and the final diagnoses were sent to Zambian clinicians via the internet. This article describes the spectrum of diagnoses made via telepathology for the Zambian population. Also, we analyze the concordant and discordant data between this telepathology method and traditional microscopy in a developing country. Moreover, we provide possible solutions for providing pathology services in other underdeveloped countries.

Cytologic evaluation of image-guided fine needle aspiration biopsies via robotic microscopy: A validation study

Background:

This study carried out was to assess the feasibility of using robotic microscopy (RM) for cytologic evaluation of direct smears from fine needle aspiration biopsy (FNAB).

Methods:

Three board-certified cytopathologists reviewed representative direct smears from 40 image-guided FNABs using RM and subsequently re-reviewed the same smears using conventional microscopy. Adequacy of the smears and cytologic diagnosis, as determined using the two approaches, were compared for each individual cytopathologist (intraobserver) and between the three cytopathologists (interobserver). The intraobserver and interobserver discrepancies were analyzed and discussed in a follow-up consensus conference.

Results:

For assessment of adequacy, there were high concordance rates (intraobserver: 92.5–97.5%; interobserver: 90–92.5%), with a few discrepancies involving distinctions between suboptimal and satisfactory smears. Analysis of diagnostic interpretations showed correct classification of 92.5–95% (intraobserver) or 90–92.5% (interobserver) of benign and malignant cases combined, with the discrepancies being between benign and atypical cells in the benign group, and between suspicious and malignant in the malignant group. Within the malignant group, 94% of cases were accurately subclassified via RM. The quality of images viewed by using RM was rated adequate (fair or good) for 95% of the slides.

Conclusions:

The results demonstrate that cytologic evaluation of direct smears from FNABs using RM is feasible. Problems encountered included the longer times needed to evaluate cases with thick, bloody smears and/or low numbers of diagnostic cells, and difficulties in recognizing neuroendocrine differentiation and mimics of hepatocellular carcinoma.

Informatics for practicing anatomical pathologists: marking a new era in pathology practice

Informatics can be defined as using highly advanced technologies to improve patient diagnosis or management. Pathology informatics had evolved as a response to the overwhelming amount of information that was available, in an attempt to better use and maintain them. The most commonly used tools of informatics can be classified into digital imaging, telepathology, as well as Internet and electronic data mining. Digital imaging is the storage of anatomical pathology information, either gross pictures or microscopic slides, in an electronic format. These images can be used for education, archival, diagnosis, and consultation. Virtual microscopy is the more advanced form of digital imaging with enhanced efficiency and accessibility. Telepathology is now increasingly becoming a useful tool in anatomical pathology practice. Different types of telepathology communications are available for both diagnostic and consultation services. The spectrum of applications of informatics in the field of anatomical pathology is broad and encompasses medical education, clinical services, and pathology research. Informatics is now settling on solid ground as an important tool for pathology teaching, with digital teaching becoming the standard tool in many institutions. After a slow start, we now witness the transition of informatics from the research bench to bedside. As we are moving into a new era of extensive pathology informatics utilization, several challenges have to be addressed, including the cost of the new technology, legal issues, and resistance of pathologists. It is clear from the current evidence that pathology informatics will continue to grow and have a major role in the future of our specialty. However, it is also clear that it is not going to fully replace the human factor or the regular microscope.

State of the art of teledermatopathology

Teledermatopathology may involve real-time transmission of images from distant locations to consulting pathologists by the remote manipulation of a robotic microscope. Alternatively, the static store-and-forward option involves the single-file transmission of subjectively preselected and captured areas of microscopic images by a referring physician. The recent introduction of virtual slide systems (VSS) involves the digitization of whole slides at high resolution thus enabling the user to view any part of the specimen at any magnification. Such technology has surmounted previous restrictions caused by the size of preselected areas and specimen sampling for telepathology. In terms of client access, these VSS may be stored on a virtual slide server, made available on the Web for remote consultation by pathologists via an integrated virtual slide client network. Despite store-and-forward teledermatopathology being the most frequently used and less expensive approach to teledermatopathology, VSS represents the future in this discipline. The recent pilot studies suggest that the use of remote expert consultants in diagnostic dermatopathology can be integrated into daily routine, teleconsultation, and teleteaching. The new technology enables rapid and reproducible diagnoses, but despite its usability, VSS is not completely feasible for teledermatopathology of inflammatory skin diseases as the performance seems to be influenced by the availability of complete clinical data. Improvements in the diagnostic facility will no doubt follow from further development of the VSS, the slide processor, and of course training in the use of virtual microscope. Undoubtedly, as technology becomes even more sophisticated in the future, VSS will overcome the present drawbacks and find its place in all facets of teledermatopathology.

Virtual microscopy as an enabler of automated/quantitative assessment of protein expression in TMAs

Tissue Microarrays facilitate high-throughput immuohistochemistry; however, there are key bottlenecks apparent in their analysis, particularly when conducting microscope-based manual reviews. Traditionally Tissue Microarray assessments were performed using a microscope where results were either transcribed or dictated and subsequently entered into flat-file spreadsheets. This process is labour intensive, prone to error and negates the advantages of the high-throughput Tissue Microarray format. In addition, human interpretations of staining intensity parameters are highly subjective and therefore prone to inter- and intra-observer variability. The advent of Virtual Slides has permitted the review of tissue slides across the Internet. In addition, this new technology enables the creation of software solutions to assist in the manual and automated review of Tissue Microarrays, through the use of computer aided image analysis. There are numerous academically developed and commercially available applications which assist in Tissue Microarray reviews; functionality of these systems range in complexity and application domains. The review which follows describes these systems and outlines technical considerations to be assessed when deciding on a Tissue Microarray workflow solution.

Spatial resolution requirements for acquisition of the virtual screening slide for digital whole-specimen breast histopathology

We examined the effect of lateral spatial resolution and reader specialty on the accuracy of detection of breast cancer. The motivation for this pilot study was the need to acquire and display very large data sets in whole-specimen 3D digital breast histopathology imaging. The ultimate goal is to determine the minimum resolution adequate for detection of malignancy. Twenty-three histologic slides were selected from breast pathology cases and digitized at 2 sampling distances (3.2 and 1.9 microm pixels). Images were viewed by 14 pathologists, of whom 5 had breast pathology as their primary specialty. The readers assessed the likelihood of malignancy on a 5-point Likert scale, and provided a provisional diagnosis. For the detection task, sensitivity, specificity, overall accuracy of detection, and area under the receiver-operator curve were calculated. An overall diagnostic score, and scores grouped by malignancy type, were also computed. Outcome measures were examined for significant resolution and specialty effects. Increasing the lateral resolution significantly improved accuracy in diagnosis (P=.004) but no effect was found for detection. Breast specialists achieved significantly higher scores for all outcome measures except specificity. Differences in performance between the 2 groups of readers tended to be greater for the diagnostic task compared to detection, especially at the higher resolution. However, specimen coverage may also be a significant factor. Factors related to the readers may have also affected performance in this study. Based on these results, a more comprehensive study should examine pixel sizes between 0.7 and 1.9 microm.

Assessment of diagnostic accuracy and feasibility of dynamic telepathology in China

To assess the feasibility, including diagnostic accuracy and time cost, of a real-time telepathology system with pathologic slides, 600 cases covering a wide spectrum of lesions from 16 organ systems were tested. The "correct" diagnosis (gold standard) was established as a consensus by 2 experienced pathologists. The cases were first examined by 4 pathologists at different levels of experience with dynamic telepathology. Cases were then reviewed by the same pathologists using light microscopy in a blinded fashion 3 weeks to 2 months later. A diagnosis, together with reading times for telepathology and light microscopy, was recorded for each case. Diagnostic accuracy by telepathology was 94.8% (569/600), 93.3% (560/600), 91.6% (550/600), and 97% (388/400) for pathologists A, B, C, and D, respectively. Telepathologic diagnosis was concordant with the gold standard and with direct microscopy, with a mean of 94.2% and 99.26%, respectively. Most cases (510 or 85%) were diagnosed in 15 to 40 minutes by telepathology, with a mean of 17.0 minutes. The time needed to review a slide by telepathology was 3 to 4 times longer than that of standard light microscopy. All 4 pathologists were able to render a diagnosis in all cases. Our results showed that robotic telepathology is sufficiently accurate for primary diagnosis in surgical pathology, but modifications in laboratory protocols, telepathology hardware, and internet speed are needed to reduce the time necessary for diagnosis by telepathology before this method may be deemed suitable for use in a busy practice.

Frozen-section diagnosis by wireless telepathology and ultra portable computer: use in pathology resident/faculty consultation

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.

Feasibility and diagnostic agreement in teledermatopathology using a virtual slide system

We investigated the feasibility and diagnostic agreement of a virtual slide system (VSS) in teledermatopathology. Forty-six biopsy specimens from inflammatory skin diseases were selected and scanned with a VSS at the Research Unit of Teledermatology, Medical University of Graz, Graz, Austria. Images were stored on a virtual slide server on which a specific Web application suited for telepathology (http://telederm.org/research/dermatopath/) runs. Twelve teleconsultants from 6 different countries reviewed the 46 cases, working directly on the Web application. Telediagnoses agreed with gold standard and conventional diagnosis with an average of 73% and 74%, respectively. Complete concordance among all teleconsultants with gold standard and conventional diagnosis was found in 20% of the cases. In 10 cases in which complete clinical data were missing, the average agreement of telediagnosis with gold standard diagnosis and conventional diagnosis decreased to 65% and 66%, respectively. Only 3 of 4 cases of inflammatory skin diseases were correctly diagnosed remotely with VSS. The system that we have used, despite its usability, is not completely feasible for teledermatopathology of inflammatory skin disease. Moreover, the performance seems to have been influenced by the availability of complete clinical data and by the intrinsic difficulty of the pathology of inflammatory skin diseases.

Virtuelle Mikroskopie

Only recently fast-paced developments in computer technology allowed for the digitization of complete histologic slides. The resulting virtual slides may be viewed via webbrowser by any number of pathologists or students independent of time and location. Usage of a virtual microscope simply requires a computer workstation with a fast internet connection, which opens this technology to a broad public. A virtual microscopy system consists of three components: acquisition, server and client. Such systems are under development by different commercial and academic bodies worldwide. We have developed a virtual microscope system called vMic (http://www.vmic.unibas.ch) which provides virtual slides of very high image quality. Several successfully held online slide seminars and a histology course for students in dentistry are freely accessible in the internet. With the commercial availability of ultra rapid and easy-to-use slide scanners and the fast improvements of technology virtual microscopy will offer many applications in teaching, research and diagnostics. Thanks to additional functionalities, real microscopes will most likely be replaced by computer workstations in a couple of years.

Static telepathology in cancer institute of Tehran university: report of the first academic experience in Iran

Telepathology is the practice of pathology, which allows quick and timely access to an expert opinion at a distance. We analyzed our new experience in cancer Institute of Tehran University of Medical Sciences with the iPath telepathology server of Basel University. One hundred sixty one cases in a period of 32 months were consulted. These cases received for second evaluation but the definite diagnosis could not be made in this centre. The number of images per case ranged from 3 to 32 (mean: 8). Except one case all cases were evaluated by consultants. Definite final diagnosis was achieved in 88/160 (54.7%). Recommendations for further evaluation were offered in 42/160 cases (26%). Major discrepancies were encountered in 30/160 cases (19%). Thirty-nine of the cases (24.3%) were reported within 1 day. The rate of achieving final diagnosis was higher in histological group rather than cytological ones. Increase in number of H&E images had no significant effect on achieving a definite final diagnosis. The rate of achieving final diagnosis in this study is much lower than other similar studies, which could be due to inappropriate sampling images, a potential cause of misdiagnosis in static telepathology. The other possible reason is that all of the cases in this study were problematic cases that a definite diagnosis could not be made for them even in primary consultation. The mean time for achieving a final diagnosis was also more than other studies, which could be for the reasons mentioned above.