Practical Successes in Telepathology Experiences in Africa

The State of Telepathology in Africa in the Age of Digital Pathology Advancements: A Bibliometric Analysis and Literature Review

Telepathology emerges as a vital tool, offering significant promise for enhancing pathology services in Africa, a region historically challenged by healthcare access and resource limitations. This review explores the development, adoption, and impacts of telepathology in Africa through a comprehensive bibliometric analysis and literature review. A methodical search in PubMed for publications up to 2024 revealed 119 pertinent studies, out of which 47 met the inclusion criteria for a focused review on telepathology's role in African healthcare settings. This research has charted a clear trajectory of growing interest in telepathology, as evidenced by the annual increase in related publications and robust international collaboration. It underscores the expanding utility of telepathology in diagnostics, education, and research within Africa, particularly in domains like dermatopathology, neuropathology, and, notably, oncology. The integration of artificial intelligence into telepathology presents new frontiers for enhancing diagnostic accuracy and efficiency. However, the review also identifies persistent challenges such as infrastructural inadequacies, a shortage of skilled professionals, and regulatory hurdles. The study highlights the indispensable role of international partnerships in advancing telepathology in the region. This review proposes a strategic pivot toward "leapfrogging," an approach that allows Africa to skip traditional developmental hurdles by directly adopting cutting-edge technologies and practices.

Digital pathology systems enabling quality patient care

Pathology laboratories are undergoing digital transformations, adopting innovative technologies to enhance patient care. Digital pathology systems impact clinical, education, and research use cases where pathologists use digital technologies to perform tasks in lieu of using glass slides and a microscope. Pathology professional societies have established clinical validation guidelines, and the US Food and Drug Administration have also authorized digital pathology systems for primary diagnosis, including image analysis and machine learning systems. Whole slide images, or digital slides, can be viewed and navigated similar to glass slides on a microscope. These modern tools not only enable pathologists to practice their routine clinical activities, but can potentially enable digital computational discovery. Assimilation of whole slide images in pathology clinical workflow can further empower machine learning systems to support computer assisted diagnostics. The potential enrichment these systems can provide is unprecedented in the field of pathology. With appropriate integration, these clinical decision support systems will allow pathologists to increase the delivery of quality patient care. This review describes the digital pathology transformation process, applicable clinical use cases, incorporation of image analysis and machine learning systems in the clinical workflow, as well as future technologies that may further disrupt pathology modalities to deliver quality patient care.

Increasing access to pathology services in low- and middle-income countries through innovative use of telepathology

INTRODUCTION

In low- and middle-income countries (LMICs), surgical care can be limited by access to pathology services. In Uganda, the pathologist-to-population ratio is less than 1 to 1 million people. The Kyabirwa Surgical Center in Jinja, Uganda, created a telepathology service in collaboration with an academic institution in New York City. This study demonstrated the feasibility and considerations of implementing a telepathology model to supplement the critical pathology needs of a low-income country.

METHODS

This was a retrospective, single-center study of an ambulatory surgery center with pathology capability using virtual microscopy. The remote pathologist (also known as a telepathologist) controlled the microscope and reviewed histology images transmitted across the network in real time. In addition, this study collected demographics, clinical histories, the surgeon's preliminary diagnoses, and the pathology reports from the center's electronic medical record.

RESULTS

Nikon's NIS Element Software was used as a dynamic, robotic microscopy model with a video conferencing platform for communication. An underground fiber optic cable established Internet connectivity. After a two-hour tutorial session, the lab technician and pathologist were able to proficiently use the software. The remote pathologist read (1) pathology slides with inconclusive reports from external pathology labs, and (2) tissues labeled by the surgeon as suspicious for malignancy, which belonged to patients who lacked financial means for pathology services. Between April 2021 and July 2022, tissue samples of 110 patients were examined by a telepathologist. The most common malignancies on histology were squamous cell carcinoma of the esophagus, ductal carcinoma of the breast, and colorectal adenocarcinoma.

CONCLUSION

With the increasing availability of video conference platforms and network connections, telepathology is an emerging field that can be used by surgeons in LMICs to improve access to pathology services, confirming histological diagnosis of malignancies to ensure appropriate treatment.

Challenges in the diagnosis and management of IBD: a sub-Saharan African perspective

With the exception of South Africa, inflammatory bowel disease (IBD) has long been considered uncommon in sub-Saharan Africa (SSA) with a dearth of peer-reviewed publications from the subcontinent. This most likely reflects underreporting as some cases may be missed due to the high burden of infectious diseases which may closely mimic IBD. In addition, many countries in SSA have limited endoscopic capacity, inadequate access to diagnostic imaging and a notable scarcity of histopathologists, radiologists and gastroenterologists. Beyond these obstacles, which significantly impact patient care, there are many other challenges in SSA, particularly the unavailability of key IBD therapies. In this review, we discuss barriers in diagnosing and managing IBD in SSA, as well as some of the initiatives currently in place to address these short comings.

The use of Vsee videoconferencing for live telepathology in Rwanda, a potential solution for resource-limited area

Objective

The shortage of pathologists is a worldwide problem that is more severe in Africa. One of the solutions is the use of telepathology (TP); however, most of the TP systems are expensive and unaffordable in many developing countries. At the University Teaching Hospital of Kigali, Rwanda, we assessed the possibility of combining commonly available laboratory tools into a system that can be used for diagnostic TP using Vsee videoconferencing.

Methodology

Using an Olympus microscope (with a camera) operated by a laboratory technologist, histologic images were transmitted to a computer whose screen was shared, using Vsee, with a remotely located pathologist who made the diagnoses. Sixty consecutive small biopsies (≤6 glass slides) from different tissues were examined to make a diagnosis using live Vsee-based videoconferencing TP. Vsee-based diagnoses were compared to pre-existing light microscopy-based diagnoses. Percent agreement and unweighted Cohen's kappa coefficient of the agreement were calculated.

Results

For agreement between conventional microscopy-based and Vsee-based diagnoses, we found an unweighted Cohen's kappa of 0.77 ± 0.07SE with a 95% CI of 0.62-0.91. The perfect percent agreement was 76.6% (46 of 60). Agreement with minor discrepancy was 15% (9 of 60). There were 2 cases of major discrepancy (3.30%). We were unable to make a diagnosis in 3 cases (5%) because of poor image quality related to the instantaneous internet connectivity problems.

Conclusion

This system provided promising results. However, additional studies to assess other parameters which can affect its performance are needed before this system can be considered an alternative method of providing TP services in resource-limited settings.

Diagnostic validation of a portable whole slide imaging scanner for lymphoma diagnosis in resource-constrained setting: A cross-sectional study

Background

Telepathology utilizing high-throughput static whole slide image scanners is proposed to address the challenge of limited pathology services in resource-restricted settings. However, the prohibitive equipment costs and sophisticated technologies coupled with large amounts of space to set up the devices make it impractical for use in resource-limited settings. Herein, we aimed to address this challenge by validating a portable whole slide imaging (WSI) device against glass slide microscopy (GSM) using lymph node biopsies from suspected lymphoma cases from Sub-Saharan Africa.

Material and methods

This was part of a multicenter prospective case-control head-to-head comparison study of liquid biopsy against conventional pathology. For the portable WSI scanner validation, the study pathologists evaluated 105 surgical lymph node specimens initially confirmed by gold-standard pathology between February and December 2021. The tissues were processed according to standard protocols for Hematoxylin and Eosin (H&E) and Immunohistochemistry (IHC) staining by well-trained histotechnicians, then digitalized the H& E and IHC slides at each center. The digital images were anonymized and uploaded to a HIPAA-compliant server by the histotechnicians. Three study pathologists independently accessed and reviewed the images after a 6-week washout. The agreement between diagnoses established on GSM and WSI across the pathologists was described and measured using Cohens' kappa coefficient (κ).

Results

On GSM, 65.5% (n=84) of specimens were lymphoma; 25% were classified as benign, while 9.5% were metastatic. Morphological quality assessment on GSM and WSI established that 79.8% and 53.6% of cases were of high quality, respectively. When diagnoses by GSM were compared to WSI, the overall concordance for various diagnostic categories was 93%, 100%, and 86% for lymphoma, metastases, and benign conditions respectively. The sensitivity and specificity of WSI for the detection of lymphoma were 95.2% and 85.7%, respectively, with an overall inter-observer agreement (κ) of 0.86; 95% CI (0.70-0.95).

Conclusions

We demonstrate that mobile whole slide imaging (WSI) is non-inferior to conventional glass slide microscopy (GSM) for the primary diagnosis of malignant infiltration of lymph node specimens. Our results further provide proof of concept that mobile WSI can be adapted to resource-restricted settings for primary surgical pathology and would significantly improve patient outcomes.

Digital pathology world tour

Objective

Digital pathology (DP) is currently in the spotlight and is rapidly gaining ground, even though the history of this field spans decades. Despite great technological progress, the adoption of DP for routine clinical diagnostic use remains limited.

Methods

A systematic search was conducted in the electronic databases Pubmed-MEDLINE and Embase. Inclusion criteria were all published studies that encompassed any application of DP.

Results

Of 4888 articles retrieved, 4041 were included. Relevant articles were categorized as "diagnostic" (147/4041, 4%) where DP was utilized for routine diagnostic workflow and "non-diagnostic" (3894/4041, 96%) for all other applications. The "non-diagnostic" articles were further categorized according to DP application including "artificial intelligence" (33%), "education" (5%), "narrative" (17%) for reviews and editorials, and "technical" (45%) for pure research publications.

Conclusion

This manuscript provided temporal and geographical insight into the global adoption of DP by analyzing the published scientific literature.

The role of telepathology in improving cancer diagnostic and research capacity in sub-Saharan Africa

Non-communicable disease (NCD), including cancer, disproportionately affect Low- and Middle-Income Countries (LMICs). This inequity is in part due to limitations of pathology services, both human and infrastructural. While significant improvements have been made to address these gaps, creative approaches that are mindful of regional priorities, cultural differences, and unique local challenges are needed. In this perspective, we will describe the implementation of telepathology services in sub-Saharan Africa (SSA) that serve as cornerstones for direct patient care, multi-disciplinary care coordination, research programs, and building human capacity through training. Models and challenges of system implementation, sustainability, and pathologist engagement will be discussed. Using disease and site-specific examples, we will suggest metrics for quality control and improvement initiatives that are critical for providing high-quality cancer registry data and necessary for future implementation of therapeutic and interventional clinical trials.

Building Perinatal Pathology Research Capacity in Sub-Saharan Africa

Introduction

Over two million stillbirths and neonatal deaths occur in sub-Saharan Africa (sSA) annually. Despite multilateral efforts, reducing perinatal mortality has been slow. Although targeted pathologic investigation can often determine the cause of perinatal death, in resource-limited settings, stillbirths, early neonatal deaths, and placentas are rarely examined pathologically. However, the placenta is a key source of diagnostic information and is the main determinant of fetal growth and development in utero, influencing child health outcomes.

Methods

In 2016, our collaborative intercontinental group began investigating infectious perinatal death and adverse child health outcomes in Uganda. We developed and initiated a 4-day combined didactic/practical curriculum to train health workers in placental collection, gross placental examination, and tissue sampling for histology. We also trained a local technician to perform immunohistochemistry staining.

Results

Overall, we trained 12 health workers who performed gross placental assessment for > 1,000 placentas, obtaining > 5,000 formalin-fixed tissue samples for research diagnostic use. Median placental weights ranged from 425 to 456 g, and 33.3% of placentas were < 10th percentile in weight, corrected for gestational age. Acute chorioamnionitis (32.3%) and maternal vascular malperfusion (25.4%) were common diagnoses.

Discussion

Through a targeted training program, we built capacity at a university-affiliated hospital in sSA to independently perform placental collection, gross pathologic examination, and placental tissue processing for histology and special stains. Our training model can be applied to other collaborative research endeavors in diverse resource-limited settings to improve research and clinical capacity and competency for diagnostics and management of stillbirth, neonatal death, and child health outcomes.

The role of telepathology in diagnosis of pre-malignant and malignant cervical lesions: Implementation at a tertiary hospital in Northern Tanzania

Introduction

Adequate and timely access to pathology services is a key to scale up cancer control, however, there is an extremely shortage of pathologists in Tanzania. Telepathology (scanned images microscopy) has the potential to increase access to pathology services and it is increasingly being employed for primary diagnosis and consultation services. However, the experience with the use of telepathology in Tanzania is limited. We aimed to investigate the feasibility of using scanned images for primary diagnosis of pre-malignant and malignant cervical lesions by assessing its equivalency to conventional (glass slide) microscopy in Tanzania.

Methods

In this laboratory-based study, assessment of hematoxylin and eosin stained glass slides of 175 cervical biopsies were initially performed conventionally by three pathologists independently. The slides were scanned at x 40 and one to three months later, the scanned images were reviewed by the pathologists in blinded fashion. The agreement between initial and review diagnoses across participating pathologists was described and measured using Cohen’s kappa coefficient (κ).

Results

The overall concordance of diagnoses established on conventional microscopy compared to scanned images across three pathologists was 87.7%; κ = 0.54; CI (0.49–0.57).The overall agreement of diagnoses established by local pathologist on conventional microscopy compared to scanned images was 87.4%; κ = 0.73; CI (0.65–0.79). The concordance of diagnoses established by senior pathologist compared to local pathologist on conventional microscopy and scanned images was 96% and 97.7% respectively. The inter-observer agreement (κ) value were 0.93, CI (0.87–1.00) and 0.94, CI (0.88–1.00) for conventional microscopy and scanned images respectively.

Conclusions

All κ coefficients expressed good intra- and inter-observer agreement, suggesting that telepathology is sufficiently accurate for primary diagnosis in surgical pathology. The discrepancies in interpretation of pre-malignant lesions highlights the importance of p16 immunohistochemistry in definitive diagnosis in these lesions. Sustainability factors including hardware and internet connectivity are essential components to be considered before telepathology may be deemed suitable for widely use in Tanzania.

Digital health in oncology in Africa: A scoping review and cross-sectional survey

BACKGROUND

Low- and middle-income countries, especially in Africa, face a growing cancer burden. Adoption of digital health solutions has the potential to improve cancer care delivery and research in these countries. However, the extent of implementation and the impact of digital health interventions across the cancer continuum in Africa have not been studied.

AIMS

To describe the current landscape of digital health interventions in oncology in Africa.

METHODS

We conducted a scoping literature review and supplemented this with a survey. Following the PRISMA for Scoping Reviews guidelines, we searched literature in PubMed and Embase for keywords and synonyms for cancer, digital health, and African countries, and abstracted data using a structured form. For the survey, participants were delegates of the 2019 conference of the African Organization for Research and Training in Cancer.

RESULTS

The literature review identified 57 articles describing 40 digital health interventions or solutions from 17 African countries, while the survey included 111 respondents from 18 African countries, and these reported 25 different digital health systems. Six articles (10.5%) reported randomized controlled trials. The other 51 articles (89.5%) were descriptive or quasi-experimental studies. The interventions mostly targeted cancer prevention (28 articles, 49.1%) or diagnosis and treatment (23 articles, 40.4%). Four articles (7.0%) targeted survivorship and end of life, and the rest were cross-cutting. Cervical cancer was the most targeted cancer (25 articles, 43.9%). Regarding WHO classification of digital interventions, most were for providers (35 articles, 61.4%) or clients (13, 22.8%), while the others were for data services or cut across these categories. The interventions were mostly isolated pilots using basic technologies such as SMS and telephone calls for notifying patients of their appointments or results, or for cancer awareness; image capture apps for cervical cancer screening, and tele-conferencing for tele-pathology and mentorship. Generally positive results were reported, but evaluation focused on structure and process measures such as ease of use, infrastructure requirements, and acceptability of intervention; or general benefits e.g. supporting training and mentorship of providers, communication among providers and clients, and improving data collection and management. No studies evaluated individualized clinical outcomes, and there were no interventions in literature for health system managers although the systems identified in the survey had such functionality, e.g. inventory management. The survey also indicated that none of the digital health systems had all the functionalities for a comprehensive EHR, and major barriers for digital health were initial and ongoing costs, resistance from clinical staff, and lack of fit between the EHR and the clinical workflows.

CONCLUSION

Digital health interventions in oncology in Africa are at early maturity stages but promising. Barriers such as funding, fit between digital health tools and clinical workflows, and inertia towards technology, shall need to be addressed to allow for advancement of digital health solutions to support all parts of the cancer continuum. Future research should investigate the impact of digital health solutions on long-term cancer outcomes such as cancer mortality, morbidity and quality of life.

Accuracy of Pathologic Diagnosis in Patients With Lymphoma and Survival: A Prospective Analysis From Botswana

PURPOSE

With intense HIV epidemics, southern African countries have a high burden of classic Hodgkin lymphoma (CHL) and non-Hodgkin lymphoma (NHL). However, suboptimal access to pathology resources limits subtype classification. We sought to assess the diagnostic accuracy of specimens classified as lymphoma and to determine association between discordant pathologic diagnosis and overall survival.

METHODS

Seventy patients with CHL or NHL and treated at three Botswana hospitals from 2010 to 2016 were analyzed. Local pathologic assessment relied primarily on morphology. All cases underwent secondary US hematopathology review, which is considered gold standard.

RESULTS

The median follow-up was 58 months. The overall reclassification rate was 20 of 70 cases (29%). All 20 CHL cases were correctly classified in Botswana, and mixed cellularity was the most common subtype, diagnosed in 11 (55%) cases. Of 47 confirmed NHL cases, diffuse large B-cell lymphoma was the final US diagnosis in 28 cases (60%), another aggressive B-cell NHL in nine (19%), an indolent B-cell NHL in six (13%), and T-cell NHL in four (9%). Common types of diagnostic discordance included NHL subtype reclassification (11 of 20, 55%) and CHL reclassified as NHL (7 of 20, 35%). Concordant versus discordant diagnosis after secondary review was associated with improved 5-year overall survival (60.1% v 26.3%, P = .0066). Discordant diagnosis was independently associated with increased risk of death (adjusted hazard ratio 2.733; 95% CI, 1.102 to 6.775; P = .0300) even after stratifying results by CHL versus NHL.

CONCLUSION

In this single prospective cohort, discordant pathologic diagnosis was associated with a nearly three-fold increased risk of death. Limited access to relatively basic diagnostic techniques impairs treatment decisions and leads to poor patient outcomes in low-resource countries.

Haematological malignancies in sub-Saharan Africa: east Africa as an example for improving care

Haematological malignancies account for almost 10% of all cancers diagnosed in sub-Saharan Africa, although the exact incidences and treatment outcomes are difficult to discern because population-based cancer registries in the region are still underdeveloped. More research on haematological malignancies in sub-Saharan Africa is required to establish whether these cancers have a natural history similar to those diagnosed in high-income countries, about which more is known. Several factors negatively affect the outcome of haematological malignancies in sub-Saharan Africa, showcasing a need for improved understanding of the clinicobiological profile of these cancers to facilitate prevention, early detection, diagnosis, and appropriate treatment through increased capacity building, infrastructure, community awareness, coordinated resource mobilisation, and collaboration across the world. The east African governments have pooled resources for common investments to tackle non-communicable diseases, developing the East Africa's Centres of Excellence for Skills and Tertiary Education project funded by the African Development Bank, an initiative that could be replicated for the care of haematological malignancies in other countries in sub-Saharan Africa. TRANSLATION: For the French translation of the abstract see Supplementary Materials section.

Evaluating the success of the tele-pathology system in governmental hospitals in Kuwait: an explanatory sequential mixed methods design

BACKGROUND

Telepathology is the practice of reviewing and exchanging pathological images through telecommunication systems to obtain diagnoses remotely. Studying the factors that make such a system successful and favourable is important to ensure the merits of its implementation in clinical practice.

OBJECTIVE

This study aims to evaluate the success of a telepathology system from the users' perspectives, using specific evaluation criteria, namely: system quality, information quality, technical service quality, user satisfaction, and benefits.

METHODS

A sequential explanatory mixed methods design was adopted in this study, which consists of two phases. Initially, a questionnaire was distributed via WhatsApp to all of the pathologists (total: 45) working at governmental hospitals in Kuwait. Followed by, semi-structured interviews with ten senior pathologists.

RESULTS

Forty pathologists responded to the questionnaire, giving an 89% response rate. There were 42.5% of the respondents aged between 35-44 years old, and 52.5% were male. The quantitative results reveal that most of the respondents were satisfied with the quality of the telepathology system with a mean of 2.6025 (Standard Deviation (SD) = 0.47176), whereas they were dissatisfied with the quality of the information with a mean of 2.4100 (SD = 1.580) and the technical support services with a mean of 2.2750 (SD = 0.99535). In addition, there was disagreement on the benefits of telepathology in clinical practice among the pathologists with a mean of 2.4667 (SD = 0.77552). The qualitative results indicate that the lack of interest in and little experience with using the system were behind the general dissatisfaction of most of the respondents. All of the interviewees were satisfied with the performance of the telepathology system and considered it successful; however, the quality of the technical support services, including training workshops, was deemed deficient.

CONCLUSION

This study concluded that telepathology system in Kuwait is functioning well and has been successful in its implementation; however, pathologists are dissatisfied with it, mainly due to the deficient quality of the technical support services provided. In addition, the successful implementation of such advanced technologies requires careful steps to be taken on multiple levels: technical, organisational, and managerial. Recommendations were suggested.

Effectiveness of a Cloud-Based Telepathology System in China: Large-Sample Observational Study

BACKGROUND

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.

OBJECTIVE

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.

METHODS

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.

RESULTS

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 P=.01; other groups: adjusted P<.001); 82.88% cases were diagnosed in 48 hours. There was a discrepancy between the diagnosis and final diagnosis for 11 cases, including 4 false-positive cases and 7 false-negative cases. The sensitivity and specificity were 97.66% and 98.49%, respectively. The diagnostic accuracy of the system was 98.05%, with no statistical difference from the final diagnosis in the hospital (P=.55). By using this system, a total of US $300,000 was saved for patients every year.

CONCLUSIONS

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.

Safety and efficacy of rituximab in patients with diffuse large B-cell lymphoma in Malawi: a prospective, single-arm, non-randomised phase 1/2 clinical trial

BACKGROUND

There are no clinical trials involving patients with diffuse large B-cell lymphoma (DLBCL) in sub-Saharan Africa since antiretroviral therapy (ART) for HIV became widely available in this region. We aimed to establish the safety and efficacy of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) in patients with DLBCL in Malawi.

METHODS

This prospective, single-arm, non-randomised phase 1/2 clinical trial was done at Kamuzu Central Hospital Cancer Clinic (Lilongwe, Malawi). Eligible patients were adults (aged 18-60 years) with newly diagnosed DLBCL, an Eastern Cooperative Oncology Group performance status of 0-2, a CD4 count of 100 cells per μL or higher (if HIV-positive), measurable disease by physical examination, an absolute neutrophil count of 1000 × 10⁹ cells per L or higher, a platelet count of 100 × 10⁹ platelets per L or higher, a serum creatinine concentration of 132·60 μmol/L or less, a total bilirubin concentration of 34·21 μmol/L or less, a negative urine pregnancy test in women of childbearing potential, and no previous cytotoxic therapy. Pregnant or breastfeeding women, and individuals with CNS involvement from DLBCL, chronic hepatitis B infection (unless they were receiving tenofovir plus lamivudine), or any other comorbidities that would compromise the protocol objectives were excluded. Eligible patients received intravenous rituximab 375 mg/m², cyclophosphamide 750 mg/m², doxorubicin 50 mg/m², and vincristine 1·4 mg/m² (maximum 2 mg/m²), and oral prednisone 100 mg or an equivalent drug every 21 days for up to six cycles. HIV-positive patients received concurrent ART. The primary outcome was the proportion of patients with National Cancer Institute Common Terminology Criteria for Adverse Events grade 3 or 4 non-haematological toxic effects or treatment-related deaths after six cycles of treatment. Secondary efficacy outcomes included the proportion of patients with a complete response after six cycles of treatment, and progression-free survival and overall survival at 12 months and 24 months. This trial is registered with ClinicalTrials.gov, NCT02660710.

FINDINGS

Between Aug 1, 2016, and July 31, 2019, 76 patients were screened, of whom 37 were eligible for the study and received R-CHOP. The median age of patients was 44 years (IQR 39-49) and 16 (43%) were women. Of all 37 patients, 20 (54%) had stage III or IV DLBCL, and the age-adjusted international prognostic index was 2 or higher in 25 (68%) patients. 27 (73%) patients were HIV-positive, with a median CD4 count of 208 cells per μL (IQR 144-422), and 21 (78%) patients were receiving ART at enrolment. Patients completed a median of six cycles (IQR 4-6). Grade 3 or 4 non-haematological toxic effects were reported in 12 (32% [95% CI 19-49]) patients, the most common of which was infection (nine [24%] patients). Of 16 (43%) deaths, ten were due to progression of DLBCL, four were due to treatment-related complications, and two were due to other causes, yielding a treatment-related mortality of 11% (95% CI 4-26%). Grade 3 or 4 neutropenia was observed in 26 (70%) patients, and grade 3 or 4 anaemia was observed in 11 (29%) patients. A total of 22 (59%) patients had a complete response. Overall survival was 68% (95% CI 50-80) at 12 months and 55% (37-70) at 24 months, and progression-free survival was 59% (42-73) at 12 months and 53% (35-68) at 24 months.

INTERPRETATION

R-CHOP could be feasible, safe, and efficacious in patients with DLBCL in Malawi. This is the first completed clinical trial on DLBCL focused on sub-Saharan African populations. Given the paucity of data on treatment of DLBCL from this region, these results could inform emerging cancer treatment programmes in sub-Saharan Africa.

FUNDING

The University of North Carolina Lineberger Comprehensive Cancer Center.

Can pathology diagnostic services for cancer be stratified and serve global health?

BACKGROUND

Before initiating cancer therapy, a diagnostic tumor tissue sample evaluated within a pathology laboratory by a pathologist is essential to confirm the malignancy type and provide key prognostic factors that direct the treatment offered.

METHODS

Pathology evaluation includes multiple expensive reagents, complex equipment, and both laboratory and pathologist technical skills. By using breast cancer as an example, at a minimum, key tumor prognostic information required before the initiation of treatment includes subtype, tumor grade, tumor size, lymph node status when possible, and biomarker expression determined by immunohistochemistry for estrogen receptor. The additional determination of biomarker expression of progesterone receptor and human epidermal growth factor receptor (HER2) is the standard of care in high-resource settings, but assays may not be affordable in low-income and middle-income countries.

RESULTS

With positive tests, patients are eligible for either tamoxifen (for estrogen receptor-positive/progesterone receptor-positive cancers) or monoclonal antibody therapy (for HER2-positive cancers). For settings in which endocrine therapy and/or HER2-targeted therapy is unavailable, biomarker studies have no utility, and high-resource setting standards for pathology evaluation and reporting are unachievable. Resource-stratified pathology evaluation guidelines in cancer diagnosis have not been developed, in contrast to excellent comprehensive, resource-stratified clinical guidelines for use in low-income and middle-income countries, and these are long overdue.

CONCLUSIONS

The challenges of pathology evaluation in the context of global health are being met by innovative solutions, which may change the face of pathology practice.

Photomicrograph-Based Neuropathology Consultation in Tanzania

OBJECTIVES

Since neuropathologic diagnosis in the developing world is hampered by limitations in technical infrastructure, trained laboratory personnel, and subspecialty-trained pathologists, the use of telepathology for diagnostic support, second-opinion consultations, and ongoing training holds promise as a means of addressing these challenges. This study aims to assess the utility of static teleneuropathology in improving neuropathologic diagnoses in low- and middle-income countries.

METHODS

Consecutive neurosurgical biopsy and resection specimens obtained at Muhimbili National Hospital in Tanzania between July 1, 2018, and June 30, 2019, were selected for retrospective, blinded static-image neuropathologic review followed by on-site review by an expert neuropathologist.

RESULTS

A total of 75 neuropathologic cases were reviewed. The agreement of static images and on-site glass diagnosis was 71% with strict criteria and 88% with less stringent criteria. This represents an overall improvement in diagnostic accuracy from 36% by general pathologists to 71% by a neuropathologist using static telepathology (or from 76% to 88% with less stringent criteria).

CONCLUSIONS

Telepathology offers a promising means of providing diagnostic support, second-opinion consultations, and ongoing training to pathologists practicing in resource-limited countries. Moreover, static digital teleneuropathology is an uncomplicated, cost-effective, and reliable way to achieve these goals.

Telepathological evaluation of paediatric histological specimens in support of a hospital in Tanzania

Background/Objective

In a project of telepathology (TP) between German pathologists and a hospital in Tanzania, trained technical assistants have uploaded digital histological images onto the internet-based platform ipath. The diagnoses from 486 paediatric specimens were analysed.

Methods

The investigation included diagnoses, either primarily done via TP or secondarily after a further workup of the paraffin-embedded tissue, which was sent to Germany for cases which could not be solved via TP. In the latter, the initial TP-diagnoses were compared with the results after re-evaluation.

Results

The median age was 11 years. The cohort comprised 390 benign diseases (80.2%) and 96 malignant diseases (19.8%). For benign diseases, the most frequent anatomic sites were lymph nodes, skin, and soft tissue, breast, and head&-neck. Frequent diagnoses were non-specific inflammations and benign tumors. In malignant diseases, the most sites were lymph nodes, skin, soft tissue, head&neck, and ovary and the most frequent diseases sarcomas and lymphomas. The paraffin embedded tissue of 179 cases (36.3%) was shipped to Germany. With the concordance analysis, we could discover the mandatory necessity for the possibility of second opinion in difficult cases.

Conclusion

An exclusively TP-support cannot meet all requirements of modern medical diagnostics. The education of local pathologists is imperative.

Designing a novel hybrid healthcare teleconsultation network: a benchtop study of telepathology in Iran and a systematic review

BACKGROUND

Growing demand for medical services has increased patient waiting time due to the limited number or unbalanced distribution of healthcare centers. Healthcare teleconsultation networks are one of the potentially powerful systems to overcome this problem. Medical pathology can hugely benefit from teleconsultation networks because having second opinions is precious for many cases; however, resource planning (i.e., assignment and distribution of pathology consultation requests) is challenging due to bulky medical images of patients. This results in high setup and operational costs. The aim of this study is to design an optimal teleconsultation network for pathology labs under the supervision of medical sciences universities in Tehran, Iran.

METHODS

To avoid the setup cost, we first propose a modified hybrid peer-to-peer (P2P) overlay architecture for our telepathology network, using Iran's National Healthcare Information Network (SHAMS) as the underlying infrastructure. Then we apply optimization techniques to solve the request assignment and distribution problems in the network. Finally, we present a novel mathematical model with the objective of minimizing the variable operational costs of the system.

RESULTS

The efficiency of the proposed method was evaluated by a set of practical-sized network instances simulated based on the characteristics of SHAMS. The results show that the presented model and architecture can obtain optimal solutions for network instances up to 350 nodes, which covers our target network.

CONCLUSIONS

We believe that the proposed method can be beneficial for designing large-scale medical teleconsultation networks by adjusting the constraints according to the rules and conditions of each country. Our findings showed that teleconsultation networks in countries with strong information technology (IT) infrastructures are under the influence of consultation fees, while in countries with weak IT infrastructure, the transmission costs are more critical. To the best of our knowledge, no research has so far addressed resource planning in medical teleconsultation networks using optimization techniques. Besides, the target network, i.e., pathology labs under the supervision of medical sciences universities in Tehran and the SHAMS network, are discussed for the first time in this work.

Prospective study of Burkitt lymphoma treatment in adolescents and adults in Malawi

Burkitt lymphoma (BL) is common in sub-Saharan Africa (SSA). In high-income countries, BL is highly curable with chemotherapy. However, there are few prospective studies from SSA describing nonpediatric BL and no regional standard of care. Thirty-five participants age 15 years or older with newly diagnosed BL were enrolled in Malawi from 2013 to 2018. Chemotherapy was administered according to institutional guidelines, with concurrent antiretroviral therapy if HIV infected. Median age was 21 years (range, 15-61) and 15 participants (43%) were HIV infected. Twenty-seven participants (77%) had stage III to IV disease, and 19 (54%) had Eastern Cooperative Oncology Group performance status >1. Among HIV-infected participants, median CD4 count was 130 (range, 29-605) and 10 (67%) had suppressed HIV viral load. Four participants (11%) died before receiving chemotherapy. First-line chemotherapy consisted of: cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) (n = 22 [71%]); infusional etoposide, prednisolone, vincristine, cyclophosphamide, and doxorubicin (n = 4 [13%]); high-dose methotrexate-based chemotherapy (n = 4 [13%]); and rituximab plus CHOP (n = 1 [3%]). Among 28 evaluable participants, 14 (50%) achieved a complete response. Median overall survival (OS) was 7 months; 1-year OS was 40% (95% confidence interval [CI], 24%-56%). Sixteen (73%) of 22 deaths were a result of disease progression. Compared with CHOP, more intensive chemotherapy was associated with decreased mortality (hazard ratio, 0.24; 95% CI, 0.05-1.02; P = .05). This is among the best characterized prospective cohorts of nonpediatric BL in SSA. Most deaths resulted from progressive BL. Patients who received more intensive therapy seemed to have better outcomes. Defining optimal approaches is an urgent priority in SSA.

AMAFRICA, a patient-navigator program for accompanying lymphoma patients during chemotherapy in Ivory Coast: a prospective randomized study

Background

Previous studies have indicated that accompanying socially underserved cancer patients through Patient Navigator (PN) or PN-derived procedures improves therapy management and reassurance. At the Cancer Institute of Toulouse-Oncopole (France), we have implemented AMA (Ambulatory Medical Assistance), a PN-based procedure adapted for malignant lymphoma (ML) patients under therapy. We found that AMA improves adherence to chemotherapy and safety. In low-middle income countries (LMIC), refusal and abandonment were documented as major adverse factors for cancer therapy. We reasoned that AMA could improve clinical management of ML patients in LMIC.

Methods

This study was set up in the Abidjan University Medical Center (Ivory Coast) in collaboration with Toulouse. One hundred African patients were randomly assigned to either an AMA or control group. Main criteria of judgment were refusal and abandonment of CHOP or ABVD chemotherapy.

Results

We found that AMA was feasible and had significant impact on refusal and abandonment. However, only one third of patients completed their therapy in both groups. No differences were noted in terms of complete response rate (CR) (16% based on intent-to-treat) and median overall survival (OS) (6 months). The main reason for refusal and abandonment was limitation of financial resources.

Conclusion

Altogether, this study showed that PN may reduce refusal and abandonment of treatment. However, due to insufficient health care coverage, its ultimate impact on OS remains limited.

Re-evaluation of challenging telepathological diagnoses in support of a hospital in Tanzania

Since 2007, a hospital in Tanzania has been supported with histopathological reports via telepathology (TP) by German pathologists. For this, the Internet-based platform iPath is used. The aim of this study was to analyse the rate of discrepancies in defined diagnostic groups. After shipment of paraffin-embedded tissue to Germany, specimens were processed according to recent diagnostic standards. All diagnoses were grouped into eight benign and 11 malignant main categories. The comparison comprised the following categories: 1, identical diagnosis; 2, mild discordance; 3, correct distinction between benign and malignant process, 4, false malignant; 5, false benign; and 6, no primary diagnosis possible. The cohort comprised 396 benign and 336 malignant diseases. Of the benign diseases, 62% were category 1, 23% category 2, 2% category 3, 6% category 4 and 7% category 6. Of the malignant diseases, 42% were category 1, 16% category 2, 12% category 3, 14% category 5 and 15% category 6. Exclusive support with static TP cannot meet all requirements of modern medical diagnostics. However, the project shows a approach for how pathologists in industrial countries can help low-income countries. In difficult cases, the opportunity for a final work-up using additional methods must be given for useful diagnostic purposes.

Utilization of fine needle aspiration cytology at Kamuzu central hospital

Background

Fine needle aspiration cytology (FNAC) has been widely accepted to be a safe, accurate, prompt and inexpensive procedure for diagnosis of both neoplastic and infectious diseases in adult and pediatric populations. Despite its value for diagnosis, FNAC is underutilized in resource limited countries. We reviewed the utilization of FNAC after it was introduced at Kamuzu Central Hospital (KCH).

Methods

A retrospective review of all FNAC performed at KCH laboratory during the period of January 2012 to July 2014 was conducted using an electronic database from KCH laboratory. We evaluated factors associated with a diagnostic sample using multivariate logistic regression model.

Results

750 FNAC were reviewed from 722 patients: 56.9% were adults >15 years and 54% were female. The number of FNAC increased annually from 56 (2012) to 379 (2013) to 315 (up to July 2014). Of 750 FNAC, 56.4% were performed by non-pathologists. The most common sites were lymph nodes (38.1%), abdomen (25.8%), breast (16.3%), and head & neck (15.7%). Most of the samples (77.6%) were diagnostic. FNAC was more likely to be diagnostic if performed by pathologists versus non-pathologists (OR 1.78, 95% CI 1.20–2.64), in 2013 compared to 2012 (OR 1.95, 95% CI 1.05–3.56), or performed on a deep lesion versus a subcutaneous lesion (OR 1.71, 95% CI 1.15–2.5), or if samples were taken from the head and neck (OR 2.4, 95% CI: 1.39–4.39), and abdomen (OR 2.66, 95%CI1.59–4.42) compared to those from the lymph nodes. The odds of a diagnostic test did not differ significantly according to gender, HIV status, or age groups.

Conclusion

Most FNACs successfully diagnosed the presence or absence of disease, with substantial improvements over time. However, training for non-pathologists may facilitate more diagnostic results.

How I treat Burkitt lymphoma in children, adolescents, and young adults in sub-Saharan Africa

Burkitt lymphoma (BL) is the most common pediatric cancer in sub-Saharan Africa (SSA), and also occurs frequently among adolescents and young adults (AYAs), often associated with HIV. Treating BL in SSA poses particular challenges. Although highly effective, high-intensity cytotoxic treatments used in resource-rich settings are usually not feasible, and lower-intensity continuous infusion approaches are impractical. In this article, based on evidence from the region, we review management strategies for SSA focused on diagnosis and use of prephase and definitive treatment. Additionally, potentially better approaches for risk stratification and individualized therapy are elaborated. Compared with historical very low-intensity approaches, the relative safety, feasibility, and outcomes of regimens incorporating anthracyclines and/or high-dose systemic methotrexate for this population are discussed, along with requirements to administer such regimens safely. Finally, research priorities for BL in SSA are outlined including novel therapies, to reduce the unacceptable gap in outcomes for patients in SSA vs high-income countries (HICs). Sustained commitment to incremental advances and innovation, as in cooperative pediatric oncology groups in HICs, is required to transform care and outcomes for BL in SSA through international collaboration.