TELEPATHOLTELEPATHOLOGYOGY

PRESENTER : DR.GURLEEN

OBEROI

MODERATOR: DR. RIDDHI

JAISWAL

INDEXINDEXImportant Terminologies Introduction Brief history Types of telepathology Applications Telepathology vis-a-vis

Teleradiology ProblemsTelepathology in India

IMPORTANT IMPORTANT TERMINOLOGIESTERMINOLOGIES AND AND ABBREVIATIONS ABBREVIATIONS

Virtual MicroscopyVirtual Microscopy  

A method of

posting microscope images on, and transmitting them over, computer networks. This allows independent viewing of images by large numbers of people in diverse locations. It involves a synthesis of microscopy technologies and digital technologies

Biopsy

Frozen Section

P

Histology WorkflowHistology WorkflowFrom Tissue Sample to Histological From Tissue Sample to Histological ExaminationExamination

Specimen Examination

Histo-processing Sectioning Staining

TissueSample

Microscope Slide(s)

Surgery Center Histology Lab

P

Pathologist Office

P Step that requires Pathologist

Microscopic Examination

P

In pathology, imaging begins in histology!

Digital Slide

Workflow Management

Virtual MicroscopyVirtual MicroscopyDigital Slide Creation, Management & AnalysisDigital Slide Creation, Management & Analysis

Biopsy

Specimen Examination

Histo-processing Sectioning Staining

TissueSample

Digital Slide(s)

Surgery Center Histology Lab

Frozen Section

PP

Pathologist Office

P Step that requires Pathologist

Microscopic Examination

Scanning

P

Image Analysis

Conferencing

A Digital SlideA Digital SlideA classical whole slide

image is formed by imaging an entire physical (glass) slide, field by field, and then ‘knitting” these fields together to form a seamless montage

The main virtual slide collection is the "Juan Rosai's collection of surgical pathology seminars", curated by USCAP.

With some display software, one can pan and zoom around the image set

Digital PathologyDigital Pathology

It is an image-based information environment enabled by computer technology that allows for the management of information generated from a digital slide. Digital pathology is enabled in part by virtual microscopy.

LAN : Local Area NetworkWAN: Wide Area NetworkISDN: Integrated Services For Digital NetworkL I S : Laboratory Information

System WSI : Whole Slide ImagingRTIS : Real Time Telepathology

Imaging System

INTRODUCTIONINTRODUCTION TELEPATHOLOGY is the practice

of pathology at a distance. It uses telecommunications technology to facilitate the transfer of image-rich pathology data between distant locations for the purposes of diagnosis, education, consultation and research.

HISTORYHISTORY An academic pathologist Dr. Ronald S.

Weinstein is known as the “father of Telepathology”

One of the earliest instances of telepathology took place in boston in 1968.

Ronald S. Weinstein coined the term “telepathology” in 1986. In a medical journal editorial, Weinstein outlined the actions that would be needed to create remote pathology diagnostic services.

In Norway, Eide and Nordrum implemented the first sustainable clinical telepathology service in 1989.This is still in operational decades later.

A Telepathology system consists of:

A conventional microscope. A method for video capture. A computer. Telecommunication links between

sending and receiving site and A work station at the receiving

site with a high quality monitor to view the images.

Digital Pathology Digital Pathology EnvironmentEnvironmentScan  View Manage

Analyze Integrate

Sharing

WHY ARE WE TRYING TO WHY ARE WE TRYING TO IMPLEMENT IMPLEMENT TELEPATHOLOGY IN OUR TELEPATHOLOGY IN OUR SYSTEM?? SYSTEM??

Telediagnosis Teleconsultation Teleconferencing With this access to global expert pathologists

is no longera limiting factor. Telepathology has been shown

to be applicable for: Anatomical pathology including :- Intra-operative consultation (frozen sections), Surgical pathology (second opinions,

immunostains), Telecytology (e.g., on-site evaluation) Ultrastructural pathology, as well as

Clinical pathology including -telehematology, microbiology (e.g. parasitology), and chemistry (e.g.,

interpretation of gels).

The most recent advances in digital imaging techniques promise to change the life style of pathologist from the microscope to the computer screen. There are “Virtual slides” where the entire slide is scanned at a very high resolution and can be viewed by multiple pathologists and without any loss of resolution

TYPES OF TYPES OF TELEPATHOLOGYTELEPATHOLOGY

Static (Store and Static (Store and Forward) TelepathologyForward) Telepathology

Static (still) images (photographs) selected by referring provider sent to consultant

Requires skillful image collection by referrer

Advantages◦ Simple - minimal hardware needs

(computer, camera)◦ Inexpensive - hardware and image

transmission (Internet)◦ Adaptable - many computer systems can

be adaptedDisadvantages

◦ Image selection – referrer ◦ Real time interaction - difficult◦ Not suitable for primary diagnosis by

surgical pathologist at a distance Example: Armed Forces Institute of

Pathology consultation service

Dynamic TelepathologyDynamic TelepathologyReal-time (television) images Real-time (television) images selected by referrer as if operating selected by referrer as if operating a two-headed microscope.a two-headed microscope.

Hybrid Dynamic/Store and Hybrid Dynamic/Store and Forward (HDSF) Forward (HDSF) TelepathologyTelepathologyCombines both store and forward and Combines both store and forward and dynamic telepathology functionsdynamic telepathology functions

Advantages◦ Dynamic and store and forward imaging

functions available◦ Real time interaction with consultant◦ Image transmission speed

Disadvantages◦ More complex than static TP (camera(s),

computer system, accessories)◦ More expensive than static TP - requires

broad bandwidth◦ Image selection by sender.

Robotic Hybrid Robotic Hybrid Dynamic/Store and Dynamic/Store and Forward (HDSF) Forward (HDSF) TelepathologyTelepathology

Hybrid - combines both dynamic and store and forward telepathology functions

Robotic - image selection at remote site (robotic microscope) controlled by consultant at the hub site

Advantages◦ Robotic control of remote microscope

allows distant pathologist to view slides completely

◦ Real time interaction with referrer/clinician◦ Allows performance of frozen sections

Disadvantages◦ Most complex telepathology system◦ Most expensive telepathology system -

requires broad bandwidth telecommunications

Dynamic Robotic Dynamic Robotic TelepathologyTelepathology

1 Tissue examined/sectioned by Pathologist in Agra.

2

3

54

6

7

8

9

H & E Sections made

Slides put onto stageof robotic microscope

WAN

Hub Pathologist examines slides using robotic microscope

Slides read in Lucknow

Pathologist dictatesreport to PA

PA enters report

Report reviewed, printed signed, faxed

RouterRouter

VENDORSVENDORSAperioBioimageneOlympus (nanozoomer)Omnyx 3DHistechLeica

ApplicationsApplications1)Remote access of slides:

Frozen Sections (night calls,intraoperative consultations and remote sites)

Telepathology for 2nd opinionwww.secondslide.comwww.pathxchange.com

Multi-institution collaborative studies Retrospective and prospective collections

of cases for world wide knowledge database, case series studies,etc

Telepathology can have a crucial role in Education And Training in the following ways:-

Online cases and images are excellent tools of education, supplementing standard books.

The virtual slide technology can reduce the number of microscopes in a class.

Telepathology is an excellent tool to distribute material from small biopsies that defy too many replicate sections. This helps in external quality assurance. Participants can see and discuss the same images and maintain a record for future reference.

Example : www.uscap.org a well known site for these purposes.

Clinical applicationsClinical applications

Archival & viewing of data: Tumor Boards. Quality Assurance. Publications ( digital slide access as a part of

case reports and case series in the future?) Teaching sets for rare cases. Scan in key diagnostic slides for outside

review cases, to avoid having to borrow back slides for clinical or academic needs.

Access old cases for comparison for frozen sections and current cases

Teleradiology Vis-à-Vis Teleradiology Vis-à-Vis TelepathologyTelepathology

Whilst teleradiology has taken off in a big way, in contrast, telepathology is still not that widespread. Multiple factors are responsible for this situation:-

images produced in radiology are already digitised.

Teleradiology has reached a stage where international standards for image acquisitions, storage and transfer have already been set.

Radiologists are trained to interpret images and comprehend the underlying principles of digital imaging and factors influencing their quality.

Radiology images are viewed at a comparatively limited range of magnifications whereas in histopathology, selected areas may be viewed at a very wide range of magnification.To digitise all the material on a slide at a resolution of x 1000 results in data files of differing magnitude much larger than digital radiology images.

ISSUES NEEDING ISSUES NEEDING EVALUATIONEVALUATIONScanned image qualityImage management software

(interface with LIS system if intend for clinical use)

Image analysis softwareTechnical supportStability of vendor in the marketGood fit between your need and

vendor’s strong points

Problems in Problems in TelepathologyTelepathologyIf used for routine workload

(telemicroscopy), the problem arises if the centre lacks a pathologist who can use the facility well or is ill trained to read digital images.

Acceptance of responsibility by the local pathologist for the final telepathology report that goes out is a point to be considered.

Technical standards for image capture, storage and transfer need to be well set.

While viewing distant virtual slides, the factor of time lag has to be considered which does not happen in a light microscope set up.

If a lab solely relies on telepathology, there can be damaging loss of local expertise.

Telepathology may prove difficult in cases of large complex specimens that need to be grossed well and dissected in person.

PRACTICAL ISSUESPRACTICAL ISSUESCost (machine, software, storage & personal)Time for scan: 15x15 mm tissue

◦ 20x < 1min; 40 x 6-7 minMemory: 20X scan: 250 MB; 40X scan: 800 MB

◦ 1TB can hold 2,070 slides (assuming 500 MB/slide), or 4000 slides for 20x (250 MB)

Microscope Imaging Microscope Imaging

Histology slides

If we try to send all information on a glass slide,It is more than 2.7GB/slide.

For Static Image Telepathology, a referring pathologist has to be able to select appropriate diagnostic fields. To select suitable fields for consultation requires experienceNeeded virtual slide

TELEPATHOLOGY IN INDIATELEPATHOLOGY IN INDIA India was not lagging far behind in the field of

telepathology. The first taste of telepathology in India was provided at a symposium organized in the 50th Annual Conference of the Indian Association of Pathologists and Microbiologists in Mumbai in 2001 aptly named Telepathology: Today and Tomorrow

A telepathology quiz page was opened in the popular pathoindia.com e-group

http://ipath.ch is a free site offering an open source framework for building web- and email-based telemedicine applications.

With the experience of pathoindia.com came telepathologyindia.com (now telepathology.org.in).The use of "telepathology quizes" with images of cases hosted at telepathology.org.in has caught the imagination of pathologists.

The experience of Desai et al. in using static telepathology consultation between a tertiary cancer centre (Tata Memorial Hospital) and a rural cancer hospital (Nargis Dutt Memorial Cancer Hospital) in Barshi, Maharastra is an eye-opener.There was a big contribution by various organizations such as Department of Telecommunications (DOT), Mahanagar Telephone Nigam Limited (MTNL), and Bharat Sanchar Nigam Limited (BSNL).

ConclusionsConclusionsMultiple telepathology modalities

exist.Must balance clinical needs vs cost.Users must be flexible and

updated, but do not have to be computer experts

Strong support of telecommunications network is essential.

REFERENCESREFERENCES  Weinstein, RS; Graham, AM; Richter, LC; Barker, GP; Krupinski, EA;

Lopez, AM; Yagi, Y; Gilbertson, JR; Bhattacharyya, AK et al. (2009), "Overview of telepathology, virtual microscopy and whole slide imagining: Prospects for the future", Hum Pathol 40(8): 1057–1069, doi:10.1016/j.humpath.2009.04.006,PMID19552937

Kumar, S (2009), "Telepathology: An Audit", in Kumar S, Dunn BE (editors), In: Telepathology (Springer-Verlag Berlin Heidelberg): 225–229

Kayser, K; Molnar, B; Weinstein, RS (2006), "Digital pathology virtual slide technology in tissue-based diagnosis, research and education.", VSV Interdisciplinary Medical Publishing (Berlin): 1–193

Dunn, BE; Choi, H; Recla, DL; Kerr, SE; Wagenman, BL (2009), "Robotic surgical telepathology between the Iron Mountain and Milwaukee Department of Veterans Affairs Medical Centers: a 12-year experience", Hum Pathol 40 (8): 1092–1099,doi

Graham, AR; Bhattacharyya, AK; Scott, KM; Lian, F; Grasso, LL; Richter, LC; Henderson, JT; Carpenter, JB; Lopez, AM; Barker, GP; Weinstein, RS; Weinstein, R. S. (2009), "Virtual slide telepatholgoy for an academic teaching hospital surgical patholgoy quality assurance program", Hum Pathol 40 (8): 1129–1136,doi:10.1016/j.humpath.2009.04.008,PMID 19540562

Information Resource Management Plan 2007/08,British Columbia Ministry of Health Knowledge Management and Technology Division, retrieved November 23, 2011