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In last part of this blog series we explore challenges caveats and future of WSI.


In order to integrate WSI into routine clinical pathology practice, an infrastructure needs to be developed in the pathology department (37, 60, 66, 75, 111). This infrastructure consists of: (i) hardware for scanning slides, storing the scanned images, transmission of the images to pathologists, and the interfaces necessary to display the images and report interpretations; and (ii) the software to facilitate the workflow of the image movement, display, and reporting of the results. Additionally, for remote teleconsultation, features like security of protected patient information, process validation, as well as regulatory, medicolegal, and billing issues need to be added. However, there are many unresolved issues, as outlined below, which still need to be addressed before WSI finds its place in routine application across the wide specialty of pathology (37, 51).


The cost of procurement, implementation, and operational costs of WSI may be prohibitive, especially for small pathology laboratories due to huge initial cost of the scanners and additional hidden costs of training of staff and pathologists, technical support, digital slide storage systems, and regulatory or licensing costs (43, 112). Technological support for telepathology further compounds these costs. A recently published cost-benefit analysis at a large-volume academic center with slides in excess of 1.5 million showed a projected $1.3 million savings over a 5-year period (113). However, the same analysis needs to be undertaken for smaller laboratories and low-resource settings.

Technological Issues

Scanning the whole slide/smear is a tedious and time-consuming process at present. Scanning times can vary from 1 to 5 min for a small biopsy to 5–20 min for a surgical specimen and 3–5 min for a liquid-based cytology smear (58). Another limitation with currently available scanners is the requirement of massive data storage capacity. Scanning at × 40 magnification of a 1-mm2 area results in a file size of 48 megabytes. Hence, majority of the WSI systems incorporate image compression algorithms (JPEG, JPEG 2000, LZW) to reduce the file size, however that introduces image artefacts. Some scanners offer the ability of multi-resolution representation (pyramid representation) where the field of view on the screen is inversely proportional to the magnification being viewed (43). Majority of the WSI systems utilize a content management system with specific programming in order to display the virtual slides in a consistent and specific manner (43). Currently, there are vendor-dependent limitations with WSI systems. Some vendors use proprietary modules with limited scope of cross-browser compatibility or seamless execution on multiple devices.

Professional Barriers

Unlike radiology where digital systems obviate the need of making films, WSI in pathology does not reduce the laboratory’s workload since glass slides still need to be prepared to be scanned. However, WSI does allow for streamlined navigation of the slides at various magnifications without the fear of accidentally breaking a slide at the microscope. The current WSI systems allow for batch-wise scanning of slides, thus improving the efficiency of the laboratory (8, 43, 113).

Other issues include available bandwidth of the network at the pathologists’ workplace, security issues related to information technology, and installation of compatible browsers. However, with progress in information technology, the systems shall continue to be upgraded for improved speed and compatibility with browsers (60).

The FDA approval of WSI in primary surgical pathology diagnosis does open up the issue of legal implications for the reporting pathologists. The relevant regulatory agencies (such as CLIA) need to put forth their guidelines in light of the expected changes with adoption of WSI by pathologists.

Regulatory Issues

Though FDA has accorded its approval for use of WSI in surgical pathology practice in 2018, the other subspecialties of pathology still have a long path to tread towards this goal. At the same time, validation of WSI for introduction into the surgical pathology practice is still merely a recommendation of the CAP. Regulations also need to be put in place regarding the archiving, retrieval, and access rights of the virtual slide library so formed (8, 38, 113).


WSI is an exciting and promising technology with various advantages and a few challenges. The future of WSI lies in having an ideal vendor-neutral archive wherein a single software-hardware solution allows single viewing, storage, and retrieval with no barriers of the data source. This coupled with the promise of artificial intelligence, pathology is poised for new discoveries and solutions (81, 92)


1) Availability of high-resolution 3-dimensional imaging, especially for tumors, would improve the use of this technology with correlation between radiologic imaging and WSI (64).

2) Multispectral imaging, when applied to WSI, would offer the ability to characterize chromatic properties and support color-based classification and multi-labelling studies (58).

3) Refinement of AI and machine learning algorithms would allow the pathologists contribute in a larger role in improving patient management and outcomes (51).

Virtual microscopy using whole slide scanning is an area of profound and rapid technologic development with numerous applications in the field of pathology. Despite its several advantages and claims of it being equivalent to conventional microscopy, the adoption of this technique has been rather slow even in the developed nations. The barriers referred to in this paper currently preclude the wide application of whole slide scanning in the resource constrained medical institutions of the developing world. Apart from the technical and cost-related issues, regulatory and validation requirements also need to be adequately addressed, especially for the developing nations. Nevertheless, WSI does provide a golden opportunity for pathologists to guide its evolution, standardization, and implementation by playing a key role in defining/ refining guidelines, designing the resource specific digital pathology laboratories, and propagating standardized educational modules to train the next generation of virtual pathologists.

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Sambit K Mohanty, MD

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