Use of dynamic telepathology in Mohs surgery: a feasibility study

The role of teledermatology in Mohs micrographic surgery: a review

This paper explores the role of teledermatology (TD) in Mohs micrographic surgery (MMS) at various stages of patient care. The study aims to assess the benefits, limitations, and patient experiences surrounding TD integration into MMS practices. We conducted a PubMed search using keywords related to TD and MMS, categorizing selected articles into pre-operative, intra-operative, and post-operative stages of MMS. TD reduced waiting times (26.10 days for TD compared to 60.57 days for face-to-face [FTF]) and consultation failure rates (6% for TD vs. 17% for FTF) for MMS preoperative consultations. It also shortened time to treatment by two weeks and led to notable travel savings (162.7 min, 144.5 miles, and $60.00 per person). Telepathology facilitated communication and decision-making during MMS, improving accuracy and efficiency, especially in challenging cases requiring collaboration where physical presence of another surgeon or pathologist is not feasible. Telepathology definitively diagnosed benign lesions and malignant tumors in 81.8% of cases (18/22). Additionally, there was a 95% agreement between conventional light microscopy diagnosis and telepathology in tumors (19/20), and 100% agreement for all 20 Mohs frozen section consultations. For post-operative follow-up, telephone follow-up (TFU) and text messaging proved effective, cost-efficient alternatives with high patient satisfaction (94% in New Zealand and 96% in the U.K.) and early complication identification. This study underscores TD's multifaceted benefits in MMS: enhanced patient experience preoperatively, improved communication during surgery, and cost-effective postoperative follow-up. Limitations include the financial expense and technical issues that can arise with TD (connectivity problems, delays in video/audio transmission, etc.). Further studies are needed to explore emerging TD modalities in post-operative patient management. The integration of TD into MMS signifies a progressive step in dermatological care, offering convenient, cost-effective, and better solutions with the potential to enhance patient experiences and outcomes.

Systematic Review of the Use of Telepathology During Intraoperative Consultation

OBJECTIVE

To compare studies that used telepathology systems vs conventional microscopy for intraoperative consultation (frozen-section) diagnosis.

METHODS

A total of 56 telepathology studies with 13,996 cases in aggregate were identified through database searches.

RESULTS

The concordance of telepathology with the reference standard was generally excellent, with a weighted mean of 96.9%. In comparison, we identified seven studies using conventional intraoperative consultation that showed a weighted mean concordance of 98.3%. Evaluation of the risk of bias showed that most of these studies were low risk.

CONCLUSIONS

Despite limitations such as variation in reporting and publication bias, this systematic review provides strong support for the safety of using telepathology for intraoperative consultations.

A feasibility study of virtual slides in surgical pathology in China

China's huge territorial expanse and its imbalance of regional economic development have resulted in an uneven distribution of experienced pathologists. Developing telepathology for consultation is of special relevance to China. We developed a newly designed telepathology workstation, which includes a small file size of each slide, permitting easy transmission, storage, and manipulation, and a feedback function, and also evaluated its feasibility in surgical pathology in China. Four hundred cases covering a broad spectrum of surgical pathology problems were investigated in a blinded fashion by the 2 pathologists using this virtual microscope system. These cases were then randomized and re-reviewed a second time with light microscope. Diagnoses and time spent for each diagnosis were recorded for both methods. The diagnostic accuracies achieved by viewing glass slides and virtual images were 97.25% (389 of 400) and 95.5% (382 of 400) for pathologist A and 96.25% (385 of 400) and 94.75% (379 of 400) for pathologist B, respectively. There was no significant diagnostic discrepancy between the 2 methods for the 2 pathologists. The average times for viewing a virtual slide were 3.41 and 5.24 minutes for pathologists A and B, respectively, whereas the average times for viewing a glass slide were 1.16 and 3.35 minutes for pathologists A and B. There was a statistical difference between the time costs of the 2 methods. However, the slight time increase using virtual slides is less than that using dynamic telepathology and traditional consultation, and is acceptable to the pathologists. These results showed that this newly designed virtual microscope system have an acceptable diagnostic accuracy that is of practical value and may be suitable for application in China.

Cost-effective dynamic telepathology in the Mohs surgery laboratory utilizing iChat AV videoconferencing software

BACKGROUND

Dynamic telepathology is the real-time transmission of histologic images from one pathologist to another by means of telecommunications technology.

OBJECTIVE

The objective was to determine whether dynamic telepathology can be accomplished accurately and inexpensively by use of readily available off-the-shelf consumer products and software.

METHODS

We attached a standard, consumer-grade, digital video camera to a microscope in the Mohs surgery laboratory and then transmitted via the Internet real-time histologic video images and audio to a consultant dermatopathologist by means of iChat AV videoconferencing software (Apple Computer Inc., Cupertino, CA). In the first part of the study, 20 unknown formalin-fixed, paraffin-embedded slides from tumors typically seen in a Mohs practice were evaluated by the consultant dermatopathologist. In the second part of the study, the Mohs surgeon consulted the dermatopathologist on 20 Mohs frozen section slides in which the surgeon had a particular question (e.g., "Is this part of a pilosebaceous unit or is this basal cell carcinoma?").

RESULTS

The video images were adequate for pathologic interpretation. There was agreement between conventional light microscopy and dynamic telepathology diagnosis in 19 of 20 tumors. There was complete agreement for all 20 Mohs frozen section consultations.

CONCLUSION

Dynamic telepathology can be accomplished accurately and inexpensively by use of readily available consumer products and software.

Multiple subclinical syringomatous proliferations encountered during Mohs surgery for basal cell carcinoma

BACKGROUND

Examination of Mohs surgery frozen sections may lead to discovery of incidental benign neoplasms such as syringomas.

OBJECTIVE

An unusual occurrence of numerous subclinical syringomatous proliferations discovered during Mohs surgery for a basal cell carcinoma that posed a diagnostic and management dilemma is reported.

METHODS

Clinical records and histologic sections are examined.

RESULT

Multiple syringomatous proliferations were noted around a basal cell carcinoma during Mohs surgery. A few foci were atypical appearing and focally extending into the deep dermis causing a diagnostic dilemma. All atypical syringomatous proliferations were excised. Evaluation of final Mohs margins by permanent sections and biopsies of normal-appearing facial skin showed multiple benign syringomas.

CONCLUSION

Although solitary subclinical syringomas have been described in association with basal cell carcinomas, the occurrence of multiple syringomas and syringomatous proliferations has not been previously reported. Dermatologists should be aware of the existence of this phenomenon and consider permanent section evaluation to better determine nature of unusual incidental tumors identified in frozen sections during Mohs surgery.

An automated tissue preclassification approach for telepathology: implementation and performance analysis

Telepathology is generally defined as the use of telecommunications technologies in the practice of anatomic or surgical pathology. In the usual telepathology scenario, a remotely located pathologist views images of tissues samples in order to render a diagnosis of the biopsy. Some telepathology systems involve interactive remote control of a microscope-based imaging system which delivers diagnostic quality imagery to the remote pathologist. The usefulness of such interactive systems depends on minimizing the end-to-end delays involved in controlling the robotic microscope, manipulating the tissue sample, and acquiring and transmitting the high-resolution image. An approach to minimizing end-to-end delay involves adding "intelligence" to the image acquisition system so that it can gather, classify, rank, and transmit diagnostically useful images in a semiautonomous fashion. In this research, we develop image analysis and ranking techniques which can improve the end-to-end performance of a robotic telepathology imaging system. Our semiautonomous image collection system uses morphological techniques to extract seed points for suspicious regions, a novel region growing algorithm to segment the regions of interest, and heuristically motivated expert system ranking techniques to select diagnostically relevant "next-step" image acquisitions. Diagnostic relevance of our segmentation and ranking algorithms is established via subjective and objective testing of the system. In subjective testing, pathologists Agree or Strongly Agree that all segmented regions are diagnostically relevant with probability greater than 0.75. In objective testing, 84% of "next-step" images acquired by our algorithms coincide with the areas most likely to be chosen by a pathologist.

Trends in the use of cameras and computer technology among dermatologists in New York City 2001-2002

BACKGROUND

Photography and computers can enhance dermatologic visit documentation and care.

OBJECTIVE

To determine dermatologists' use of cameras and computers.

METHODS

We surveyed computer and camera use during the Dermatologic Society of Greater New York's meetings in January 2001 and 2002.

RESULTS

Approximately 75% of dermatologists can use computers. Between 2001 and 2002, 35-mm film camera use by attending and resident dermatologists fell from 60% to 47% and 43% to 32%, respectively, and digital camera increased from 25% to 38% and 35% to 59%, respectively. Approximately 50% of dermatologists use instant cameras. Approximately 15% of dermatologists use no camera. Most find images useful; however, medical dermatologists usually image only interesting patients, and dermatologic surgeons image almost all patients. Approximately 15% of dermatologist used electronic medical records (EMRs).

CONCLUSION

Computers and cameras are widely used but have not changed dermatologic practice. Images are not used to track skin disease or integrated with EMRs nor are EMRs widely used, probably because of difficulty of use and limited computer literacy. Where images appear to add value, for example, for preoperative and postoperative documentation among dermatologic surgeons, camera use is common, suggesting that utility drives technology adoption.