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.

1. TTEELLEEPPAATTHHOOLLOOGGYY
PRESENTER : DR.GURLEEN
OBEROI
MODERATOR: DR. RIDDHI
JAISWAL

2. IINNDDEEXX
Important Terminologies
 Introduction
 Brief history
 Types of telepathology
 Applications
Telepathology vis-a-vis Teleradiology
 Problems
Telepathology in India

3. IIMMPPOORRTTAANNTT TTEERRMMIINNOOLLOOGGIIEESS
AANNDD
AABBBBRREEVVIIAATTIIOONNSS

4. VViirrttuuaall MMiiccrroossccooppyy
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

5. HHiissttoollooggyy WWoorrkkffllooww
FFrroomm TTiissssuuee SSaammppllee ttoo HHiissttoollooggiiccaall EExxaammiinnaattiioonn
Biopsy
Frozen
Section
P
Specimen
Examination
Histo-processing
Sectioning Staining
Tissue
Sample
Microscope
Slide(s)
Surgery Center Histology Lab
P
Microscopic
Examination
Pathologist Office
P
P Step that requires Pathologist
In pathology, imaging begins in histology!

6. Scanning
Digital
Slide
VViirrttuuaall MMiiccrroossccooppyy
DDiiggiittaall SSlliiddee CCrreeaattiioonn,, MMaannaaggeemmeenntt && AAnnaallyyssiiss
Biopsy
Workflow Management
Specimen
Examination
Histo-processing
Sectioning Staining
Tissue
Sample
Digital Slide(s)
Surgery Center Histology Lab
Frozen
Section
P
P
Microscopic
Examination
Pathologist Office
P
P Step that requires Pathologist
Image Analysis
Conferencing

7. AA DDiiggiittaall SSlliiddee
A 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

9. DDiiggiittaall PPaatthhoollooggyy
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.

10. LAN : Local Area Network
WAN: Wide Area Network
ISDN: Integrated Services For Digital
Network
L I S : Laboratory Information System
 WSI : Whole Slide Imaging
RTIS : Real Time Telepathology Imaging
System

11. IINNTTRROODDUUCCTTIIOONN
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.

12. HHIISSTTOORRYY
 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.

14. 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.

16. DDiiggiittaall PPaatthhoollooggyy EEnnvviirroonnmmeenntt
Scan
View
Manage
Analyze
Integrate
Sharing

18. WWHHYY AARREE WWEE TTRRYYIINNGG TTOO
IIMMPPLLEEMMEENNTT TTEELLEEPPAATTHHOOLLOOGGYY
IINN OOUURR SSYYSSTTEEMM????

19. Telediagnosis
Teleconsultation
Teleconferencing
With this access to global expert pathologists is no
longer
a 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

20. 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

29. TTYYPPEESS OOFF TTEELLEEPPAATTHHOOLLOOGGYY

30. SSttaattiicc ((SSttoorree aanndd FFoorrwwaarrdd))
TTeelleeppaatthhoollooggyy
 Static (still) images (photographs)
selected by referring provider sent to
consultant
 Requires skillful image collection by
referrer

31. Advantages
◦ Simple - minimal hardware needs (computer, camera)
◦ Inexpensive - hardware and image transmission
(Internet)
◦ Adaptable - many computer systems can be adapted
Disadvantages
◦ 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

32.  DDyynnaammiicc TTeelleeppaatthhoollooggyy
RReeaall--ttiimmee ((tteelleevviissiioonn)) iimmaaggeess sseelleecctteedd bbyy
rreeffeerrrreerr aass iiff ooppeerraattiinngg aa ttwwoo--hheeaaddeedd
mmiiccrroossccooppee..
HHyybbrriidd DDyynnaammiicc//SSttoorree aanndd
FFoorrwwaarrdd ((HHDDSSFF)) TTeelleeppaatthhoollooggyy
CCoommbbiinneess bbootthh ssttoorree aanndd ffoorrwwaarrdd aanndd ddyynnaammiicc
tteelleeppaatthhoollooggyy ffuunnccttiioonnss

33. 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.

34.  RRoobboottiicc HHyybbrriidd
DDyynnaammiicc//SSttoorree aanndd FFoorrwwaarrdd
((HHDDSSFF)) TTeelleeppaatthhoollooggyy
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

35. 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

36. DDyynnaammiicc RRoobboottiicc TTeelleeppaatthhoollooggyy
3
Slides put onto stage
of robotic microscope
1 Tissue examined/sectioned by
Pathologist in Agra.
2
4 5
6
7
8
9
H & E Sections made
WAN
Hub Pathologist
examines slides using
robotic microscope
Slides read in Lucknow
Pathologist dictates
report to PA
PA enters
report
Report reviewed, printed
signed, faxed
Router Router

37. VVEENNDDOORRSS
Aperio
Bioimagene
Olympus (nanozoomer)
Omnyx
3DHistech
Leica

38. AApppplliiccaattiioonnss
1)Remote access of slides:
 Frozen Sections (night calls,intraoperative
consultations and remote sites)
 Telepathology for 2nd opinion
www.secondslide.com
www.pathxchange.com
 Multi-institution collaborative studies
 Retrospective and prospective collections
of cases for world wide knowledge
database, case series studies,etc

39. 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.

42. CClliinniiccaall aapppplliiccaattiioonnss
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

43. TTeelleerraaddiioollooggyy VViiss--àà--VViiss
TTeelleeppaatthhoollooggyy
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.

44. 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.

45. IISSSSUUEESS NNEEEEDDIINNGG EEVVAALLUUAATTIIOONN
Scanned image quality
Image management software
(interface with LIS system if intend for
clinical use)
Image analysis software
Technical support
Stability of vendor in the market
Good fit between your need and
vendor’s strong points

46. PPrroobblleemmss iinn TTeelleeppaatthhoollooggyy
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.
Technical standards for image capture, storage
and transfer need to be well set.

47. 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.

48. PPRRAACCTTIICCAALL IISSSSUUEESS
Cost (machine, software, storage & personal)
Time for scan: 15x15 mm tissue
◦ 20x < 1min; 40 x 6-7 min
Memory: 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)

49. MMiiccrroossccooppee IImmaaggiinngg
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
experience
Needed virtual slide

50. TTEELLEEPPAATTHHOOLLOOGGYY IINN IINNDDIIAA
 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.

51. 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).

52. CCoonncclluussiioonnss
Multiple 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.

53. RREEFFEERREENNCCEESS
 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