OBJECTIVE Describing challenges and opportunities related to telepathology set up, quality assurance and quality control especially in low-resource settings.
METHODS The Butaro Cancer Centre is located in the Northern rural province of Rwanda. It is a public institution and a referral cancer centre with a support of Partners in Health, a non-profit organization. Since 2016, telepathology equipment was installed in the pathology laboratory with the support of American Society for Clinical Pathology, to facilitate cancer diagnosis with collaboration with different US-based volunteer pathologists. We are here sharing our three years experience in using telepathology for cancer diagnosis in low-resource setting.
RESULTS Having telepathology services contributed in cancer diagnosis especially in facilitating expert consultation for challenging cases. Instead of sending paraffin embedded tissue blocks or glass slides for review and diagnosis, a slide scanner was used to generate digital whole slide images that were uploaded in the system and sent to reviewers using the image management software. The system offers a combined static and dynamic telepathology. The reviewer can generate printable final report with additional notes for educational purpose. The quality assurance and quality control requires production of high quality glass slides without processing artifacts, selection of best representative slides to share, validation process of the whole system, training of staff involved in its use, image calibration and selection of recipient reviewers. The main challenges of using telepathology in resource-limited settings remain the cost of equipment and software, the equipment maintenance fee, the availability of a stable and broad-bandwidth internet network and the cost of storage of generated digital slides.
CONCLUSION Telepathology is a potential powerful tool in cancer diagnosis especially in areas with shortage of pathologists. However, there are many challenges that may retard its expansion. Partnership with local health institutions, manufacturers and laboratories in developed institutions can play a key role in bringing solutions.

More than 80% of children diagnosed with cancer live in developing countries. In contrast to developed countries where overall survival for children with cancer ranges between 70-90%, almost 70% of children in developing countries die from their disease. Several factors including the lack of dedicated paediatric oncology services, shortage of health workers trained in the management of childhood cancers, treatment related mortality, malnutrition and treatment abandonment. As of 2016, there was only one trained paediatric oncologist at the Uganda cancer Institute, the oldest and largest cancer treatment centre in Uganda. There was dire need to develop local capacity to diagnose and treat childhood cancers in Uganda. Pragmatic approaches to deal with the shortage of trained paediatric oncologists needed to be devised. The Global HOPE approach. To address the need for paediatric oncologists in Uganda, the idea of a Paediatric Haematology and Oncology fellowship training was conceived. The objective was to develop specialised training program that was comparable to the west, but was cost effective. The Paediatric Haematology and Oncology Program is a collaboration between Makerere University, Mulago National Referral Hospital, the Uganda Ministry of Health and Baylor College of Medicine (BCM) /Texas Children’s Hospital. The program has both local and visiting international faculty from BCM to train the fellows. To improve the fellows learning experience, approaches such as black board, videoconferences, and tumour boards are key training strategies. Lectures and information are shared on line between fellows in Uganda and experts in the USA. This approach has been successful. Eight specialists have graduated from the program, and are currently leading Haematology and Oncology programs in their countries. The program currently has 6 on going fellows, all from East Africa, and 6 more from 4 countries in Africa have enrolled for the academic year starting September 2019.

The Horn of Africa project has the ambitious goal to create a network of pathology laboratories in different Countries of the Horn of Africa. Since 2010, APOF has been carrying out a project at the Balbala hospital, Republic of Djibouti, to create a pathology department which at present is fully equipped, including 4 technicians and 2 pathologists. In 2015, APOF received a request from the Hargeisa Hospital in Somalia for the creation of a pathology department. Three years after the Military Hospital in Djibouti asked APOF to create a novel and fully equipped laboratory of Pathology, including telepathology service. APOF has launched a project for a network of pathology laboratories using the "Hub & Spoke" method, in which the pathologists operating at the Balbala hospital will provide diagnostic activity by telepathology for the nearby Military Hospital and Hargeisa Hospital, which have no pathologists. The Microvisioner software, a microscope and a CCD camera allows the scanning of entire slides in a manual process performed by the lab technicians after a 3-hour training. Once the virtual slide is saved on the workstation the remote pathologist can immediately access it. The transmission capacity was very low but with WaidX, an innovative solution for Telemedicine, we obtained an emission bandwidth of more than 5 Mbps, allowing a telepathology activity of good level. We presented this device at World Cancer Congress 2018, held in Malaysia, together with an oncological case discussed via a remote tumor board, bringing together medical oncologists and pathologists on different Countries. The Hub & Spoke method can optimize local resources and will be hopefully extended to other regions of the Horn of Africa. Finally, telepathology could play a pivot role in remote tumour boards, in which various specialists discuss a clinical case to propose a shared tailored diagnosis and therapy.