1. Real-Time Telepathology for Subspecialty Consultation Nikolaj Lagwinski, MD September 10 th, 2007

2. 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

3. 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

4. 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)

6. System installation Remote site (Main campus) –Staff computer running a Java- enabled web browser –No specific software requirements –High-speed internet access

7. 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

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

9. Data analyzed Reasons for deferring TP impression Concordance rates Dates –Telepathology consult –Final signout

10. Results 50 cases 10 subspecialty pathologists –2 GI –3 GYN –2 ENT –1 Breast –2 GU

11. 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%)

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. Thank you This study was made possible by a grant from the CAP Foundation underwritten by Olympus of America, Inc

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