Telepathology

Telepatholgy is the practice of pathology at a distance . there are three types: static image based, dynamic/ real time/dynamic robotic, and virtual or whole slide imaging. uses of telepathology, advantages and problems.

1. Telepathology Dr. D. ANAMIKA

2. Telepathology  is the practice of pathology at a distance by visualizing an indirect image on a video monitor screen rather than viewing a specimen directly through a microscope. It uses telecommunications technology Facilitates transfer of image-rich pathology data between distant locations For the purpose of diagnosis, education, and research

3. Performance of telepathology depends on the pathologist who selects the video images for analysis and the renders the diagnoses. Verbal and visual communication can take place via video conferencing.

4. History An academic pathologist, Ronald S. Weinstein M.D., coined the term “ telepathology ” in 1986.  Dr. Weinstein is known to many as the "father of telepathology ". 

5. Basic requirements for telepathology Microscope High resolution camera (750 x 500 resolution is the minimum, 1K x 750 ideal), Image capture board or card in a computer (Windows or Macintosh) Software to manage the images Internet access Telecommunication system to transmit images.

6. Process in digital imaging

7. Types of telepathology systems Telepathology systems are divided into three major types: Static image-based systems,  Dynamic / Real-time systems, Virtual slide systems/ whole slide imaging (WSI).

8. Static telepathology Most reasonably priced and usable systems. It is the capture and digitalization of a group of macroscopic and microscopic images selected by a pathologist or pathologist assistant Transmitted through electronic means to a telepathologist .

9. This transmission is usually done by electronic mail (e-mail) or by a file transfer protocol (FTP) With e-mail, the image files are sent as attached files in a message containing the basic information about the case.

10. The FTP is used to send files directly into a web server from which the telepathologist can download them. This includes both the images and the information about the case in a web page and give simultaneous access to several pathologists in different parts of the world .

11. Advantages: Simple and inexpensive Can be used without any special telecom equipment other than a standard PC modem and Internet account. Less investment in technology Shorter learning curve Higher resolution than dynamic real-time methods, because the real-time requires large amount of memory.

12. Disadvantages Limited view of field (many pathologist may not be willing to offer a definite diagnosis) Non representative images

13. "Dynamic" telepathology Dynamic systems are used to support online, interactive sessions where images are transmitted continually as the specimen is moved on the microscope stage during the process of examination. Involves the transmission of microscopic slide images to recipient in real time via live telecommunication. With the implementation of remote robotic microscope, recipients can completely control the magnification and slide. Robotic - image selection at remote site (robotic microscope) is controlled by consultant at the hub site

14. Real time robotic microscope This robotic system controls following elements: movement of the microscopic plate, changing objectives, and focusing and light adjustment

15. A live videophone link is normally provided to allow continuous two-way communication between the participants.

16. A modality of dynamic telepathology, in the absence of a telerobotic system, is to use a telepathologist assistant who operates the microscope in the remote location and moves the plate following telephone instructions from the telepathologist This systems provide the telepathologist with an overview image of the specimen at low resolution This is accompanied by images at medium resolution , which show the constantly changing microscopic fields according to the movement of the plate.

17. With real-time systems, the consultant actively operates a robotically controlled motorized microscope located at a distant site—changing focus, illumination, magnification, and field of view—at will. Either an analog video camera or a digital video camera can be used for robotic microscopy.

18. Advantages Better field of view Real time consultation Planes of focus can be addressed

19. Limitations Dependence on assistant in case of non-robotic microscope Absence of on-site pathologist Requires investment in technology- high-speed network and better imaging equipment Dynamic telepathology has to be accomplished between centers using the same operating system (software). Dynamic telepathology requires more than 128 kbit /s bandwidth

20. The cost of the equipment and the computer programs fluctuate between $20,000 and $90,000 US and they are affordable only by large hospital and/or academic institutions. The actual cost of a good high-resolution digital camera is between $5,000 and $10,000 US.

21. Virtual slide systems Utilize automated digital slide scanners that create a digital image file of an entire glass slide (whole slide image). This file is stored on a computer server and can be navigated at a distance, over the Internet, using a browser.  Digital imaging is required for virtual microscopy. Digital pathology requires high quality scans free of dust, scratches, and other obstructions. 

22. Virtual slide scanner

23. Real-time and virtual slide systems offer higher diagnostic accuracy when compared with static-image telepathology.  Virtual slide telepathology is emerging as the technology of choice for telepathology services. However, high throughput virtual slide scanners (those producing one virtual slide or more per minute) are currently expensive.

24. Advantages: Fidelity of diagnostic material Portability Ease of sharing Archival Ability to make use of computer aided diagnostic tools – image algorithm. Simultaneous viewing/teleconferencing High resolution images and rapid interpretation Automated scanning

25. DRAWBACKS: Real-time systems perform best on local area networks (LANs), but performance may suffer if employed during periods of high network traffic High speed networks Expense is an issue with real-time systems and virtual slide systems . Also, virtual slide digital files are relatively large, often exceeding one gigabyte in size .  Storing and simultaneously retrieving large numbers of telepathology whole-slide image files is difficult.

26. Uses of telepathology Primary consultation for cytology or histopathology Second opinion in difficult cases Intraoperative consultations e.g. for rapid frozen section diagnosis  Dynamic telepathology required, but high cost. Retro-consultation Worldwide knowledge database/ Digital archieves Digital slide conferencing Education, eg : virtual slide box Competency assessment Research

27. Another benefit can be gaining direct access to subspecialty pathologists such as a renal pathologist, a neuropathologist, or a  dermatopathologist , for immediate consultations. Time consumption, labor and cost intensive exchanges of specimens by post or other means of transportation can be avoided

28. Teleradiology Vs Telepathology S.NO TELEPATHOLOGY TELERADIOLOGY 1. Original specimen is usually a glass slide; image must be digitised before transmission Images produced in radiology are already digitised 2. Original quality of images may be lost as a result of digitisation of images None of the original diagnostic information has been lost or degraded 3. Criteria still being established Well-established international standards in radiology for image acquisition, storage and transfer 4. No comparable requirement for training and assessment in digital imaging techniques in histopathology Radiologists trained to understand factors that influence digital image quality 5. Histopathology selected areas viewed at a very wide range of magnifications; larger number of data files Images viewed at a relatively limited range of magnification;fewer data files

29. Advantages of telepathology Telepathology can help pathologists in India who commonly practice in smaller labs dealing with routine histopathology or in smaller hospitals when they come across unconventional cases. Without handing over blocks, a real-time consultation with discussion can take place with telepathology, between two pathologists This is better than a conventional consultation as the local pathologist observes and understands the diagnostic approach taken by the expert.

30. Viewing images cuts out on the money and travel time of a pathologist 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. Video clips from case conferences can be a part of routine training.

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

32. Problems in Telepathology If 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.

33. 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. Image resolutions may be inadequate for assessing nuclear chromatin pattern or glomerular pathology. If a lab solely relies on telepathology, there can be damaging loss of local expertise .

34. Training of new pathologists can become a problem because they need to see and examine all kinds of actual specimen. Telepathology may prove difficult in cases of large complex specimens that need to be grossed well and dissected in person .

35. Hybrid Telepathology Simultaneous transmission of both real-time microscopy and static images • 2 major components located at the 1) remote site and 2) service provider site (receiving site) The best choice is a "hybrid system" motorized microscopes, remote control, a scanner for slide digitization, This achieve the best characteristics from each system without respective disadvantages. This choice has been applied to Rovigo province health structures, and Trecenta hospital,USA

36. Telepathology in India Static telepathology link between Tata Meomorial Hospital and Nurgis-Dutt rural cancer hospital in 2000 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 Upto 2004, 299 telepathology consultations 98% concordance rate 48% cases reported within 8 hrs and 91% in 3 days

37. Future perspectives • High-speed scanning : 15x15 mm tissue area at 40x in <1 min Technology for Scanning fluorescent slides Storage costs remain a limiting factor for digital archiving

38. References 1)Weinstein RS, Graham AR, Richter LC, Barker GP, Krupinski EA, Lopez AM,  et al . Overview of telepathology , virtual microscopy, and whole slide imaging: Prospects for the future. Hum Pathol 2009;40:1057-69.   2)Organizational model for a telepathology system Diagnostic Pathology 2008, 3( Suppl 1):S7 3)Weinstein RS, Descour MR, Liang C, Bhattacharyya AK, Graham AR, Davis JR,  et al . Telepathology overview: From concept to implementation. Hum Pathol 2001;32:1283-99. 4)Weinstein RS, Bhattacharyya AK, Graham AR, Davis JR. Telepathology : A ten-year progress report. Hum Pathol 1997;28:1-7.   5)Introduction to telepathology:chapter 1;Sajeesh kumar Various internet sources.

39. Thank you