Robotic surgical telepathology between the Iron Mountain and Milwaukee Department of Veterans Affairs Medical Centers: a twelve year experience.

Since mid-1996 we have operated a diagnostic robotic telepathology (TP) system at the Iron Mountain, Michigan, Department of Veterans Affairs Medical Center (VAMC) from the Milwaukee, Wisconsin VAMC, located some 220 miles away. No on-site pathologist is present in Iron Mountain. Instead, an experienced, well-trained pathologist assistant, under direction of pathologists located in Milwaukee, is responsible for tissue grossing and sectioning. The pathologist assistant places slides onto the stage of the robotic microscope, which is then controlled by pathologists in Milwaukee. Each case read by TP is subsequently read by light microscopy (LM) by the same pathologist. Three distinct phases of TP have been recognized. Our experience during Phase I (mid-1996 through early 1999) has been published previously. During Phase II (early 1999 through mid-2004), one of the two senior telepathologists in Phase I retired and three junior pathologists were hired. During Phase III (mid-2004 though June 2008), two new junior pathologists were hired and ASAP Imaging (Apollo Telemedicine, Inc., Falls Church, VA) was implemented. The number of TP case opportunities in Phases I, II and III was 2,200; 5,841 and 3,512; respectively resulting in a total of 11,553. A total of 1,834 cases were deferred to LM for a variety of reasons. The number of TP diagnoses rendered in Phases I, II and III was 2,144; 4,636 and 2,939; respectively, for a total of 9,719. The major discordance rates in Phases I, II and III were 0.33%, 0.45% and 0.20%, respectively with an overall rate of 0.35%. Pathologist-specific discordance rates were not significantly different and ranged from a low of 0.12% to a high of 0.77%, while case deferral rates were significantly different (P < 0.0001) and ranged from 2.5% to 28.7%. In general, no relationship between deferral rate and discordance rate was noted. Iron Mountain clinicians have expressed great satisfaction with the services provided by their off-site pathologist colleagues.

Primary mediastinal embryonal carcinoma masquerading as chronic pancreatitis.

Primary mediastinal embryonal cell carcinomas are aggressive tumors commonly presenting between the ages of 20-50 years with pulmonary symptoms (e.g., cough, chest pain, and hemoptysis), as well as extrapulmonary symptoms due to pressure on adjacent structures. Here we describe a 72-year-old man who remained undiagnosed for a prolonged period of time because of intractable epigastric pain. The patient was thought to have chronic pancreatitis for several months until a chest computed tomography scan demonstrated the mass. This case exemplifies that embryonal cell carcinoma may present in older age groups. It also illustrates the importance of including mediastinal tumors in the differential diagnosis of chronic epigastric pain and the need for further investigations to identify these tumors.

Robotic surgical telepathology between the Iron Mountain and Milwaukee Department of Veterans Affairs Medical Centers: a 12-year experience.

Since mid-1996, we have operated a diagnostic robotic telepathology (TP) system at the Iron Mountain, MI, Department of Veterans Affairs Medical Center (VAMC) from the Milwaukee, WI, VAMC, located some 220 miles away. No on-site pathologist is present in Iron Mountain. Instead, an experienced, well-trained pathologist assistant, under direction of pathologists located in Milwaukee, is responsible for tissue grossing and sectioning. The pathologist assistant places slides onto the stage of the robotic microscope, which is then controlled by pathologists in Milwaukee. Each case read by TP is subsequently read by light microscopy (LM) by the same pathologist. Three distinct phases of TP have been recognized. Our experience during phase I (mid-1996 to early 1999) has been published previously. During phase II (early 1999 to mid-2004), 1 of the 2 senior telepathologists in phase I retired, and 3 junior pathologists were hired. During phase III (mid-2004 to June 2008), 2 new junior pathologists were hired, and ASAP Imaging (Apollo Telemedicine, Inc., Falls Church, VA) was implemented. The number of TP case opportunities in phases I, II, and III was 2200, 5841, and 3512, respectively, resulting in a total of 11 553. A total of 1834 cases were deferred to LM for a variety of reasons. The number of TP diagnoses rendered in phases I, II, and III was 2144, 4636, and 2939, respectively, resulting in a total of 9719. The major discordance rates in phases I, II, and III were 0.33%, 0.45%, and 0.20%, respectively, with an overall rate of 0.35%. Pathologist-specific discordance rates were not significantly different and ranged from a low of 0.12% to a high of 0.77%, whereas case deferral rates were significantly different (P < .0001) and ranged from 2.5% to 28.7%. In general, no relationship between deferral rate and discordance rate was noted. Iron Mountain clinicians have expressed great satisfaction with the services provided by their off-site pathologist colleagues.

Unsedated transnasal endoscopy accurately detects Barrett's metaplasia and dysplasia.

BACKGROUND: Unsedated transnasal upper endoscopy has a diagnostic yield comparable with that of sedated conventional upper endoscopy. The ability of transnasal upper endoscopy to detect Barrett's metaplasia or dysplastic change has not been systematically evaluated. The aim of this study was to assess the feasibility of transnasal upper endoscopy for surveillance of patients with Barrett's esophagus and to evaluate its histopathologic yield for Barrett's metaplasia and dysplasia. METHODS: Thirty-two patients with Barrett's esophagus were evaluated with conventional upper endoscopy and transnasal upper endoscopy. An effort was made to recruit patients known to have dysplasia. Quadrantic biopsy specimens were taken with standard (conventional upper endoscopy) and pediatric (transnasal upper endoscopy) biopsy forceps at procedures performed at least 1 week apart. Two blinded pathologists evaluated the specimens. RESULTS: Transnasal upper endoscopy detected Barrett's metaplasia histopathologically in 31 of 32 patients. Level of agreement for presence of dysplasia in biopsy specimens obtained between conventional upper endoscopy and transnasal upper endoscopy was excellent (k = 0.79). Interobserver agreement for dysplasia in specimens obtained by conventional upper endoscopy (k = 0.61) and by transnasal upper endoscopy (k = 0.61) were similar. Intraobserver agreement between conventional upper endoscopy and transnasal upper endoscopy biopsy specimens for dysplasia by pathologist 1 (k = 0.73) and pathologist 2 (k = 0.75) were also similar. No significant adverse effects were noted. CONCLUSIONS: Transnasal upper endoscopy is feasible and accurate for identification and histopathologic confirmation of Barrett's metaplasia with a histopathologic yield for dysplasia comparable with conventional upper endoscopy.