TELEPATHOLOGY THROUGH THE INTERNET

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TELEPATHOLOGY THROUGH THE INTERNET

• Carlo Alberto Beltrami
• Dept. of Pathology, University of Udine, Italy

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TELEPATHOLOGY

• Is the practice of Pathology at distance
• The visual information managed by the pathologist
  is peculiar no knowledge about number and
  characteristics of images is available a priori
• As a consequence, telepathology has grown less
  rapidly than other specialities (e.g.
  teleradiology)

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TELEPATHOLOGYApplications

• Remote Consultation
• Distant Intraoperative Diagnostic Service
• DistributedReference Case Archive
• Remote Morphometry Lab
• Quality Assessment

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REMOTE DIAGNOSIS

• Static telepathology on selected images
• Dynamic telepathology guided by local pathologist
• Dynamic-robotic real-time telepathology

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INTERNET TELEMEDICINE

• management of information
• cooperation among workgroups

• Management of a particular type of medical
  information
• cooperation among medical professionals

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TELEPATHOLOGYRemote Consultation

• Aid in solving difficult diagnostic problems by
  sending the cases to (distant) expert
  pathologists
• usually carried out by using mail or courier
• no need for realtime

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TELEPATHOLOGY

• BASIC REQUIREMENTS
• Simpleness
• Thrift
• Rapidity

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REMOTE CONSULTATION ON INTERNET

• Realised through Internet Electronic Mail with
  MIME extension
• Asynchronous process sender and recipient
  interact only with the local mail server through
  SMTP and POP
• no real-time
• It is possible to easily carry out multiple
  consultations

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INTERNET ELECTRONIC MAIL

• Protocol for exchange of text messages
• Client/Server paradigm
• It is composed by
• definition of the message format RFC822
• definition of the communication protocol (SMTP,
  Simple Mail Transfer Protocol) RFC821
• Additional protocol for reading e-mail POP (Post
  Office Protocol) RFC1725

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MULTIMEDIA ELECTRONIC MAIL

• Exchange of multimedia messagesMultipurpose
  Internet Mail ExtensionRFC1521-1522
• Extension of e-mail protocol, backward compatible
• text, sounds, images, movies using standard
  e-mail infrastructures

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TELEPATHOLOGYON INTERNET
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REMOTE CONSULTATION ON INTERNET

• We tested the suitability of multimedia
  electronic mail for remote consultation
• by evaluating the accuracyof the remote
  diagnosis performedon hypermedia histologic
  casesof gastrointestinal pathology
• USING ALREADY AVAILABLE HWSW

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MATERIALTelepathology workstations

• UDINE
• HARDWAREMacintosh IIFx, NuVista framegrabber,
  Sony 3CCD, Zeiss Axiophot
• MAIL CLIENTEudora v1.5.1

• TRENTO
• HARDWARELeitz Quantimet, HP700
• MAIL CLIENT elmv2.3.7, with mpack1.4 for MIME
  encoding

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THE TWO LOCATIONS
Trento
Udine
160 km (300 km)
NORTH-EAST ITALY
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Telepathology using Internet Multimedia
Electronic Mail Remote Consultation on
Gastrointestinal Pathology.

• Della Mea V, Forti S, Puglisi F, Bellutta P,
  Finato N, Dalla Palma P, Mauri F, Beltrami CA.
• Journal of Telemedicine and Telecare 1996 228-34

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MATERIAL Cases

• 58 consecutive cases of gastrointestinal
  pathology (gastritis, carcinoma, lymphoma,
  others)
• Gold standard local diagnosis, obtained directly
  through the microscope
• Selection of representative images
• Transmission of images and brief clinical history
  using e-mail

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MATERIALS Images

• Udine 640x480, RGB 24bit (900 Kb)
• Trento 512x512, RGB 24bit (786 Kb)
• JPEG compression (lossy method with variable
  compression levels corresponding to variable
  quality)151 ratio after some test

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RESULTS Images

• Observed compression rates 61-401
• File dimensions 18-158 Kbytes
• Different stainings -gt different
  compression(e.g. mod.Giemsa images greater
  ratios)

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RESULTS Cases

• Each case required an average of 5.9(2-11)
  images
• Average time needed for transmission about 25
  minutes, depending on network traffic and number
  of delivered images(not so important in this
  approach)

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RESULTS Diagnosis

• The overall agreement was reached in 50 out of 58
  casesAgreement86, K-statistic0.835,
  plt0.001
• 2 cases insufficient images for a diagnosis

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Expert consultation in Pathology through the
Internet melanoma vs benign melanocytic tumours.

• Della Mea V, Puglisi F, Forti S, Delendi M, Boi
  S, Mauri F, Dalla Palma P, Beltrami CA.
  J.Telemedicine and Telecare 1997 3
  (Suppl.1)17-19.

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Methods statistical evaluation

• The chance-corrected agreement between local and
  remote diagnosis is assessed by the k-statistic.

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Results diagnoses

• local pathologist 6 malignant lesions, 14
  benign
• remote pathologist 9 malignant lesions, 10
  benign, 1 insufficient.
• Agreement 78.95, k0.58, plt0.002
• Remote diagnosis on the specimens remote
  pathologist agreed with all but two local
  diagnoses
• benign lesion instead of malignant lentigo,
• melanoma instead of Spitz nevus

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Results images

• 5.31.3 images per case
• 56.234.5 Kbytes per image(compression ratio
  13.71)
• 298185 Kbytes per case

Without JPEG compression, a similar case would
use 4.07 Mbytes thus compressed cases are 7.3
of uncompressed ones, and this reduces
transmission time of 92.7.
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Fine needle aspiration cytology of the breast a
preliminary report on telepathology through
Internet multimedia electronic mail

• Della Mea V, Puglisi F, Bonzanini S, Forti S,
  Amoroso V, Visentin R, Dalla Palma P, Beltrami CA
• Modern Pathology 1997 10636-641.

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Materials and Methods

• N of cases (FNAB) 49
• Local diagnosis (through the microscope)
• Selection of the representative images
• Acquisition and compression
• Transmission by e-mail (Internet)
• Remote diagnosis
• Validation of the results

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Materials and Methods Validation of the results

• Golden standard histology
• Chance-corrected agreement k-statistic
• Sensitivity, specificity, positive predictive
  value, negative predictive value, efficacy.

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Materials and MethodsImages

• Mail agent Pathmail v0.62 (Eudora light)
• Acquisition 640 x 480 pixels
• JPEG format
• Compression ratio 25 1

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ResultsImages

• Total 137 images
• Average 2.8 images/case
• Volume/image mean 35 Kbytes/image

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ImagesComparison between breast cytology and
gastrointestinal pathology
Gastrointestal pathology
Breast cytology
N images/case 2.8 4.5 Volume/image 35
Kbytes 54.9 Kbytes Volume/case 98
Kbytes 248 Kbytes
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ResultsDiagnostic agreement

• local vs remote
• 81.6 (k0.63, p lt 0.001)
• local vs histology
• 84.2 (k0.66, p lt 0.001)
• remote (telecytology) vs histology
• 81.6 (k0.61, p lt 0.001)

histology 37/49 cases
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Results

• Sensitivity (TP) 87.5 83.3
• Specificity (TN) 83.3 81.8
• Pos Pred Value 91.3 90.9
• Neg Pred Value 76.9 69.2
• Efficacy 86.1 82.8

Local
Remote
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Conclusions

• A good agreement between local and remote
  pathologists seems to be obtainable on
  cytological diagnoses of breast lesions by using
  Internet e-mail for telecytology purposes

OK
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Telepathology for frozen sections

• 150 consecutive cases
• 3 different local pathologists with different
  experience
• evaluation of acquisition and transmission times
• evaluation of diagnostic validity

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Telepathology for frozen sectionspreliminary
results

• acquisition time acceptable (4 minutes/case)
• diagnostic validity 96.7
• no significant differences among differently
  skewed pathologists
• No stable performance of the Internet (18
  minutes, up to 3 hours)

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Conclusions

• Internet e-mail is a low-cost telepathology tool
  that does not force pathologists to use new
  machines or new technological products as often
  occurs when informatics meets medicine.

The End
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The Italian Telepathology Network

• Udine, Verona, Milano, Ferrara, Ancona, Bari,
  Messina, Sassari
• telediagnosis, telequantitation, distant
  teaching, quality control
• Due to start in 1998

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TELEPATHOLOGY

• BASIC REQUIREMENTS
• Simpleness
• Inexpensiveness
• Quickness