Q & A
Q. How is it possible to get a second opinion quickly on a biopsy, cytology, or bone marrow slide when the hospital or laboratory is situated in a remote area outside the United States? I am interested in knowing because my hospital and medical school are located in Nepal.
A. Through our nonprofit organization, Pathologists Overseas, we have sent many volunteer pathologists to work in developing countries over the past 10 years and brought back hundreds of cases to the United States. We are familiar with the problem of trying to obtain a second opinion when practicing in a rather isolated environment. We have been using the traditional glass and paraffin method, but we are investigating the use of electronic methods for consultations.
When we operate full-time projects in Kenya, Nepal, and Madagascar, volunteers go back and forth every two or three weeks, and, in addition, expatriates from the hospitals also return home periodically. When challenging cases are encountered, the volunteers bring the slides, blocks, and, sometimes, fixed tissue home for consultation. The consultant's opinion is relayed back to the project site by fax or e-mail. More than 100 consultations have been processed successfully this way over the years. The advantage of this method is that the consultant can work up the case thoroughly with special stains and immunologic markers. The main disadvantage is that the turnaround time can be up to three or four weeks. In urgent situations, international couriers, such as DHL, are used to transport the slides and blocks to the United States for consultation. This costs about $50 and is not practical for routine use.
The advent of the Internet has made it possible to set up a telepathology system for consultation, and we have done this. Most major cities, even those in developing countries, have connections to the Internet. However, the bandwidth generally precludes any real-time connection. At Patan Hospital in Nepal and at our SALFA project site in Madagascar, for example, the connection speed is 28.8 kbps. The time difference between the United States and these overseas sites also makes any real-time consultation impractical. We are convinced, therefore, that the only practical solution is off-line transmission of the electronic image(s).
The February 2001 issue of CAP TODAY provides a good discussion of digital imaging. The most sophisticated system is to digitally capture the entire slide and upload the image to a server connected to the Internet. It may take a remote site a few hours to upload the image because of the slow bandwidth, but the consultant can view the image via a higher-speed connection. These systems typically cost more than $100,000 to set up and have not gained popularity beyond a few academic centers supported by research grants.
A more practical approach is to capture still images of selected microscopic fields and transmit them via e-mail attachments. A turnkey digital camera setup can be acquired for between $2,000 and $5,000. Recent reports1 indicate that some off-the-shelf digital cameras can take photomicrographs of reasonable quality through the microscope's eyepiece. One such camera is the Nikon CoolPix 900. In Dr. Victor Lee's hospital, St. Jude Medical Center in Fullerton, Calif., it's used routinely to take photomicrographs for conference presentations. A local machinist fashioned an adaptor to hold the camera steady against the eyepiece, making it easier for the photographer. The CoolPix 900, with 1.3 megapixels, produces adequate image quality. A used model typically sells for $300 on the Internet auction sites. The more up-to-date models—950 and 990—sell for about $500 and $900, respectively.
We sent a CoolPix 900 camera to our project site in Madagascar and taught the pathologists and trainees how to use it. Recently, Pathologists Overseas' headquarters in the United States received excellent digital images of a soft tissue tumor removed from a Madagascar patient and forwarded images to about 30 pathologists (volunteers with the overseas program) in the United States, Canada, and France. Within a few days, about 20 replies with diagnoses were returned to the Pathologists Overseas project in Antananarivo, Madagascar. The advantage of this system is its low cost (no additional costs after the initial investment of about $400 for the hardware) and the timeliness with which results can be sent back to the project site (within 24 hours). The chief disadvantage is that an experienced pathologist is needed to select the appropriate fields to photograph. Therefore, this system will not work at remote locations without a pathologist on-site.
Finally, don't overlook the availability of local consultations. The Tribuvan University Teaching Hospital in Katmandu has a pathology training program and a knowledgeable staff. Patan Hospital also has an experienced pathologist. It would be helpful if you and others were to develop a local network to share interesting and challenging cases.
Heinz R. Hoenecke, MD
Victor W. Lee, MD, PhD