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Digital Whole Slide Imaging for Patient Care in Toronto
Dr. Andrew J. EvansStaff Pathologist & Associate Professor
Department of PathologyUniversity Health Network, Toronto, Ontario, Canada
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Disclosure
• Leica Microsystems
• Aperio
• Vendor/client relationship only
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UHN Whole Slide Imaging Telepathology
1) Primary frozen section diagnosis
2) Sub-specialty pathology service to hospitals in Northeastern Ontario
3) Maintaining 24/7 sub-specialty coverage of transplant pathology services
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• No on-site pathologist
• 2-10 frozen sections
per week (mostly
neurosurgery)
University Health Network
~ 1 mile
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TWH Frozen Sections: The Problems to Be Solved
• Single pathologist traveled to TWH– Inefficient process - traveling and waiting
– Disruptive to workflow – 99% of departmental activity occurs at TGH
• delays in regular sign-out affecting other UHN patients
– No possibility for consultation on difficult cases.• Compromised diagnostic accuracy• Unnecessary deferred diagnoses
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Due Diligence
• In-house training and validation (18 months)
• Medical Malpractice Insurance Provider (CMPA)
• UHN Medical Advisory Committee
• Health Canada – Therapeutic Products Program– telepathology does not involve “medical devices”
• Surgeon Education
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The Robotic System: November 2004-October 2006
• 350 frozen sections
• accurate
• deferral rate < 10%
• slow (~ 10 minutes/slide)
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Whole-Slide Imaging: October 2006-Present
• > 1300 frozen sections
• 90% from neurosurgery
• 98.5-100% accuracy (month to month)
• 14-16 minute turnaround time
• 7.5% deferral rate
• 2 pathologists review all deferrals
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Whole Slide Imaging Telepathology
• Easy consultation with colleagues – better for patient care
• Essentially no learning curve – transition from robotic in 1 month
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Whole-Slide Imaging: Cases Requiring Re-Scanning
• Image quality is not a problem!
• < 2% of cases– poor-quality slide
• folds in tissue• section too thick• freezing artifact
• No difference with microscope
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UHN Partnerships in Northeastern Ontario
• Timmins (2005) and Sault Ste. Marie (2006)
• Shortage of pathologists, no sub-specialists
• No pathologist in Timmins 1-2 weeks/month
• Glass slides shipped to UHN– Limitations:
• Frozen sections• Lost/damaged slides• Delays with transporting slides
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Timmins & District Hospitals - April 2008
• consultations
• frozen sections> 60 patients
• completely digital
within 2 years
Google Maps 2008
> 400 miles
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Sault Area Hospitals - October 2008
• consultations
Google Maps 2008
> 400 miles
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Transplant Telepathology at UHN
• Orthotopic liver transplant program
• ~ 600 post-transplant biopsies/year– 2 – 5 urgent biopsies/week (same day or next
morning results)
Practical Issues: - 3 liver pathologists
- absence for CME activities
- consultation with on-call colleagues after hours
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UHN Liver Transplant Whole-Slide Imaging Telepathology
• 31 biopsies– 17 for cellular rejection– 3 potential donor biopsies– 11 for non-transplant medical liver disease
• Hepatologists and surgeons highly satisfied with service
• 1 missed diagnosis: donor liver frozen section 1AT deficiency on paraffin sections requiring special stain– would not have made this diagnosis on the frozen section
with a microscope
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Skin
Renal
Cardiac
Other Sub-specialty Consults
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Whole Slide Imaging Telepathology:Summary of UHN Experience
• SAFE, RELIABLE and ACCURATE
• Tremendous value added:• Primary frozen section diagnoses• Consultations between colleagues• Providing timely service to remote hospitals• 24/7 support to transplant programs
• Similar “niche” applications in the United States most definitely exist.
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