Volume 78, October 2025, 152493Author links open overlay panel, Highlights•

Pathologists need to understand the challenges of smartphone assisted telepathology.

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This article gives tips on pathology image acquisition and sharing with smartphone.

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In future artificial intelligence powered co-pilot systems can assist smartphones.

AbstractObjectives

Many practicing pathologists of the current generation have used smartphone-assisted telepathology at some point in time or the other. The use case may vary-second opinions, social media posts, teaching, and so on. This has largely been made possible by the recent improvements in smartphone cameras, better smartphone microscope adaptors, and faster internet. This review aims to provide insights into the different techniques, practical applications, limitations, and prospects of smartphone-assisted telepathology.

Methods

We provide a ready reference for all practicing pathologists who want to use smartphone-assisted telepathology more effectively. The review is based on literature available on MEDLINE and personal observations and experiences.

Results

Smartphone-assisted telepathology despite its limitations is here to stay. With the introduction of 5G internet, internet speeds are bound to improve. However, the extent of this improvement would ultimately decide how far the smartphone can disrupt the world of telepathology.

Conclusion

Learning to use the smartphone effectively for telepathology is important for all pathologists. It is a silent revolution that is slowly but surely changing the way pathologists interact with each other professionally.

Introduction

The advent of telepathology has forced a change- from seeing the slides under a microscope to seeing images on the screen. Slowly but surely the acceptance of images on the screen to diagnose cases has increased. At the same time, smartphones have been increasingly used to both acquire and visualize pathology case images. These images have been used for teaching, social media posts, personal discussions of interesting cases, and teleconsultation.

Telepathology is defined as the practice of pathology at a distance. It involves sharing of pathology images and data for the purpose of research, diagnosis and education. [1] Telepathology techniques include- static telepathology, dynamic (real time) telepathology, hybrid telepathology, whole slide imaging, mobile assisted telepathology and artificial Intelligence integrated telepathology. [2] Telepathology has taken rapid strides in the last decade with the widespread use of whole slide imaging (WSI). WSI involves scanning the entire slide at various magnifications and creating a high resolution digital image which can then be analysed on a computer or mobile. [3] However large size of the image files has been its Achilles' heal. This raises a very fundamental question- why do we need to scan the slides at all? If we can send high-quality live images of the histopathology slide via a fast internet connection (Live Dynamic non-robotic telemicroscopy), telepathology consults can start resembling clinical telemedicine consults. However, it is easier said than done. It would require a technician to relay the live images through microscope mounted digital camera or mobile phone camera via broadband internet or 5 g connection. This technician would follow the instructions of the trained pathologist viewing the live images on the other end. Usually, it is very difficult to find a person with the skillset needed to remotely operate the microscope according to the instructions of the pathologist to examine the slide. Hence access to the entire slide utilizing a whole slide image is invaluable in circumstances where a skilled operator is not available at the site. It also gives the added advantage of viewing the case multiple times which is sometimes needed for difficult cases.

While this scenario may become a reality in the not-too-distant future, the improvement in smartphone cameras and fast internet has already popularized the use of static images. There is virtually no difference in the images acquired by high-end smartphone cameras with suitable adaptors and microscope-mounted digital cameras at this point.

Section snippetsThe smartphone camera

The biggest advantage of smartphone photography is the relative ease of taking and sharing images. In the first decade of this century, smartphones with digital cameras became ubiquitous, and image-sharing applications like Facebook and Twitter allowed users to instantaneously share images over the internet. [4] Continuous improvement in the smartphone camera resolution has resulted in image quality that is at par with digital cameras. [5]

However, with the availability of multiple rear cameras

Smartphone adaptors

Bellina and Missoni were the first to describe a free-hand technique to capture microscopic images with a smartphone without the use of a smartphone adaptor. [7] The technique is very simple however it requires much practice and cannot be used for taking multiple images at a stretch. Many photography enthusiasts developed smartphone scope adaptors that could be attached to telescopes, binoculars, and microscopes to utilize smartphone cameras to capture high-quality images. [8] Three startup

Internet speed

The improvement in smartphone cameras only solves one part of the problem. The next challenge is to send high-quality images or videos to the reviewer in real time. Image-sharing apps like Facebook (Meta Platforms Inc.,California, United States of America) and X (formerly twitter) (X Corp. a subsidiary of X holding Corp., California, United States of America) became popular among pathologists for sharing cases due to two reasons- improvements in smartphone cameras and 4G internet speeds. A

Applications best suited for smartphone-assisted telepathology

The usual software applications used for smartphone-assisted telepathology include WhatsApp, (WhatsApp, Inc., Mountain View, CA, USA) and email. [17,18] The advantages of WhatsApp include the instant sharing of images, an option to discuss the case in real-time, and a user-friendly interface. [18] However, one disadvantage is the reduction in the file size as Whatsapp shrinks the images so that a large number of images can be sent at the same time. An easy way to counter this is to send the

The display at the receiver end

The optimum utilization of high-quality images for telepathology requires a high-resolution large display. The initial studies utilized the smartphone display for visualizing the images at the receiver end. [20] However, later studies utilized large-sized LED [light-emitting diode] television screens attached by high-definition multimedia interface [HDMI] port to the laptop for visualizing the static and dynamic images. [17,21] [Fig. 5(a)].

The present-day 40-in. plus LED televisions

Key issues with the use of static images

Since the use of static images is the most widely used mode of smartphone-assisted telepathology, it is pertinent to summarize the key issues faced while using them. The problem of pixilation of images has largely been solved with higher resolution cameras and faster internet. Pixels are the small squares of color information that form the image. So when an image is magnified it becomes blurred, an effect called pixilation. [20]

However, the major issue with the use of static images is the issue

Regulatory concerns

Smartphone-assisted telepathology has largely been used for second opinions and teaching. While whole slide imaging systems have been tried for use in primary diagnosis of histopathology cases, widespread adoption is still a distant dream. In the United States of America, telepathology practitioners must be licensed to practice medicine in the state where the patient is located and not just where the pathologist is practicing. They must also be board-certified in pathology or a related

Ethics and patient confidentiality

Pathologists have traditionally shared interesting cases and snippets by way of case reports and images published in research journals. However, with increasing importance given to impact factors in journal publishing, the number of case reports published has come down. This created a vacuum that was filled by social media. Pathologists took to social media in a big way to share thoughts, images, and rare findings and also to collaborate. [6,26] However, with such a large number of images

Impact of COVID-19 on smartphone assisted telepathology

The COVID-19 pandemic challenged histopathology practice in a big way. Lockdowns and staff shortages forced the hospital administrations to look for digital pathology alternatives. [28] As a result, the initial hesitation of pathologists to embrace digital pathology was gone, as circumstances forced them to adapt to the diagnostic challenges of digital pathology. As we move into the 21st century, extremes of weather, climate change, and viral pandemics are a new reality, and smartphone-assisted

Current data on the efficiency of smartphone-assisted telepathology

Smartphone-assisted telepathology has been used for remote diagnosis of malaria. [29] The basic design approaches used for this purpose include the lensless approach, on-lens approach, and attachment-based approach. [30]. Lensless microscopy uses the shadows cast by microscopic objects to reconstruct the images. It uses diffraction patterns, shadow imaging, and computational reconstruction. A lensless design allows for a more compact configuration and eliminates the requirement for optical

Artificial intelligence and augmented reality

However since artificial intelligence can play a big role in how pathologists diagnose disease in the future, some recent publications have tried to apply the machine learning algorithms trained on whole slide imaging data to smartphone-acquired images. Since the algorithms are trained on whole slide images, they typically underperform on smartphone images. One way to circumvent this problem is to use an enhancement network to suitably modify the smartphone images. [50] The other approach is to

Smartphone integrated microscopes

The microscope manufacturers have already introduced new models with dedicated slots for smartphones so that there is no need for smartphone adaptors and the field of view included in the images is larger. A variation of this theme is the Liquid Crystal Display (LCD) integrated microscope which has the eyepiece assembly replaced by a large-sized tablet computer that is directly attached to the optical pathway of the microscope. [57] This not only helps the pathologist to sit upright while

Scenarios ideal for smartphone-assisted telepathologySmartphone-assisted telepathology is currently being used for:1.

Taking images for tumor board meetings.

2.

Sharing interesting cases on social media.

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Frozen section second opinion.

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Documentation for quality assurance.

5.

Teleconsultation.

However, as we progress to faster internet, the possibilities are many.-Videoconsultation, artificial intelligence-based diagnosis, and live streaming on YouTube (Alphabet Inc., California, United States of America) to name a few. [38]

Whole slide imaging versus smartphone- who wins

The simple answer is- “both”. While a cursory look might suggest that the two are competing against each other, a more detailed analysis would show that both technologies can flourish side by side. They are both on the same side of the divide- pathologists doubting telepathology and those embracing telepathology. Once the hesitation is taken care of, pathologists can find their use cases for the two technologies.

Smartphones have replaced personal computers on many fronts-finance, communication,

Minimum specifications for a smartphone to be used for telepathologyThough there are no standard guidelines for the smartphone, following are the general specifications recommended for telepathology based on personal experience1.

Display – High-resolution display (Full High Definition or higher) with peak brightness of 1000 nits and higher, If using the phone for dynamic images, a refresh rate of 120 Hz would be ideal.

2.

Camera: At least 12 MP resolution for primary sensor

3.

RAM: At least 6 to 8 GB RAM. (Gigabytes Random Access Memory)

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Storage: At least 128 GB storage

Options for users without internet access

For users with no or limited access to the internet, the store and forward method of telepathology can be suitably modified. The images can be captured and locally stored on the hard disk and then transferred to specialists via physical media (Universal Serial Bus, USB or Compact Disc, CD). Similarly, for mobile telepathology, the images can be captured and stored for later transmission. The images captured by smartphone can also be uploaded to the intranet of the hospital or institution. These

Conclusion and recommendations

To conclude, smartphone-assisted telepathology has benefitted from the recent technological advances in smartphone technology and will achieve its full potential only when faster mobile internet services become more widely available at affordable rates. All pathologists must be aware of these innovations since artificial intelligence and augmented reality will change the way pathology is practiced. in the future. The smartphone (which is as capable as any mini-computer) will also adapt itself

CRediT authorship contribution statement

Nadeem Tanveer: Writing – review & editing, Writing – original draft, Supervision, Resources, Formal analysis, Data curation, Conceptualization. Farhat Naz: Writing – review & editing, Writing – original draft.

Presentation at a meeting

None.

Informed consent

Not applicable.

Consent for publication

Not applicable.

Ethical approval

Not needed.

Ethics statement

The institutional ethics committee at our institute does not mandate ethics clearance for review articles.

The research confirms to the ethical principles of the declaration of Helsinki.

Declaration of Generative AI and AI-assisted technologies in the writing process

The authors have nothing to disclose.

Funding

This study was not supported by any funding.

Declaration of competing interest

The authors declare that they have no conflict of interest.

Acknowledgments

The authors thank Dr. Neha Garg, Dr. Kaniyappan Nambiar and Dr. Swati for their help in clicking the images used in Fig. 1, Fig. 2, Fig. 3.

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