focus on technology: how important is resolution in telecytopathology?

7
Focus on Technology How Important Is Resolution in Telecytopathology? Rachel Q. McMahon, BS, CT 1 ; Erin E. McCarthy, BS, CT 2 ; Scott J. Hetzel, MS 3 ; Kasturi Das, MD 4 ; and Jimmie Stewart III, MD 5 BACKGROUND: The authors conducted an analysis of 2 telepathology systems with different resolutions to determine how resolution affects the pathologists’ ability to provide preliminary diagnoses for fine-needle aspirations (FNA). METH- ODS: FNA cases evaluated by telepathology between February 1, 2011 and January 18, 2012 were reviewed. Concordance indices between preliminary and final diagnoses were calculated for cases assessed with two proprietary systems (the Remote Meeting Technologies iMedHD system and the Olympus NetCam system) using 3 diagnostic classifications (nega- tive, atypical, and suspicious/positive). A Wilcoxon rank-sum test was used to compare the number of passes necessary to determine adequacy. RESULTS: In total, 298 NetCam cases and 26 iMedHD cases were evaluated. The concordance index, which was calculated using the 3 classifications, was 0.943 (95% confidence interval, 0.922-0.963) for NetCam compared with 0.951 (95% confidence interval, 0.898-1.000) for iMedHD. The mean value for the number of passes required to determine adequacy was 2.2 for NetCam and 2.1 for iMedHD (P 5.838). CONCLUSIONS: The results from sta- tistical analyses demonstrated no difference in the concordance indices between preliminary and final diagnoses or in the number of passes necessary to render adequacy between the 2 telepathology systems. However, because it had higher resolution along with other features, the iMedHD system achieved greater user satisfaction. Cancer (Cancer Cytopathol) 2014;122:546-52. V C 2014 American Cancer Society. KEY WORDS: telepathology; telecytopathology; immediate evaluations; preliminary diagnoses; fine-needle aspirations. INTRODUCTION Telepathology is defined by the College of American Pathologists as the practice of pathology in which a pathol- ogist views digitized or analog images (video or still) and renders an interpretation for inclusion in a formal diag- nostic report or for documentation in the patient record. The College of American Pathologists further categorizes telepathology into different modes, including static telepathology (interpretation based on prese- lected, still images), dynamic telepathology (viewing real-time images), and whole-slide imaging. 1 The use of telepathology as an educational and diagnostic tool has been on the rise since the mid 1980s. 2,3 It has recently proven to be sufficient for making timely and accurate preliminary diagnoses of specimens obtained by fine-nee- dle aspiration (FNA). 2,4–6 For the purposes of this article, this technology is referred to hereinafter as telecytopa- thology, because it is solely used for the assessment FNA specimens. Studies increasingly are demonstrating high concordance and accuracy rates for preliminary diagnoses provided by dynamic telecytopathology versus direct microscopic evaluation. One 2008 study reported a Corresponding author: Rachel McMahon, BS, CT, Cytopathology Laboratory/D4-259, University of Wisconsin Hospital and Clinics, 600 Highland Avenue, Madison, WI 53792; Fax: (608) 263-6453; [email protected] 1 Department of Cytopathology, University of Wisconsin Hospital and Clinics, Madison, Wisconsin; 2 Department of Cytology, Wisconsin State Laboratory of Hygiene, Madison, Wisconsin; 3 Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, Wisconsin; 4 Department of Pathology, North Shore-LIJ Hospital Systems, Lake Success, New York; 5 Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Received: October 30, 2013; Revised: December 16, 2013; Accepted: December 20, 2013 Published online March 27, 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/cncy.21404, wileyonlinelibrary.com 546 Cancer Cytopathology July 2014 Original Article

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Page 1: Focus on technology: How important is resolution in telecytopathology?

Focus on Technology

How Important Is Resolution in Telecytopathology?

Rachel Q. McMahon, BS, CT1; Erin E. McCarthy, BS, CT2; Scott J. Hetzel, MS3; Kasturi Das, MD4;

and Jimmie Stewart III, MD5

BACKGROUND: The authors conducted an analysis of 2 telepathology systems with different resolutions to determine

how resolution affects the pathologists’ ability to provide preliminary diagnoses for fine-needle aspirations (FNA). METH-

ODS: FNA cases evaluated by telepathology between February 1, 2011 and January 18, 2012 were reviewed. Concordance

indices between preliminary and final diagnoses were calculated for cases assessed with two proprietary systems (the

Remote Meeting Technologies iMedHD system and the Olympus NetCam system) using 3 diagnostic classifications (nega-

tive, atypical, and suspicious/positive). A Wilcoxon rank-sum test was used to compare the number of passes necessary

to determine adequacy. RESULTS: In total, 298 NetCam cases and 26 iMedHD cases were evaluated. The concordance

index, which was calculated using the 3 classifications, was 0.943 (95% confidence interval, 0.922-0.963) for NetCam

compared with 0.951 (95% confidence interval, 0.898-1.000) for iMedHD. The mean value for the number of passes

required to determine adequacy was 2.2 for NetCam and 2.1 for iMedHD (P 5.838). CONCLUSIONS: The results from sta-

tistical analyses demonstrated no difference in the concordance indices between preliminary and final diagnoses or in the

number of passes necessary to render adequacy between the 2 telepathology systems. However, because it had higher

resolution along with other features, the iMedHD system achieved greater user satisfaction. Cancer (Cancer Cytopathol)

2014;122:546-52. VC 2014 American Cancer Society.

KEY WORDS: telepathology; telecytopathology; immediate evaluations; preliminary diagnoses; fine-needle aspirations.

INTRODUCTION

Telepathology is defined by the College of American Pathologists as the practice of pathology in which a pathol-

ogist views digitized or analog images (video or still) and renders an interpretation for inclusion in a formal diag-

nostic report or for documentation in the patient record. The College of American Pathologists further

categorizes telepathology into different modes, including static telepathology (interpretation based on prese-

lected, still images), dynamic telepathology (viewing real-time images), and whole-slide imaging.1 The use of

telepathology as an educational and diagnostic tool has been on the rise since the mid 1980s.2,3 It has recently

proven to be sufficient for making timely and accurate preliminary diagnoses of specimens obtained by fine-nee-

dle aspiration (FNA).2,4–6 For the purposes of this article, this technology is referred to hereinafter as telecytopa-

thology, because it is solely used for the assessment FNA specimens.

Studies increasingly are demonstrating high concordance and accuracy rates for preliminary diagnoses

provided by dynamic telecytopathology versus direct microscopic evaluation. One 2008 study reported a

Corresponding author: Rachel McMahon, BS, CT, Cytopathology Laboratory/D4-259, University of Wisconsin Hospital and Clinics, 600 Highland

Avenue, Madison, WI 53792; Fax: (608) 263-6453; [email protected]

1Department of Cytopathology, University of Wisconsin Hospital and Clinics, Madison, Wisconsin; 2Department of Cytology, Wisconsin State

Laboratory of Hygiene, Madison, Wisconsin; 3Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, Wisconsin;4Department of Pathology, North Shore-LIJ Hospital Systems, Lake Success, New York; 5Department of Pathology and Laboratory Medicine,

University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin

Received: October 30, 2013; Revised: December 16, 2013; Accepted: December 20, 2013

Published online March 27, 2014 in Wiley Online Library (wileyonlinelibrary.com)

DOI: 10.1002/cncy.21404, wileyonlinelibrary.com

546 Cancer Cytopathology July 2014

Original Article

Page 2: Focus on technology: How important is resolution in telecytopathology?

diagnostic concordance rate of 97% and a diagnostic

accuracy of 99% when comparing diagnoses rendered by

telecytopathology with the original diagnoses of previ-

ously finalized cases.4 Alsharif et al observed a discrepancy

rate as low as 1.8% between the preliminary diagnosis

established by telecytopathology and the final diagnosis of

371 cases.5 Kim et al reported that there was no significant

statistical difference between preliminary diagnoses estab-

lished by telecytopathology and on-site rapid diagnoses

compared with the respective final diagnoses of 40 pancre-

atic specimens obtained using endoscopic ultrasound

(EUS).6 The use of telecytopathology also reduces work

flow interruptions for pathologists whose offices may be

at a great distance from the FNA procedure area(s).7–9

Heimann et al reported that providing immediate assess-

ments by dynamic telecytopathology saved pathologists

30 minutes on average per procedure compared with pro-

viding on-site immediate assessments.2 A 2012 study

indicated that the mean procedure time for pathologists

was 0.2 hours when telecytopathology was used versus

0.74 hours for conventional on-site evaluations.10 Finally,

Kim et al reported an average total of 7.5 minutes spent

by the cytopathologist in rendering a rapid assessment for

FNA procedures by telecytopathology.6

In light of the increasing popularity of telecytopa-

thology, several imaging systems have become available,

making it difficult to decide which system would best suit

a growing cytopathology FNA service. The cytopathology

laboratory at the University of Wisconsin Hospital and

Clinics (UWHC) has access to 2 different dynamic telecy-

topathology systems, allowing for a direct comparison to

be made between the 2 in terms of diagnostic accuracy,

ease of use, and cost effectiveness. The current retrospec-

tive study was performed to compare the RMT iMedHD

system (Remote Meeting Technologies, Melville, NY)

with the Olympus NetCam system (Olympus, Center

Valley, Pa) largely with regard to resolution using statisti-

cal analysis as well as practical value.

MATERIALS AND METHODS

Background

The cytopathology laboratory at UWHC has been using

dynamic telecytopathology to provide preliminary diagno-

ses of cytologic specimens since 2005 using the Olympus

NetCam system for FNAs guided by ultrasound (US),

computed tomography (CT), EUS, and endobronchial

ultrasound (EBUS). In February 2011, the UWHC cyto-

pathology department began providing preliminary diag-

noses for FNA procedures at Watertown Regional Medical

Center (WRMC), a facility located approximately 47 miles

from UWHC, using the RMT iMedHD system. Table 1

outlines the specifications of the 2 systems.

A cytotechnologist is responsible for attending FNA

procedures at which he or she makes slides from the FNA

material (1 is air dried and 1 is fixed in ethanol for each

pass), stains the air-dried slides using Hema-Diff stain,

and screens them for adequacy. Before screening the slides

TABLE 1. Comparison of the Remote Meeting Tech-nologies iMedHD System and the Olympus NetCamSystem

RMT iMedHD (Remote

Meeting Technologies,Melville, NY)

Olympus NetCam(Olympus, Center Valley, Pa)

Workstation components

Microcast HD Pro-Lite

Camera and control box

(OPTRONICS, Goleta,

Calif); rmtiServ-900 HD

video encoder; cat5e ether-

net cable; microscope with

C-mount; desktop PC and

monitor

DP 70-72 digital camera (Olym-

pus, Center Valley, Pa); Micro-

Suite Five Software; PCI

graphics card with hard drive;

microscope with C-mount;

desktop PC and monitor

Resolution

1920 3 1080 Pixels, 60

frames per second; HD

performance (see Fig. 1)

800 3 600 Pixels; optimized for

static imaging (see Fig. 2)

Software

Web-based system, no

software required

Requires the Olympus MicroSuite

Five imaging software to be

loaded on each transmitting

workstation

Controls

Independent viewing

controls allow each guest

viewer to adjust the color,

brightness, and contrast

Only the system operator has

control over the camera

parameters

Security

Invitation and

authentication are required

for any participant to view

the streaming images,

providing heightened

security

No invitation or authentication

required, but all participants

must log into the hospital

intranet to view the images

Cost

Approximately $30,000

(includes charges for initial

project management,

intelligent video equipment

solution package and

image-capture feature) and

approximately $6600 per

year for ongoing yearly

service/support and RMT

MultiView5

Pricing information is not

available, because this system

is no longer available for

clinical use

Abbreviations: Cat5e, enhanced category 5 cable; HD, high definition; PC,

personal computer; PCI, peripheral component interconnect.

Focus on Technology/McMahon et al

Cancer Cytopathology July 2014 547

Page 3: Focus on technology: How important is resolution in telecytopathology?

at 1 of 5 telecytopathology stations located outside of the

laboratory, the cytotechnologist will open the telecytopa-

thology program on the computer so the cytopathologist

on service can view the material from the laboratory or

from his or her office. The cytotechnologist is then able to

display diagnostic areas for the cytopathologist while pro-

viding pertinent clinical information and discussing the

case over the telephone. The clinician who performed the

FNA can see what the cytopathologist is viewing on the

computer monitor and can communicate by telephone as

well if needed. Once a preliminary diagnosis is established

by the cytopathologist, this information is conveyed to

the performing clinician by the cytotechnologist or

directly over the telephone by the cytopathologist.

Because the cytopathologist does not physically

attend the FNA procedures, it is possible to have 2 or

more procedures in different departments happening

simultaneously, thereby increasing the number of cases

for which he or she is available for guidance. Providing an

immediate adequacy assessment improves patient care

and clinician satisfaction by reducing the number of

repeat FNA procedures, and the addition of a preliminary

diagnosis allows for early triage of patients for the appro-

priate treatment plan. For example, patients in UWHC’s

endocrine thyroid FNA clinic may be scheduled for surgi-

cal evaluation if a preliminary diagnosis of atypical or

greater is reached. However, no definitive surgery is per-

formed until the final diagnosis is made.

Analysis

The study began with a query of the specimen database

for all of the FNA cases on which telecytopathology was

used at UWHC and WRMC between February 1, 2011

and January 18, 2012. At the time of data collection, there

were 3 cytopathologists on staff at UWHC with an experi-

ence range of approximately 8 to 25 years, and there were

6 cytotechnologists with an experience range of 6 months

to 20 years. Only the organ systems that are routinely

aspirated at both locations, including thyroid, lung,

lymph nodes, liver, and salivary gland, were included. All

of the specimens were obtained by the radiology depart-

ments of both institutions using CT or US guidance.

Cases that were given a preliminary diagnosis of

“nondiagnostic” were excluded, because as these results

were attributed to sampling error.

A statistical analysis was performed to determine

whether there was a higher concordance rate between pre-

liminary and final diagnoses for those cases that were

assessed using the RMT iMedHD system compared with

the cases that were assessed using the Olympus NetCam

system. The concordance indices and 95% confidence

intervals (CIs) between the preliminary and final diagno-

ses were calculated using the methods described in Harrel

et al.11 The indices were calculated using 3 classifications

(negative, atypical, and suspicious/positive). We chose to

combine the suspicious and positive categories because, in

many cases, a preliminary diagnosis of suspicious was

given only because the pathologist wanted to review the

fixed slides (stained with Papanicolaou stain) and/or cell

block material before making a positive diagnosis. To

compare the preliminary and final diagnoses of our cases,

both sets of data had to have matching diagnostic catego-

ries. Because the “nondiagnostic” category was eliminated

from our analysis, this led to the exclusion of 1 UWHC

case for the calculation of concordance indices; that case

was given a preliminary diagnosis of “atypical” but later

was finalized as “nondiagnostic.” The overall percentage

of preliminary diagnoses that matched the corresponding

final diagnoses also was calculated. Finally, a Wilcoxon

rank-sum test was used to compare the number of passes

necessary before a diagnosis was rendered at each location.

All statistical tests were 2-sided, with the significance level

set at 0.05.

RESULTS

In total, 298 cases from UWHC and 26 cases from

WRMC were evaluated (Table 2). The concordance index

for UWHC was 0.943 (95% CI, 0.922-0.963) compared

with a concordance index of 0.951 (95% CI, 0.898-

1.000) for WRMC. These results indicate that there was

no significant difference in concordance between prelimi-

nary and final diagnoses at the 2 locations.

There was no significant difference (P 5 0.838) in

the number of passes necessary to render adequacy between

the 2 sites. The mean 6 standard deviation number of

passes for UWHC was 2.2 6 1.5 passes, and the median

was 2 passes.1–3 For WRMC, the mean 6 standard devia-

tion number of passes was 2.1 6 1.2 passes, and the median

was 1.5 passes1–3 (Table 3). Table 4 provides a breakdown

of preliminary diagnoses in relation to the respective final

diagnoses. Table 5 indicates the percentage of cases in

which the preliminary and final diagnoses matched.

It is worth noting that the disparity in the number of

cases evaluated by the Olympus NetCam system and the

Original Article

548 Cancer Cytopathology July 2014

Page 4: Focus on technology: How important is resolution in telecytopathology?

RMT iMedHD system could be considered a limitation

in this study. Although the statistical analyses conducted

in this study are valid even with a significant difference in

sample sizes, a similar study using more equivalent sample

sizes could be beneficial to confirm our results.

DISCUSSION

The results of our statistical analysis indicate no signifi-

cant difference in the concordance indices or in the num-

ber of passes necessary to render adequacy between the

Olympus NetCam system at UWHC and the RMT

iMedHD system at WRMC. This is somewhat surprising,

because it is counterintuitive to observe no difference

between a system with a substantially higher resolution

and another system with a much lower resolution. A par-

tial reason for this is the presence of a cytotechnologist on

site at the FNA procedure. Several studies have acknowl-

edged that a competent on-site operator is essential to the

successful use of a telecytopathology system.2–5,7,10 Per-

sonnel trained in cytomorphology can rapidly locate and

emphasize diagnostic areas on a slide. Transmitting these

areas on high magnification allows the cytopathologist to

make a preliminary diagnosis with relatively high accuracy

and few FNA passes. If individuals with a variably lower

level of training were used to operate the telecytopathol-

ogy system, then the lower resolution might have caused a

more significant difference.

Overall, our data demonstrate that both telecytopa-

thology systems allow cytopathologists to make accurate

preliminary diagnoses. Table 4 indicates the number of

cases in each diagnostic category that were upgraded,

downgraded, or remained in the same category once final-

ized. One case, a lymph node specimen from UWHC

(which subsequently was excluded from the concordance

index calculations), was given a preliminary diagnosis of

“atypical” and was later finalized as “nondiagnostic.” The

preliminary diagnosis was based on the presence of

necrotic material, which can be suggestive of carcinoma.

Upon review of all of the slides, the case was deemed

“nondiagnostic” because of the lack of viable cellular

material; the slides contained only inflammation and

necrosis. Similar discrepancies because of a paucity of

diagnostic material are not uncommon in telecytopathol-

ogy.2,4,5 Lack of diagnostic material is also a universal

problem for on-site evaluations. Another outlier on Table

4 was a lymph node specimen from UWHC that was

given a preliminary diagnosis of “negative” and was later

finalized as “positive.” The cytopathologist arrived at this

diagnosis after reviewing the flow cytometry results, which

revealed a lymphoproliferative disorder. Flow cytometric

analysis is routinely used to determine lymphoprolifera-

tive disorders that morphology cannot reliably diagnose.

Heimann et al reported a similar discrepancy in which a

bone aspirate originally called “blood and increased

white blood cells present” was later proven to be a B-cell

TABLE 2. Total Number of Cases From WatertownRegional Medical Center and University of Wiscon-sin Hospital and Clinics by Specimen Type

No. of Cases

Specimen Type UWHC WRMC Total

Liver 7 3 10

Lung 104 8 112

Lymph node 105 2 107

Salivary gland 17 2 19

Thyroid 65 11 76

Total 298 26 324

Abbreviations: UWHC, University of Wisconsin Hospital and Clinics;

WRMC, Watertown Regional Medical Center.

TABLE 3. Number of Passes Required to Make aPreliminary Diagnosis

No. of Passes

Variable UWHC (n 5 298) WRMC (n 5 26)

Median 2 1.5

Interquartile range 1-3 1-3

Mean 2.2 2.1

Standard deviation 1.5 1.2

Abbreviations: UWHC, University of Wisconsin Hospital and Clinics;

WRMC, Watertown Regional Medical Center.

TABLE 4. Cases Categorized by Preliminary Diag-nosis and Respective Final Diagnosis

Final Diagnosis

PreliminaryDiagnosis Nondiagnostic Negative Atypical

Suspicious/Positive

UWHC

Negative 0 65 12 1

Atypical 1 6 19 23

Suspicious/

positive

0 0 4 167

WRMC

Negative 0 9 2 0

Atypical 0 0 1 1

Suspicious/

positive

0 0 0 13

Abbreviations: UWHC, University of Wisconsin Hospital and Clinics;

WRMC, Watertown Regional Medical Center.

Focus on Technology/McMahon et al

Cancer Cytopathology July 2014 549

Page 5: Focus on technology: How important is resolution in telecytopathology?

lymphoma after flow analysis.2 Table 5 demonstrates that

the majority of cases with a preliminary diagnosis of

“suspicious/positive” or “negative” were finalized in the

same diagnostic categories. There were more discrepancies

in the “atypical” category, because those diagnoses were

often upgraded or downgraded after the eventual review

of fixed slides and/or cell block material. This appears to

be a common scenario; Kern et al reported in a similar

study that 40% of 48 specimens that were reported as

inadequate during rapid assessment using telecytopathol-

ogy were shifted later into a diagnostic category upon

review of additional material or results from ancillary

studies.9

Although both telecytopathology systems were suffi-

cient for the pathologists to make an accurate preliminary

diagnosis, there are several other factors to consider when

comparing the Olympus NetCam and the RMT

iMedHD systems (Table 1). Most notably, we have

observed that the higher resolution (1920 3 1080 pixels)

and high-definition performance of the RMT iMedHD

system provides a much clearer image than the Olympus

NetCam system (800 3 600 pixels). This allows for better

TABLE 5. Percentage of All Cases in Which the Preliminary and Final Diagnoses Matched

UWHC WRMC

Diagnosis Preliminary Final Matched, % Preliminary Final Matched, %

Negative 78 65 83.3 11 9 81.8

Atypical 49 19 38.8 2 1 50

Suspicious/positive 171 167 97.7 13 13 100

Total 298 251 84.2 26 23 88.5

Abbreviations: UWHC, University of Wisconsin Hospital and Clinics; WRMC, Watertown Regional Medical Center.

Figure 1. This screenshot was taken of the cytopathologist’s monitor during a telecytopathology session using the RMT iMedHD

system (Remote Meeting Technologies, Melville, NY). This field of view represents papillary thyroid carcinoma at high-power

magnification (340). The iMedHD system displays a full screen image of the field of view, providing a clear view of the diagnostic

cells.

Original Article

550 Cancer Cytopathology July 2014

Page 6: Focus on technology: How important is resolution in telecytopathology?

discernment of cellular detail and, in some cases, leads to a

shorter wait time before a preliminary diagnosis is estab-

lished (Figs. 1, 2). Figure 1 is a screenshot taken of the

cytopathologist’s monitor during a telecytopathology ses-

sion using the RMT iMedHD system, and Figure 2 is a

screenshot that was taken on the same monitor using the

Olympus NetCam system. Both images represent the

same field of view at high power (original magnification,

340) of papillary thyroid carcinoma. The RMT

iMedHD system displays a full screen image of the field of

view, providing a clear view of the diagnostic cells;

whereas the NetCam system displays a smaller image

within the browser window.

No software additions to the telecytopathology

workstations are needed when using the web-based RMT

iMedHD system, unlike the Olympus NetCam, which

requires loading the Olympus MicroSuite Five imaging

software program into each transmitting workstation.

The RMT iMedHD system is somewhat easier to use for

both the pathologist and the cytotechnologist, in that it

has independent viewing controls for each guest viewer, so

that he or she can adjust the color, brightness, and contrast

of the transmitted image as desired. The Olympus Net-

Cam MicroSuite Five imaging software only allows the

cytotechnologist driving the microscope to have control

over the camera parameters. Although this causes no great

difficulty in most cases, it can lead to delays if a cytopa-

thologist wants an image adjustment and requires the

cytotechnologist to have a higher level of knowledge about

the workings of the MicroSuite Five software. The RMT

iMedHD system provides more internal security than the

Olympus NetCam, because it requires an invitation and

authentication for any participant to view the streaming

images, which are streamed under appropriate encryption.

Therefore, violations of the Health Insurance Portability

and Accountability Act are not an issue with RMT

iMedHD. However, such violations are not a concern

with the Olympus NetCam either, because all participants

must log onto the hospital intranet to view the cases. If a

faculty member is outside the hospital and needs to view a

case using the Olympus NetCam, then he or she must use

a virtual private network provided by the hospital

Figure 2. This screenshot was taken of the cytopathologist’s monitor during a telecytopathology session using the Olympus Net-

Cam system (Olympus, Center Valley, Pa). This field of view represents papillary thyroid carcinoma at high-power magnification

(340). The NetCam system displays a smaller image within the browser window, and nuclear detail is more difficult to discern

than with the iMedHD image (see Fig. 1).

Focus on Technology/McMahon et al

Cancer Cytopathology July 2014 551

Page 7: Focus on technology: How important is resolution in telecytopathology?

information technology department and sign into the

monitored hospital intranet. Finally, no patient informa-

tion is transmitted by telecytopathology on either system,

because any pertinent patient identification is communi-

cated by a concurrent telephone call.

From our own experience, we have observed that,

when trying to access the images from an off-site location,

the Olympus NetCam has a more pronounced lag time

than the RMT iMedHD system. The images streaming

on the RMT iMedHD system are refreshed at a higher

rate (60 frames per second) than those on the Olympus

NetCam, making the RMT iMedHD system more suita-

ble for use at remote locations. This is likely because of

the high-definition video camera purchased with the

RMT iMedHD system. Some lag time does occur with

this system and camera as well, but it is largely negligible

on a high-bandwidth network connection.

One drawback to the RMT iMedHD system is that

it comes at a higher cost than other telecytopathology sys-

tems on the market. The cost of 1 RMT iMedHD work-

station at UWHC is approximately $30,000 (this

includes charges for initial project management, intelli-

gent video equipment solution package, and image cap-

ture feature). The cost for ongoing, yearly service and

support and RMT MultiView5 (which allows for up to 5

concurrent viewers) is approximately $6600 per year. A

direct price comparison with the Olympus NetCam sys-

tem is not available, because that system is no longer mar-

keted for clinical use. A system comparable in price to the

Olympus NetCam is the Nikon DS-Fi2-L3 (Nikon,

Tokyo, Japan), a firmware-based system available for

approximately $7000. This system offers a maximum

resolution of 2560 3 1920 pixels with a maximum of 10

frames per second as per promotional sales information.

However, anecdotally, this resolution is not typically used

during telecytopathology sessions because of the low

frames per second available. A maximum of 37 frames per

second can be achieved during live display mode with a

lower resolution, allowing for faster transmission of

images.

In conclusion, our analysis demonstrates that a lower

resolution system can be used to provide preliminary diag-

noses with about the same statistical accuracy as a higher

resolution system. Many factors aside from resolution

contribute to the success of using telecytopathology for

preliminary diagnosis of FNA specimens. These factors

include ease of software use, internet/intranet bandwidth,

security factors, cost of the system, and personnel on site

at the FNA procedure. Although the lower resolution sys-

tem is sufficient for use on our FNA service, the RMT

iMedHD telecytopathology system allows the cytopatho-

logists at UWHC to make preliminary diagnoses with

considerable ease and confidence.

FUNDING SUPPORT

No specific funding was disclosed.

CONFLICT OF INTEREST DISCLOSURES

The authors made no disclosures.

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Original Article

552 Cancer Cytopathology July 2014