**4. Gross pathology imaging and 3D printing**

Three-dimensional (3D) printing uses 3D data to produce 3D physical models has been a powerful discovery and engine in science and medicine. Starting with computer-aided design (CAD) models for industry, 3D manufacturing is entering at the full title in medicine for undergraduate and postgraduate education [19]. Computer software can build up the model from a series of photographs on cross-sections that resemble to realistic sections from the original model. 3D printing is attained by placing down consecutive layers of powdered material or liquid plastic resins which are used to build 3D models at high temperature and sliced with laser technology. In the setting of 3D printing, the most critical techniques include ink-jetting, deposition modeling, laminated object manufacturing (LOM), and laser sintering. The ink-jet technique uses a method similar to two-dimensional (2D) inkjet printers whereby it deposits liquid plastic resins in striated lines. Infused deposition modeling a technique is applied to extruding and layering filaments of thermoplastic materials, which are melted. LOM uses a laser cutter technique of shaping and sticking (gluing) layers of plastic films or paper. Finally, laser sintering includes stereolithography and selective laser sintering with curing photopolymers by a UV laser (stereolithography) and

**161**

**5. Telepathology**

*Digital Pathology: The Time Is Now to Bridge the Gap between Medicine and Technological…*

fusing small particles such as thermoplastic metal, ceramic, or glass by high-power laser (selective laser sintering) [20]. 2D digital photographs, sequential X-rays, and images of computed tomography (CT)/magnetic resonance imaging (MRI) are useful to create 3D CAD models by software reconstruction and laser scanning of objects. MRI was used in the past in guiding dissection of specimens for teaching purposes [21]. 3D printing has been used in orthopedic surgery and vascular surgery to guide surgeons during procedures [22–24]. The 3D reconstruction may revive anatomic pathology museums with the possibility to create several 3D models for undergraduate and postgraduate teaching. These specimens can be scanned by CT or MRI and the information provided be used to develop singular 3D models that may be produced for hundreds of learners. The advantages are that the learners do not need to be exposed to toxic solutions, such as formaldehyde, that students do not need to overcrowd a classroom or a museum hall, but they have no hassle in examining each specimen with time and investigate details. It may be very encouraging and reassuring when learners discover and participate in the inspection of the sample at the same time. There is the advantage to go back to the sample at any time. These specimens are durable, not infectious, and not fragile like the original ones. The robustness of these specimens will also allow the reproducibility of teaching in classes of the future. There is also the opportunity to utilize precious digital photographic collections in building 3D models of specimens that are not available anymore. 3D printing can create realistic models of almost any complex profile or geometric feature with extreme accuracy and opportunities are invaluable at this time. Some 3D printers with price ranging from hundreds of dollars to several thousands of dollars are commercially available. 3D printed models can then be used to demonstrate very complex lesions such as congenital heart defects of different age, including the transposition of the great arteries and hypoplastic ventricles. There will be enormous resources for learning using 3D printed models for undergraduate and postgraduate students, anatomic pathology residents, radiology residents, and other medical practitioners such as surgeons for educational and training purposes. Teaching curricula can be implemented with 3D models. While we expect the cost of living increases over time, in the next couple of decades the rate at which the price of a college education has gone up is utterly alarming. A 3D model may cost approximately \$ 500, but the price may increase to several thousand in case of extreme accuracy. Production costs of 3D models do not need to spike up the admission fees to college and universities enormously. With increased demand, 3D computing and modeling will potentially become more affordable on mass production. At rounds or multidisciplinary clinical team meetings, 3D models can be used to teach topography of pathological lesions and adopt the best therapy possible. Current 3D printing of human anatomic pathology specimens is a reality but merits further investigations for application in teaching college and university students. The increase in complexity of CAD software will allow reaching that level of

accuracy for the complete satisfaction of the learning process.

The introduction of microscope-integrated telepathology systems enables geographically remote stakeholders to view the live tissue histology slide as seen by the study pathologist within the local microscope. Telepathology is the practice of pathology at a distance using technologies. Although the concept and first telepathology devices are now more than 20 years old [25–27], the introduction of quad-core processors and 5G technologies is renovating this nearby field of virtual microscopy. Simultaneous online viewing and dialog between study pathologist and remote operators in high-speed intranet or internet platform is becoming a

*DOI: http://dx.doi.org/10.5772/intechopen.84329*

#### *Digital Pathology: The Time Is Now to Bridge the Gap between Medicine and Technological… DOI: http://dx.doi.org/10.5772/intechopen.84329*

fusing small particles such as thermoplastic metal, ceramic, or glass by high-power laser (selective laser sintering) [20]. 2D digital photographs, sequential X-rays, and images of computed tomography (CT)/magnetic resonance imaging (MRI) are useful to create 3D CAD models by software reconstruction and laser scanning of objects. MRI was used in the past in guiding dissection of specimens for teaching purposes [21]. 3D printing has been used in orthopedic surgery and vascular surgery to guide surgeons during procedures [22–24]. The 3D reconstruction may revive anatomic pathology museums with the possibility to create several 3D models for undergraduate and postgraduate teaching. These specimens can be scanned by CT or MRI and the information provided be used to develop singular 3D models that may be produced for hundreds of learners. The advantages are that the learners do not need to be exposed to toxic solutions, such as formaldehyde, that students do not need to overcrowd a classroom or a museum hall, but they have no hassle in examining each specimen with time and investigate details. It may be very encouraging and reassuring when learners discover and participate in the inspection of the sample at the same time. There is the advantage to go back to the sample at any time. These specimens are durable, not infectious, and not fragile like the original ones. The robustness of these specimens will also allow the reproducibility of teaching in classes of the future. There is also the opportunity to utilize precious digital photographic collections in building 3D models of specimens that are not available anymore. 3D printing can create realistic models of almost any complex profile or geometric feature with extreme accuracy and opportunities are invaluable at this time. Some 3D printers with price ranging from hundreds of dollars to several thousands of dollars are commercially available. 3D printed models can then be used to demonstrate very complex lesions such as congenital heart defects of different age, including the transposition of the great arteries and hypoplastic ventricles. There will be enormous resources for learning using 3D printed models for undergraduate and postgraduate students, anatomic pathology residents, radiology residents, and other medical practitioners such as surgeons for educational and training purposes. Teaching curricula can be implemented with 3D models. While we expect the cost of living increases over time, in the next couple of decades the rate at which the price of a college education has gone up is utterly alarming. A 3D model may cost approximately \$ 500, but the price may increase to several thousand in case of extreme accuracy. Production costs of 3D models do not need to spike up the admission fees to college and universities enormously. With increased demand, 3D computing and modeling will potentially become more affordable on mass production. At rounds or multidisciplinary clinical team meetings, 3D models can be used to teach topography of pathological lesions and adopt the best therapy possible. Current 3D printing of human anatomic pathology specimens is a reality but merits further investigations for application in teaching college and university students. The increase in complexity of CAD software will allow reaching that level of accuracy for the complete satisfaction of the learning process.

## **5. Telepathology**

The introduction of microscope-integrated telepathology systems enables geographically remote stakeholders to view the live tissue histology slide as seen by the study pathologist within the local microscope. Telepathology is the practice of pathology at a distance using technologies. Although the concept and first telepathology devices are now more than 20 years old [25–27], the introduction of quad-core processors and 5G technologies is renovating this nearby field of virtual microscopy. Simultaneous online viewing and dialog between study pathologist and remote operators in high-speed intranet or internet platform is becoming a

*Interactive Multimedia - Multimedia Production and Digital Storytelling*

help to increase the accuracy of pathology diagnosis and reporting. The introduction of algorithms that allow the machine to follow the diagnostic procedure operated by the pathologist using an eye tracking system and algorithms able to identify the discrepancies of pathology reports before signing out will help in the aim to reach extreme accuracy in medicine. The breakdown of geographical barriers operated by WSI will be implemented by the next step of a new healthcare system where AI will support the diagnostic procedure. There will be an enhanced collaboration allowing pathologists to seek second opinions more quickly, collaborating with multidisciplinary care teams more effectively, and distribute workloads across sites more evenly. Data from patient's history and unique risk factors will be studied by a background algorithm allowing the pathologist to have a companion for suggested differential diagnoses. The integration of data across clinical systems, lab examinations, and radiology with pathology images applying artificial intelligence to derive understandings is called computational pathology, which is far more convoluted than a file with stacked images of a glass slide. This revolution will implement the highest levels of accuracy and can be implemented to any specialty. This scenario is happening now as evidenced by the most recent congress of European urologists. Prof. Guo from Nanjing, China, claimed that smart software could diagnose prostate cancer as well as a pathologist (https://eau18.uroweb.org/smart-software-can-diagnose-prostatecancer-as-well-as-a-pathologist/). All these algorithms seem to reconnect to the Bayes' theorem, which benefits us finding the probability of an event A given event B, written P(A|B), in terms of the probability of B given A, written P(B|A), and the single probabilities of A and B. Consequently, P(A|B) = P(A) \* P(B|A)/P(B). Thus, in this scenario, event A is the event the patient has a specific disease, and event B is the event that the patient's test is positive. Thus, P(B|notA) represents the probability of a "false positive" rate, i.e., the patient's test is positive even though the patient does not have the disease. If the specific disease has an incidence of one in 10,000 people and a specific test has an accuracy of 99%, P(B|A) = 0.99, P(A) = 0.0001, and P(B) may be

consequent by conditioning on whether event A does or does not occur, i.e.,

passes the people who truly have the disease.

**4. Gross pathology imaging and 3D printing**

P(B) = P(B|A) \* P(A) + P(B|notA) \* P(notA) or 0.99 \* 0.0001 + 0.01 \* 0.9999. Thus, the ratio the pathologist gets from Bayes' theorem is less than 1%. This result relies on the disease, which is very rare. The number of false positives significantly sur-

Three-dimensional (3D) printing uses 3D data to produce 3D physical models has been a powerful discovery and engine in science and medicine. Starting with computer-aided design (CAD) models for industry, 3D manufacturing is entering at the full title in medicine for undergraduate and postgraduate education [19]. Computer software can build up the model from a series of photographs on cross-sections that resemble to realistic sections from the original model. 3D printing is attained by placing down consecutive layers of powdered material or liquid plastic resins which are used to build 3D models at high temperature and sliced with laser technology. In the setting of 3D printing, the most critical techniques include ink-jetting, deposition modeling, laminated object manufacturing (LOM), and laser sintering. The ink-jet technique uses a method similar to two-dimensional (2D) inkjet printers whereby it deposits liquid plastic resins in striated lines. Infused deposition modeling a technique is applied to extruding and layering filaments of thermoplastic materials, which are melted. LOM uses a laser cutter technique of shaping and sticking (gluing) layers of plastic films or paper. Finally, laser sintering includes stereolithography and selective laser sintering with curing photopolymers by a UV laser (stereolithography) and

**160**

reality in many countries. Telepathology is an efficient and cost-effective means for inter-professional histopathology consultation, pathology working groups, and peer review, facilitating collaboration and sound science and economic benefits by enabling more timely and informed clinical decisions. In 1986, the mane of telepathology was coined by Dr. Ron Weinstein. Differently, from the meta- or diachronous virtual microscopy, telepathology is a singular specifically synchronous two-way communication between the host and recipient. Telepathology has also been variously named: teleconsultation, telemicroscopy, teleconferencing, remote robotic microscopy, and web conferencing. In 1987, Weinstein first reported telepathology and the network of pathology diagnostic services on breast tissues by remote workstation-controlled light microscope attached to a highresolution video camera and a telecommunication linkage [28]. Since the 1990s, similar analog technologies have been used for remote intraoperative frozen section services in northern Norway of Scandinavia [29, 30]. Telepathology is currently used for several fields of pathology, including cytopathology and ultrastructural pathology [31–36]. The approval of the Food and Drug Administration of the United States (US FDA) of these different methodologies has broadened a field in laboratory services, which was not known before [37, 38]. The three major telepathology supported systems currently used are static, real-time, and, of course, virtual microscopy. In the static system, pre-captured still digital images are deposited on a secure server with encryption. The disadvantages of static telepathology are that the operator controls everything including acquiring the images, while the audience is passive participants. In teleconsultation, the consultant histopathologist has no remote control of the physical microscopic glass slide and has limited fields of view to examine. Static TP systems are, nevertheless, welcome in some parts of the world with limited resources, shortages of particularly trained personnel, and lack of continuing professional education programs [39]. Tele-oncology has been proved to facilitate access to care and decrease health care costs with teleconsultations may take place in a syn-, asynchronous, or blended format. There are a few examples of successful applications that include cancer telegenetics, bundling of cancer-related telepathology-supported applications, remote chemotherapy supervision, symptom management, survivorship care, palliative care, and multidisciplinary approaches to increase access to cancer clinical trials [40]. It is careful to be a simple, cost-effective, reliable and efficient means to provide diagnostic and educational support to pathologists in the developing world improving pathology and laboratory medicine in low-income and middle-income countries. New technologies, including point-of-care testing and telepathology, can partake a substantial role in service delivery of laboratory medicine and pathology if used appropriately [41]. The physical geography of Canada is extensively varied with boreal forests prevailing throughout the country and ice areas prominently in northern Arctic regions and through the Rocky Mountains, and the flat Canadian Prairies in the southwest of the country. There is the vast distance between some parts of the country and telepathology is playing a significant role in some areas [42–44]. In the University Health Network (UHN), is a multi-site academic institution in Toronto. The UHN comprises several downtown hospitals and remote hospitals in Northern Ontario, WSI has been effectively utilized for telepathology in primary intraoperative frozen section diagnosis and secondary/tertiary teleconsultation [43, 45]. Likewise, in the Province of Quebec, the implementation of the telepathology project (Eastern Quebec) provides uniform frozen section diagnosis and teleconsultation services across a vast geographic region comprising up to 21 sites [44]. Real-time and WSI/ virtual microscopy in telepathology systems may be implemented in the Prairies

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*Digital Pathology: The Time Is Now to Bridge the Gap between Medicine and Technological…*

as well as in Northern Western territories. The future may be brighter because of

There is a terrific increase of time pathologists spend on the internet to search for pathologies, criteria or images that may help them in narrowing the differential diagnosis of challenging cases. The advances in computing power, cheaper prices for single device, and the exponential growth of web search for online learning resources have permitted the launch of platforms that are internet-based that are helping for publication and digital education. There are numerous digital atlases online, and there is a proliferation of multiple web-based technologies for continuing professional development of human and veterinary pathologist at a pace that we were not thinking before [46–57]. Telepathology using smartphones and tablets with Skype and its alternatives, including FaceTime, Viber, Talky, WeChat, and WhatsApp, among others, for live, synchronous online communication are feasible for clinical and educational uses [58]. The purpose of an iPad tablet or similar android device to download digitalized images of gross and microscopic pathology from a Web server for E-learning has been found to provide a satisfactory solution in low-resource countries as well as in the middle- and high-resource countries, because the pathologist can directly access the information at fingertip [59]. In a review of social media use in medical education, the incorporation of social media tools boosted the engagement of the learners, feedback from the audience and tighter collaboration and professional development [60–64]. Although probably up to a few years ago, the most commonly cited challenges were technical issues, variable learner motivation, and privacy/security concerns, currently, the high-speed internet, the increased competition among learners in a highly competitive world, and the use of https protocols with 2-key authentication seem to have demolished

**7. Artificial intelligence as the "third revolution in pathology"**

In the 1980s the introduction of immunohistochemistry or the application of immunologic methods using antibodies against specific epitopes in situ directly on the tissue allowed a complete change of various diagnoses based exclusively on morphologic criteria. The identification of cell of origin and differentiation pathways allowed the re-classification of numerous pathologies, e.g., malignant Non-Hodgkin's lymphomas with the acquisition of knowledge that will shape the advancements in hematology and hematopathology for decades [65, 66]. The introduction of genomic and proteomic platforms may also represent an important revolution, probably, the second one after the immunohistochemistry. The genomic and proteomic medicine identified a new niche in medicine that has been focused for years from investigators of public health issues, i.e., precision medicine [67–71]. The "Third Revolution" in pathology is probably represented by the artificial intelligence (AI) [72]. AI is defined as intelligence demonstrated by machines, differently from the natural intelligence displayed by humans and specific animals. Thus, any device that perceives its surroundings and takes actions that maximize its chance of successfully achieving its goals may be considered showing an AI behavior. The correct acquisition and interpretation of external data and the integration of such data and results with the surrounding is the principle of the adoption by the machine of flexible adaptation.

*DOI: http://dx.doi.org/10.5772/intechopen.84329*

faster networks and fast digitalization.

the above-raised challenges.

**6. Social media and mobile device use**

*Digital Pathology: The Time Is Now to Bridge the Gap between Medicine and Technological… DOI: http://dx.doi.org/10.5772/intechopen.84329*

as well as in Northern Western territories. The future may be brighter because of faster networks and fast digitalization.
