Background
Transplantation pathology is an emerging subspecialty that requires fundamental working knowledge of transplantation immunology, familiarity with histopathologic manifestations of immunologic effector mechanism and thorough understanding of clinical management problems.
Limited exposure to these areas often results in a sense of uneasiness for many practicing pathologists.
Aim
The goal of this project was to develop a dedicated, practical and functional Transplant Telepathology System capable of rapid and interactive real time consultations; the main purpose was to provide a rapid second opinion consultation.
Methods
The pathologists involved in this study were all members of the Division of Transplantation Pathology at University of Pittsburgh Medical Center Health System in Pittsburgh; the referring pathologist was stationed at the newly developed Mediterranean Institute of Transplantation and Advanced Specialized Therapies (ISMETT) in Palermo, Italy.
The system was developed in house starting “from scratch”, which provided to opportunity to specifically adapt the system and software for the needs of transplantation (e.g. continuous coverage and links to previous cases, etc.). A static image telepathology architecture supporting both real time interaction sessions and the capacity to run in a store and forward mode was chosen.
Results
Milestones in achieving functionality included: 1) improvements in image capture and sharpening techniques; 2) inclusion of low power (1X) images and 3) software upgrades, which allowed for more efficient case viewing and administrative monitoring and triage of cases.
Of 102 cases transmitted, 78 were posted for a second opinion consultation and 1 for primary diagnosis, which included 49 transplant pathology cases [pre-OLTx (n=20; 25 %, post-OLTx (n=13; 19 %), pre-op Ktx (n=2; 1%), post-op KTx n=12; 15%)] and 30 general pathology cases. Six frozen section consultations (5 real time) were requested (5 donor liver wedge/ needle biopsy and one native liver wedge biopsy obtained during a potential liver resection operation).
Overall case analysis showed diagnostic agreement between the referral and consultant pathologist diagnosis in 67/78 (86%) and a request was made for a glass slide review in 4 (5%) of cases. Disagreement was found in 11(14%): 8 were minor and little or no impact on patient care, whereas the remaining three had the potential to significant impact patient care.
Conclusion
Telepathology is a practical and useful tool applicable to the practice of transplantation telepathology, but requires a multi-disciplinary team for ongoing support and development. Our system has the potential to enable directed case sharing, including confidential patient information, over a large user group or consortium arrangement. The advantages and disadvantages for the referring and consultant pathologists, pitfalls and sources of error and possible applications of the system will be discussed.