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From Microscopy to Whole Slide Digital Images:

A Century and a Half of Image Analysis
Clive R. Taylor, MA, MD, DPhil

Abstract: In the year 1850, microscopes had evolved in quality to

the point that the rst pathologists emerged from the
treacherous swamps of medieval practice onto the relatively
rm ground that histopathology seemed to oer. These early
pathologists began to practice the art of image analysis, and
diagnostic surgical pathology was born. Today the traditional
microscope, in the hands of an experienced pathologist, is
established as the gold standard for diagnosis of cancer and
other diseases. Nonetheless, it is a tool and a technology that is
more than 150 years old. Rapid advances in the capabilities of
digital imaging hardware and software now oer the real
possibility of moving to a new level of practice, using whole slide
digital images for diagnosis, education, and research in
morphologic pathology. Potential eciencies in work ow and
diagnostic integration, coupled with the use of powerful new
analytic methods, promise radically to change the future shape
of surgical pathology.
Key Words: digital pathology, virtual pathology, whole slide
imaging, quantitative immunohistochemistry, history of microscopy, picture acquisition communication systems, morphometrics, telepathology, FDA approval of digital imaging,
electronic medical record
(Appl Immunohistochem Mol Morphol 2011;19:491493)

arly in the 19th century improvements in manufacture

of lenses allowed production of aordable, high
quality, compound microscopes (Fig. 1). Scientists of
the day eagerly extended their studies from gross
observations of whole organs, or whole organisms, to
the new microscopic level of tissues, cells, and subcellular
structure. The impact on the Biological Sciences and on
Medicine was enormous. It was on the microscope stage
that the Royal Microscopic Society was founded in 1839,
shortly to be followed by one of the rst courses in
histology at a medical school (John Hughes Bennett;
Edinburgh in 1842) and arguably the rst text book of

Received for publication June 14, 2011; accepted June 14, 2011.
From the Department of Pathology, HMR, Keck School of Medicine,
University of Southern California, Zonal Avenue, Los Angeles, CA.
The authors declare no conict of interest.
Reprints: Clive R. Taylor, MA, MD, DPhil, Department of Pathology,
HMR 311, Keck School of Medicine, University of Southern California,
2011, Zonal Avenue, Los Angeles, CA 90033 (e-mail: cltaylor@
Copyright r 2011 by Lippincott Williams & Wilkins

Appl Immunohistochem Mol Morphol

histopathology (Cellularpathologie, Rudolph Virchow

in 1858). In this rapidly changing environment, the rst
pathologists emerged from the treacherous swamps of
medieval practice onto the relatively rm ground that
histopathology seemed to oer.1 A new branch of
medical sciences was born, with surgical pathologists,
practicing the rudiments of their art, practicing nothing
more nor less than image analysis, albeit on a personal,
subjective basis.
One hundred fty years later the accumulated
literature and experience of surgical pathology has grown
to such an extent that it is the gold standard for
diagnosis of many diseases. Even in this molecular age
cancer treatment is rarely initiated without a tissue
diagnosis. However, the methods of microscopic examination have changed relatively little in more than a
century. Hematoxylin and eosin, and other biological
stains in common use today, were rst introduced in the
1850s. The introduction of formalin xation (Blum uid
4% formaldehyde) in 1893 was a leap forward and it
remains by far the most commonly used method of
fixation today. Immunohistochemistry was developed in
1974, and entered general use in the next 2 decades. Still in
2011, diagnosis is accomplished by a pathologist, examining glass slides at a microscope; but new computer-based
technologies offer the real prospect of radical change.
Radiology shares with pathology a foundation of
interpreting images for diagnostic purposes. A little over a
decade ago radiology went digital over a remarkably
short period of time. The change was technology driven,
and it radically changed the way in which radiology is
practiced today. To date, digital imaging has found more
limited application in pathology, primarily for education
and research, with diagnostic use limited to isolated
telepathology applications, and a few immunohistochemical quantitative analyses.2,3 A crucial dierence from
radiology is that pathologists begin, not with a digital le,
but with a piece of tissue, that must be xed, embedded,
cut and stained, before obtaining a digital image. Current
pathology practice is that glass slides are distributed to
the pathologist, and diagnosed by the usual light
microscopic approach, as they have been for hundred
and more years. Selected slides may then be digitally
scanned on an elective basis, for research or educational
purpose, or for performance of quantitative algorithms.
However, scan time has been prohibitively slow, adding
greatly to the time required for a pathologist to complete
a case when using digital imaging methods.

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Appl Immunohistochem Mol Morphol

FIGURE 1. Image analysis in Pathology, circa, 1870. Brass

binocular microscope by Henry Crouch, London. n. 1055;
glass slides in ivory mounts. Personal collection of the

Today, scan times for routine whole slide images

have fallen below 1 minute. Resolution and reproducibility
similarly have improved. Although there are analogies with
digital cameras, whole slide imaging (WSI) generally refers
to capturing a digital image of an entire tissue section
(digital or virtual pathology). With a WSI, it is
possible to examine any and all parts of the section at
dierent magnications, in strict analogy to the microscope and the glass slide. Areas of interest can also be
annotated for review by self or by other observers in
consultation, locally or remotely. In addition, the digital
le lends itself to the use of powerful analytical tools not
available by orthodox micrscopy.2,4 The WSI usually is
obtained with a  20, or more recently a  40, objective,
and displayed at  20 or  40, with digital zoom
capability. WSI digital les are correspondingly large, in
fact larger than a computed tomographic scan le.
Attendant problems of handling such large les are being
addressed, one productive approach being the integration
of pathology scanners with existing Picture Acquisition
Communication Systems radiology modules present in
most hospitals.
Presently, WSIs are used for frozen section consultation, general consultation (internal and external or

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Volume 19, Number 6, December 2011

remote second opinions), education, prociency testing,

and certain semiquantitative analyses. Perkel5 has made
the point that a glass slide can only be on one
microscope at a time, whereas a digital WSI can be in
many places at once, hence its value for multicenter
conferences, as a practical alternative to moving around
sets of slides, or residents, or pathologists, or all 3. With
respect to quantication, widespread realization among
clinicians that the reproducibility of HER2 tests across
dierent institutions was very poor,6,7 led to intense focus
upon improving the method, including the use of proper
control systems coupled with image analysis for consistent interpretation. The general tenet that image analysis
is more reproducible for semiquantitative interpretation of immunohistochemical stains, exemplied by Her2,
ER, and PR, has been reinforced by the MediCare
decision to pay a premium for reporting these tests using
an approved algorithm. A number of companies have
gained Food and Drug Administration (FDA) approval
for such algorithms, each of which is analyte, reagent,
immunohistochemistry staining platform, and scanner
type specic. Many other applications are in the pipeline.
A visit to the exhibitors forum at the recent US Canadian
Academy of Pathology meeting in March 2011 leaves an
observer with no doubt that digital imaging and analysis
represents the fastest growing eld of application in
surgical pathology.
With increasing numbers of departments acquiring
WSI scanners, the possibility exists of departing from the
current practice of distributing batches and trays of glass
slides to multiple, widely dispersed pathologists, and
instead routinely scanning all (or most) glass slides
within the histology laboratory as soon as they are
completed (Fig. 2). WSI digital les would then be
distributed by Picture Acquisition Communication Systems or the laboratory information system to the
pathologists, not glass slides, unless specically requested.
Work ow, data archiving, and recall, and service
assignments in pathology will then change to a more
exible, more ecient digital work place, similar to the
evolution that has occurred in radiology.
Once this point is reached in leading institutions,
further progression is inevitable. In analogy with Apps
for smart phones, software for new image analysis
techniques will then proliferate. Routine use of these
Apps, namely algorithms for computer-assisted recognition of cells and subcellular features, will extend the
capabilities of pathologists beyond subjective morphologic
diagnosis, and will add new diagnostic morphologic criteria,
beyond the present compass of the human eye. Similarly, a
menu of new validated, FDA-approved algorithms will
extend beyond current HER2, ER, and PR analyses to
permit in situ quantication of a fast and ever growing
range biologically important molecules in tissue sections.
Signicant obstacles remain, technical, logistical,
and regulatory, but none are insurmountable.
Technology will wait for no one. Logistics will
follow economics, as always. In the end, regulatory
agencies, including the FDA, will nd ways to allow the

2011 Lippincott Williams & Wilkins

Appl Immunohistochem Mol Morphol

Volume 19, Number 6, December 2011

From Microscopy to Whole Slide Digital Images

The fully digitized

surgical pathology




Apply Bar code


Bar code

by bar code
Web interface

Selected Apps

FIGURE 2. Image analysis in Pathology, circa, 2012. In the fully digitized surgical pathology department, glass slides are
produced by histology, stained, including special stains such as immunohistochemistry and scanned as soon as available. Digital
files are then distributed to specified pathologists by name; location is immaterial, provided that secure high speed internet access
is available. Where quantifiable assays (eg, HER2; ER) are ordered, these are registered in the barcode, scored by approved
algorithms, and included in the digital file provided to the pathologist. The pathologist may also elect to use other software
programs (Apps) to assist diagnosis, such as mitotic counts, nuclear size analysis etc. Reporting and archiving is into the
electronic medical record, with the option of copies to the patient.

discipline to advance, at which point histopathologic

diagnosis, teaching, and research will all be integrated
under a digital format, and the discipline will have
entered a new phase, with numerous new possibilities,
many as yet unforeseen.


1. Taylor CR. Principles of Immunomicrocopy. In Immunomicroscopy;
A Diagnostic Tool for the Surgical Pathologist. Saunders Elsevier.
p.3. 2006. http://www.elsevier.com.
2. Krenacs T, et al. Digital Microscopy the upcoming revolution in
histopathology teaching, diagnostics, research and quality assurance.
Microscopy: Science, Technology, Applications and Education. Ed.

2011 Lippincott Williams & Wilkins



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