Basic rules for the security of frozen section diagnosis through image transmission between anatomo-pathologists.

Telemedicine can provide an alternative solution to the lack of medical resources in areas where the population is no longer dense enough to justify the temporary or permanent presence of certain specialists such as anatomo-pathologists. In the long run certain pre-operational frozen section examinations cannot be carried out without putting the quality of healthcare at stake. The telematic transmission of macro and microscopic images of lesions, under the supervision of a surgeon, to an anatomo-pathologist consultant located off premises allows for the maintenance of equitable care of acceptable quality.

Telepathology diagnosis by means of digital still images: an international validation study.

Telepathology affords the means to provide pathological diagnosis and consultation to remote sites. However, before telepathology can become an acceptable medical tool, it will be vital to determine the diagnostic accuracy of this technology. We report the results of a single-blind study of the accuracy of diagnosis performed using computerized still images obtained from a telepathology workstation used in a French telepathology network. Four pathologists, each working alone, reviewed a total of 200 cases of routine surgical pathology (50 cases each), and performed diagnosis based on both computer CD-ROM still images (CD) and conventional glass slides (GS). Concordance between GS and CD diagnosis, as well as accuracy, were determined. Other factors related to performance were also measured, including diagnostic certainty, reasons for uncertainty, and causes of diagnostic error. Overall, there was good agreement between CS and CD diagnosis. There was 87.5% concordance between CS and CD diagnosis, and comparison to consensus (correct) diagnosis showed accuracy of 95.5% and 88.5% for GS and CD diagnosis, respectively. Marked variability in accuracy of CD diagnosis was observed among the four pathologists, and issues related to image selection and/or quality appeared responsible for 60% of the diagnostic errors. The lack of sufficient images and clinical information were frequently cited as reasons for diagnostic uncertainty, as well as feelings of insufficient expertise. It is likely that the opportunity for interaction with the referring pathologist and the use of subspecialty consultants would likely improve the performance of telepathology.

Evaluation of an international telepathology system between Boston (USA) and Dijon: glass slides versus telediagnostic television monitor.

A telepathology network developed by Resintel (Dijon) has proved valuable in interactive situations, where two physicians converse by telephone, showing each other the part of the lesion they wish to discuss. In future this interactive process could be replaced by an electronic mailing service in which a limited number of images are taken from the slide, but this technique needs to be assessed in comparison with traditional microscopic diagnosis, when the pathologist can screen the entire slide. The present study compared diagnoses achieved through the traditional methods of current pathology practice with diagnoses achieved through a selection of images on a telediagnostic TV monitor. The kappa coefficient between the two protocols was 0.26 (SE = 0.06), which allows us to conclude that there is a fair reliability between video and glass slide diagnoses.

[Contribution of computers and telepathology in cancerologic pathology]. / Apport de l'informatique et de la télépathologie en anatomocytopathologie cancérologique.

The histologic or cytologic diagnosis of a tumoral lesion may be sometimes very difficult to do even for a senior pathologist. Nevertheless, it is necessary to recognize a malignant process with reliability and security. The usual way to solve some difficult problems is firstly to search documentations in books or atlas and then to discuss the slides in common. Sometimes it is necessary to dispatch the original documents to a national or international expert. Now computers are used in any private or public department of Pathology. Some new informatics developments allow to send good digitized pictures to an expert and to discuss with him. It is also possible to elaborate a data base of digitized images which can be edited on CD-Rom. We describe the development and the use of these technics in France and elsewhere. It seems that they could have an increasing role for quality assurance in tumoral pathology.

Telepathology in France. Justifications and developments.

Since 1985, the French National Association ADICAP (Association for the promotion of computer use in Cytology and Anatomic Pathology) has been active in the creation a microscope workstation for developing a bank of digitized images to be used for diagnostic and educational purposes. In 1989 one of the authors (P. Dusserre) has created a first telepathology network using this workstation. Since then, 32 workstations have been set up in private and public Departments of Pathology. Two of them are located overseas, in the Martinique and Guadeloupe islands. In this paper, the authors describe this system, called Transpath, which is a multi-purpose and modulable workstation. 3-years experience and several accuracy tests have shown that the quality of transmitted images ensure a reliable diagnosis in more than 95% of cases. It has been decided to extend this service to other French overseas territories and to develop a group of experts. The images bank will also be developed and recorded on CD-ROM. The authors intend to participate in a future European project (PILOT project, i.e. Pathology International and Local Operational Telematics), with the purpose of establishing real intercommunication between European and other networks on a worldwide basis.

Evaluation of a telepathology system between Boston (USA) and Dijon (France): glass slides versus telediagnostic TV-monitor.

The objective of this work was to compare diagnoses achieved through the traditional methods of current pathology practice versus diagnoses achieved through a selection of image on a telediagnostic TV-monitor. The Kappa coefficient between the two protocols of k = 0.26 SE(k) = 0.06 z = k/SE(k) = 4.3 (p < 0.001) allows us to conclude that there is a good reliability between video and glass slide diagnoses.

The emergence of international telemedicine: no ready-made solutions exist.

Sending images to the far end of the world and establishing a diagnosis that may save one human life is a technological success which is very extremely gratifying, scientifically. But it's only the first, though essential, stage towards developing an international telemedicine network. The difficulties of conforming the telemedicine network to technical standards, administrative regulations, and existent national and supranational legislations are presented in this paper; there are often no ready-made solutions to these problems.

[Factors determining the choice between mastectomy and conservative treatment in the Côte-d'Or department (France). The Côte-d'Op6 register of gynecological cancers]. / Facteurs ayant déterminé le choix entre mammectomie et traitement conservateur pour cancer du sein entre 1982 et 1990 dans le département de la Côte-d'Or. Registre des cancers gynécologiques de Côte-d'Or.

The aim of this study is to check, for a defined period and within a geographic area, whether the increased use of breast conserving treatment was related to changes in tumor characteristics, or whether changes in therapeutical practice persisted after adjustment on patients and tumor characteristics. From 1982 to 1990, 1,952 women with invasive carcinomas were registered in the French "departement" of Côte-d'Or. Seventeen hundred and seven non metastatic patients were treated by loco-regional surgery. A breast conserving surgery was performed in 60% of cases. The incidence of this treatment raised from 32% in 1982 to 73% in 1987. In univariate analysis, factors determining the type of tumor excision were: age, hormonal status, tumor size, tumor location, "clinical seriousness", nodal status, multiple tumors, inflammatory tumors, neoadjuvant treatments and year of diagnosis. Age and tumoral factors remained significant in a logistic regression analysis. Other factors being constant, the odds ratios of mastectomy was 12.9 times lower in 1987-1990 than in 1982, and 2.1 times lower than in 1985-1986, showing a "period effect". Ninety four percent of patients treated by breast conserving surgery were irradiated post operatively, showing that the clinical research recommendations were well transferred to the clinical practice in this department.

Telepathology: a new tool of pathology? Presentation of a French national network.

The field of pathology is constantly growing and the responsibility of the pathologists has progressively increased in the decision of application of some efficient but aggressive therapies. They justify the increasing necessity of discussion between pathologists about the diagnoses of difficult or rare or severe lesions. It is now possible to discuss at distance on good definition digitized images transmitted through I.S.D.N. A French experimental network between 12 workstations has been introduced since 2 years. Difficult or severe diagnoses have been immediately solved in 85% of the discussed cases. It remain legal problems and the necessity of an evaluation protocol which could be discussed at a European level. The increase of technical progress and, above all, the decrease of the costs might favour the development of telepathology. The workstation of the pathologist in the year 2000 could be the combination of a microscope, a HD-TV-camera and a personal computer with many softwares allowing treatment and transmission of numerous pictures.

[Prostatic specific antigen and prostatic pathology. Value of preoperative blood assay. Preliminary study apropos of 709 case reports]. / Antigène spécifique de prostate et pathologie prostatique valeur du dosage sérique pré-opératoire. Etude préliminaire à propos de 709 observations.

Prostate specific antigen (PSA) is a prostate tissue marker detected by immunostaining in 97% of specimens examined. Tissue staining is variable and cancers are more heterogeneous than normal or hyperplastic prostate. Serum PSA levels in patients with normal or hyperplastic lesions are 12 ng/ml + 19 and are positively correlated with the weight of the gland. In patients with carcinoma serum PSA levels are 216 ng/ml + 782 and are positively correlated with tumor spread. PSA assay is of little value for screening for prostatic carcinoma. However, carcinoma of prostate is more frequent when PSA levels are above 10 ng/ml and the level of 50 ng/ml indicates capsular penetration, seminal vesicle or lymph node involvement or metastatic spread.

[Fibro-inflammatory polyps of the stomach. Review of the literature apropos of 2 cases]. / Les polypes fibro-inflammatoires de l'estomac. Revue de la littérature à propos de 2 cas.

About two fibroid inflammatory polyps of the stomach and 84 similar cases previously reported in the world literature the authors describe the anatomo-clinical features of this entity. The two sexes are equally affected by such a lesion which occurs with a maximum of frequency during the 6th and the 7th decades. More often an epigastralgia with or without anemia is the main symptom of this polyp which is located in the antral submucosa (95% of the cases). A sessile or pedunculated mass is discovered by gastric endoscopy and may be resected during this investigation. Histologic examination shows a well limited fibroblastic proliferation around vessels and an inflammatory infiltration with a variable density of eosinophilic polynuclear cells. The presence of these elements is not a proof for the allergic nature of the polyp: blood eosinophilia is absent or rare and the serum IgE level is not changed.

[An incidence study of digestive cancers in a well defined population. Results of two years registration in the departement of Côte d'Or (author's transl)]. / Incidence des cancers digestifs dans une population bien définie. Bilan de deux années d'enregistrement dans le département de la Clote-d'Or.

A systematic registration of mortality and morbidity from digestive cancers was started in January 1976 in the French department of COTE-D'Or (population 455,727). In the course of two years 913 new cases of digestive cancers were recorded. Nearly half of these cancers were colorectal cancers. The survey gives informations on histology, stage of the disease and survival. The morbidity survey allows comparison with the incidence rate of digestive cancers in other countries.

[Malignant lymphomas in Burgundy, France (1976--1977): a new approach using computerized pathological diagnoses (author's transl)]. / Les lymphomes malins en Bourgogne (1976--1977). Etude de leur fréquence par la méthode informatique anatomopathologique.

Pathology laboratories in the Burgundy region have recently been equipped with mini-computers using the same software and working method. This report brings together their histological records, stored on magnetic discs, and describes the first results of this regional data base. Malignant lymphomas were chosen as a pilot study and evaluated between January 1976 and December 1977. After a brief presentation of the method, 246 cases of malignant lymphoma are analysed: 95 of Hodgkins disease, 103 of non-Hodgkins malignant lymphoma of the nodes and 48 cases of extranodal non-Hodgkins malignant lymphoma. The distribution of patients in terms of sex and ten year age groups is analysed, together with the various incidence rates for a year in Burgundy and in its four administrative units (Cote-d'Or, Nievre, Saone-et-Loire and Yonne).

A complete form of testicular feminisation syndrome; a light and electron microscopy study.

A case is described of testicular feminisation syndrome in a 19-yr-old patient with a normal female appearance. A laparotomy with removal of the gonads was performed. The latter looked like testes with intraparenchymal nodules. Light and electron microscopy study of these nodules revealed the presence of immature seminiferous-like tubules and of Leydig cell clusters. The tubules were filled with clear Sertoli cells, few degenerative dark cells and scanty spermatogonia. Thin collagen bundles surrounded the tubules and the foci of Leydig cells without any crystals of Reinke. The immaturity of all these cellular components could be connected with a mutation at a repressive locus which could be responsible for the abnormalities observed in the different steps of androgen action at target cell level.