This article summarizes key observations from the poster "Virtual Pathology: A Remote Cytology Experience", presented at the USCAP Annual Meeting 2024.
Authors: Hannah R. Krigman, Cory T. Bernadt, Ryan J. Hardy, Jon H. Ritter, H. Michael Isaacs, R. Cody Weimholt
Institution: Washington University School of Medicine, Department of Pathology
Digital pathology and telecytology are increasingly used to support remote cytology diagnosis, particularly in procedures involving fine needle aspiration cytology and touch preparation of core biopsies. These procedures require rapid evaluation of a tissue or fluid sample to guide treatment and ensure diagnostic adequacy.
Rapid On-Site Evaluation (ROSE pathology) is a standard component of cytology workflows. It allows a pathologist to review cytology specimens during a procedure, supporting primary diagnosis, identifying infection or malignancy, and guiding clinical management. Traditionally, this process depends on direct microscope-based review of a glass slide.
This study demonstrates a telecytology workflow where cytology specimens are reviewed remotely using digital pathology and slide imaging technology. Glass slides prepared at remote sites were reviewed using live digital slide imaging, allowing a pathologist to perform real-time interpretation without being physically present.
Fine needle aspiration cytology and touch preparation of core biopsies were used for cases involving sites such as the thyroid, lymph nodes, lung, liver, pancreas, and salivary gland. These procedures required rapid assessment of cytology specimens to determine adequacy and support immediate diagnostic decision-making.
During these procedures, ROSE pathology plays a critical role. Immediate review of cytology specimens helps determine whether sufficient diagnostic material has been obtained and supports specimen triage during the procedure. Without telecytology, delays in diagnosis can increase wait time, affect treatment decisions, and reduce overall efficiency. Telecytology enables a pathologist to guide sampling and interpretation remotely, improving turnaround time and supporting diagnostic accuracy across multiple sites.
Although digital pathology is often associated with whole slide imaging, this implementation relied on real-time slide imaging rather than fully scanned slides. However, the use of digital slides and image-based review still supports effective telecytology workflows.
The telecytology system was designed to support multiple hospitals through centralized digital pathology infrastructure. A pathologist was assigned to cover remote sites and was notified of each procedure via pager alerts. Communication during the procedure was conducted using Microsoft Teams, allowing real-time interaction between the laboratory and the reviewing pathologist.
Slides were prepared onsite by histotechnology staff and digitized using a Grundium Ocus 20x portable slide scanner. This slide imaging technology provided a thumbnail overview of the glass slide at low magnification, followed by higher magnification for detailed cytology analysis.
The system enabled dynamic navigation of digital slides, similar to microscope review, although high-power navigation was slower compared to traditional microscopy. This required adaptation of technique and workflow during interpretation.
The system supported remote slide review and communication between the onsite laboratory and the reviewing pathologist.
Over a three-month period, the telecytology workflow supported 103 fine needle aspiration procedures, including 83 ROSE cases, as well as 2,275 surgical pathology cases and 31 touch preparation cases. Cytology specimens included tissue samples and fluid samples from the thyroid, lymph nodes, lung, liver, pancreas, and salivary gland, all requiring real-time interpretation to guide treatment and diagnostic decisions.
Remote cytology diagnosis focused primarily on adequacy assessment and, in some cases, primary diagnosis. When compared with final pathology reports, overall agreement was reasonable, although discordant cases were observed. Eight fine needle aspiration cases were discordant, most involving nondiagnostic or indeterminate interpretations that were later determined to be benign, along with one case of malignancy misclassification.
Among touch preparation cases, five discordances were identified, primarily related to inadequate tissue sampling or missed lesions. Overall, these findings reflect real-world telecytology performance and highlight both the capabilities and limitations of remote interpretation compared with traditional microscope-based pathology workflows.
Several factors influenced diagnostic accuracy and efficiency. Image quality was critical, as staining quality and slide preparation directly affected visibility of cytology specimens. Pale staining reduced contrast, making interpretation more challenging.
Navigation at high magnification required adaptation, as slide imaging systems differ from traditional microscope workflows. However, training and intraprocedural feedback improved slide quality and overall performance.
In many cases, particularly thyroid fine needle aspiration cytology, adequacy assessment was the primary goal rather than definitive diagnosis. Under-calling adequacy was more common than over-interpretation, reflecting a cautious diagnostic approach.
These results highlight the importance of workflow optimization, technique adaptation, and coordination between laboratory staff and pathologists in digital pathology systems.
This implementation demonstrates that telecytology and digital pathology can improve operational efficiency and expand access to cytology services. Remote cytology diagnosis enables a pathologist to support multiple sites, reducing the need for onsite staffing and improving workflow management.
Key benefits include:
Improved access to cytology expertise for healthcare providers
Reduced repeat biopsy procedures through immediate adequacy assessment
Enhanced turnaround time and workflow efficiency
Scalable diagnostic support across multiple sites
These findings align with broader developments in digital pathology, where remote interpretation and image-based workflows are increasingly used to enhance diagnostic access and efficiency.
This study represents a single-institution experience with a limited number of cases. Diagnostic discrepancies occurred, particularly in complex cytology specimens and cases with inadequate or nondiagnostic material. In addition, performance depended on consistent slide preparation, staining quality, and reliable digital imaging equipment. Navigation limitations and differences from microscope workflows also impacted efficiency.
These limitations highlight the need for continued development of digital pathology systems, improved training, and optimization of telecytology workflows.
This poster demonstrates that telecytology using digital pathology and slide imaging technology is feasible for remote cytology diagnosis in clinical practice.
While not a replacement for conventional microscopy, telecytology supports diagnostic workflows, improves efficiency, and enhances access to cytology services. Continued advances in digital pathology technology, workflow integration, and staff training may further improve diagnostic accuracy and patient care.
A curated collection of digital pathology studies and references is available on Grundium’s website.
