Consultation on urological specimens from referred cancer patients using real-time digital microscopy: Optimizing the workflow

Abstract

Introduction: Centralization of cancer treatment entails a reassessment of the diagnostic tissue specimens. Packaging and shipment of glass slides from the local to the central pathology unit means that the standard procedure is time-consuming and that it is difficult to comply with governmental requirements. The aim was to evaluate whether real-time digital microscopy for urological cancer specimens during the primary diagnostic process can replace subsequent physical slide referral and reassessment without compromising diagnostic safety.

Methods: From May to October 2014, tissue specimens from 130 patients with urological cancer received at Næstved Hospital's Pathology Department, and expected to be referred for further treatment at cancer unit of a university hospital, were diagnosed using standard light microscopy. In the event of diagnostic uncertainty, the VisionTek digital microscope (Sakura Finetek) was employed. The Pathology Department at Næstved Hospital was equipped with a digital microscope and three consultant pathologists were stationed at Rigshospitalet with workstations optimized for digital microscopy. Representative slides for each case were selected for consultation and live digital consultation took place over the telephone using remote access software. Time of start and finish for each case was logged. For the physically referred cases, time from arrival to sign-out was logged in the national pathology information system, and time spent on microscopy and reporting was noted manually. Diagnosis, number of involved biopsies, grade, and stage were compared between digital microscopy and conventional microscopy.

Results: Complete data were available for all 130 cases. Standard procedure with referral of urological cancer specimens took a mean of 8 min 56 s for microscopy, reporting and sign-out per case. For live digital consultations, a mean of 18 min 37 s was spent on each consultation with 4 min 43 s for each case, depending on the number of digital slides included. Only in two cases could a consensus regarding the diagnosis not be reached during live consultation; this did not, it should be noted, affect patient treatment. Complete agreement between conventional and digital histopathology diagnosis was reached in all the 53 patients referred to central pathology units. The participating pathologists were in general comfortable using live digital microscopy, but they emphasized that a fast internet connection was essential for a smooth consultation.

Discussion and conclusion: An almost perfect agreement between live digital and conventional microscopy was observed in this study. Live digital consultation allowed cases to be referred from local hospitals to central cancer units without the standard delay caused by shipment. Only a few preselected specimen slides for each patient were presented in live consultation, which reduced the time spent on diagnosis compared to using the conventional method. Implementation of real-time digital microscopy would result in quicker turnaround and patient referral time, and with careful selection of relevant specimen slides for consultation, diagnostic safety would not be compromised.

Keywords: Digital pathology; digitalization; real-time consultation; telemedicine; telepathology; virtual microscopy.

Figure 1

Specimen workflow of the reassessment process: ordering and handling of the diagnostic specimen, including all glass slides and in some cases also the tissue blocks, where the patient is referred to a university hospital for further specific cancer treatment

Figure 2

Arrangement of the VisionTek Digital Microscope workstation (a) and the digital workstation of the consultant pathologist (b). Remote access to Næstved Hospital is achieved on the rightmost computer, in this case showing a split screen with a prostate core biopsy at the top and the corresponding immunohistochemical stain at the bottom. The middle screen shows the LIS with an open speech recognition window at the front. The leftmost screen is used for correspondence and access to the electronic patient case record

Figure 3

Time expenditure and number of cases presented during the study. (a) Mean estimated time spent on individual slides on a weekly basis throughout the study. The red dots represent the actual time expenditure per week (minutes per slide), whilst the dotted line represents the regression (P = 0.274, r² = 0.085). (b) Number of consultation cases on a weekly basis throughout the study. The red dots represent the mean number of cases during the individual week, while the dotted line gives the regression (P = 0.183, r² = 0.123)