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REVIEW ARTICLE
Year : 2020  |  Volume : 16  |  Issue : 4  |  Page : 703-707

Telepathology: An update on applications, latest advances, and current status in Indian scenario


1 Department of Oral Pathology and Microbiology and Periodontics, Mahe Institute of Dental Sciences and Hospital, Mahe, Puducherry, India
2 Department of Oral Pathology and Microbiology, Mahe Institute of Dental Sciences and Hospital, Mahe, Puducherry, India

Date of Submission05-Jun-2017
Date of Decision15-Aug-2017
Date of Acceptance26-Feb-2018
Date of Web Publication26-Oct-2018

Correspondence Address:
Ajeesha Feroz
Department of Oral Pathology and Microbiology, Mahe Institute of Dental Sciences and Hospital, P. O. Palloor, Chalakkara, Mahe - 673 310, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_477_17

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 > Abstract 


Pathologists have been using their tool of trade, “the microscope,” since the early 17th century, but now diagnostic pathology or tissue-based diagnosis is characterized by its high specificity and sensitivity. Technological telecommunication advances have revolutionized the face of medicine, and in pursuit of better health-care delivery, telepathology has emerged. Telepathology is the practice of diagnostic pathology performed at a distance, with images viewed on a video monitor rather than directly through the (light) microscope. This article aims to provide an overview of the field, including specific applications, practice, benefits, limitations, regulatory issues, latest advances, and a perspective on the current status of telepathology in Indian scenario based on literature review.

Keywords: Literature review, microscope, teledentistry, telepathology, virtual pathology


How to cite this article:
Feroz A, Mohammed Feroz T P, Bastian T S, Selvamani M. Telepathology: An update on applications, latest advances, and current status in Indian scenario. J Can Res Ther 2020;16:703-7

How to cite this URL:
Feroz A, Mohammed Feroz T P, Bastian T S, Selvamani M. Telepathology: An update on applications, latest advances, and current status in Indian scenario. J Can Res Ther [serial online] 2020 [cited 2020 Sep 23];16:703-7. Available from: http://www.cancerjournal.net/text.asp?2020/16/4/703/244218




 > Introduction Top


Pathologists have been using their tool of trade, “the microscope,” since the early 17th century, when it was first introduced by Antony Van Leeuwenhoek and modified by Robert Hooke. Diagnostic pathology or tissue-based diagnosis is now characterized by its high specificity and sensitivity when compared to other diagnostic medical disciplines such as radiology, clinical pathology, or endoscopic imaging techniques.

Diagnostic pathology, as with most medical specialties, is currently facing a growing demand to improve quality and is considered as the focus of all modern developments in medicine, which can be subsumed under the headlines of molecular biology including molecular genetics, electronic or digital communication, and computerized medicine. These two developments in the last decade have immensely altered the daily work of the diagnostic pathologist. However, molecular biology applications have improved detailed diagnosis of numerous diseases, especially cancer, infectious diseases, or transplant problems.[1] Technological telecommunication advances have revolutionized the face of medicine, and in pursuit of better health-care delivery, teledentistry has emerged, which have also become of great boon to diagnostic pathologists.

“Telepathology is the practice of diagnostic pathology performed at a distance, with images viewed on a video monitor rather than directly through the (light) microscope.”[2] Telepathology is the acquisition of histological, cytological, and macroscopic images for transmission along telecommunication pathways for diagnosis, consultation, or continuing medical education.[3]

Telepathology is under the subtype of telemedicine which can be used conveniently among medical professionals.[4] Rather than using images of glass slides through the light microscope, pathological samples can be sent as electronic images and stored effortlessly. Today, telepathology is widely used in consultation, diagnosis, documentation, and medical education. It helps overcome the problem of nonavailability of immediate pathologist in some distant areas.


 > Definition and History of Telepathology Top


The term, telepathology, was first defined by Ronald Weinstein et al. as the “practice of pathology over a long distance.”[5] John Sinard defined it as “the use of any of the telemicroscopy technologies to make the primary diagnosis for the specimen from a remote site.”[5]

Telemicroscopy technologies can be considered as milestones in the history of telepathology, which started as early as 1960 with trials of the National Aeronautics and Space Administration, followed by specialized medical trials (skin biopsies) held at the Massachusetts General Hospital, Boston, USA.[6] The pioneer work of online telepathology with routine frozen-section applications was performed in Europe by the Telepathology Team of the University of Tromsö, Norway, in 1988. In the meantime, offline telepathology trials with multiple contemporary experts' consultation started in Heidelberg, Germany. The first international congress discussing solely telepathology aspects was held at Heidelberg in 1992.[1]

In the 1990s, a hybrid dynamic-robotic telepathology system was invented in Northern Norway in the 1990s. After 10 years, virtual microscopy was marketed.[7] Since 1968, after the first instance of telepathology, the exponential growth of technology over the years has brought telepathology and the art of digital imaging to grow by leaps and bounds.[8]


 > Classification of Telepathology Top


Telepathology is classified into three modes: static (or store and forward), dynamic (or real time), and hybrid (or virtual).[5],[9]

Static telepathology (or store and forward)

Static telepathology is the simplest mode of telepathology. Here, the images are initially preselected and the digitization of representative image is done by the sender pathologist.[5] Later on, these images are transmitted to a remote telepathologist via E-mail or the Internet services. One of the attracting features of static telepathology is the low building up fees as no special software is required to view the images and it requires only some basic components for setting up such as microscope, camera, and Internet.[9] However, there are few drawbacks encountered such as the possibility of missing a potential diagnostic area with a glass slide, lack of clarity at low-power magnification, lack of focus in still image, inappropriate field selection by the submitting pathologist.[9] Although this is a comparatively less efficient method, there have been isolated reports of a concordance of even as high as 95%–100% between glass slide and telepathology diagnosis.

Dynamic telepathology (or real time)

The dynamic telepathology system is the most appropriate system for frozen-section telepathology and undermanned area.[10],[11] In this method, the transmission of microscopic slide images to the recipient is done in real time via live telecommunication.[10],[12] With the implementation of remote robotic microscope, recipients can also control the magnification as well as the slide. However, this sophisticated system is relatively expensive and not easy to maintain. It is fitted with charge-coupled device video camera, high-resolution video monitors, proprietary software, and dedicated, high-performance hardware (computer). Besides that, it needs a stable and broad-bandwidth telecommunication link between the sender and the recipient.[6] Dynamic telepathology has now revolutionized the field with a concordance rate of 99%–100% reported between telepathology and light microscopy diagnosis.[8]

Hybrid telepathology (or virtual)

Hybrid telepathology using nonrobotic real-time telepathology combines both static and dynamic telepathology systems.[5] They have advantages of both the systems. Series of images are automatically stitched together in software, compressed to a single-file form in this system.[5] Once the dynamic telepathology session starts, these images are transmitted, thereby hastening the consultation process of recipient as less time is required to control the robotic microscope. This system is beneficial in providing immediate consultations and improved patient care. It has varied success rates [Table 1], [Table 2], [Table 3].
Table 1: Types of telepathology and their applications

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Table 2: Technological requirements

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Table 3: Components in implementation of telepathology

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 > Applications Top


Delivery of critical health care at a distance

Lack of pathologists has always been the major problem in many small pathology departments, because many residences in rural areas are unable to obtain even total primary medical care. With telepathology, some of the emergency pathological analyses such as intraoperative frozen section can be performed without pathologist. When the laboratory technologist processes the specimen locally, a pathologist examines the gross in another location.[13] At the same time, the pathologist will provide some guidances to the technologist via monitor. Hereafter, the pathologist can examine digital images and provide his diagnosis by a phone. The advantage is that pathologists do not need to actually travel to provide the service.[14]

Distant education

Telepathology provides a vital role in medical education. The traditional classrooms which involved the use of glass slides and high-quality microscopes are now beginning to be replaced with digital imaging.[15] Digital imaging offers significant advantages over the traditional method, especially to document the true appearances of the pathological changes to eliminate inaccuracies resulting from variations in descriptive ability.

The conventional cytological glass slide examination is time consuming as only one person can view it at a time.[15],[16] Moreover, it is expensive to make glass slides with a variety of pathologies.

As pathology is a visual science, the inclusion of quality digital images into lectures, teaching handouts, and electronic documents is crucial.[17]

Interoperative pathological analysis

Telepathology can be used for obtaining consultation from pathologist in another location.[18] During a surgery, tumor-free margins in a tissue-sparing manner can be recognized even without a pathologist. The unnecessary excision of benign region in a lesion can be avoided.[12]

Conference discussions among distant pathologists

Pathologists are also unevenly distributed around the globe, with half of trained pathologists residing in the developed countries. Telepathology has been used to provide pathology services to developing countries with no or limited access to pathology or subspecialty pathology. Another key benefit is better access to consultations. This is true for isolated pathologists needing a second opinion, but also for those sending expert referrals to subspecialist pathologists.

Storage

Digital imaging storage offers significant advantages over the traditional method. Digital slides can be stored for a long time as the color of stains will not fade over time. On the contrary, the glass slides may break, fade, and can be lost easily. Besides that, the expenditure for setting up and maintaining the traditional method will be much more expensive.[18],[19]


 > Disadvantages Top


High cost of the new technology

The cost for building a new digitized system has limited the implementation of telepathology.[20] The high cost of equipment and the maintenance fee for this complex system are unaffordable by most of the small laboratories, especially in the developing countries. The implementation will ultimately fail if the equipment and system cannot be adequately maintained by the trained professionals. Moreover, as the file sizes for whole-slide imaging is very large, the prices for its image storage are relatively high.[5] Huge amount of funds is spent merely on storages without even including back-up storage.

Low rate of acceptance

Telepathology implementers need to ensure that targeted pathologists, technicians, and surgeons accept the new system and the new work environment.[21] Pathologists can be reluctant to base a diagnosis on images sent by another pathologist. Technicians need to trust distant pathologists to guide them through the digitization process. Surgeons may also mistrust the diagnosis of an unfamiliar pathologist.

Inconvenient slide selection

Although the applications of the dynamic telepathology system are incredible, in the aspect of slide movement and selection, dynamic telepathology has a higher degree of difficulty compared to conventional light microscopy.[22] When the receiving and sending stations are of two different time zones, also, it creates inconvenience for the diagnosing pathologist. There is an increased risk of missing critical diagnostic areas and few artifacts which may lead to misdiagnosis.

Legal and security issues

The implementation of telepathology practice arises a lot of legal- and security-related issues such as physician licensing issues, indemnification issues, insurance issues, and other contractual issues.[23] Protection of electronic data should also be taken into consideration, when patients' details and images are being transferred over Internet. These issues can be dealt partially using private networks.


 > Implementation Challenges Top


Individual barriers

First, the clinicians need to trust the image- and telepathology-based diagnosis. Unfamiliar pathologists and new work environment always is a barrier. Technologic hurdles are faced by clinicians and technicians who are less familiar with information technology.[24]

Organizational barriers

The health organizations face important challenges such as financing, workflow reengineering, and diagnosis accountability.[25] One prominent issue is about the accountability of the consulting pathologist for the diagnosis. Thus, telepathology raises accountability issues relating to information privacy and the extent of coverage provided.


 > Advances in Telepathology Top


Virtual slides

Virtual slides are special type of digitized slides where one can see the slide in different magnifications, just like a microscope, and without the help of multiple images. Image acquisition of an entire microscopic slide is done at all magnifications available on the microscope. The software drives the motorized stage to acquire all fields of view and then seamlessly stitches the fields into a single image. These virtual slides have extremely large file size, sometimes exceeding 1.5 GB and hence cannot be transferred easily with the present network bandwidth limitations. Such slides are therefore stored in “virtual slide boxes” where database storage can be done on a central server. Virtual slide viewers have been developed for use with this virtual slide database and rapid and interactive visualization with any portion of the image and at any magnification is possible.[26]

Digital imaging

The use of modern digital cameras rather than chemical photography has the added advantages of lower running costs, early archiving, dissemination, transmission, and even better storage.[27]

Optimizing images without falsifying them using software such as Adobe Photoshop[28] can also augment an image to exactly what is observed on gross examination or under the microscope.

The transition to the digital medium has opened up copious applications for gross as well as histopathologies in the form of three-dimensional (3D) image. At microscopic level, 3D digital simulations provide and may become a possible future necessity for the practice of digital diagnostic pathology.[14],[27],[29]

Miniature microscope arrays

The fourth-generation telepathology imaging system uses miniature microscope arrays. In this system, output from about 100 miniaturized microscopes is concurrently captured by 100 individual digital images.[30] The result is a virtual slide that can be produced in minutes. Such systems promise to transform histopathological laboratories in the very near future.

Whole-slide imaging

This denotes a digitalized image of entire histopathology slide or a selected area of it. These images have high resolution and quality, which offers access to all areas on a slide. The images produced by this technique can be viewed on personal computers, laptops, or iPhones in any magnification.[15]


 > Telepathology in India Top


Telepathology in India is still in the evolving stages. Even though much development has taken place around the world, especially in the field of digital imaging and virtual slides, in Tele-learning or distance learning, or in remote diagnosis, the practice of telepathology in India still revolves around static telepathology.

The first experience of telepathology in India was introduced 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.[31] Since then, a number of symposia and workshops were held on telepathology in various parts of the country which contributed to popularize this tool both at the national and at the state level. A revolutionary progress was the opening of telepathology quiz page in the popular pathoindia.com, an e-group where interesting cases were put in the form of a quiz. From pathoindia.com came telepathologyindia.com presently called as telepathology.org.in.[32] In this website, anyone can present a case, and judgment is done based on the replies one gets, this sort of tel-e-learning is indeed very popular. Telepathology.org.in also attempted to provide free consultancy service to various pathologists in India.

The first experience of telepathology in India by Desai et al.[32] using static telepathology consultation between a tertiary cancer center (Tata Memorial Hospital) and a rural cancer hospital (Nargis Dutt Memorial Cancer Hospital) in Barshi, Maharashtra, was truly revolutionary. The authors made a mark in the annals of telepathology with the existing telecommunication facilities and a 56 k modem, which provided an excellent telepathology consultation and a concordance rate of 90.2%.

In spite of recent government initiatives to improve the telecommunication facilities, the exact usage and applications of the technology are not very well known. Standardized applications of these methods are yet not identified or are thought to be underutilized in pathology laboratories across the country. A standardized method of obtaining, storing, and sharing digital images is obligatory to lead to better diagnosis techniques and consultation methods for pathology diagnosis.

The major drawbacks faced in India are the suboptimal preparation of slides. A major reason for the failure of telepathology consultation, unavailability, and inability of experts to come to a conclusive diagnosis is the absence of a rapport between the sending pathologist and the consultant pathologist. The distant pathologist would rather not give a diagnosis based on images sent by an unfamiliar party. Moreover, there has been a resistance from senior histopathologists in India regarding the promotion of telepathology. This is probably due to the misconceptions lingering about telepathology.


 > Conclusion Top


Great technological advances are taking place throughout the world in the field of telepathology. From its genesis as an interesting idea, telepathology and digital pathology is now becoming a valuable tool in clinical and research pathology. More precise and speedy diagnosis of lesions is the ultimate goal of pathology practice, regardless of the methods/instruments used. Thus, integrating telepathology and digital pathology into the mainstream diagnostic would revolutionize the lifestyle of pathologists from microscope to computer screen.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

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