Clinical and Financial Implications of Second-Opinion Surgical Pathology Review.

OBJECTIVES: Second-opinion pathology review identifies clinically significant diagnostic discrepancies for some patients. Discrepancy rates and laboratory-specific costs in a single health care system for patients referred from regional affiliates to a comprehensive cancer center ("main campus") have not been reported. METHODS: Main campus second-opinion pathology cases for 740 patients from eight affiliated hospitals during 2016 to 2018 were reviewed. Chart review was performed to identify changes in care due to pathology review. To assess costs of pathology interpretation, reimbursement rates for consultation Current Procedural Terminology billing codes were compared with codes that would have been used had the cases originated at the main campus. RESULTS: Diagnostic discrepancies were identified in 104 (14.1%) patients, 30 (4.1%) of which resulted in a change in care. In aggregate, reimbursement for affiliate cases was 65.6% of the reimbursement for the same cases had they originated at the main campus. High-volume organ systems with low relative consultation reimbursement included gynecologic, breast, and thoracic. CONCLUSIONS: Preventable diagnostic errors are reduced by pathology review for patients referred within a single health care system. Although the resulting changes in care potentially lead to overall cost savings, the financial value of referral pathology review could be improved.

In-laboratory breast specimen radiography reduces tissue block utilization and improves turnaround time of pathologic examination.

BACKGROUND: This study was performed to determine whether in-laboratory specimen radiography reduces turnaround time or block utilization in surgical pathology. METHODS: Specimens processed during a 48-day trial of an in-lab cabinet radiography device (Faxitron) were compared to a control group of specimens imaged in the mammography suite during a prior 1-year period, and to a second group of specimens not undergoing imaging of any type. RESULTS: Cases imaged in the mammography suite had longer turnaround time than cases not requiring imaging (by 1.15 days for core biopsies, and 1.73 days for mastectomies; p < 0.0001). In contrast, cases imaged in-lab had turnaround time that was no longer than unimaged cases (p > 0.05 for core biopsies, lumpectomies and mastectomies). Mastectomies imaged in-lab required submission of fewer blocks than controls not undergoing any imaging (mean reduction of 10.6 blocks). CONCLUSIONS: Availability of in-lab radiography resulted in clinically meaningful improvements in turnaround time and economically meaningful reductions in block utilization.

Data-Driven Development of an Institutional "Gross-Only" Policy for the Examination of Select Surgical Pathology Specimens.

OBJECTIVES: To determine diagnostic, workflow, and economic implications of instituting a gross-only policy at our institution. METHODS: Retrospective (2017) key word searches were performed to identify "gross-only" cases for which microscopic evaluation could potentially be omitted, but was performed, and those who underwent gross evaluation per surgeon request. Cases were evaluated for type(s), part(s), block volume, turnaround time, demographics, and diagnosis. Laboratory costs and reimbursement were evaluated. RESULTS: In total, 448 potential gross-only cases with 472 specimens consisted of atherosclerotic plaques (33.5%), bariatric stomach/bowel (32.6%), hernia (15.7%), heart valves (12.7%), and other (5.9%). Four (2.6%) bariatric surgery cases had Helicobacter pylori infection; these were the only cases with "significant" histologic findings. Cost analysis revealed that converting all potential gross-only specimens to gross only would result in overall losses based on average reimbursements, most influenced by bariatric specimens (Current Procedural Terminology code 88307), comprising 65.2% of estimated loss. CONCLUSIONS: Establishing a gross-only policy should be guided by established recommendations but institutionally individualized and data driven. It was reasonable for us to establish a gross-only policy for most evaluated specimens, while excluding bariatric stomach specimens in which microscopic pathology could be missed, given the lack of H pylori screening at our institution.

Prostate Biopsy Processing.

OBJECTIVES: Current protocols for processing multiple prostate biopsy cores per case are uneconomical and cumbersome. Tissue fragmentation and loss compromise cancer diagnosis. We sought to study an alternate method to improve processing and diagnosis of prostate cancer. METHODS: Two sets of sextant biopsy specimens from near-identical locations were obtained ex vivo from 48 prostate specimens. One set was processed in the standard fashion while the other was processed using the BxChip, a proprietary biomimetic matrix that accommodates six cores on a single chip. Parameters including grossing, embedding, sectioning and reading time, length of tissue, and degree of fragmentation were compared. RESULTS: A significant reduction (more than threefold) in preanalytical and analytical time was observed using the multiplex method. Nonlinear fragmentation was absent, in contrast to standard processing. CONCLUSIONS: The BxChip reduced tissue fragmentation and increased efficiency of prostate biopsy diagnosis. It also resulted in overall cost savings and significantly increased tissue length.

Cost Effectiveness of Intraoperative Gross Examination in Colorectal Resections: A Retrospective Review of 200 Consecutive Cases.

CONTEXT.­: Intraoperative pathology consultation is an important tool for many surgical procedures and is deemed appropriate when the pathology result immediately alters surgical management. OBJECTIVE.­: To evaluate the utility of intraoperative gross examinations of colorectal resections and to better understand the associated costs. DESIGN.­: The pathology database of our institution was searched for colorectal resections for primary disease, and those cases were separated into 3 categories: frozen section performed, intraoperative gross examination performed, and no intraoperative consultation. We reviewed 270 cases during a 15-month period. RESULTS.­: Of the 270 cases, 200 (74.1%) had an intraoperative gross examination. In 34 of the 200 cases (17%), additional specimens were taken and, therefore, required operative note review to ascertain whether the additional specimens taken were based on the findings from the intraoperative gross examination. After reviewing the operative notes for those 34 cases, none (0%) were a result of the gross findings reported. The average associated time for intraoperative gross examinations was 27.67 minutes (including transport). The billable costs exceeded $7000 during the study period, and the cost of the pathology assistant's time per case was $22.10. CONCLUSIONS.­: Our study demonstrates that no change in surgical management was a result of gross examination of colorectal resection specimens and that the associated costs were significant. Decreasing unnecessary consultations will directly save the health care system money by eliminating billable services and will also increase the efficiency of the pathology department by reducing the opportunity costs for the time of the pathologist and the pathology staff.

Routine Pathologic Evaluation of Plastic Surgery Specimens: Are We Wasting Time and Money?

BACKGROUND: Recent health care changes have encouraged efforts to decrease costs. In plastic surgery, an area of potential cost savings includes appropriate use of pathologic examination. Specimens are frequently sent because of hospital policy, insurance request, or habit, even when clinically unnecessary. This is an area where evidence-based guidelines are lacking and significant cost-savings can be achieved. METHODS: All specimen submitted for pathologic examination at two hospitals between January and December of 2015 were queried for tissue expanders, breast implants, fat, skin, abdominal pannus, implant capsule, hardware, rib, bone, cartilage, scar, and keloid. Specimens not related to plastic surgery procedures were excluded. Pathologic diagnosis and cost data were obtained. RESULTS: A total of 759 specimens were identified. Of these, 161 were sent with a specific request for gross examination only. There were no clinically significant findings in any of the specimens. There was one incidental finding of a seborrheic keratosis on breast skin. The total amount billed in 2015 was $430,095. CONCLUSIONS: The infrequency of clinically significant pathologic examination results does not support routine pathologic examination of all plastic surgery specimens. Instead, the authors justify select submission only when there is clinical suspicion or medical history that warrants evaluation. By eliminating unnecessary histologic or macroscopic examination, significant cost savings may be achieved.

Utility of Additional Tissue Sections in Surgical Pathology.

BACKGROUND: To avoid diagnostic errors such as missed diagnosis and errors in staging tumors due to inadequate tissue sampling, pathologists submit additional sections (AS). OBJECTIVE: This study assessed frequency, diagnostic yield, distribution, and cost of AS. METHOD: Among 1542 AS cases, we calculated mean AS per case; fraction of AS that altered diagnosis or stage; AS variation by tissue, malignant versus benign lesions, presence or absence of neoadjuvant therapy, mass, margin, lymph nodes, or other source, resident versus pathologist assistant (PA) dissector; and AS cost per case. RESULTS: Overall 9.2 ± 8.8 AS were collected per case. In only 3.8% (58/1542) of cases AS altered diagnosis or stage. Urinary bladder cases provoked the most AS: 19.5 ± 15.1 per case. Significantly more AS came from malignant versus benign lesions (10.8 ± 9.7 vs 7.6 ± 7.5, P = <.0001) and from specimens treated with neoadjuvant therapy versus malignant lesions not so treated (12.3 ± 9.4 vs 10.3 ± 9.8, P = .02). Lymph nodes were sampled more heavily compared with mass, margin, and other sites combined (11.8 ± 11.4 vs 8.9 ± 8.4, P = .003), but in 78.4% (1209/1542) of cases, AS were from mass. Of diagnosis or stage altering AS cases, two thirds (38/58) were from masses, one fifth (11/58) from lymph nodes, a 10th (6/58) from margins, and a 20th (3/58) from other specimen sites. Resident versus pathologist assistant dissection caused no significant AS difference. AS contributed 40% cost per case. CONCLUSIONS: AS per case ranged widely; their diagnostic yield was low; they were highest in urinary bladder specimens, in malignant and particularly neoadjuvant-treated lesions. Although lymph nodes were most heavily sampled, most AS were from masses. Resident dissection did not increase AS and cost of AS was high.

Cost Analysis of Operating an Anatomic Pathology Laboratory in a Middle-Income Country.

Objective: To examine the cost of operating an anatomic pathology laboratory in a teaching hospital in Malaysia. Once the cost is determined, compare it with the costs of operating other laboratories in the same hospital, and operating anatomic pathology laboratories in other countries. Methods: Cost and workload data were obtained from hospital records for 2015. Time allocation of staff between laboratory testing and other activities was determined using assumptions from published workload studies. Results: The laboratory received 20,093 cases for testing in 2015, and total expenditures were US $1.20 million, ie, $61.97 per case. The anatomic pathology laboratory accounted for 5.2% of the laboratory budget at the hospital, compared to 64.3% for the clinical laboratory and 30.5% for the microbiology laboratory. We provide comparisons to a similar laboratory in the United States. Conclusions: Anatomic pathology is more costly than other hospital laboratories due to the labor-intensive work, but is essential, particularly for cancer diagnoses and treatment.

Routine pathologic examination of tonsillectomy specimens: A 10-year experience at a tertiary care children's hospital.

OBJECTIVE: To review histopathologic diagnoses from tonsillectomy specimens and determine whether routine pathologic exam is necessary. METHODS: Pathology reports of patients undergoing tonsillectomy from 2005 to 2014 at our pediatric tertiary care hospital were reviewed. Histopathologic diagnoses were recorded with special attention to identification of malignancy. RESULTS: A total of 8807 paired tonsil specimens were sent to pathology over a 10-year course. Gross analysis was performed on all. Microscopic histopathologic analysis was performed on 612 (6.95%) specimens with all but one demonstrating strictly reactive lymphoid hyperplasia. The single specimen (0.16%) demonstrated follicular hyperplasia with focal necrotizing granulomatous lymphadenitis without organisms identified on special staining. The surgeon requested pathologic diagnosis to rule out lymphoma in 4 of 8087 (0.05%) of the specimens. No malignancies were identified. The approximate charges for gross examination of a paired tonsillectomy specimen and microscopic examination were $136.10 and $294.54, respectively. Over the 10 year period of the study, total charges were estimated at $1,115,340 (gross) and $180,258 (microscopic). DISCUSSION: Microscopic analysis of tonsil specimens is unlikely to identify abnormal pathology that changes patient management. This study suggests that neither gross nor microscopic pathologic examination of tonsillectomy specimens is necessary on a routine basis. Histologic analysis of tonsils should be requested only on a case by case basis when clinical suspicion for malignancy is high. Avoiding routine pathologic exam of tonsils may be cost effective and medically safe.

Changing Dermatopathology Protocols for Processing Small Skin Biopsies: Decreases in Slide Quantity Does Not Affect Patient Care and Allows for Optimal Efficiency.

In dermatopathology, no standard protocol exists for processing small biopsy specimens. In our original protocol, 2 routine initial slides per biopsy were prepared. For 1003 biopsies, we noted how often the second slide helped in diagnosis or eliminated the need for additional deeper sections. After obtaining these data, we switched to processing only 1 initial slide (new protocol) and again evaluated 1003 biopsies. During the original protocol, the second slide never helped to make a diagnosis that was not apparent on the first slide. When deeper sections were ordered (10.4% of cases), they helped in the diagnosis 34.6% of the time. In the new protocol, deeper sections were ordered in 15.9% of cases and helped in the diagnosis 32.7% of the time when ordered. Comparing rates of deeper sections ordered showed no significant difference for benign, inflammatory/reactive, and premalignant/malignant groups (P > 0.1). However, there was a significant increase in deeper sections ordered for melanocytic lesions from 16.9% to 32.3% (P < 0.05). Also, a significantly greater percentage of punch biopsies (31.5% and 42.0% in the respective protocols) required deeper sections than shave biopsies (7.4% and 12.6% in the respective protocols). Switching protocols, the estimated annual cost savings is $2890. The majority of cases at our institution are properly diagnosed using only 1 slide. From our study findings, we conclude that 1 slide preparation for small biopsies is the best practice for our institution and one that does not affect diagnostic accuracy, reduces costs, and helps in effective time management.

A quality initiative of postoperative radiographic imaging performed on mastectomy specimens to reduce histology cost and pathology report turnaround time.

Breast pathology relies on gross dissection for accurate diagnostic work, but challenges can necessitate submission of high tissue volumes resulting in excess labor, laboratory costs, and delays. To address these issues, a quality initiative was created through implementation of the Faxitron PathVision specimen radiography system as part of the breast gross dissection protocol; this report documents its impact on workflow and clinical care. Retrospective data from 459 patients who underwent simple or modified radical mastectomy at our institution between May 2012 and December 2014 were collected. Comparison was made between the mastectomy specimen control group before radiography use (233 patients, 340 breasts) and Faxitron group that underwent postoperative radiography (226 patients, 338 breasts). We observed a statistically significant decrease in mean number of blocks between control and Faxitron groups (47.0 vs 39.7 blocks; P<.0001), for calculated cost savings of US $146 per mastectomy. A statistically significant decrease in pathology report turnaround time was also observed (4.2 vs 3.8days; P=.038). Postoperative mastectomy specimen radiography has increased workflow efficiency and decreased histology costs and pathology report turnaround time. These findings may underestimate actual benefits and highlight the importance of quality improvement projects in anatomical pathology.

Low-cost workflow improvement reduces gastrointestinal block use 17% by altering classic histotechnology testing.

OBJECTIVES: Gastrointestinal (GI) biopsy specimens were previously limited to four per cassette to facilitate established internal technical work practices and histotechnology best practice guidelines. We evaluated the workflow of these biopsy specimens. METHODS: We implemented three specific changes: (1) up to 10 GI biopsy specimens could be placed in each cassette, (2) histotechnologists would no longer orient GI biopsy specimens, and (3) embedding would be in a straight line rather than diagonal. We evaluated the effects of these changes on total block numbers, quality of slides, and perceptions of staff. RESULTS: The mean number of cassettes used was reduced 17% for GI biopsy cases, or an overall decrease of 3% of total blocks processed by our histopathology laboratory. Slide quality was unchanged. Staff reported increased job satisfaction. CONCLUSIONS: This simple, low-cost, low-effort process change yielded immediate and significant time savings for grossing and histology staff, increased job satisfaction, and challenges conventional histotechnology teaching.

Current projects in Pre-analytics: where to go?

The current clinical practice of tissue handling and sample preparation is multifaceted and lacks strict standardisation: this scenario leads to significant variability in the quality of clinical samples. Poor tissue preservation has a detrimental effect thus leading to morphological artefacts, hampering the reproducibility of immunocytochemical and molecular diagnostic results (protein expression, DNA gene mutations, RNA gene expression) and affecting the research outcomes with irreproducible gene expression and post-transcriptional data. Altogether, this limits the opportunity to share and pool national databases into European common databases. At the European level, standardization of pre-analytical steps is just at the beginning and issues regarding bio-specimen collection and management are still debated. A joint (public-private) project entitled on standardization of tissue handling in pre-analytical procedures has been recently funded in Italy with the aim of proposing novel approaches to the neglected issue of pre-analytical procedures. In this chapter, we will show how investing in pre-analytics may impact both public health problems and practical innovation in solid tumour processing.

Development of an intraoperative pathology consultation service at a free-standing ambulatory surgical center: clinical and economic impact for patients undergoing breast cancer surgery.

BACKGROUND: Second surgeries represent a significant detriment to breast cancer patients. We examined the impact an intraoperative pathology consultation service had on multiple facets of breast cancer surgery. METHODS: We compared the 8 months before the establishment of a pathology laboratory, when intraoperative pathology consultation was not available, with the 8 months subsequent, when it was performed routinely. RESULTS: The average number of surgeries per patient decreased from 1.5 to 1.23, and the number of patients requiring one surgery increased from 59% to 80%. Re-excisions decreased from 26% to 9%. Frozen section allowed 93% of node-positive patients to avoid a second surgery for axillary lymph node dissection. A cost analysis showed savings between $400 and $600 per breast cancer patient, even when accounting for fewer axillary lymph node dissections based on the American College of Surgeons Oncology Group Z0011 data. CONCLUSIONS: Incorporation of routine intraoperative margin/sentinel lymph node assessment at an outpatient breast surgery center is feasible, and results in significant clinical benefit to the patient. Use of frozen section decreased both the time and cost required to treat patients.

Breast capsulectomy specimens and their clinical implications.

BACKGROUND: Plastic surgeons routinely submit breast capsulectomy surgical specimens for pathologic evaluation. However, clinically significant findings are rarely identified. In an effort to reduce health care costs and the unnecessary use of hospital resources, this study reviews the efficacy of submitting breast capsulectomy specimens for pathologic examination. METHODS: All patients from The Methodist Hospital in Houston, Texas, during the years 2000 to 2008 who underwent breast capsulectomy were selected for by Current Procedural Terminology codes 19370 and 19371 (open periprosthetic capsulotomy and periprosthetic capsulectomy of the breast, respectively). A total of 264 patients qualified for the study, and their pathology reports were reviewed. RESULTS: The pathology reports of 434 capsulectomy specimens in 264 patients revealed benign capsules in 206 patients (78.0 percent). Additional findings, including inflammation, calcification, granuloma, and necrosis, were identified in an additional 57 patients (21.6 percent). One patient (0.4 percent) had carcinoma identified within a breast capsule. This was a patient known preoperatively to have recurrent invasive ductal carcinoma that extended into the surrounding capsule. Therefore, none of the 264 capsulectomy specimens revealed new neoplasms, occult disease, or other clinically significant findings that changed the patient's postoperative treatment. CONCLUSIONS: No clinically significant findings were identified in this review of breast capsulectomy specimens in 264 patients. However, the cost for such pathologic examinations was substantial. In an effort to reduce health costs and the unnecessary use of hospital resources, breast capsulectomy specimens may not necessarily need to be routinely submitted for surgical pathologic evaluation.

Utility of pathologic evaluation following removal of explanted orthopaedic internal fixation hardware.

This report questions the cost and effectiveness of routinely sending explanted hardware to pathology for evaluation. Forty-six consecutive patients who had symptomatic hardware removed were enrolled in this study. Pathology reports following hardware removal were obtained, and charts were reviewed for these patients. The pathology department was contacted for related departmental procedure codes, and hospital billing records were obtained regarding the cost of the procedure. In all cases, the pathology reports gave the gross diagnosis of "hardware" and the gross description included the measurements of the internal fixation hardware removed. In no case did the report alter the plan of the attending physician. The healthcare system may benefit by subspecialty review of the current practice of sending internal fixation devices to pathology for evaluation. We recommend a single radiographic view along with proper documentation in the postoperative report to confirm the removal of internal fixation hardware in lieu of pathologic evaluation.

Re-establishing a surgical pathology service in Kumasi, Ghana: case report and discussion of barriers and key elements of a successful collaboration between low- and high-resource countries.

At Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, a breakdown of technical equipment and lack of pathologists resulted in closure of the surgical pathology laboratory in 2004. At an international meeting in January 2005, 1 USA and 1 Norwegian pathologist were asked if their departments could help with the pathology problem at KATH. This article describes the proposals, the barriers encountered, and the key elements of the final successful collaboration between a low-resource and a high-resource country. The proposal to the USA hospital focused on receiving specimens for diagnosis. A detailed proposal was not developed, as several key operational barriers were identified early on, including legal issues, technical capacity issues, and staff capacity issues. The proposal to the University Hospital of North Norway (UNN) resulted in development of a 5-year plan to reestablish surgical pathology at KATH. Two KATH technicians came to UNN and trained in the histopathology laboratory for 3 months. On their return, they started producing slides at KATH. Since April 2006, weekly shipments of hematoxylin and eosin (H & E) stained slides have been sent to UNN by courier service. When needed, paraffin blocks are sent on request. In March 2006, 2 young Ghanaian physicians were received as trainees at the UNN to do full resident work and training with the aim of being approved as specialists in pathology in Ghana by 2010. Full surgical pathology service and training of new pathologists on site are expected to be reestablished at KATH by 2010.

Structured electronic template for histopathology reports on colorectal carcinomas: a joint project by the Cancer Registry of Norway and the Norwegian Society for Pathology.

Both individual patient treatment and cancer registries depend on adequate histopathology reports. To ensure the quality of these reports, professional organizations have published guidelines on minimum data sets for various cancer types. Norway has a population of 4.6 million, and all individuals have a unique identification number. As required by law, relevant information on cancer is submitted to the Cancer Registry of Norway. A closed, national health data network has been established facilitating electronic transferal between various institutions. The Cancer Registry and the Norwegian Society for Pathology have jointly established a nationwide project to (i) develop standardized templates in database format for histopathology reports on cancer resection specimens and (ii) develop an Extensible Markup Language (XML) standard to facilitate future electronic transfer of cancer reports from hospitals to the Cancer Registry. A minimum data set template for reporting colorectal carcinoma resection specimens and the Extensible Markup Language standard have been established. The template is based on international guidelines and classification systems. For most key parameters, pull-down menus with predefined alternatives have been constructed. The template is fully integrated into software being used by all pathology laboratories in Norway. Since the introduction of the template in April 2005, the template had been used for reporting 430 (93%) of 462 colorectal resections at 2 pilot laboratories (Akershus University Hospital [Lørenskog, Norway] and Stavanger, University Hospital [Stavanger, Norway]), demonstrating that high and consistent quality can be ascertained. Pathologists have found the template both time saving and user friendly. The template is now gradually implemented nationwide.

Histopathological examination of intervertebral disc specimens: a cost-benefit analysis.

OBJECT: Routine histopathological examination of intervertebral disc specimens is commonly performed in North American hospitals, but recent studies have questioned the utility of this practice in cases where the indication for surgery is a benign process such as degenerative disc disease. In this study, we have performed a cost-benefit analysis of this practice. METHODS: We performed a cost-benefit analysis of routine histopathological examination of 1775 routine (non-neoplastic and non-infectious indications for surgery) and 70 non-routine (suspected neoplastic or infectious indications for surgery) discectomy specimens obtained over an eight-year period (1996 and 2004). Chart reviews were used to determine if any histopathology findings were clinically significant (i.e., affected subsequent patient care). Total costs were calculated. A literature review was conducted to compare our results with other published series. RESULTS: We found four unexpected histopathology results among 1775 specimens obtained from routine cases, one of which was clinically significant. We calculated costs of $42,165.25 per unexpected histopathological finding and $168,625 per clinically significant histopathological finding. For non-routine surgeries, the cost per abnormal pathological finding was $116.67. CONCLUSIONS: In routine cases, histopathological examination of disc specimens is not justified. The decision to send specimens for pathological examination should be based on the surgeon's judgment.

A feasibility study of virtual slides in surgical pathology in China.

China's huge territorial expanse and its imbalance of regional economic development have resulted in an uneven distribution of experienced pathologists. Developing telepathology for consultation is of special relevance to China. We developed a newly designed telepathology workstation, which includes a small file size of each slide, permitting easy transmission, storage, and manipulation, and a feedback function, and also evaluated its feasibility in surgical pathology in China. Four hundred cases covering a broad spectrum of surgical pathology problems were investigated in a blinded fashion by the 2 pathologists using this virtual microscope system. These cases were then randomized and re-reviewed a second time with light microscope. Diagnoses and time spent for each diagnosis were recorded for both methods. The diagnostic accuracies achieved by viewing glass slides and virtual images were 97.25% (389 of 400) and 95.5% (382 of 400) for pathologist A and 96.25% (385 of 400) and 94.75% (379 of 400) for pathologist B, respectively. There was no significant diagnostic discrepancy between the 2 methods for the 2 pathologists. The average times for viewing a virtual slide were 3.41 and 5.24 minutes for pathologists A and B, respectively, whereas the average times for viewing a glass slide were 1.16 and 3.35 minutes for pathologists A and B. There was a statistical difference between the time costs of the 2 methods. However, the slight time increase using virtual slides is less than that using dynamic telepathology and traditional consultation, and is acceptable to the pathologists. These results showed that this newly designed virtual microscope system have an acceptable diagnostic accuracy that is of practical value and may be suitable for application in China.