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10.1177_10406387241241270
10.1177_10406387241241270
review-article2024
VDIXXX10.1177/10406387241241270Telepathology in veterinary medicine: scoping reviewRogers et al.
Review
Teleconsulting is not a new phenomenon, and it is increas- slide) and whether the image is stored (static telepathology,
ingly used in veterinary medicine as technology improves. WSI, or ROI scans) or viewed in “real-time” (robotic
Furthermore, teleconsulting gained prominence during the microscopy).8,31
COVID-19 pandemic as veterinary clinics looked for alterna- When first described in the human pathology literature,
tives to in-person consultation.7 Telepathology is a subset of the role of telepathology in distributing much-needed
teleconsulting, defined as performing pathology interpreta- pathology expertise to rural areas was emphasized.32 In
tion at a distance.12,33 Although the term telepathology was North America, many rural veterinary practices are geo-
first introduced in 1986, the earliest recorded instance of tele- graphically distant from the laboratory and veterinary spe-
pathology occurred in 1969 when microwave-based telecom- cialists, making teleconsulting particularly valuable. These
munication was used to transmit live black-and-white images clinics serve all species of animals, and rapid test results are
of histology slides and blood smears.3,32 Fifty years later, key to client satisfaction and timely therapeutic decisions.24
there have been significant advances in information technol- Additionally, rapid results are vital in production animal
ogy and telecommunications; as a result, telepathology has operations in which understanding the cause of disease is
become more sophisticated, more readily accessible, and paramount not only to the overall health of the herd but also
more frequently used in human and veterinary medicine.6,21 to identification of emerging, zoonotic, or foreign animal
Telepathology involves the acquisition of cytologic, diseases; food safety; and public health.1 Poor access to test-
hematologic, histologic, or macroscopic images for trans- ing can result in delayed or empirical treatment, inappropri-
mission along telecommunication pathways for diagnosis, ate use of antimicrobials, increased risk of disease outbreaks,
consultation, education, and research.3 This process can and diminished passive surveillance. Further understanding
include static telepathology, also known as offline or store-
and-forward, and dynamic or “real-time” pathology.8,20,31 Faculty of Veterinary Medicine (Rogers, Galezowski, Goldsmith,
Digital microscopy (DM) can be further separated into Legge, Waine, Zachar, Davies) and Library and Cultural Resources
robotic microscopy, region of interest (ROI) digital micros- (Ganshorn), University of Calgary, Calgary, Alberta, Canada.
copy, or whole-slide imaging (WSI). Visualization of the *These authors contributed equally to this work.
sample on a computer is the common thread that links these 1
Corresponding author: Jennifer L. Davies, Faculty of Veterinary
modalities, but they differ in how much of the slide is avail- Medicine, University of Calgary, 11877 85th St NW, Calgary, Alberta
able for viewing (individual fields, ROIs, or the entire T3R 1J3, Canada. jdav@ucalgary.ca
Telepathology in veterinary medicine: scoping review 491
Table 1. MEDLINE database search strategy used for our scoping review on the use of telepathology in veterinary medicine.
Table 2. CAB Abstracts (Ebsco) database search strategy used for our scoping review on the use of telepathology in veterinary
medicine.
Query Results
1 ("remote consult*" or "virtual consult*" or telemedicine) AND (patholog* or microscop* or cytolog* or 110
cytopatholog* or "digital h#ematolog*" or imaging or scanning or (imag* N2 analy*) or necrops*)
2 telepatholog* or telecyto* or "remote patholog*" or "remote cyto*" 32
3 S1 OR S2 133
4 veterinary or livestock or cattle or horse* or sheep or swine or pig or pigs or poultry or chicken* or turkey* 2,196,795
5 S3 AND S4 25
examination solely for teaching students were not consid- Data items
ered the performance of pathology interpretation at a dis-
We extracted the following data items from the literature.
tance and thus were excluded according to step 2c.
•• Country of corresponding author
Data charting process •• Study design
•• Purpose of study or publication
The same 2 independent reviewers charted data in Excel •• Division of pathology: gross pathology, histopathol-
(Microsoft) and tested the data charting process with the first ogy, cytology/hematology
10% of articles to ensure clarity and consistency. No revi- •• End-users: pathologists, education or students, con-
sions were necessary after the testing. Any conflicts were sulting, veterinarians, producers, or owners
resolved between the 2 reviewers. If consensus was not •• Whether the telepathology was performed in static,
reached, the conflict was brought to the team of content real-time, or by ROI, or WSI, as defined below:
experts for review. A single reviewer compiled the charted ○ Static telepathology: storage and transfer of static
data for synthesis. images (i.e., photographs of microscope slides or
Telepathology in veterinary medicine: scoping review 493
Figure 1. Number (n) of articles identified, screened, and included for our scoping review on the use of telepathology in veterinary
medicine. From: Page MJ, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71.
doi: 10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.org/
postmortems) for analysis at a time other than the •• Summary of overall conclusions
actual viewing of the slide or postmortem.8,9
○ Real-time telepathology: any telepathology in
Critical appraisal
which the postmortem or microscope slide is being
viewed concurrently by the referring veterinarian We did not perform a critical appraisal of the literature
and anatomic or clinical pathologist, including because this was a scoping review.
robotic microscopy.8,31
○ ROI digital microscopy: a subset of digital micros-
Synthesis of results
copy that uses image-stitching software to create a
low magnification image of a slide, then selects We used descriptive statistics to summarize the findings, pre-
ROI at higher magnification, and stitches the sented via a combination of tables, figures, and descriptive
images into a small file of embedded magnifica- text. We identified and discussed literature gaps and potential
tions.8 novel means of telepathology.
○ WSI: digitization of an entire glass slide that uses
software to create a digital image. Software emu-
Results
lates the use of a light microscope on the com-
puter.9 Following de-duplication, we screened 86 pieces of literature
•• Form of communication used: telephone, email, video and included 17 articles1–3,5,6,8–11,15,17,19,20,24,27,29,31 after the
conferencing, still-images, digital microscopy slides, full-text review (Fig. 1). Of these, 8 were primary research
or other articles, 2 were conference proceedings, 2 were review arti-
•• Technology used for interpretation: digital or virtual cles, and 5 were gray literature. All articles were published in
still-images, digital or virtual microscopy slides, real- 2003 or later. Corresponding authors were from 7 different
time video, post-procedural video, written or oral countries: Canada (2), Germany (2), India (1), Italy (3), Swe-
description, or other den (1), United Kingdom (3), and USA (5; Table 3).
494 Rogers et al.
We divided the study objectives for included articles into microscopy, and WSI technology has been validated for his-
3 broad categories: 1) to evaluate and validate a tool, applica- topathology, cytology, and hematology.4,13,16,18,22,28 Further-
tion, or technique (8 articles); 2) to describe the novel use of more, a commercial WSI histopathology system received
telepathology (1 article); or 3) to review, overview, or inform U.S. Food and Drug Administration approval for primary
potential users about the technology available for telepathol- diagnostic use in 2017. We found only 3 studies addressing
ogy (8 articles; Table 3). the validation of WSI in veterinary pathology, with good
We found that the included literature covered 3 divisions agreement between WSI and light microscopy for the histo-
of pathology, with some articles covering more than 1 divi- logic diagnosis of canine cutaneous tumors,5 the evaluation
sion: gross pathology (2 articles), histopathology (6 articles), of cytologic samples of canine lymphoma,9 and the evalua-
and cytology/hematology (12 articles). We found 4 modes of tion of canine and feline cytologic samples.10 There is a pau-
telepathology: static, real-time, ROI, or WSI. The mode in 6 city of WSI validation studies addressing the wide array of
articles was static telepathology; in 1 article, real-time telepa- histopathology, cytology, and hematology samples seen at
thology; in 1 article, ROI; and in 8 articles WSI. The authors veterinary diagnostic laboratories, highlighting the need for
did not state the mode for 1 article. We found technology used future research as DM becomes more commonplace.
for telepathology included digital photos (5 articles), aug- We identified more articles examining the use of DM for
mented reality (1 article), and digital microscopy (10 articles). cytology than for histopathology and found similarities and
We found communication for telepathology was through an differences in how the technology is used between the 2 dis-
application or online platform (9 articles), remote video (1 ciplines. Common to both disciplines is the increasing usage
article), email (4 articles), or a portal or shared drive (2 arti- of DM, specifically WSI, at diagnostic laboratories, allowing
cles). The authors did not state the communication used in 1 for rapid, worldwide transmission of pathology data for pri-
article. The end-users of the telepathology techniques or tech- mary diagnosis and second opinions; global access to a pool
nology were veterinarians only (6 articles), pathologists only of remote-working pathologists; digital archive of images for
(6 articles), or a combination of students, veterinarians, and/ secure, potentially permanent, and rapid retrieval; resident
or pathologists (5 articles; Table 3). training; image analysis; and the promise of artificial intelli-
We grouped findings from the included articles into 4 gence.5,10,31 However, with the ease of processing and stain-
broad categories: 1) the technology or technique investigated ing of cytology and hematology slides in-clinic combined
has potential but requires refinement and/or development (5 with more reliable and affordable equipment and telecom-
articles); 2) the technology was effective and viable in the munication platforms, a unique feature of telecytology is its
situations applied (5 articles); 3) the technology has major ability to connect the community practitioner to the clinical
advantages and is increasingly being used (6 articles); or 4) pathologist.11,19,27,29 Telecytology in community practice
the technology should not replace conventional microscopy ranges from the use of static images to the use of in-clinic
(1 article; Table 3). digital slide scanners to send images or scanned slides to a
remote clinical pathologist.11,19,27–29 Thereby, telecytology
accelerates the diagnostic process by eliminating the com-
Discussion plexities and delays associated with shipping glass slides to
Interestingly, very few articles met our inclusion criteria, the laboratory, resulting in rapid analysis and results. It is
indicating a relative paucity of literature describing the use particularly suited to facilitating intra-operative diagnosis
of telepathology in veterinary medicine compared to the and decision-making.29 In contrast, the complexities of tis-
increasing use of this technology within veterinary diagnos- sue processing and slide staining for histopathology samples
tic laboratories.15 Most of the veterinary literature focused on require that specimens are still sent to the laboratory, rather
microscopy, both cytology and histopathology, which is not than processed in-clinic, where slides can then be scanned
surprising as development of digital microscopy techniques and interpreted by an anatomic pathologist.14,31 Alongside
started in the mid-1980s for human medicine.32 Forms of the benefits listed above, DM use within the histotechnol-
DM used in veterinary medicine included static telepathol- ogy laboratory has brought new challenges, including
ogy, ROI microscopy, and increasingly WSI. DM has been increased steps to convert the glass slide to a digital image
transformed by the development of WSI systems, and WSI is with additional requirements for IT hardware and software,
now considered superior to both static and robotic telepa- ongoing maintenance, and increased staff time.6 However,
thology.6,23 DM has been adopted by veterinary pathologists telepathology does allow increased connection between cli-
for consulting, research, teaching, archiving, and increas- nician and histopathologist where required, with cases more
ingly primary diagnostic work in large laboratories using easily shared as captured images or by live sharing of com-
WSI as their primary technology for evaluation of histologic puter screens.14,31
and cytologic slides.6 Only 2 of the articles that we included in our scoping
In medicine, systematic studies addressing the reliability review focused on gross anatomic telepathology, which
of DM in daily routine pathology laboratories show that reflects a lack of publication on its use in veterinary medi-
interactive DM has a high concordance comparable to light cine. Those authors looked at the use of virtual feedlot
495
1
2
6
4
7
9
10
11
16
12
20
18
21
25
26
30
28
Total
2
X
Canada
2
Article author
X
X
Germany
1
X
India
3
X
X
Italy
1
X
Sweden
3
X
X
X
Country of corresponding
UK
5
X
USA
2
X
Conference proceedings
1
X
Cross-sectional
1
X
Case report
Study design
2
X
X
Review
6
X
X
X
X
X
Case-control
5
X
X
X
X
X
Grey literature
2
X
X
Anatomic–Gross
6
X
X
X
X
Anatomic–Histology
pathology
X
X
X
X
X
X
X
X
X
X
Division of
Cytology/Hematology
X
X
X
X
X
X
X
Veterinarians
12 10 2
X
X
Students
End-users
X
X
X
X
X
X
X
X
X
X
X
Pathologists
11 6
X
X
X
X
Static
Mode
1
X
Real-time
1
X
Region of Interest
8
X
X
X
X
X
X
X
Whole slide images
9
X
X
X
X
X
X
X
X
App/online platform
1
X
Remote video
4
X
X
X
X
Email
2
X
X
Communication
Portal/shared drive
6
X
X
X
X
Digital images
1
X
Augmented reality
X
X
X
X
X
X
X
X
X
Digital microscopy
10 8
X
X
X
X
X
X
X
Table 3. Summary of characteristics and study data for included literature for our scoping review on the use of telepathology in veterinary medicine.
1
X
Technology purpose
8
X
X
X
X
X
X
Review, overview, or inform
5
X
X
X
X
Telepathology has potential but requires refinement
5
X
X
X
Technology is effective where applied
6
X
X
X
X
X
There are major advantages and increasing use
1
X
Conventional microscopy is superior to telepathology
Study conclusions
496 Rogers et al.
postmortems through still-images and the use of virtual real- solutions will rely on telecommunication companies to
ity for meat inspection in pigs at the slaughterhouse.1,2 While improve service to remote communities.
specific in their use, these 2 studies are precursors to other Limitations of our scoping review include the possibility
potential uses of telepathology for postmortem examina- that we missed literature due to the exclusion criteria or
tions, particularly the use of augmented reality. In many search terms used. Private laboratories may have commer-
regions of North America, large geographic distances cially sensitive information that is not publicly available;
between farms and diagnostic laboratories prohibit the sub- hence, we may not have included information on the extent
mission of whole large animal carcasses for postmortem of telepathology used by some companies. In addition, mate-
examination. As a result of this barrier and others, it is esti- rial available on commercial laboratory websites is largely
mated that < 1% of cattle that die before slaughter undergo promotional and did not fit the inclusion criteria of our study.
postmortem examination, representing a huge gap in surveil- For these reasons, company-based writing on the subject
lance.1 While still-images for gross anatomic telepathology may have been excluded, introducing bias. Much informa-
or digital postmortem examinations certainly have utility, tion is shared and discussed at national and international
they are associated with significant limitations, including the meetings and as part of educational webinars, but this infor-
static nature of the images and lag time between the postmor- mation will not have been available for our scoping review.
tem and the examination of the digital photographs. These Potential biases of the reviewers, for example, because of
limitations leave clinicians and pathologists at a disadvan- personal experiences with telepathology, may also have
tage. Not all organ systems may be examined, photographs influenced the way the information was collated and reported.
may be biased by the prosector’s interpretation, and appro- In conclusion, we found gaps in the literature on the use
priate samples may not have been harvested for histopathol- and validation of telepathology in veterinary medicine
ogy and ancillary testing. Video streaming and augmented despite the widespread use of DM by private veterinary diag-
reality can improve access to testing for these remote and/or nostic laboratories. The literature gap is especially large for
underserved rural communities. Veterinarians serving these its use in gross pathology, and this reflects the limited publi-
areas with minimal infrastructure or expertise in anatomic cation of its use in veterinary medicine. These gaps suggest a
pathology could remotely connect with a pathologist to con- need for future research studies focused on validating WSI
sult on difficult cases. Through real-time telepathology, the technology for a wide array of veterinary samples and the
pathologist could assist the on-site veterinarian with the utility of real-time telepathology supporting field postmor-
postmortem examination and consult on tissue sampling for tem examinations. Telepathology has exciting potential,
further testing. Technicians and producers could also be especially in serving remote and underserved communities,
trained in areas without consistent veterinary care to perform but will need refinement and commitment to its develop-
assisted field postmortem examinations. Indeed, both studies ment. Clearly, telepathology use is increasing in veterinary
included in our review were similar in that they promoted the medicine, and current and future pathologists must keep pace
use of technicians for the on-site fieldwork, freeing the vet- with the changing technology and identify novel uses to
erinarian or specialist to perform the diagnostic tasks.1,2 In advance the profession.
the current period of food-animal and rural mixed-animal
veterinarian shortages across North America, delegating Declaration of conflicting interests
more fieldwork to technical staff could be beneficial.26 It The authors declared no potential conflicts of interest with respect
may increase the job satisfaction of technical staff by allow- to the research, authorship, and/or publication of this article.
ing them to perform higher-level tasks for which they can be
trained, and can decrease the pressure on the veterinarian’s Funding
time while still meeting the producer’s needs. Improving The authors received no financial support for the research, author-
access to testing is of tremendous benefit to the health and ship, and/or publication of this article.
welfare of animals, public health, and food safety, especially
in remote and underserved areas. The latter may be of par-
ORCID iDs
ticular importance for remote Indigenous communities that
rely on subsistence hunting. Lindsay Rogers https://orcid.org/0000-0001-7884-7701
Unfortunately, the uptake of real-time gross telepathology Dayna Goldsmith https://orcid.org/0000-0002-5619-4540
is not without challenges, which may account for the gap in Erin Zachar https://orcid.org/0000-0001-8902-7389
literature. Many remote and underserved areas also have
Jennifer L. Davies https://orcid.org/0000-0002-7668-6817
poor telecommunications infrastructure. This leads to obvi-
ous challenges with connecting via video or augmented real-
ity. To date, solutions rely on phone conversations and Supplemental material
photographs, such as digital postmortem examinations.1 True Supplemental material for this article is available online.
Telepathology in veterinary medicine: scoping review 497