Development of VR (Virtual Reality) Based Pathology
Practice SystemSohei Kitazawa1), Ryuma Haraguchi1), Riko Kitazawa2)
1) Graduate School of Medicine, Ehime University
2) Ehime University Hospital, Division of Diagnostic Pathology

1. Introduction

Pioneered by DX: Building a Virtual Classroom Digital
Learning (VCDL) Environment to Achieve New Normal

VR (Virtual Reality) is a computer-generatedEducation”(The applicant is Hiroshima University). As

technology that allows users to experience, throughpart of this project, Ehime University worked on theVR devices such as head-mounted displays, artificial

development of a pathology education system using VR

spaces that do not exist in actual reality. Unlike VR,

in academic year 2021 under the theme“Construction ofAR (Augmented Reality) is based on the real world anda VR pathology training room by merging macroscopic

that is augmented or supplemented by superimposing

and microscopic images”.

information on it, using mainly devices such as

In medical education, pathology requires particularsmartphones and tablets. It is used in the well-known

delicacy of images, and the high resolution ofPokémon Go game and in showing the conceptualized

microimages requires a fairly large file size for eachappearance of a yet-to-be completed building constructedindividual subject. In the university syllabus, pathology

on part of the surrounding landscape. MR (Mixed Reality),

lectures are progressing from general pathology toon the other hand, is similar to AR in that it is based on

systemic pathology for each organ. In this process, thethe real world. In other words, it is a technology that

normal macro- and microstructures of the human body

creates a world that combines VR and AR. These VR,

are seriously taken into consideration. Since a lack ofAR, and MR technologies are sometimes collectively

understanding of normal structures will not lead to areferred to as XR (Cross Reality, eXtended Reality),

deeper understanding of pathology, the lecture should

because of many unclear attributes where the boundaries

always incorporate a review of anatomy and histology.

among them are not clear (Barteit, 2021).

The VR system allows visual and vivid side-by-side

VR is already being actively used in various medical

comparison of normal and pathological structures,fields. In particular, it is very useful in surgicalmaking it possible to give more effective lectures. In thesimulations (Verhey, 2020) and in infection control

process, various difficulties were encountered, such as theeducation (Luo, 2021) because it teaches the trainee inlimitations of the VR system and the mode of cooperating

learning advanced medical techniques while forestallingwith and the stance of software development companies.

the risk of invasive procedures on actual patients andWe look forward to introducing some of our experiencesof infection by the medical personnel. It also has theto date with others in the hope that our observations

advantage of training a large number of participants

will be considered by lecturers who may be involved orunder the uniform standards. Thus, the use of VR isinterested in instruction using the VR system.

developing in the medical field, and its implementation is
expected to broadcast widely. Efforts have already been
initiated to utilize VR in the various fields of pathology.
Presently, Ehime University has been selected as a

2. Project Background
2.1 Remote education under the COVID-19 pandemic

partner in a project by the Ministry of Education, Culture,

The Coronavirus outbreak from Wuhan city in ChinaSports, Science and Technology (MEXT) to promotespread rapidly, causing worldwide loss of life anduniversity reform under “Paradigm Shift in Learning

inflicting tremendous economic losses. In addition to the

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overcrowding of medical facilities, students were forced

Institute (https://vracademy.jp) had the aptitude forto stay home and many classes had to be conductedjoint development. The company manages classes in theremotely. At the same time, the low diffusion rate ofbasics of VR programming, and some of their graduates'

digital devices other than smartphones was distressing.

product is available on their website; it stood out as a

At Ehime University, faculty and the student body wereviable developer with teaching capabilities. The company

forced to deal with the sudden decision of conducting

was contacted by e-mail, and after receiving their consent

pathology lectures and practice remotely.

that were the grant application not approved, all plans

As previously described (Kitazawa, 2021), considerable“to date” would be scrapped. A ZOOM meeting wasdifficulty was encountered in procuring equipment,

convened with the person in charge of development andvideo delivery methods, and in evaluating the level ofthe director of the VR Design Institute to explain ourcomprehension, proficiency and feedback. In the process,concept of developing a VR setup. After their consonance,

the present study led to interest in VR in the belief thatagreement was reached to jointly develop our pathology

students could take part actually in practical training

practice system. The design of the required 3D images

within a virtual space than in viewing videos alone inand other details were readied before the grant was

their rooms. The initial idea was that if the students

approved. In our communications with the VR Design

could create a simulated training room through an avatar

Institute, the basics of the background knowledge ofthat represented them, as in social games in the Internet

pathology practice, tissue and macroscopic specimens

society, they would not feel detached and could practiceand other aspects were explained to them. Videos ofwith “others” regardless of their location. Nonetheless,operating the virtual slide screen (the whole slide image)with limited time and funds, the difficulty of constructing

used in practice sessions and relevant information was

a VR space where students could congregate and of

given to the person in charge. In the whole process ofdeveloping a system that included the management ofdeveloping the project, no face-to-face meetings werethe space, was recognized. The focus was then directed

held with the development staff; all information was

at developing an individual participation system using

exchanged through Internet conferencing and e-mail.

VR goggles. A pair of VR goggles (Oculus Quest 2,

The grant application was accepted and development of

now renamed Meta Quest 2) was actually purchased

the VR system was implemented. The most important

to experience what the VR world was like. Although

aspect in the development process was making specificsome drawbacks need to be overcome, that the system

requests regarding the design of virtual space the client

could in the near future be applied to student practice of-the pathologist- envisioned. Regardless of differences inpathology and pathological diagnosis is foreseeable. The

the degree of difficulty, virtual design allows the creation

grants for the promotion of university reforms were toof the desired space with almost no limitations, giving thebe used entirely for software development; consequently,

programmer a high degree for improvisation. Therefore,

search for a relevant company was initiated.

having a solid image prepared and based on a storyboard
is essential.

2.2 Meeting with system-and-software developer

Having the programmers create three or more models

Only a limited number of companies with extensive

for detailed operation, then selecting one of them, orexperience in developing medical-related VR systems ismodifying the one closest to the original concept wasavailable, and even after consulting with the university

effective. The following five basic design aspects wereadministrative staff, introduction to a company that couldemphasized. (1) During practical training it should behandle VR development for an individual enterprise waspossible to follow the actual training manual with currentchallenging. When applying for grants, quotations werevirtual slides in the VR space and on the virtual monitor.

needed from VR system-development companies, but our(2) Images of normal structures, organs and such canbeing VR novices, where to start was uncertain. Google

be displayed side by side. (3) By viewing macroscopic

search came up with several prospective VR development

organ findings and pointing to an altered area, thecompanies with experience in the development andcorresponding microscopic image of the altered area canproduction of user-friendly educational software,

be viewed. (4) All operations should be consistent, and by

through joint development with several universities,

mastering one operation, the user should be able to carrythat even beginners could readily use. The VR Designout other operations. (5) The system should be operable

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by“hand gestures”only without any intervening handoperated contrivance. The five prerequisites were set as
the basis of the VR course, but that their implementation
would be challenging in terms of both time and funds inaccommodating all aspects of each pathology specimen
was anticipated. Therefore, completing some of thediseases of the circulatory organs was set as the goal. Forother diseases of other organs, agreement was reachedwith the VR Design Institute to modify some of thecompleted programs and to adopt the same process forcreating a prototype that could be completed whenevertime and funds were available. For details such as theshapes of touch buttons, several typical patterns wereselected while testing the operation of the device.

3. The Prototype

Figure 2. Normal heart with histology tags for virtual
microscopic images.

can create data from an actual heart, a VR model of a

Based on the above discussions, three models weretypical heart is constructed and color-coded with mainly

produced as prototypes of specific VR systems. One

red and blue tones to create a 3D image of the heart. 3D

prototype was ultimately produced by integrating theimages are then created by reference to human anatomy

merits of each.

atlases and other reference material and a beginner'sguide, and colored red for arteries and blue for veins,regardless of the actual natural color tones. For ischemic
heart disease, data of the normal heart is modified and
3D data is created, as shown in Figure 3, assuming thecase of a ruptured myocardium on the 5th day after theonset of an acute myocardial infarction in a patient witha history of myocardial infarction.

Figure 1. Opening menu of VR pathology practicesystem.

See video link https://youtu.be/KeIHuNsiq4I for theactual user's view. On the first screen (Figure 1), the 3D
images of the human body slowly rotate for the user tomake a selection from the body to the organ. The menu
is arranged in an arc showing the circulatory, respiratory,
nephrological-urinary, etc., system that can be selectedby touching a virtual button. When one of the systems,for example the cardiovascular, is selected, a sub-menu
appears for the user to select the normal cardiovascular
structure and related diseases (Figure 2).
By selecting the heart, a normal heart appears that canFigure 3. 3D view of ischemic heart disease with muralrupture.

be handled and magnified. Although a real 3D scanner
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The status of the coronary arteries is also madediscernible, so that the ruptured unstable plaque that is
the source of the acute myocardial infarction can be seenin the coronary artery at the infarction site (in this case,the anterior descending branch). The software used tocreate, color, and reform the 3D data of the macroscopicorgans is free software called Blender (https://www.
blender.org). Since constructing specific data from scratch
is very labor-intensive, there is a limit to what can beaccomplished at one institution in preparing macroscopic
images corresponding to various diseases. By touching alesion in the macroscopic image, as shown in Figure 4, avirtual microscopic image appears on a virtual monitor.

Figure 5. View of person using the VR system.

limited space such as a home, the content of the practicaltraining would not be visible to persons in the vicinity.
The trainee would conduct macroscopic and microscopic
operations without concern for those around who may
feel intrigued seeing a person wearing goggles andpushing, pulling and grasping thin air (Figure 5).

4. Problems pending construction of theVR educational system
In the process of constructing the system, the Internet
was perused for websites of archived 3D images we could
access. While relatively numerous themes developed
Figure 4. Virtual microscopy images on virtualmonitors.

for gross anatomical practice were available (manyof them for a fee), very few 3D materials dealt withpathology. Sharing actual human gross organs or glass

Then using a virtual slide on an alternative virtual

slides for microscopy practice among many institutions ismonitor, the microscopic image is enlarged, reduced andchallenging, but VR 3D data being digital can be shared

moved, by scale bars and cursors. This whole image isamong and archived by multiple institutions. Pathologist

then modified to allow enlarging and reducing the screen

societies are also making progress in the use of virtualwith both hands and moving it with one hand, resulting

slides for pathology core images, education programs,

in one all-inclusive screen configuration. The multiple

and various case review meetings. Taking this one step

virtual monitors floating in space and the microscopic

further and accumulating data on typical macroscopic

images being zoomed in and out and moved by hand

images of pathological organs after determining certain

gestures conjures a scene from a science fiction movie,

standard formats is warranted.

foreshadowing pathological diagnosis without the use

Although a method of converting photos of actualof optical microscopes and actual monitors. This VR

organs into digital data with the use of 3D scanners

system will reduce space and cost of the training, since

is available, scanning bloodstained organs on a slab at

the macroscopic and microscopic views of the normal

autopsy is unseemly. Reforming and coloring the images

and altered organ can be viewed simultaneously on onebased on the 3D digital data of normal organs, as done

common user interface. Furthermore, once one system,in this project, would be practical. When the system ise.g. the cardiovascular is mastered, it would be easy tonear completion minor modifications can be introduced

conceptualize and run another system through the sameprovided they are within the specifications and withininterface thus promoting efficient learning. Even in abudget. The client needs to understand, however, that an130

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additional grant would be required for each modification
after the completion and delivery of the system. In theoriginal grant application, the use of friendly avatars wasexplained as the orientation of prospective high school
students visiting open-campus days, who could acquaintthemselves with the VR system. In the present VRsystem, however, the plan to include avatars resembling
faculty members, was not included by an oversight, and

6. References
Barteit, S. (2021)“Augmented, mixed, and virtual reality-basedhead-mounted devices for medical education: systematicreview”, JMIR Serious Games 9(3): e29080
Luo, Y. (2021)“Design of a virtual reality interactive training
system for public health emergency preparedness for major
emerging infectious diseases: theory and framework”, JMIT
Serious games 9(4): e29956

the memorandum explaining the pathological findings

Kitazawa, S. (2021) “Experience in remote lecture on

gleaned during the course had not been completed. We

pathology:a topic of this month”, Pathology and Clinicalbecame aware that these details were missing from ourMedicine 39(4): 412-415grant application after the completion of the software,Verhey J.T. (2020) “Virtual, augmented, and mixed reality

and that major changes in the specifications would entail

applications in orthopedic surgery”, International Journal ofadditional funds.

Medical Robot 16(2): e2067

Currently, the software development environment andthe treatment of programmers is at a very delicate stage,
and bargaining for intellectual creativity after deliveryof the system seems impractical. Because expensive
VR goggles apparatus were needed to introduce VR,
it was not possible to ask all students’ opinion. Whenthe department-assigned undergraduate students
experienced the VR education, they all commented thatthey participated more actively in the learning process
because they had to select the images and move themaround by themselves, compared to passively watching
videos at home. The construction of a system thatfacilitates lecture practice beyond the actual distancein an interactive VR space with the lecturer is a futureissue. As an advanced version of this system, we areconstructing a system that can simulate pathology
practice in a more practical way by utilizing VR180, andare promoting education that explains pathology-related
techniques and allows students to experience autopsies,
which we expect will contribute to post-coronaryeducation.

5. Conclusion
Although our experience with VR was limited, weshared with VR Design Institute some information on
the construction of a practical pathology training systemusing VR. The VR environment can be shared by many,and further development in this field is foreseeable,
including pathology education, training of medical
specialists, and histopathological diagnosis.

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