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Whole Slide imaging technology and its applications: Current and emerging perspectives -III

Lets dive into applications of Digital pathology in part-III of this blog series.


Health care facilities are witnessing extensive digitization with inclusion of digital imaging connected to hospital information systems, LIS, picture archiving, and communication systems. Pathology laboratories equipped with WSI facility would fall into place well in such a setting with varied applications in diagnosis, education, and research (11, 34,37, 42,43).


WSI has gained wide acceptance for education, at the tumor boards, and for presentations, research, and quality assurance (QA) (4,43-46). Digitized slides are more interactive compared to glass slides, can be easily shared anywhere at any time, and can help standardize training and research material. Many authors have highlighted its use in undergraduate medical education, pathology residents and fellow training (45-48). Unlike glass slide teaching sets, digital slides do not fade, break, or disappear. Digital slides also offer the ability to standardize images, permit annotation, and can provide a wide case range for trainees (48,49). Digital teaching sets can be accessed on a server over a network, are available to multiple users, and can be developed to contain test modules for trainees. WSI can also facilitate preparation and conduct of tumor boards through obviating the need of a multi-headed microscope or microscope with projection attachment or acquisition of multiple static images of a case (50,51). This is because WSI offers higher quality images with annotation, greater educational value for clinicians, involves less preparation time than photographing cases, and permits real-time flexibility (e.g. easy to add on cases, perform side-by-side viewing, and gives access to the entire slide which allows one to answer “on-the-spot” questions) (52). It is also useful in E-education, virtual workshops, and for proficiency testing (53). The use of this technology in Quality Assurance (QA) programs in Surgical pathology and Cytopathology can help in cost cutting and overcoming transportation difficulties, as also minimizing the potential second-reviewer bias by hiding the initial diagnosis (10, 30, 54). Online WSI resources such as College of American Pathologists (CAP) Virtual Slide Box, Digital Pathology Association hosted repository, and the Cancer Digital Slide Archive offer virtual slide sets for training and learning purposes. Virtual slides are also being used in pathology conferences and meetings to promote interactive learning and provide ease of visualization of multiple images of different stains in conjunction with relevant clinical material (30). Electronic publication of text books and articles in scientific journals has also opened new panoramas of scientific communication (55). Utilization of WSI-generated high-quality virtual images has proven to be the single most upgrade for pathology journals, thus empowering the readers to be involved in a scientifically based diagnostic approach to the lesion described (56).


Over the last few years, WSI has been utilized in primary frozen section diagnosis and secondary/tertiary teleconsultation (43,51, 57-59). The advantages include access to an entire digitized slide or even an entire case (set of slides), automated scanning, the high resolution of images available for review, rapid interpretation time, and the ability of teleconferencing.

A high concordance rate between WSI-based frozen section and permanent section diagnosis or on-site interpretation has been demonstrated in several studies (11,37, 60). However, further studies on a range of different pathologies are required to validate the utility and limitations of WSI. Successful implementation requires: effective planning and communication, a willingness to adjust old routines without compromising quality, and histo-technologists who are able to provide consistently high-quality frozen section slides (41,61,62).


WSI is increasingly being used in the daily practice of surgical pathology, particularly for teleconsultation and certain quality assurance practices, such as obtaining second opinions (31,63,64). However, it raises a question whether WSI will be utilized for making routine pathologic diagnoses, ushering in the era of the “slideless” laboratory, especially after the COVID-19 pandemic (60,65,66). The adoption of digital pathology has been slower than in radiology partly due to the fact that in pathology, digital data is acquired in a slightly different manner from that in radiology (31,67,68). Although both fields require an imaging modality to collect primary data, in radiology, images begin as digital data whereas pathology images have to be converted from an analog substrate into a digital format (67-69).

Rendering routine pathologic diagnoses using WSI is feasible if the images truly represent an accurate digital reproduction of the scanned glass slide which can be saved, archived, reviewed, and later retrieved without any degradation (70). Moreover, apart from integration with the LIS, the routine use of WSI requires seamless connectivity over broadband networks, efficient workstations, cost-effective storage solutions, and standards-based informatics transactions for integrating information (63,71). Discrepancies between digital and glass slide diagnoses may be attributed to inadequate clinical data, missed tissue on the digital slide, and the pathologists’ lack of experience using a WSI system (72). One study demonstrated that using a virtual slide system, correct diagnosis was made in 66% of cases without clinical data provided compared to a correct diagnosis of 76% when clinical data was provided (72). Therefore, in order for WSI to become an accepted diagnostic modality, the provision of adequate medical information (e.g. gross pathology description, prior pathology reports, clinical history, imaging and other relevant laboratory parameters etc.) will need to be weaved into the imaging system (63,73,74).

Digital slides offer several advantages in terms of fidelity of the diagnostic material, portability, ease of sharing, retrieval of archival images, and ability to make use of computer-aided diagnostic tools (e.g. image algorithms) (37, 62, 75, 76). WSI has also permitted new business models of care in pathology (78). For example, virtual IHC service provided by large national laboratories. After the remote reference laboratory performs staining and slide scanning services, the referring pathologist is provided with full access to these IHC slides for interpretation or referral to a teleconsultant (43). In the near future, the adoption of standards, validation guidelines, automation of workflow, creation of new revenue streams, and nuances of clinical digital practice will likely dictate a new standard of care for primary pathologic interpretations (11, 77-80).


WSI offers advantages in enhancing objectivity in the interpretation of IHC used in tumor diagnosis, prognosis, and evaluation of biomarkers for targeted therapy (1,81,82). A study reported a concordance of 90% between WSI and glass slides of HER2/neu expression in breast cancer (81). Application of automated image analysis with algorithm-based scoring for the prognostic markers can assist in improving the scoring protocols and thereby enhance the efficacy of targeted therapies (82). Also in electron microscopy, a virtual ultrathin slide allows the pathologists to navigate the slide in their office while noting the exact location of the specific features. Apart from this, WSI technology can be valuable for obtaining consultation on ultrathin sections from experts located in higher centres (83).


The role of WSI in Cytopathology has been increasing but there are certain obstacles such as the inherent complexity of scanning, higher scanning time, and storage costs (10,84-87). The scanning of cytology smear is difficult as well as complex because of its three dimensional character (85). Consequently, it is essential to integrate z-stacking or multiplane scanning feature into the systems intended for use in cytopathology (87). Alternative approach includes the conversion of z-stacks of images into video frames and storing the stack as a high-efficiency video coding file(s). Subsequent video compression has demonstrated to exceed the JPEG compression with comparable image quality (88). A comparison of conventional glass slides and WSI in 10 cervical and 20 non-gynecologic cytology cases showed similar diagnostic concordance between the two modalities among the reviewing cytopathologists (89). Another recent study comparing WSI with glass slides of thin-layer cervical specimens demonstrated 95.3% concordance rates, paving the way for WSI use in routine cytologic diagnosis (86). A study by Wright et al evaluated the efficiency of WSI in cervico-vaginal cytology highlighting issues such as a lack of familiarity with the technology, difficulty in detecting few abnormal cells in the smears, problems with hyperchromatic nuclei, dark and crowded groups of cells, and massive image file size leading to increased duration of scanning (90). Certain problems encountered while using WSI in cytology smears compared to the histology sections, include (a) presence of dense overlapping tissue fragments making it difficult for scanners to focus on the cells, (b) red cell contamination of the smear and/or background acellular material(s) leading the scanner to focus on red cells and/or the background material rather than the cells of interest, (c) smears with scant cellularity making z-stacking difficult, and (d) need to remove the screening marks/dots before scanning (for which keeping a photographic record of the diagnostic screening marks is recommended) (91). Papanicolaou- and H&E-stained smears often have cells in multiple planes due to wet fixation, and thus require z-scanning to obtain a crisp, high quality image. On the other hand, air-dried Romanowsky-stained smears can be scanned with only x and y-axes, as air drying flattens the cells thus minimizing the requirement of z-stacking (91,92).

Given the ongoing need for a cytologic diagnosis, the trend of using WSI in Cytopathology may possibly increase in future as minimally invasive procedures to obtain material for genetic/ molecular analysis are used. The possibility to scan whole slides and to organize them in structured databases accessible via the Internet would represent a powerful educational resource. The examples of rare cases can be shared without the risk of stain fading or loss or breakage of slide(s).

In next part of this series we will explore WSI in Artificial intelligence.


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Sambit K Mohanty, MD

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