INTRODUCTIONCorrect pathologic diagnosis of cancer is crucial for the optimal selection of therapy [1]. A large subset of tumors require an extensive panel of immunostains for accurate diagnosis [2,3] and often require timely expert consultation. However, some developing countries do not have any pathologists [4], or the available pathologists lack the resources and/or training for specialized diagnoses such as pediatric cancers [5,6]. A number of initiatives, such as the International Union Against Cancer Telepathology Consultation Center (UICC-TCC) [7] in Berlin, Germany, and iPath [8] in Basel, Switzerland, have sought to provide remote pathology consultation via telecommunications. Although such consultations are invaluable for improving patient care, they are not fully effective in the absence of skilled sample preparation and immunohistochemical (IHC) staining at the remote sites.The International Outreach Program (IOP) of St. Jude Children's Research Hospital (St. Jude) has long offered telemedicinebased twinning programs to develop local capacity in developing countries [5]. The Instituto Materno Infantil de Pernambuco (IMIP) in Recife, Brazil (a resource-poor region), is one such partner site [9]. To enhance the quality of pediatric cancer diagnosis at IMIP, the St. Jude Department of Pathology has collaborated with this institution to provide brief, focused training in the U.S.A. for IMIP pathologists, including the use and interpretation of common IHC stains. This training was followed by mentoring and quality control via telecommunications (''telepathology'').Two methods of telepathology consultation are available. Dynamic telepathology supports real-time, interactive consultations in which images are transmitted continually. This method requires more sophisticated and costly equipment and communication infrastructure than does the second method, static consultation, which supports interactive sessions in which only static images are stored and then forwarded for review. We assessed the improvement in diagnostic accuracy that resulted from intensive training of a general pathologist in pediatric cancer histopathology, the implementation of IHC, and telepathology support. We also compared the effectiveness of the two telepathology methods for providing diagnostic review.
METHODS
Pathologist TrainingA junior pathologist newly hired by IMIP with 6 years of medical school training including 18 months of internships, a 2-year anatomical pathology residency, and 6 months of training in oncological surgical pathology was invited to undergo training. IHC staining was not available in the IMIP pathology laboratory at that time, and all histological diagnoses were based on hematoxylin and eosin (H&E) staining only. Because the trainee lacked fluency in English, she received the first 3 months of training in general pathology at the Mayo Clinic's Department of Pathology, from a Portuguese-speaking pathologist with experience in cancer diagnosis. She then completed 3 months of training at St. Jude. The training ...