Informatics, digital & computational pathology
Digital & computational pathology
Intraoperative consultation

Minor changes: 24 September 2020

Copyright: 2020,, Inc.

PubMed Search: Telepathology intraoperative consultation

Robin L. Dietz, M.D.
Liron Pantanowitz, M.D.
Page views in 2020 to date: 105
Cite this page: Dietz RL, Pantanowitz L. Intraoperative consultation. website. Accessed September 30th, 2020.
Definition / general
  • Also known as frozen section via telepathology
  • Transmission of images to a remotely located pathologist during intraoperative consultation / frozen section
  • Broadly classified into static, dynamic, robotic, whole slide imaging and hybrid (J Pathol Inform 2014;5:39, J Pathol Inform 2016;7:26)
  • Static image telepathology with still photographs (snapshots)
    • Advantages: low bandwidth requirement and quick image transmission with small image files, digital cameras (including cell phones) widely available, low cost and no complex software needed
    • Disadvantages: skilled person is required onsite to take photos, image quality depends on the experience of the photographer and only limited portion of tissue / slide examined
  • Dynamic telepathology with transmission of a video stream
    • Advantages: low bandwidth requirement, remote pathologist can view more regions of a slide, overcomes focus issues and relatively low cost
    • Disadvantages: skilled person is required onsite to examine (drive) slide, may have lag in video transmission and video files infrequently archived
  • Robotic telepathology with remote pathologist controlling a remote microscope
    • Advantages: no dependence on a person with microscopy skills to drive a stage, no delayed scan time, lower bandwidth requirements, access to freely navigate the entire slide, ability to select different magnification, real time control of focus
    • Disadvantages: someone still needs to load a slide on the device, high cost, more complex software and IT setup
  • Whole slide imaging (WSI) involves scanning a glass slide to generate a digital (whole slide) image (J Pathol Inform 2015;6:49)
    • Advantages: high resolution image, access to the entire slide and WSI can be archived
    • Disadvantages: someone still needs to load a slide on the device to be scanned, relatively more expensive, larger footprint of device, high bandwidth requirements, longer time to scan whole slide and transmit large files, small tissue fragments or individual cells may fail to scan, inability to focus in Z axis (unless Z stack scanned) and proprietary file formats may need dedicated image viewers
    • Hybrid (multimodal) uses a combination of the other techniques (e.g. WSI and robotic live microscopy) (J Pathol Inform 2016;7:26)
  • Panoramic imaging uses a digital camera to stitch together a whole slide image in real time while a user examines slides on a conventional microscope
  • Gross telepathology for transmitting images of intraoperatively removed specimens (macroscopy)

Contributed by Liron Pantanowitz, M.D.

Hybrid WSI / robotic scanner

Frozen section suite

Diagrams / tables

Images hosted on other servers:

Network topology
for interinstitutional
frozen section

  • Telepathology during intraoperative consultation (remote frozen section reads), especially for access to expert subspecialists (e.g. neuropathologists) and during nonbusiness hours (e.g. on call at night and weekends) with comparable accuracy to glass slides (Am J Clin Pathol 2020;153:198)
  • Teleconsultation for a second opinion among pathologists
  • Nonclinical use cases (e.g. education, proficiency testing, quality assurance, archiving)
  • Increased access to subspecialty pathologists which leads to improved patient care
  • Decreased travel time for pathologists covering multiple locations and taking call at home
  • Comparable accuracy to glass slides (Am J Clin Pathol 2020;153:198)
  • Reassuring for general pathologists to know they have backup for difficult frozen sections
  • Return on investment:
    • Fewer subspecialized pathologists are needed at each location
    • Permits revenue generating complex surgery (e.g. neurosurgery) to be performed without having subspecialized pathology services onsite at each facility
Potential limitations
  • Preanalytical factors:
    • Improper tissue sampling
    • Slide artifacts (tissue folds, air bubbles, excess mounting medium)
  • No access to view gross specimens
  • Handling multiple frozen sections and multiple specimens simultaneously
  • Depending on the mode of technology, limited access to examine the entire slide
  • Image related problems: poor focus, limited resolution, color discrepancy and corrupt image file
  • End user unfamiliarity with the telepathology system
  • Difficult / borderline pathology cases (e.g. dysplasia, screening for microorganisms)
  • Higher deferral rate
  • Potential delayed turnaround times
  • Downtime (e.g. telepathology system failure)
  • Pathologist mindset (technophobia, reluctance, fear of making an error)
  • System selection to match telepathology system with clinical need and available resources
  • Deployment with appropriate IT infrastructure (sufficient network bandwidth, HIPAA security)
  • Validation according to CAP guidelines (e.g. 60 cases for glass versus digital with 2 week washout)
  • Downtime policy and procedure
  • Documentation (e.g. state that telepathology was performed in the pathology report)
  • Maintenance (regular IT checks that the system is online and operational)
  • Quality assurance program (monitor frozen final discrepancy and deferral rates)
  • Business operations (hospital privileges, malpractice coverage, avoid Stark law antikickback violations)
Board review style question #1
What is the telepathology modality where a remote pathologist can control the microscope stage and objectives at the location where a frozen section slide was prepared?

  1. Dynamic
  2. Panoramic
  3. Robotic
  4. Static
  5. Whole slide imaging
Board review answer #1
C. Robotic telepathology. The ability to remotely control the microscopic stage and objectives is a feature of robotic telepathology systems.

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Reference: Intraoperative consultation
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