WhatsApp (WhatsApp®, Inc., Mountain View, California,
USA) is one of the most widely used free smartphone
applications allowing two or more users to exchange
messages, images, audio or video easily and quickly via
an Internet connection
1. It has been used efficiently
among pathologists to obtain a fast second opinion, share
interesting aspects of daily cases, and increase the awareness
and interest of students in pathology
2-5. This platform
also serves as an alternative to the microscope-mounted
digital cameras particularly for the ones in undeveloped
countries devoid of these devices
6. Cytopathologists
and those interested in cytopathology (CPs) have been
increasingly using WhatsApp to take advantage of these
benefits and more.
WhatsApp users typically send photographs as “image files”
either from their Gallery file or by tapping the camera icon
in the recipient’s profile. This conventional way of sharing
naturally decreases the quality of images after delivery
to save storage memory. However, low-quality images
from cytopathology cases yield blurred cellular details
when zoomed in, which is not convenient for a precise
cytopathologic evaluation.
In this article, an image sharing technique called “highresolution
image sharing (HIS)” is described where the
quality of images is maintained and zooming in does not
significantly impair the cytologic details in contrast with
the conventional way.
A compound light microscope, Carl Zeiss Axio Scope A1
(Carl Zeiss Microimaging GmbH, Göttingen, Germany),
was used to obtain the microphotographs. The eyepiece
and objective lenses of the microscope were cleaned using
a lens tissue. A few drops of xylene were used to remove
balsam from the objective lenses. The light was centered
and the substage condenser was focused.
The slides from three different cases were obtained from
the pathology slide archive. Each slide was selected for
its distinctive cytologic features. The area selected for
photography was an area with multiple prominent nucleoli
in Case 1 with a diagnosis of reactive mesothelial cells; an
area with intranuclear cytoplasmic pseudoinclusion in
Case 2 with a diagnosis of papillary thyroid carcinoma; and
an area with dysplastic cells in Case 3 with a diagnosis of
low-grade squamous intraepithelial lesion.
All the slides were cleaned and then placed on the stage of
the microscope. The photographs are taken manually using
a Samsung Galaxy S6 smartphone (Samsung Electronics
Co. Ltd., South Korea) through one eyepiece. In the camera
settings, the aspect ratio was set to 16:9 (16 megapixels
(MP)) with a 5K resolution (5312 x 2988). The rear camera
was first cleaned of dust with a piece of tissue.
The HIS technique is described for each of the most
commonly used mobile operating systems, Android and
iOS (Figures 1A-F-2A-J). At the time this article was written,
WhatsApp versions for Android and iOS devices were
2.18.380, updated on 11 December, 2018, and 2.18.111,
updated on 14 December, 2018, respectively.
Click Here to Zoom |
Figure 1: Step by step explanation
of how to send images without
compromising the quality for
Android users. A) Open the
recipient’s profile, tap the paper
clip icon (arrow) and select
“Document”. B) Select “Browse
other docs...” . C) Select the
images you want to share. To
browse all image files, touch the
option on the upper left corner
D) For multiple image selection,
hold your touch on one of the
images, then tap on the other
images one by one. After that, tap
“Open” on the upper right corner.
E) Send the images.
F) The image(s) are sent.
(A Samsung Galaxy S6
smartphone on Android version
7.0 was used) |
Click Here to Zoom |
Figure 2: Step by step explanation of how to send images without compromising the quality for iOS users. A) Open Gallery and select
the images. B) Select “Save to Files”. C) Select one of either file. D) Tap “Add”. E) Open the recipient’s profile and tap the Attach (+) icon.
F) Select “Document” file. G) Tap “Locations” if the image(s) are not seen in the default file. H) Select the file in which you saved your
images. I) Select the images and tap “Send”. For multiple image selection, tap “Select” on top of the screen and then tap on the images one
by one. J) The image(s) are sent. (An iPhone 6S smartphone on iOS version 12.1.2 was used) |
Each photograph was sent via the conventional and HIS
methods to a recipient on WhatsApp. The areas of interest
were equally zoomed in on the matching images until
seeing the cellular details, and then screenshot images were
taken for comparison of the two methods.
The initial sizes of the photographs were 1.8 megabytes
(MB), 4.79 MB, and 1.38 MB in the of Case 1, Case 2,
and Case 3, respectively. After sending them via the
conventional way, the sizes of the images decreased to 64
kilobytes (KB), 174.64 KB, and 41.55 KB, respectively. The
resolutions decreased from 5312 x 2988 to 747 x 1328 for
all images. However, the sizes and resolutions of the images
were fully maintained in all images after sending via the
HIS technique.
Zooming-in on the shared images on WhatsApp revealed
that the cytological details were excellent on X200 and
X400 magnifications and of much greater quality on X100
magnification using the HIS technique compared to the
conventional method (Figure 3A-F).
Click Here to Zoom |
Figure 3: These images display
zoomed-in areas from the
microphotographs taken at X100,
X200, and X400 magnification.
A, B) Case 1, reactive mesothelial
cells, (Papanicolaou stain; x100)
C, D) Case 2, papillary thyroid
carcinoma, (Giemsa stain; x200).
E, F) Case 3, low-grade squamous
intraepithelial lesion, stain
(Papanicolaou; x400).
When zooming in on the
images, the cytologic details
are severely blurred (A and C)
and relatively preserved (E)
using the conventional way.
However, sharing with the HIS
technique preserves the quality
of the images and the nuclear
and cytoplasmic details could
be easily evaluated (B, D, and
F). The yellow star indicates
an intranuclear cytoplasmic
pseudoinclusion in a papillary
thyroid carcinoma which can
only be seen in the image shared
by the HIS technique (D). |
The HIS technique proves that it is possible to share an
image on WhatsApp without compromising its original
size and resolution. Therefore, this technique can be easily
adapted to the cytopathologic consultations on WhatsApp.
Cellular details are of the utmost importance for a definite
cytopathologic evaluation. Therefore, it is necessary to send
high-resolution (HR) images to the recipient CP during
a consultation process on WhatsApp. The decrease in
the quality of images is one of the most important issues
deterring CPs from WhatsApp case consultations. For example, in a recent study, it was stated that both nuclear
and cytoplasmic details cannot be seen in the images
using X100 or X200 magnifications. For this reason,
400X magnification was used in 91% of 172 images and
200X magnification was used in the remaining ones for
conducting this study 6. It was also documented that there
was a discordance in 15.69% of cases between microscopic
diagnoses and smartphone diagnoses. The insufficient
quality of WhatsApp images was one of the important
reasons reported for the diagnostic discrepancies 6.
There are basically three steps to provide HR images to
the recipient CP on WhatsApp. The first step is to have
a smartphone that is capable of taking HR photographs.
Currently available smartphones on the market have more than adequate specifications to ensure interpretable
microimages with more than 10 MP, X10 zoom, and
1000 x 1000 resolution with a fast autofocus feature. For
obtaining the highest quality images, it is suggested to
use one of the latest smartphone models and make sure
of setting the highest standards in the camera options in
advance. In this article, the microimages were taken using
a smartphone model released about three years ago. Using
a recent smartphone model with higher standard camera
features would provide even greater image quality. Second,
maintenance of the light microscope should be carried out.
The user should clean the eyepiece and objective lenses,
center the light, and focus the substage condenser 7. The
third step is to take photographs through one eyepiece, whether manually or using a microscope adaptor designed
for smartphones. Fourth, an internet connection must be
enabled to upload and send the photographs via WhatsApp.
The last step is the sharing method on WhatsApp by
which the original quality of the shared images must
be preserved. There are a few ways to upload and send
microphotographs on WhatsApp without changing their
original quality 8. The simplest and most effective way
suggested in this article is called HIS and enables sending
images as “document files” instead of image files. Sending
a document is only available for users on iOS 8 and later
but there is no such specification listed for Android users.
The major drawback of this technique could be that the
shared images occupy more memory space than the
conventional way since these images are of higher quality.
It is suggested to back up and delete the HR images after
a period of time if there is a shortage of storage memory.
Another insignificant downside is a slight increase in file
transfer time. The transfer time of the images depend on
the total document size, the connection type (e.g., modem,
ADSL, LAN), and the download speed. For example, a
4 MB image using an ADSL with 8 megabits per second
download speed would take about 4 seconds to download.
Online download time calculators can be used to estimate
the time that will take to transfer images. Although the
maximum allowed number of images as document files
is not specified on the WhatsApp website, currently up to
100 MB file size is allowed at one time. Several other highquality
image sharing methods, albeit much less practical,
are also described on this website: https://www.techbii.
com/send-full-resolution-whatsapp-image/.
High-resolution image sharing would bring CPs to the
next level in WhatsApp consultations. In this author’s daily
practice, this technique has been tested and used highly efficiently. It is believed that this method will be useful not
only in cytopathology but also in other fields in pathology
and medicine where using HIS would be beneficial 6,9. In
future studies on telecytologic consultations on WhatsApp,
it is strongly suggested that images be sent using the HIS
technique to reduce the risk of interpretation errors
compared to microscopic examination pointed in the
literature 3,6.
ACKNOWLEDGEMENT
I would like to thank Ms. Beyza Bircan, who is a student
at the Department of Psychology, Eastern Mediterranean
University, for her kind help in describing the technique
for iOS users.
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