EDITORIAL

Convergence of Digital Pathology and

Artificial Intelligence Tools in Anatomic
Pathology Practice: Current Landscape
and Future Directions
Anil V. Parwani, MD, PhD, MBA*
and Mahul B. Amin, MD†

P athology continues to rapidly evolve as a specialty and solidify its central role in inter-
disciplinary medicine. The past decade has witnessed the impact of molecular pathology
Downloaded from http://journals.lww.com/anatomicpathology by BhDMf5ePHKbH4TTImqenVIdHfOa5cT8d0W9QWA+MtfB1afU7fqHs/vb2X3lj14yo on 06/21/2020

and precision medicine on our specialty, and this role continues to expand. The convergence of
continued advances in digital pathology, expanded cloud computing capabilities and easier
implementation of Artificial Intelligence (AI) applications to Pathology, allows us to be part of
an exciting digital revolution that will empower our role through Computational Pathology.
The advancement of information technologies during the past 2 decades has facilitated the
development, implementation, and use of novel technologies in the practice of pathology such
as next generation pathology and digital pathology.1 There have been significant technology
gains in pathology imaging (digital pathology) that have led to the adoption of innovative
digital pathology workflows enabling a streamlined digital workflow.2 One such advancement
has been whole slide imaging (WSI), which refers to “scanning” of entire glass slides to produce
a “digitized” version of the glass slide. Although first prototype was built over 20 years ago,3
WSI is now increasingly being used in pathology laboratories as an imaging modality to enable
access to the entire pathology caseload.4–7 In addition, in the last 5 years we have witnessed an
increasing use of machine learning (ML), deep learning (DL) and AI tools in diagnostic
pathology, research, industry, and education applications.8–15
Using digital pathology and AI tools, pathologists can take the driver’s seat in the
patient’s diagnostic journey. They can become the integrator and driver of the information as a
pathologist, instead of watching from the sidelines after looking at the morphology. Patholo-
gists can become the primary provider of the vital information for the care of the patient not
only in cancer but also in other fields such as renal pathology or lung pathology. They can start
to work with other clinical specialties such as radiology, genomics, and oncology and be the
central driving force of the diagnostic space.10
The value of a digital pathology workflow has become ever so relevant in the COVID-19
pandemic period. As laboratories and hospitals around the world continue to navigate the ever-
changing environment of the COVID-19 pandemic, more laboratories and pathologists are
finding themselves amidst situations, which demand providing remote services such as review of
frozen sections, fine needle aspirations, quality assurance (QA), consultations, resident training,
and primary diagnosis. A number of reasons contribute to this such as pathologists who are in
quarantine or are at increased risk due to age or underlying conditions. This has especially
important as pathologists look to additional and novel ways to train residents and fellows
during COVID-19 crisis.16 Furthermore, this approach also remains critical in assuring sub-
specialty input and back up from the right individuals in a practice/department or community
using digital pathology applications.
Even before the pandemic, a small, currently finite, but gradually increasing number of
laboratories around the globe have gone “100%” digital while WSI continues to gain traction
amongst pathologists for diagnostic, educational, and research purposes. With this digital
workflow, the quality of the images produced is of diagnostic quality and with the viewing
software, it is possible to have annotations and clinical metadata presented with the image,

From the *Department of Pathology, The Ohio State University Medical Center, Columbus, OH; and †Department of Pathology and Laboratory
Medicine, University of Tennessee Health Science Center, Memphis, TN.
A.V.P. serves on the advisory board for Contextvision and provides advice on deep learning and artificial intelligence applications in Anatomic
Pathology. M.B.A. serves on the advisory board for Ibex and is a consultant for Advanced Clinical providing consultations for artificial intelligence
applications in Anatomic Pathology for both these organizations.
Reprints: Anil V. Parwani, MD, PhD, MBA, Department of Pathology, The Ohio State University Wexner Medical Center, 410 W.10th AVE,
Columbus, OH 43210 (e-mail: anil.parwani@osumc.edu).
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Adv Anat Pathol  Volume 27, Number 4, July 2020 www.anatomicpathology.com | 221
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Editorial
resulting in a virtual microscope with all the clinical infor-
mation needed to sign-out the case. Many recent studies
have demonstrated the utility of WSI in teaching, QA
assessment, consultation, telepathology, image analysis, and
research use.17,18
In terms of technology, WSI captures an entire tissue
sample on a slide converting into millions of pixels, which
can be shared easily as a digital slide1 or subjected to pat-
tern-recognition learning algorithms using specialized digital
pathology software. The creation of algorithms can be
customized to create “apps” similar to the ones that are now
available on smartphones. DL neural networks may be
trained to not only recognize specific patterns on a whole
slide image of an hematoxylin and eosin slide but in addition
AI tools may also help in the interpretation of features in the
tissue that are predictive and/or prognostic.19
Despite much progress in the field of digital pathology,
adoption in the United States for the last 5 years remained
slow and only restricted to few niche applications. Several
large academic hospitals have started to build digital path-
ology programs. Large-scale clinical trials have been
conducted and demonstrated the excellent diagnostic
concordance between glass and digital slide diagnosis
rendered.20–23 Digital pathology networks have been created
and “in-sourcing” of pathology consults via digital slides
have started. Image analysis tools are now more commonly
available and quantitative algorithms may being imple-
mented in diagnostic pathology practice.24,25
Since 2017, 2 WSI vendors have Food and Drug Admin-
istration (FDA) approval in the United States for primary
diagnosis.26,27 The current relatively slow adoption of digital
pathology workflow before widespread use of AI tools
somewhat parallels what occurred with radiology. In radiol-
ogy, the switch to digital accelerated once workflow algo-
rithms and computer-aided diagnostic devices became
available.28 As digital pathology promises to improve pre-
cision diagnosis and personalized medicine, the incorporation
of algorithms in digital pathology could accelerate the adop-
tion of digital health care in both radiology and anatomic
pathology.29 This greater adoption would allow digital path-
ology to realize the benefits for patients and clinicians in terms
of rapid image sharing, image workflow streamlining, image
analysis and building powerful algorithms that can assist in
the all aspects of workflow.30 Applications of AI and ML
techniques tools are the promise of a “true” digital workflow
and intelligent systems that will provide the pathologist with
critical decision support and “smart” sign-out systems that are
“computer-assisted.” These tools, when fully developed will
likely to drive the adoption of digital pathology at a more
rapid pace than we seen today do.8,31
As we think about what are the areas in anatomic path-
ology that can benefit from DL and AI tools, we can start
thinking about categories of “helper” apps for pathologists.32,33
Using digital images, and broadly speaking, algorithms can be
divided into 2 types. Type A are akin to “workflow devices”
with an objective to improve workflow efficiencies for the
pathologists. These type of algorithms will aid the pathologist to
do “repetitive” tasks such as counting mitosis or counting nuclei
or tumor cells in a microenvironment rapidly. The workflow
devices are considered general operating systems, assisting the
laboratory and/or pathologists in their daily work by processing
and reviewing patient specimens to make a diagnosis.34
Type B are algorithms that can provide decision sup-
port and help the pathologists in making better-informed
decisions. For example, AI based-recognition of cancer in
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Adv Anat Pathol  Volume 27, Number 4, July 2020
biopsy specimens and grading of cancers (eg, breast or
prostate cancer), diagnoses of gastrointestinal polyps and
inflammatory conditions, etc. Potentially, there could be a
tool that is a “dashboard” for the patient and will highlight
the prostate or breast cancer on the needle biopsy but also
combine family history, prior pathology results and images
as well as biomarker information for the pathologist to
enable a better, robust and decision-powered diagnosis. This
information fusion is critical to the pathologist and is more
possible and enabled in a digital workflow and is at the core
of computational pathology.35
Currently, there are some commercially available DL
networks and AI tools for pathologist use. These first gen-
eration tools are promising and more and more pathologists
are starting to consider them as part of their diagnostic
workflows. As technology and infrastructure matures, and
as digital pathology adoption increases, these tools will
make an even bigger impact on the practice of anatomic
pathology, as has been the case in radiology.29,36 The suc-
cess of this workflow and adoption of “smart” algorithms
will likely also benefit from more powerful computing
resources and annotation of larger image data sets, enabling
and creating a framework for precision pathology.37–39
Digital images of glass slides can facilitate acquisition
of not only a definitive diagnosis, but also access to other
pathologists for a second opinion and specialty con-
sultations. Quality QA requirements, especially those for
suspected cancers, can be rapidly executed. Changes in QA
and consultation practices can be sufficient to promise div-
idends for patients in terms of turn-around time, safety, and
quality of care. Utilizing AI tools, the QA process of the
future anatomic pathology laboratory will be more
streamlined and enhanced by algorithms that can provide
“virtual” QA on cases already signed out be pathologists
and can be modulated or fine-tuned to focus on problem
areas or “hotspots” in the laboratory such as an error-prone
pathology specialty or a new pathologist in the system who
has been flagged for a higher diagnostic error rate.31,37,40,41
Type B applications of decision support in Anatomic
Pathology in effect offer a prospective expert grade QA,
thereby also allowing the pathologist to focus on charac-
terizing the pathology catered specifically to management
implications.
Operating digital pathology as a clinical service within
and across working medical centers will require more than
imaging scanning systems. To be useful in the clinical
environment, the digital pathology systems must interface
seamlessly with a range of supportive hospital systems. In
the experience of some early adopters, factors such as the
stability of the health system’s network, the speed of servers,
the performance of the pathologist’s workstation and
monitor, and even the functionality of the image pre-
sentation and navigation software proved more important
for the pathologists than the performance of the imaging
systems.42,43 Although hospital systems have not measured
all those parameters explicitly, it is clear that such factors,
from scanner to desktop to image integration with the lab-
oratory Information System and hospital electronic records,
can have a significant influence on the pathologist’s per-
formance. Quality improvement assessments will investigate
the performance of hospital informatics systems that inter-
face with the digital pathology network. Network per-
formance metrics will be better established to determine the
potential impact of system alternatives and recom-
mendations will be provided to improve performance.41,42,44
Adv Anat Pathol  Volume 27, Number 4, July 2020
Digital pathology is bridging the gap of time and dis-
tance by delivering care at the point of need in a clinically
time-sensitive manner, regardless of location. Real time and
delayed case reviews can easily be conducted through the
use of digital imaging, allowing pathologists in remote areas
to work with colleagues more immediately to obtain
potentially medically significant and even lifesaving con-
sultations, second opinions, diagnostic collaborations, and
subspecialty reviews.45 The latter has now been apparent in
laboratories where during COVID-19 pandemic, patholo-
gists have been successful in maintaining social distancing
which achieving excellent patient care using remote sign-
outs and reviews with residents and fellows.46
Another advantage of adopting WSI is that smaller
practices will benefit from the ability to organize virtual
practices by integrating their smaller clinic operations into
virtual hospitals. An example of this to create virtual frozen
section services that provide coverage to multiple sites by
few pathologists in difficult and challenging areas such as
neuropathology or lung pathology.45,47 Efficiencies realized
by implementing digital solutions will increase utilization of
available pathology resources at a time of diminishing
pathologist availability. Improved resource utilization will
maximize productivity, expand access to care, reduce out-
sourcing costs, and offer pathologists the ability to retain a
high level of technical proficiency through interpretation of
a variety of medical images not available in their day-to-day
practice. Furthermore, digital pathology systems will pro-
vide support to community practices with ready access to
expert pathologists and pathology subspecialists. A subset of
these consults, in the future, may be triaged by intelligent
digital pathology systems.48
A routine “analog” pathology workflow generally
involves the procurement, processing and interpretation of
glass slides locally within each hospital. In some instances,
specific cases are sent from the general/community pathol-
ogist) to a subspecialist/academic pathologist for an over-
read consult. This can also be implemented in niche areas
such as cytopathology or dermatopathology. Nonetheless,
the general pathologist serves as the “gate keeper” at com-
munity hospitals, making the initial diagnosis and then
determining which cases, if any, are referred to a sub-
specialist. A WSI scanner may be considered as a micro-
scope that is under full robotic control, attached to highly
specialized cameras containing high-performance photo
sensors and serves to produce diagnostic quality images.
Once the slides are digitized and converted to millions of
pixels, we now have massive pixel pipelines, which allow
pathologists to remotely view the images and share them. In
addition, these pixels can now be interrogated to look for
distinct features or image “signatures” using image analysis,
DL and AI tools.49 For example, an expert urological
pathologist on a busy consult day may be able to have a
“digital” assistant or “fellow” who can rapidly scan digital
slides and prepare the “sign-out” process for the day, ena-
bling the expert pathologist to rapidly turn around the
consults. This is a win-win situation for patients, health care
systems and the pathologist. Studies have demonstrated that
there is a value proposition for institutes who have imple-
mented digital pathology in the workflow in terms of effi-
ciencies gained and reduced errors with improved quality of
care.50
Today, with all the innovations in computing and
infrastructure, it is technically feasible to use WSI for rou-
tine pathologic diagnosis for general and subspecialty
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Editorial
pathology. The important aspect of this is that images are of
diagnostic quality and provide an accurate representation of
the scanned glass slide. Several studies have shown that
when those conditions are met, there is little to no difference
between a diagnoses rendered via image versus a slide and
information management is an important benefit of creating
a digital workflow for enabling the pathologist an access to
the relevant patient information in a SMART cockpit.51–53
By providing rapid access to this information, time is saved
and quality of the information is enabled.50 Once this
information and images are managed in the SMART
cockpit, the second important aspect of the value pyramid
can become available which is the ability of “image
sharing.”
The image sharing enabled by digital pathology
workflow can be for access to experts for consultation,
showing cases to a colleague for clinical and treatment
decisions or for QA or for “work-load balancing.”53,54 As
these applications of image sharing are rapidly used, the
value of digital pathology workflow will make an enormous
impact on the care of the cancer patient. These benefits are
not nearly as powerful as the third and yet not fully devel-
oped and exploited value of digital pathology, which is the
field of image analysis and computer-aided diagnosis.
Advances in the area of image analysis will provide the
pathologists with powerful tools or “helper” applications to
enable the pathologist to do manual and labor-intensive
tasks more automated including detecting “rare events”
such as finding tumor metastasis within a lymph node or
accurately quantitating the volume of tumor in specimen.9
Today’s information-based world is changing anatomic
pathology practice. Pathologists are increasingly turning a
digital workflow with some systems, which have integrated
digital slides into electronic medical records.41 These sys-
tems now allow pathologists to log into the electronic
medical record and with an integrated view of the pathology
and the patient journey, are able to provide the best diag-
nosis for their patients. Morphology-based assessment of
slides is not enough.55 Patient management teams are
demanding more information and even patients are
demanding more accuracy. Implementing a digital workflow
allows pathologists to take better control of the daily work
and the “technology environment” and give the best possi-
ble diagnosis, or “outsource” it to the plethora of multiple
entities that can “complete” the diagnosis by adding the
molecular data, immune-oncology markers56 and mutation
panels that will drive the care of the patient towards “pre-
cise” medicine.10,57
Today, there are multihospital practices or commercial
labs which have taken big steps forward by implementing
digital pathology workflows for both general and subspeci-
alty sign-out.18,54,58 With the advent of supercomputing and
the rise of cloud technology, it is easy to rapidly share
images across the globe. A challenging pathology slide from
a community hospital from rural regions can be transformed
digitally to connect to the experts with the ones who need
help with the diagnosis in minutes.59 Today, digital path-
ology slides once digitized have information and integrated
data that makes the review process more efficient and
streamlined than ever before. These technologies continue to
transform the practice of pathology. With integrated AI
tools, the combination of digital pathology and connectivity
to patient electronic medical records, pathologists are poised
to utilize all the powerful tools that will enable them to be
on par with other medical professionals who heavily
www.anatomicpathology.com | 223
Editorial
leverage technology in their medical practices such as radi-
ologists and cardiologists. This will pave the way to provide
meaningful, accurate, and more structured information in
pathology reports to move precision medicine forward.60,61
Today as there is a gradual increase in the number of
departments and laboratories that are taking steps to con-
verting to a digital workflow and starting to use them for
primary diagnosis, there is an increase in adoption and
greater awareness of digital pathology. The latter has been
accelerated by the notion that digital pathology workflow is
a prerequisite for using smart AI algorithms. Digital path-
ology is beyond the curiosity and bells and whistles phase
and is now becoming a more critical strategy in developing
pathology services such that more institutes and laboratories
are buying WSI systems. The price of converting an hema-
toxylin and eosin slide to digital is getting lower in part due
to lowering image storage costs. The information techno-
logy infrastructure that is needed to sustain a digital path-
ology program is steadily growing more affordable. Some of
the adoption challenges are starting to become easier to
resolve. More vendors are building better and more
affordable scanners of all shapes and sizes, and more ven-
dors are starting to build value-based applications sur-
rounding digital pathology—some for consultation and
others for image analysis.62,63 Pathology images are now
becoming incorporated into imaging standards such as
DICOM (Digital Imaging and Communications in Medi-
cine) and efforts have been underway to create enhanced
connectivity between systems.64
Much of the progress in pathology including digital
pathology, image analysis, DL, next generation sequencing
and AI is making an ongoing impact on the practice of
anatomic pathology. Today, as evidenced, by COVID-19
pandemic testing preparedness with sustained testing capa-
bility, laboratories around the globe have emerged as critical
components of the health care ecosystem is assisting with
COVID-19 crisis. Today, pathologists have many tools
available to them that they could only wish or dream about
a decade before. “Next generation” or “augmented” path-
ology is now here to stay, and it is up to the pathology
community to become a part of this wave or remain on the
sidelines. Is there a way forward to move digital pathology
and AI tools as a pathologist community and make it
transformative? How can we ensure that the next 5 years
will take us much forward and finally we will be able to
utilize the immense power of digital pathology, DL and
AI tools?
Today, as consumer of these technologies and believ-
ers, we feel that despite much progress in the field, the
innovations and breakthroughs are occurring in silos. There
are clearly incredible products by vendor community. There
are newer, faster scanners, innovative software as well as
complimentary technologies to improve and automate steps
in the anatomic laboratory workflow. The problem is not a
lack of innovation but an inability to connect the dots.
Vendors are not working enough together to drive creativity
and innovations Many of the image formats are still not
standardized. Even the Laboratory Information Systems
(LIS) vendors are building solutions and creating their own
versions of “pathology cockpits” while the scanning com-
panies are not able to work as closely LIS vendors to create
smoother integration. Without this integration, the innova-
tions of digital pathology and AI will not be used fully.
Today, the current generation of image analysis software
has come a long way and has the potential to create “killer”
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Adv Anat Pathol  Volume 27, Number 4, July 2020
applications for pathologist that will be more powerful;
integrating these into scanner/LIS workflow cockpits will be
essential for practice transformation and adoption.
As we navigate the COVID-19 pandemic, there is
sense of a new and renewed energy to influence patient
outcomes by all disciplines within medicine. There is
increase in adoption and a “trust” that digital pathology
systems are clinical-grade and produce diagnostic quality
images. There is a newfound excitement about these next-
generation tools such as AI and DL. These technologies
are no longer either a hype or a myth; they are here to stay
and empower. It is our opportunity to harness their infinite
potential to empower our discipline. It was a big idea at its
inception, but many small and big insights by creative
vendors, researchers, ML experts and pathologists working
together have enabled the availability of these tools to the
pathology community. This novel, integrated, workflow
will be the new norm for the future of pathology diagnostic
pathway. It is already, partially there, and in some
laboratories today is now part of the diagnostic workflow
process, with demonstrable impact on transforming
patient care.
Our goal for this special issue of Advances in Ana-
tomical Pathology is to bring together a series of key and
timely reviews from experts in the field. We dedicate this
special issue on digital pathology and AI to the pioneers and
next generation of pathologists and AI scientists who will
continue to be innovators, inventors so that we as a specialty
are better prepared to accelerate the practice of anatomic
pathology beyond the glass slide.
REFERENCES
1. Zarella MD, Bowman D, Aeffner F, et al. A practical guide to
whole slide imaging: a white paper from the Digital Pathology
Association. Arch Pathol Lab Med. 2019;143:222–234.
2. Pantanowitz L, Sinard JH, Henricks WH, et al. Validating
whole slide imaging for diagnostic purposes in pathology:
guideline from the College of American Pathologists Pathology
and Laboratory Quality Center. Arch Pathol Lab Med.
2013;137:1710–1722.
3. Catalyurek U, Beynon MD, Chang C, et al. The virtual
microscope. IEEE Trans Inf Technol Biomed. 2003;7:230–248.
4. Amin W, Srintrapun SJ, Parwani AV. Automated whole slide
imaging. Expert Opin Med Diagn. 2008;2:1173–1181.
5. Pantanowitz L, Dickinson K, Evans AJ, et al. American
Telemedicine Association clinical guidelines for telepathology.
Telemed J E Health. 2014;20:1049–1056.
6. Kaplan K, Weisburger R. Whole slide imaging: it’s time to take
another look. MLO Med Lab Obs. 2015;47:39–41.
7. Cornish TC, Swapp RE, Kaplan KJ. Whole-slide imaging: routine
pathologic diagnosis. Adv Anat Pathol. 2012;19:152–159.
8. Niazi MKK, Parwani AV, Gurcan MN. Digital pathology and
artificial intelligence. Lancet Oncol. 2019;20:e253–e261.
9. Parwani AV. Next generation diagnostic pathology: use of
digital pathology and artificial intelligence tools to augment a
pathological diagnosis. Diagn Pathol. 2019;14:138–140.
10. Weisberg EM, Chu LC, Park S, et al. Deep lessons learned:
radiology, oncology, pathology, and computer science experts
unite around artificial intelligence to strive for earlier pancreatic
cancer diagnosis. Diagn Interv Imaging. 2020;101:111–115.
11. Turner OC, Aeffner F, Bangari DS, et al. Society of
Toxicologic Pathology Digital Pathology and Image Analysis
Special Interest Group Article*: Opinion on the Application of
Artificial Intelligence and Machine Learning to Digital
Toxicologic Pathology. Toxicol Pathol. 2020;48:277–294.
12. Acs B, Hartman J. Next generation pathology: artificial
intelligence enhances histopathology practice. J Pathol. 2020;250:
7–8.
Adv Anat Pathol  Volume 27, Number 4, July 2020
13. Farnell DA, Huntsman D, Bashashati A. The coming 15 years
in gynaecological pathology: digitisation, artificial intelligence,
and new technologies. Histopathology. 2020;76:171–177.
14. Kurc T, Bakas S, Ren X, et al. Segmentation and Classification
in Digital Pathology for Glioma Research: Challenges and
Deep Learning Approaches. Front Neurosci. 2020;14:27.
15. Pantanowitz L, Sharma A, Carter AB, et al. Twenty years of
digital pathology: an overview of the road travelled, what is on
the horizon, and the emergence of vendor-neutral archives. J
Pathol Inform. 2018;9:40.
16. Roy SF, Cecchini MJ. Implementing a structured digital-based
online pathology curriculum for trainees at the time of COVID-
19. J Clin Pathol. 2020. [Epub ahead of print].
17. Parwani AV, Hassell L, Glassy E, et al. Regulatory barriers
surrounding the use of whole slide imaging in the United States
of America. J Pathol Inform. 2014;5:38.
18. Thorstenson S, Molin J, Lundstrom C. Implementation of
large-scale routine diagnostics using whole slide imaging in
Sweden: Digital pathology experiences 2006-2013. J Pathol
Inform. 2014;5:14–18.
19. Sarwar S, Dent A, Faust K, et al. Physician perspectives on
integration of artificial intelligence into diagnostic pathology.
NPJ Digit Med. 2019;2:28–34.
20. Mukhopadhyay S, Feldman MD, Abels E, et al. Whole slide
imaging versus microscopy for primary diagnosis in surgical
pathology: a multicenter blinded randomized noninferiority study
of 1992 cases (Pivotal study). Am J Surg Pathol. 2018;42:39–52.
21. Goacher E, Randell R, Williams B, et al. The diagnostic
concordance of whole slide imaging and light microscopy: a
systematic review. Arch Pathol Lab Med. 2017;141:151–161.
22. Saco A, Ramirez J, Rakislova N, et al. Validation of whole-
slide imaging for histolopathogical diagnosis: current state.
Pathobiology. 2016;83:89–98.
23. Jones NC, Nazarian RM, Duncan LM, et al. Interinstitutional
whole slide imaging teleconsultation service development:
assessment using internal training and clinical consultation
cases. Arch Pathol Lab Med. 2015;139:627–635.
24. Nunes C, Rocha R, Buzelin M, et al. High agreement between whole
slide imaging and optical microscopy for assessment of HER2
expression in breast cancer: whole slide imaging for the assessment of
HER2 expression. Pathol Res Pract. 2014;210:713–718.
25. Farris AB, Cohen C, Rogers TE, et al. Whole slide imaging for
analytical anatomic pathology and telepathology: practical
applications today, promises, and perils. Arch Pathol Lab Med.
2017;141:542–550.
26. Evans AJ, Bauer TW, Bui MM, et al. US Food and Drug
Administration approval of whole slide imaging for primary
diagnosis: a key milestone is reached and new questions are
raised. Arch Pathol Lab Med. 2018;142:1383–1387.
27. Abels E, Pantanowitz L. Current state of the regulatory
trajectory for whole slide imaging devices in the USA. J Pathol
Inform. 2017;8:23–26.
28. Dikici E, Bigelow M, Prevedello LM, et al. Integrating AI into
radiology workflow: levels of research, production, and feed-
back maturity. J Med Imaging (Bellingham). 2020;7:016502.
29. Harmon SA, Tuncer S, Sanford T, et al. Artificial intelligence
at the intersection of pathology and radiology in prostate
cancer. Diagn Interv Radiol. 2019;25:183–188.
30. Aeffner F, Zarella MD, Buchbinder N, et al. Introduction to digital
image analysis in whole-slide imaging: a white paper from the Digital
Pathology Association. J Pathol Inform. 2019;10:9–15.
31. Parwani AV. Digital pathology enhances cancer diagnostics.
MLO Med Lab Obs. 2017;49:25.
32. Tizhoosh HR, Pantanowitz L. Artificial intelligence and digital
pathology: challenges and opportunities. J Pathol Inform.
2018;9:38–45.
33. Chang HY, Jung CK, Woo JI, et al. Artificial intelligence in
pathology. J Pathol Transl Med. 2019;53:1–12.
34. Wong STC. Is pathology prepared for the adoption of artificial
intelligence? Cancer Cytopathol. 2018;126:373–375.
35. Montironi R, Cimadamore A, Massari F, et al. Whole slide
imaging of large format histology in prostate pathology:
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2020 Wolters Kluwer Health, Inc. All rights reserved.
Editorial
potential for information fusion. Arch Pathol Lab Med.
2017;141:1460–1461.
36. Filice RW. Radiology-pathology correlation to facilitate peer
learning: an overview including recent artificial intelligence
methods. J Am Coll Radiol. 2019;16(pt B):1279–1285.
37. Acs B, Rantalainen M, Hartman J. Artificial intelligence as the
next step towards precision pathology. J Intern Med. 2020.
[Epub head of print].
38. Rashidi HH, Tran NK, Betts EV, et al. Artificial intelligence
and machine learning in pathology: the present landscape of
supervised methods. Acad Pathol. 2019;6:2374289519873088.
39. Colling R, Pitman H, Oien K, et al. Artificial intelligence in
digital pathology: a roadmap to routine use in clinical practice.
J Pathol. 2019;249:143–150.
40. Ho J, Parwani AV, Jukic DM, et al. Use of whole slide imaging
in surgical pathology quality assurance: design and pilot
validation studies. Hum Pathol. 2006;37:322–331.
41. Hartman DJ, Pantanowitz L, Mchugh JS, et al. Enterprise
implementation of digital pathology: feasibility, challenges, and
opportunities. J Digit Imaging. 2017;30:555–560.
42. Hanna MG, Reuter VE, Hameed MR, et al. Whole slide
imaging equivalency and efficiency study: experience at a large
academic center. Mod Pathol. 2019;32:916–928.
43. Villa I, Mathieu MC, Bosq J, et al. Daily biopsy diagnosis in
surgical pathology: concordance between light microscopy and
whole-slide imaging in real-life conditions. Am J Clin Pathol.
2018;149:344–351.
44. Wright JR Jr. Historical insights for early adopters of whole
slide imaging. Arch Pathol Lab Med. 2018;142:161b–162b.
45. Griffin J, Kitsanta P, Perunvic B, et al. Digital pathology for
intraoperative frozen section diagnosis of thoracic specimens: an
evaluation of a system using remote sampling and whole slide
imaging diagnosis. J Clin Pathol. 2019. [Epub head of print].
46. Mukhopadhyay S, Booth AL, Calkins SM, et al. Leveraging
technology for remote learning in the era of covid-19 and social
distancing: tips and resources for pathology educators and
trainees. Arch Pathol Lab Med. 2020. [Epub head of print].
47. Wiley CA, Murdoch G, Parwani A, et al. Interinstitutional and
interstate teleneuropathology. J Pathol Inform. 2011;2:21.
48. Pantanowitz L, Wiley CA, Demetris A, et al. Experience with
multimodality telepathology at the University of Pittsburgh
Medical Center. J Pathol Inform. 2012;3:45.
49. Montalto MC. An industry perspective: An update on the
adoption of whole slide imaging. J Pathol Inform. 2016;7:18.
50. Ho J, Ahlers SM, Stratman C, et al. Can digital pathology
result in cost savings? A financial projection for digital
pathology implementation at a large integrated health care
organization. J Pathol Inform. 2014;5:33–38.
51. Girolami I, Pantanowitz L, Marletta S, et al. Diagnostic
concordance between whole slide imaging and conventional
light microscopy in cytopathology: a systematic review. Cancer
Cytopathol. 2019;128:17–28.
52. Wack K, Drogowski L, Treloar M, et al. A multisite validation
of whole slide imaging for primary diagnosis using standardized
data collection and analysis. J Pathol Inform. 2016;7:49–56.
53. Zhao C, Wu T, Ding X, et al. International Telepathology
Consultation: three years of experience between the University
of Pittsburgh Medical Center and KingMed Diagnostics in
China. J Pathol Inform. 2015;6:63–68.
54. Romero Lauro G, Cable W, Lesniak A, et al. Digital pathology
consultations—a new era in digital imaging, challenges and
practical applications. J Digit Imaging. 2013;26:668–677.
55. Jiang Y, Yang M, Wang S, et al. Emerging role of deep
learning-based artificial intelligence in tumor pathology. Cancer
Commun (Lond). 2020;40:154–166.
56. Hartman DJ, Frank M, Seigh L, et al. Automated quantitation
of CD8-positive T cells predicts prognosis in colonic adeno-
carcinoma with mucinous, signet ring cell, or medullary
differentiation independent of mismatch repair protein status.
Am J Surg Pathol. 2020. [Epub head of print].
57. Levy JJ, Salas LA, Christensen BC, et al. PathFlowAI: a high-
throughput workflow for preprocessing, deep learning and
www.anatomicpathology.com | 225
Editorial Adv Anat Pathol  Volume 27, Number 4, July 2020

interpretation in digital pathology. Pac Symp Biocomput.
2020;25:403–414.
58. Evans AJ, Salama ME, Henricks WH, et al. Implementation of
whole slide imaging for clinical purposes: issues to consider
from the perspective of early adopters. Arch Pathol Lab Med.
2017;141:944–959.
59. Buck TP, Dilorio R, Havrilla L, et al. Validation of a whole
slide imaging system for primary diagnosis in surgical
pathology: a community hospital experience. J Pathol Inform.
2014;5:43–48.
60. Sluijter CE, van Lonkhuijzen LR, van Slooten HJ, et al. The effects
of implementing synoptic pathology reporting in cancer diagnosis: a
systematic review. Virchows Arch. 2016;468:639–649.
61. King S, Dimech M, Johnstone S. Structured pathology
reporting improves the macroscopic assessment of rectal
tumour resection specimens. Pathology. 2016;48:349–352.
62. Girolami I, Marletta S, Pantanowitz L, et al. Impact of image
analysis and artificial intelligence in thyroid pathology, with
particular reference to cytological aspects. Cytopathology. 2020.
[Epub head of print].
63. Wang S, Yang DM, Rong R, et al. Artificial intelligence in lung can-
cer pathology image analysis. Cancers (Basel). 2019;11:1673–1689.
64. Clunie D, Hosseinzadeh D, Wintell M, et al. Digital imaging and
communications in medicine whole slide imaging connectathon at
Digital Pathology Association Pathology Visions 2017. J Pathol
Inform. 2018;9:6–10.

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