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Whole-slide imaging allows the entire slide to be viewed in a manner that simulates microscopy; therefore, it is widely used in telepathology. However, managing the large digital files needed for whole-slide imaging is difficult. To solve this problem, we set up the Chinese National Cloud-Based Telepathology System (CNCTPS). CNCTPS has been running for more than 4 years and has accumulated a large amount of data.
The main purpose of this study was to comprehensively evaluate the effectiveness of the CNCTPS based on a large sample. The evaluation indicators included service volume, turnaround time, diagnosis accuracy, and economic benefits.
Details of 23,167 cases submitted to the CNCTPS from January 2016 to December 2019 were collected to analyze the service volume, turnaround time, and economic benefits. A total of 564 patients who visited the First Affiliated Hospital of Zhengzhou University and obtained final diagnoses were followed up to analyze the diagnostic accuracy of the CNCTPS.
From 2016 to 2019, the service volume of the CNCTPS increased from 2335 to 9240, and the number of participating hospitals increased from 60 to 74. Consultation requests from county-level hospitals accounted for 86.57% (20,287/23,167). A total of 17,495 of 23,167 cases (75.52%) were confirmed, including 12,088 benign lesions, 5217 malignant lesions, and 190 borderline lesions. Of the cases, 3.85% (893/23,167) failed to be diagnosed for reasons such as poor slice quality and incomplete sampling. The median turnaround time was 16.93 hours and was shortened yearly (between 2018 and 2019: adjusted
The novel cloud-based telepathology system has the potential to relieve the shortage of pathologists in primary hospitals. It can also simultaneously reduce medical costs for patients in China. It should, therefore, be further promoted to enhance the efficiency, quantity, and quality of telepathology diagnoses.
Pathology diagnoses have been widely recognized as a gold standard for confirming diseases [
Telepathology is a powerful tool that can be used to address this challenge by transmitting pathology images through telecommunication [
To compensate for the shortcomings of whole-slide imaging, we established a Chinese National Cloud-Based Telepathology system (CNCTPS) based on an existing, mature telemedicine system of the National Telemedicine Center of China, with dual video and data drives, which solved the difficulty of telemedicine data interaction [
Previous studies have mainly focused on the construction and optimization of telepathology systems or analysis of the effect of system use, with a limited sample [
Participating hospitals were equipped with digital slide scanners and matched computer workstations (KF-PRO-005, Konfoong Biotech International Co Ltd), for converting traditional glass slices into whole-slide imaging. Whole-slide imaging of a slide could be completed within 40 seconds under a ×20 objective (0.47 µm/pixel) and within 100 seconds under a ×40 objective (0.5 µm/pixel). Scanning control software (K-Scanner 1.6.0.14, Konfoong Biotech International Co Ltd) and image browsing and management software (K-Viewer 1.5.3.1, Konfoong Biotech International Co Ltd) were used to control scanning and viewing in whole-slide imaging.
Whole-slide imaging and all other telepathology data were stored in dedicated servers located at the National Telemedicine Center of China to ensure the safety and speed of data storage, as well as the efficiency of data access by users. The overall design was based on a cloud-computing infrastructure service system, which was characterized by elastic expansion, high availability, and high stability. The system is equipped with wide-area and multilayer architecture, including access, application service, and data center layers (
Telepathology data storage and transmission.
A web-based telepathology consultation system and mobile app were developed. Each has different functions for applicants, coordinators, and specialists. The web version was embedded in the telemedicine collaborative service platform of the National Telemedicine Center of China [
There are 17 specialists from the Department of Pathology of the First Affiliated Hospital of Zhengzhou University who currently participate in telepathology consultation, including 8 professors and 9 associate professors specializing in different fields. The consultation is a voluntary activity with no charge. Pathologists from participating hospitals scanned and uploaded the slides to be diagnosed with patient information to the cloud platform. Coordinators from the National Telemedicine Center of China then assigned these cases to specialists (based on their specialties and fields), who are very likely to be able to provide confirmed diagnoses and valuable suggestions for corresponding therapies (
Telepathology consultation process.
The system was implemented in 3 stages. First, the participating hospitals were selected, starting in August 2015, based on medical service quality, readiness of their pathology departments and telemedicine services, and their willingness to use telepathology. Second, system hardware and software were deployed. Starting in January 2016, our technicians installed and debugged the equipment in participating hospitals. Third, personnel training and system maintenance were conducted. This included intensive training at the National Telemedicine Center of China (
To analyze the service volume, turnaround time, and economic benefits of the CNCTPS, we collected all case data submitted from January 2016 to December 2019, which included demographic and clinical data, submitted hospital, case submission time, report issuance time, telepathology diagnosis, and specialist who made the diagnosis. After removing test cases, there were 23,167 cases. Specimens had been taken from multiple organs, which were divided into 26 groups.
To analyze the diagnostic accuracy of the CNCTPS, we followed up the final diagnosis of all the 23,167 cases through the hospital information system of the First Affiliated Hospital of Zhengzhou University. We searched and found that 564 cases had also been diagnosed directly in the First Affiliated Hospital of Zhengzhou University. The diagnostic accuracy of telepathology was calculated by using the final diagnosis in the First Affiliated Hospital of Zhengzhou University as the reference.
Descriptive statistics were used to analyze characterize case data, including demographic characteristics of patients from whom samples were taken, diagnosis, histopathology type, and turnaround time. The median value and interquartile range are reported for continuous data, and percentages are reported for categorical data. The Kruskal–Wallis H test was used to compare turnaround time in different years, and the Nemenyi test was used for further multiple comparisons. The concordance between CNCTPS and final diagnoses was analyzed (complete concordance or variance with no clinical significance). The consistency was determined by the McNemar test and consistency check. All statistical analyses were performed using R software (version 4.0.0; R Foundation for Statistical Computing). All tests were 2-tailed, and
During the 4-year study period from 2016 to 2019, 23,167 cases were submitted to the CNCTPS for consultation. The service volume of the CNCTPS was n=2335 in 2016; n=4330 in 2017; n=7262 in 2018; and n=9240 in 2019, with an average annual growth rate of 41.04%. A total of 83 hospitals participated in the telepathology consultation service. The number of participating hospitals also grew, from n=60 in 2016 to n=74 in 2019 (
Participating hospitals and submitted cases from 2016 to 2019.
Hospitals of different levels have joined the CNCTPS, including 17 city-level and 66 county-level hospitals. Among 2016 and 2019, city-level hospitals and county-level hospitals applied for 2880 (2880/23,167, 12.43%) and 20,287 (20,287/23,167, 87.57%) consultations, respectively. The number of county-level hospitals applying for consultation increased from n=49 in 2016 to n=63 in 2019, and the service volume also increased from n=2095 in 2016 to n=8317 in 2019. In city-level hospitals, the number of hospitals applying for consultations did not change, while the service volume showed an overall increasing trend (
Number of participating hospitals and service volume in different levels of hospitals from 2016 to 2019.
Hospital level | 2016, n | 2017, n | 2018, n | 2019, n | |||||
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Hospitals | 11 | 9 | 14 | 11 | ||||
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Service volume | 240 | 657 | 1060 | 923 | ||||
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Hospitals | 49 | 52 | 59 | 63 | ||||
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Service volume | 2095 | 3673 | 6202 | 8317 |
The locations, from which specimens had been taken, were divided into 26 groups (
Of the 23,167 patients represented by case data, 9519 (41.09%) were male and 13,648 (58.91%) were female (
Among 17,495 confirmed cases, 12,088 were benign lesions, 5217 were malignant lesions, and 190 were borderline lesions. In total, 52.18% (12,088/23,167) benign cases and 22.52% (5217/23,167) malignant cases had been confirmed. The proportion of malignant lesions in the esophagus, lung/mediastinum, urinary, and thoracic cavity/pleura was higher than that of benign lesions (
Anatomic sites of specimens.
Anatomic site | Value (n=23,167), n (%) |
Uterus | 4074 (17.59) |
Gastrointestinal | 3643 (15.72) |
Bone and soft tissue | 2900 (12.52) |
Breast | 1488 (6.42) |
Esophagus | 1181 (5.10) |
Lung/mediastinum | 1175 (5.07) |
Thyroid | 1065 (4.60) |
Head and neck | 963 (4.16) |
Female genital organs except for uterus | 854 (3.69) |
Oral cavity | 850 (3.67) |
Urinary | 730 (3.15) |
Male genital organs | 725 (3.13) |
Hepatobiliary and pancreas | 647 (2.79) |
Respiratory tract | 595 (2.57) |
Eyes and ears | 467 (2.02) |
Skin | 422 (1.82) |
Lymphoid organs | 316 (1.36) |
Miscellaneous | 262 (1.13) |
Hydrothorax/ascites | 168 (0.73) |
Central nervous system | 145 (0.63) |
Anus and perianal | 116 (0.50) |
Abdominal cavity/peritoneum/postperitoneum | 114 (0.49) |
Others | 110 (0.47) |
Pelvic cavity | 70 (0.30) |
Adrenal glands | 46 (0.20) |
Thoracic cavity/ pleura | 41 (0.18) |
Case and patient characteristics.
Variables | Values | |
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Male | 9519 (41.09) |
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Female | 13,648 (58.91) |
Age, mean (range) | 52.86 (1 day to 98 years) | |
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Confirmed | 17,495 (75.52) |
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Needed further examinationa | 4779 (20.63) |
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Failed to be diagnosedb | 893 (3.85) |
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Benign | 12,088 (52.18) |
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Borderline | 190 (0.82) |
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Malignant | 5217 (22.52) |
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Unclear | 5672 (24.48) |
aFurther examinations included immunohistochemistry assay (4007/4779, 83.85%), clinical examinations (675/4779, 14.12%), gene detection (88/4779, 1.84%), and special staining (9/4779, 0.19%).
bThe reasons included poor slice quality (531/893, 59.46%), incomplete sampling (336/893, 37.63%) and intractable cases (26/893, 2.91%).
Histopathology distribution for 26 anatomic locations. AcPP: abdominal cavity/peritoneum/postperitoneum; CNS: central nervous system; HBP: hepatobiliary and pancreas; FGO: female genital organs.
The turnaround time, the time from transmitting whole-slide images to the issuance of diagnostic reports, was a median of 16.93 hours (IQR 32.59; mean 24.93 hours, range 100 seconds to 167.97 hours). Experts’ opinion reports were released within 12 hours in 10,244 of the 23,167 cases (10,244/23,167, 44.05%) and within 72 hours in 21,286 cases (21,286/23,167, 91.88%) (
Turnaround time for expert reports.
Time required (hours) | Cases, n (%) | Cumulative % |
Time≤12 | 10,204 (44.05) | 44.05 |
12<time≤24 | 4631 (19.99) | 64.04 |
24<time≤48 | 4366 (18.85) | 82.88 |
48<time≤72 | 2085 (9.00) | 91.88 |
Time>72 | 1881 (8.12) | 100 |
The difference in distribution of turnaround time in different years (
Turnaround time distribution.
Of 564 diagnosed by both the CNCTPS and pathologists in the hospital, 553 cases diagnosed by the CNCTPS were consistent with the final diagnosis made by pathologists in hospital; that is, the accuracy rate was 98.05%. In the other 11 cases—4 false-positive cases and 7 false-negative cases—5 of the 11 cases occurred in the uterus (
The sensitivity and specificity were 97.66% and 98.49%, respectively (
Discordant cases (between telepathology and final diagnoses).
Type | Sample source | Telepathology diagnosis | Final diagnosis | Annotation | |||||
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Case 1 | Lung/mediastinum | Poorly differentiated carcinoma | Immunoglobulin M–positive lymphoproliferative disease with alveolar epithelial atypical hyperplasia | Unlabeled immunohistochemistry results | ||||
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Case 2 | Respiratory tract | Highly differentiated squamous cell carcinoma | Squamous papillary hyperplasia with local typical hyperplasia | Intractable case | ||||
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Case 3 | Uterus | Endometrial complex hyperplasia, local atypical hyperplasia, focal canceration | Simple endometrial hyperplasia | N/Ab | ||||
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Case 4 | Uterus | Papillary squamous cell carcinoma | High-grade SILc involving glands | A bleeding background on the section | ||||
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Case 1 | Female genital organs | Vulva: chronic inflammation with low-grade SIL |
Vulva: highly differentiated squamous cell carcinoma with local superficial infiltration (depth of infiltration <1 mm) |
Unlabeled immunohistochemistry results | ||||
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Case 2 | Skin | Chronic inflammation, squamous epithelial hyperplasia with hyperkeratosis and parakeratosis | Superficial spreading malignant melanoma | Intractable case | ||||
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Case 3 | Uterus | Chronic inflammation, glandular hyperplasia | Minimal deviation adenocarcinoma | N/A | ||||
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Case 4 | Uterus | Chronic cervicitis with focal high-grade SIL and involving glands | High-grade SIL involving glands and squamous cell carcinoma in situ | N/A | ||||
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Case 5 | Thyroid | Adenomatous nodular goiter with fibrosis and chronic lymphocytic thyroiditis around | Follicular carcinoma | Unlabeled immunohistochemistry results | ||||
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Case 6 | Urinary | Mucosal polypoid hyperplasia with atypical urothelial hyperplasia | High-grade urothelial carcinoma | N/A | ||||
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Case 7 | Uterus | SIL | Squamous cell carcinoma | A bleeding background on the section |
aCases that were malignant in telepathology diagnosis but benign in final diagnosis were considered false positive.
bN/A: not applicable.
cSIL: squamous intraepithelial lesion.
dCases that were malignant in the final diagnosis but benign in telepathology diagnosis were considered false negative.
Validity of CNCTPS diagnoses.
Telepathology diagnosis | Final diagnosis | ||
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Positive, n | Negative, n | Total, n |
Positive | 292 | 4 | 296 |
Negative | 7 | 261 | 268 |
Total | 299 | 265 | 564 |
Telepathology consultation is free and avoids the need for patients having to visit higher-level hospitals. Therefore, consultation and travel costs were saved. At the same time, food costs were lower in the local area. Thus, compared with the traditional pathology consultation, diagnosis via the CNCTPS results in cost-savings of 378.5 RMB (approximately US $50) per patient (
Cost savings for each patient applied for telepathology consultation.
Type of costs | Telepathology consultation cost (RMBa) | Traditional pathology consultation cost (RMB) | Costs savings (RMB) |
Consultation costs | 0 | 148.5b | 148.5 |
Travel costsc | 0 | 200 | 200 |
Food costsc | 25 | 55 | 30 |
Total | 25 | 403.5 | 378.5 |
aRMB: Renminbi; an approximate exchange rate of 6.46 RMB = US $1 is applicable.
bTraditional consultation costs referred to the pathology consultation charges in Henan Province.
cFor each patient, one person going for a consultation was assumed. Travel and food costs were calculated using estimates of local corresponding average expenses.
The cloud-based system can quickly process data with large memory requirements, thereby overcoming the difficulties of large whole-slide imaging file management. This study reported on one of the largest cloud-based telepathology systems in China and evaluated its operation results. This study used a large sample size, which provides an in-depth practical understanding of the cloud-based telepathology system in China, and gives suggestions for further evaluations and improvements of the telepathology system. This system served 23,167 cases from 2016 to 2019. The median turnaround time was 16.93 hours, which decreased from 29.36 hours in 2016 to 9.75 hours in 2019. The diagnostic accuracy was 98.05%, and approximately $300,000 were collectively saved by patients each year. The CNCTPS has proven to be highly reliable and plays an important role in facilitating the distribution of limited senior pathologist resources in China.
A total of 83 hospitals are covered by the CNCTPS, which is the largest telepathology network in China. Compared with the 6, 24, and 60 workstations in other reported telepathology networks [
A total of 893 cases failed to be diagnosed by the CNCTPS, of which only 26 cases were complicated enough that needed to be consulted in a higher-level hospital, while others were due to incomplete sampling and poor slice quality. Standard materials and good slice preparation are the main factors affecting telepathology diagnosis [
The average turnaround time of the CNCTPS was 24.93 hours, which is shorter than the 38 hours reported by Zhou et al [
Compared to static images in the early stage of telepathology, whole-slide imaging allows the entire slide to be viewed in a manner that simulates microscopy [
Some cost-effectiveness studies have demonstrated that telemedicine can reduce costs [
To the best of our knowledge, this is the first study to comprehensively evaluate the operation of a telepathology system based on a large sample. The CNCTPS showed fast responsiveness and high accuracy. However, owing to the limited information collected by the CNCTPS, this study did not analyze the reasons for cases with long turnaround time or the reasons for false positives and false negatives. In addition, only the costs saved for patients were evaluated in the economic benefits of the CNCTPS. The economic impact of telemedicine is a collaborative and complex process in which different economic, social, and political actors can be involved [
Turnaround time and diagnostic accuracy are the main criteria used to evaluate a telepathology system, and further work is required to explore the factors that influence turnaround time and diagnostic accuracy. First, it is necessary to analyze the causes of cases with long turnaround time through a survey of pathologists, especially those with turnaround times longer than 72 hours. Second, more investigation for incorrectly diagnosed images is needed. In addition, adding a follow-up module to the CNCTPS is necessary to allow the final diagnosis result of each case to be easily followed up. Finally, a user satisfaction survey should be conducted, with thorough questionnaires or in-depth interviews, in a subsequent study to improve the system.
The CNCTPS has proven to be highly reliable. It can provide rapid telepathology diagnoses to participating hospitals that are consistent with the final diagnosis. The application of this system reduces financial costs and time for patients, facilitating the distribution of limited senior pathologist resources in China. Therefore, we believe telepathology services will become more widespread, in more regions worldwide, especially those with insufficient medical resources.
The web and app versions of the cloud-based telepathology system.
Training documents.
System operation guide for the cloud-based telepathology system.
Chinese National Cloud-Based Telepathology System
Renminbi
squamous intraepithelial lesion
This work was supported by the National Key Research and Development Program of China (grant number 2017YFC0909901).
None declared.