“Some things have to be believed to be seen.” Guy Kawasaki My...

“Some things have to be believed to be seen.”

Guy Kawasaki

My friends,

Tiresias has rightly concentrated on the developments that lead from the announced collaboration of Optiscan with the Mayo Clinic to wit, in-vivo real time digital surgical pathology; the function of Optiscan’s confocal laser endo microscope as the seeing eye of robotic surgery: the replacement of frozen section biopsies and indeed possibly biopsies in general with optical real time digital biopsy. Though he has neglected, he has not forgotten a potential much bigger, though not as exciting role of Optiscan’s digital pathology, the clinic. That is not surgical theatre or hospital, but the clinic, the office, the outpatient medicine which is where the bulk of medicine takes place. You see my friends, the exciting and the dramatic is always pictured as surgery, with sophisticated dramatic action, an intense struggle directly with the cancer cells, ensuring that the malignancy is completely extirpated. But pathology from the clinic is where more, most, pathological specimens come from. This is still mired in original histopathology that any pathologist from the mid-19th century would have no problem understanding or taking a job in any “modern” histopathological laboratory. This is where Optiscan’s real-time digital pathology really comes to the fore. Although, at first blush, this doesn't appear as exciting or as dramatic as the surgical Robotic AI-enabled instantaneous pathology in the operating room, Tiresias has no doubt that this will almost certainly be orders of magnitude bigger than what we are concentrating on at the present time. You see, the way it works at present is that lumps and bumps in tissues are excised from the skin, from the bowel, from the stomach, from the oesophagus, from the mouth, from the bladder and every other site, and that repeatedly, and often times six monthly. The specimens are picked up by pathology “taxis, circling the suburbs and clinics, taken pathology department, then mounted into wax or other material blocks, microtomed (sliced) like salami, stained with a variety of different stains, mounted onto glass slides, often dozens if not hundreds, examined by an histopathologist, who has spent years studying this art, and it is an art, often in the eye of the beholder, looking at fuzzy images of pinkish and blueish material and then supposedly giving the gold standard imprimatur as to what that pathology might be. Of course, when studies are done comparing the agreement between best pathologists in the world with the same specimens the agreement rate between them is poor. Clinicians turn a blind eye to this and pretend that these opinions are indeed the “the gold standard”, the final word, which of course it is anything but. There are new aids coming in all the time and the biggest new aid that has helped and become the crutch for diagnostically destitute, bereft and addled histopathologist is immunohistochemistry. Tiresias has talked of this and how Optiscan enables in vivo real-time immunohistochemistry and we'll come back another time to discuss this again but for today he just mentions it. He does not wish to criticise his struggling isolated and increasing in short supply histopathologists who struggle in the dark to give answers to demanding doctors, surgeons and patients. He recalls his early days at medical school learning by heart hundreds of histopathology slides and knowing that this was not something he wanted to spend his life with. But now back to the main point of this discussion which is the application in-vivo digital AI-enabled networked pathology. This is the future, and this is how it will work.

You see my friends, why go through this antiquated, inaccurate and extremely expensive process when Optiscan can provide the correct diagnosis far more cheaply at the moment of examination in the clinic. Tiresias would like to take a simple example of how this can dramatically change everything and how he sees the future. Let’s take the example on which we have discussed previously. Oral cancer or more correctly oral lesions, most of which are not actually cancer. What happens now, when one of us has a persistent small ulcer or little spot lump somewhere in our mouth. Well, of course, unless it hurts, we ignore it and hope it goes away. Then if it persists, we think and try to ignore it again. Eventually we go to a doctor. They look at it and say it's nothing or give some oral ointment to apply. Finally, if it persists, you are referred to an oral physician, if you are lucky. They will have little clue as to what this is and if it's been there a while they will biopsy. Apart from the medico-legal imperatives to biopsy, there very lucrative financial incentives to biopsy everything, and not just for the clinician but for pathologist, of course. They will throw the specimen into a jar and send it off to the pathologist. The pathologist will do what Tiresias has described above, make all the preparations examine the specimen and take a punt and to be on the safe side, for himself or herself, if they're unsure say that there could be some worrying cells with some large cells, some nuclear polychromasia etc etc and could be pre-cancer or cancer. If the biopsy has not removed the whole lesion, and mostly it won’t have, back for definitive surgical excision then. The surgeon will then assure that has remove the whole lesion, but of course he cannot know that there are no malignant cells left behind. The room for a wide margin in the mouth is not available And so it goes. Now, how it should, can and will work with Optiscan. The oral physician will have an the latest InVue instrument and examines the said lesion. Now it is not going to be all like the CEO/MD of Optiscan has done it thus far, for he is an oral physician and histopathologist he can immediately come up with appropriate topical, or systemic all immunohistochemical or genomic staining and assistance examine the lesion there and then and make the diagnosis and do the appropriate treatment there and then. Most oral physicians, oral surgeons and dentists are not histopathologists. They will need external assistance. But this will be available in real time through AI-enabled networked histopathology with expert human backup online to provide an instantaneous and correct instant diagnosis to enable appropriate treatment. It is examination, diagnosis and treatment at the one consultation. It is far more accurate. It is much quicker. It is a lot cheaper cutting out so much redundant transportation, preparation, examination and pronunciation.

And that's how it can work in many more areas. In the immediate future this can be directly applied to gastrointestinal examinations in endoscopy and colonoscopy, it can be up applied to the skin Mohs surgery, urinary bladder lesions through cystoscopy, it can be applied to not just oral but otorhinolaryngology, and all lesions that can reached.

This is but just a tiny window into the future. Tiresias has no doubt that we are now just at the cusp of where macro imaging just before the introduction of CT, MRI and ultrasound was. But how will this be billed? Tiresias has seen this too, but he has gone too long today and will definitely visit this in another missive.

Until next week