Telepathology comes of age in Norway

Human PATHOLOGY VOLUME :22

June 1991

NUMBER 6

Editorial Telepathology ‘l‘he cot~c~pl ot using Gtteo \ ittc di;igIIostic J~~ilholog~ services

Comes of Age in Norway niic1-oscx)J)\ lo J,ro-

to IwIlot~’ tocatious \\.a t.irst torIIi~tl1~ tr.stecl a5 Jxii? of’ lhc niiiltiservic-t \l;m;tchllwtts (~~JI~J-:II HosJ,it~il-l.o~~cIl ,,ZiI-J)ort talein .-\J>rIl t 96X. I.‘% (;l;lsa IIleditint~ J~n~jec.~. iIiiti;lted Mrs \VC*J’YIIIotIritcct on the stage of’ 2 IiIicroscoJx .Itt;Ictird IO ;I \,itltao c;iii~er;i. Black ;ind white images of tiislologi~: set liotb of surgical specimclis ;itltl staillcd 1~looti smt’;113 \vtw Ir~tIIsIIiitttd flx)Iil ;I relrniedic-inc site, ha 1\ 10 ttir c.liIIic ;I( (tic ail-Jx)rt, the rcfki-ring IiosJ>it;tl IIIitm ;tbxv via ;I tIii~m)w;~ve Ic.t~c~otriIii~itii~~iIio~n liri’kdgv. ‘J’tir \idc~~ wIiier;i attxhrd 10 the Iiiicr0scoJw 11icI standarct~ of commercial teJe\,isioti (-IX3 .icti\v 4c;i11 lirlrs resolving 300 to 330 test lilwi). hIan\ specinit3l~ \sYJ‘~’ viewed OJI ;i video IIioIIi(oI loc;ited a( I ht. hIas:;;~ch~lwtts ~kmer;il HosJ>ital.’ ‘l’r.kcasts wt’w live ;und iti 13.31 t imv. defining ;i dynamic iIiI;tgiIig 4\ stem. :tncl ttit. slitles niounttd 011 the IIiic.I-0scoJ)c stage ~J‘C ~iio\~etl ,it)out In ;I trc.hIiiciaIi at thr ;iirport, dirr~~ted In ttic voice ot‘ the Jx~thologist iit ttit, hospit;il. thr tli;tgIiostic site. I‘tir tectiniciari J~rovidetl intorniation 011 st;riII colors to the J~aftiologist wtirn Iieedtxl. I‘his ea~.l\-t~lqxitholog~ svcteni did not J,rovide color images ,411‘;I ~iitmis tot- thr corisultiIig Jxiftiologist to nio\~e shttes .incl cx)Iitrot other IriicroscoJx tunctioris. I‘tiv tiI-st J)ut)lic d~IiioIistlatioIi ot‘a d?!iaInic teleJxithologv svstcm iIic.orJx~r;itiri~ t\vo ;iddItioIiat t’v;itures, color- 1 idw ~JKI rot)otic 1nIcrosc0Jn. hiis on August 20, I Wti. twtwtwi Fort Willimi HeauIIiorit Arm\ hledical CcIIter (k:l kiso, ‘I‘S). whew the Jxttient. II robotic. IiIic-Ix)scx)pic-. ar~ct ;I video up-link ~vtv.2 located. and \VashingtoIl. IX:. the sitt. of the video down-link ar~ti ;I diagIiostic teleJ~;ittiology workstatioI~. .I‘he kkJ~;ittiologist in Washington, DC was Dr AlesandeIW. hlitler I II, \I ho had come fr01n Chicago to Jxirticipatc in ttic cilrriroIistI~;itioII.‘~~~ Video irxiges were trarismitted \,ia the SHS-3 (:OhlSX’I‘ satellite. using ;t 30 InHz transJx)IIdvr, ;111d the rotx~tic Inicroscope in El l’aso was wntrollt4 OVCJ- ~eleJ~hone lines tjv 1)~ Miller in

b’ashing~on. IX:. white he \ iewcct ;I hwast trcmn set tion 011 ;I color monitor. Xlso in 1!f86, the first cx~ri~mcrci;rl }~J‘O~OCyJKof ;I c.oIor videoirol~otic. telepatholoq::\ L sv5ltm \vas c‘on5tiu.ted tn (:orat)i Internation;~t ‘1 elenirtrics, Inc. as Jxirl of’ ;I cx)rJx~r;itel; financed ,joint I Illitect States~;lJ’;lIltw \.(‘Jl~LlJ-~.” I’his teleJx~thotog~ systmi incorJx)r;itvd high-definition televisiou ( I ,0.50 scan lines Jmwitlirig rcsotutiwi ot’~~pJ)ro~iliiatel~~ 700 test lines), c~ustoniic.etl analog-digital and digital-,uialog encoders atid decodtm designed to tiItW the: diagnostic imarid ;i l~roati bad kdeaging nreds of J~athotogists. c.omIiiuIiicatioIis c.haIiriet with ;i ba~ltl width of I:! I~HL. ‘l‘he technician manipulating the microscope atagc (ontrols and f’ocus at the r&rrirlg site. as iI1 the hlassachuwtts (;enrr;~l Hospital-Logall ;I\irJwrt pr(!jt‘ct, iv35 I-epl;icetl tn iricorJx~ratiIig a fulls robotic motorimd ligtlt nlicr&ope into the (:c~rat;i system. hli~~~oscoJ~e functions. including stage nic~veni’cnts, niagIlitication, a11d illumination. were J,laccd under the ~01~trol co~lsolr

ot’ the consulting pathologist aeattxi at the of 21diagnostic workstation equipped with mic roscope ~~orltrol panels and ;I high-1xw~lution video monitw. ‘I’he system inclcdetl
the remote tetepathologist scanning the histologic sections. Also inc~luded was a Llnix-hased Jjatient dar&w mxlagenlent Jmckage.“.” Forrrl.~l tests on umparahlv video svstems showed that high levels of tli;igIiostic. ;iccurIicy could be achieved using video niicrosc~oJ~\~. “‘.I ’ ,i‘tie C:or-at% svsteni 1~x4 tested at se\‘eraI universitv tiiedical ctmtt& iii ttic. United States over the nest 3 vears. ‘1%~ tirst conimercial version ot’ ;I dynmiir highresolution rolmtic relepatholyq svstt’m was nianufactured hv (brabi (hlodel LIS 1000) in the L’nitect States u~ingJapmesr video. telecomnl~lnications, and robotics h;u-dware and American conIpute~~s and software. ‘l‘his system t,ecame oper;~tional in Atlanta, GA, in May 1990, xid has been in use tor wer 1 year.

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Jxttholo$sts

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HUMAN PATHOLOGY

Volume 22, No. 6 (June 1991)

namic and static pathology imaging in a clinical environment. ‘I~he design of the telepathology system of Nordrum et al was constrained by the specifications of the telecommunications system available to the investigators. The svstem was designed to use a band width corresponciing to approximately 3:! telephone channels (ie, 0. 1 mHz). or approximately one hundredth the capacity of the Atlanta telepathology microwave channel. In contrast to the dynamic system in i\tlanta, which sends high-resolution images of moving tissue sections without Ioss of image detail. the Norwegian system is described as showing very siqnificanc image degradation when a tissue section 1s moving OJI the microscope stage. This is because of the high degree of image compression (ie. information subtraction) that is necessary to transmit representations of moving imaKes over the narrower band width Norwegian telemedlcine network. ‘I‘he strategy of the Norwegian group was to compensate for their limited band width by grabbing video images of fields of interest, storirlg them without compression, and then separately transmitting them as high-resolution static images fi)r examination by pathologists. A spinoff of this protocol was that it provided Nordrum et al with an opportunitv to evaluate the relative merits of both dynamic and static telepathology imaging, since their system is routinely operated in both modes. ‘I-hey found that motion was important for the critical steps of determining specimen orientation on the slide and for general interpretation of histologic details. l’he higher-resolution pictures produced in the static imaging mode were considered to be of’ excellent quality and appropriate for frozen section diagnoses. It should be noted that the resolution obtained by static imaging in Norway was comparable to the resolution of‘ the <;orabi I>?i- 1000 ‘I‘elepathology System in Atlanta, operatecl in the dynamic mode. ‘l‘hus, where sufficient band width is available, it is not necessary to revert to static imaging to obtain highquality images. Ghile the concept of remote diagnoses in pathology is being espoused hy a growing number of pathologists worldwide, the time line for large-scale implementation of telepathology into pathology practice is a matter for s1_“cLilatiori.“‘~” It is typically dif’ficult to preclict time lines for iiiif>lernentatioii of novel technologies early in their development.lx What might be anticipated if the evolution of imaging technologies in another field, radiology, can serve as a puide is that user demands will be for systems 01 mcreasing sophistication and capabilities once the technology is widely accepted into practice. I!’ It is reasonable to expect that if pathologists incorporate telepathology into their practices, they will begin to insist on systems that do more than provide a second opinion or disseminate educational materials, the main functions of static imagir_tg systems. For many diagnostic applications, static Ima@ng alone may be useful but insufficient for diagnostic purposes clue to limitations placed on a consulting pathologist who is given little or JIO control over the selection of microscopic fields for display on the static system’s

and the Grady Memorial Hospital. over 4 miles apart, consult with one another OJI a variety of diagrostic problems using telepathology. A private dedicated point-to-point microwave telecommunications system links the two hospitals. Images are transmitted at the rate of 30 images per second in full color at high resolution. ‘This system is also the first duplex (full) bidirectional) telepathology system. Pathologists at the Emory and Grady Hospitals C~JI both transmit and receive slide specimen images. Both hospitals have consulting pathologists on their staf’fs. T’herefore, both pathology departments rvere equipped with identical robotically controlled motorized microscopes with video cameras. to send images, and with workstations with monitors and controls for a robotic to manipulate the microscope at the microscope, other hospital. ‘I-his enables the pathologists at each institution to show slides to their colleagues at the complimentary site. Against this backdrop, a second type of telepathology system, the static imaging svsteni, has been telepadeveloped in recent years. 11’ Static ‘inia+ng thology systems ha\re the advantage of‘ b&g less expensive than dynamic systems, but have limited capabilities as well. Static imaging systems. as IveIl as other slow-scan systems, use telephone lines or equivalent channels to transmit still images instead of the costliei broad-band telecomnlunicatic,ns channels used fog full-motion dynamic systems.‘:‘.’ 1 A tracie off is that far less information is transmitted. typically a half dozen or fewer preselected microscopic fields per case. Furthermore, the consulting pathologist has no direct control over the microscope. In contrast, during a typical dynamic imaging session with a broaclband robotic telepathology system, thousands of images are transmitted as the consulting pathologist moves the microscope stage about in order to orient the specimen, select diagnostic fields. fine focus the microscope, and optimize the visualization of details in the specimen. A modern static imaging system can be thought of as a video-FAX: single static images are selected and sent at relatively slow speed to the end user. They represent an application of chip-based image grabbet board technologies. These devices provide a means to capture color video images and store them. Once stored, the images can be down loaded to another computer terminal and viewed at the convenience of the computer operator. Static imaging systems are useful for educational purposes ancl as a means for consultation in certain settings. Our experience indicates that they are a poor substitute for dynamic systems when a pathologist is unavailable to select the putative diagnostic fields in tissue specimens at the transmitting site. In this issue of Huttmtt Pathology, Nordrum et al describe a hybrid static-dynamic telepathology imaging system that they are using to provide frozen section diagnostic services to several remote hospitals in northern Norway. Ii ‘l’his report is important for two reasons: it contributes to the proof of the telepathology concept and it considers the value of both dy512

EDITORIAL (Weinstein)

niotiitot-.‘2 l‘his IS in contrast to cl~namic itnaging, wltich pro\ ides ;I ille;tIIs for twnotel~ crmtt-ollitlg all robotic tnicm)sc~opc: t‘urtctions. What IS likeI!. to happvn is that static irmging features, inducting itnap! gral~l~itig attcf digital storage anal I-ett-irval capabilities. lvill be it~cot~pot~~ited ittto the nest genetxtioti of‘ c01-nmet-cd ctytlantic tt~lepttholog~ imaging systems along the lint-s tlrsc-ritxd in K’ot-way. Ve~Idor-s 1ll;1\’ choose 10 sell the static. inqitlg nnoclUles of- f’itll-fwtitt-e relt.p;lfholog~’

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its ;tti ;ippro;t~~h to itttroducit~~ telep;ttholog\ into 0nc”s ptx2ic.e. F,nifqitig frc~iil cxperitnetits such ;tlr the northern Nol-v;;~~ leleptholog~ ptx?ject is 211 untlerstattclin? of how ;ttfv;tttc-etl video aid rot)otic~ trclttiologi~s mtghr tw used hv hut-gid pathologists and cvtol~atholoysts in the turure.- “” .l‘he! are especidly vdtt;thk txx2usr thw help to def‘inv pat-arnetcrc lot- f’ut III‘C c.linic dl I rials in adtlition to idmtifvitig practiw ;tpplic.;ttiotis 01 tttr trtc httolog!. itantic

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REFERENCES

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