Friday, November 18, 2011

Neuropathology Focus of New SNO President's Address Today


Over 1400 attendees at 2011 SNO meeting in Anaheim

                   Dr. Aldape discussed brain tumor biomarkers                
Same view as above, at 40X
Neuropathlogy took center stage at the Society for Neuro-Oncology (SNO) meeting today as Dr. Kenneth D. Aldape, neuropathogist at the University of Texas MD Anderson Cancer, was introduced as the next president of the society. Dr. Aldape also delivered an address to more than 1400 attendees about the future of surgical neuropathological reporting. Aldape's research centers on the clinical utility of brain tumor biomarkers as prognostic indicators. He described how the use of biomarkers will change the way surgical neuropathology diagnoses are rendered. He noted that the broad morphologic spectrum one sees in gliomas makes the recommendations of the World Health Organization sometimes difficult to implement. For example, the difference between a WHO grade II and grade III astrocytoma is based principally on whether or not mitotic figures are "brisk" as interpreted by the examining neuropathologist. Yet, the imprecision of that approach is obvious when one considers variables such as the diligence of the neuropathologist in identifying mitotic figures, the often equivocal morphology of apoptotic-versus-mitotic cells, as well as the variable technical quality of tissue processing and staining. The use of biomarkers will make diagnoses more reliable and will provide more useful prognostic information to the oncologist. Dr. Aldape projected onto the screen an example of a recent surgical pathology report he had generated at MD Anderson. The report highlighted the status of the several biomarkers, including G-CIMP, IDH1, pHH3, MIB1, 1p/19q deletion, and MGMT. Then, only in the last sentence of the comment, was it noted that the histology and biomarker profile was most consistent with a WHO grade III (anaplastic) astrocytoma. It was as if the WHO diagnosis and grade were a perfunctory afterthought. Finally, Aldape noted that biomarkers will become even more important in the coming years as biomarker data becomes "actionable", allowing the oncologist to personalize the treatment of a particular tumor depending on the biomarker profile. These are exciting times....

Thursday, November 17, 2011

Kois, Perry, Giannini, and Zagzag Among Neuropathologists at SNO Meeting

Neuropathologists are well represented at the Society for Neuro-Oncology (SNO) meeting going on here in Anaheim, California. Today I ran into Dr. Arie Perry of UCSF and was pleased to make the aquaintence of Dr. Nancy Kois of St. Alphonsus Hospital in Boise, ID.


I had a chance to catch up with the Mayo Clinic's Dr. Katerina Giannini who is in attendance this weekend. I also just ran into NYU's Dr. David Zagzag, who confirmed that his institution is actively seeking a neuropathologist. Anyone interested in the position can email him at dz4@nyu.edu.

Wednesday, November 16, 2011

SNO is coming down in Southern California!!

For the next couple of days, I'll be blogging live from the 16th annual meeting of the Society for Neuro-Oncology (SNO) in Anaheim, California. SNO is the most inter-disciplinary of the neurologic societies, with membership that includes neurosurgeons, neuro-oncologists, neuropathologists, radiation oncologists, neuroradiologists, pediatricians, laboratory scientists, nurses, and other specialists. According to a report from SNO's membership committee, a full 5% of SNO membership comes from the specialty of pathology. I am among that 5%. SNO's acknowledgement of the pivotal role neuropathology plays in brain tumor research and treatment is exemplified by the fact that this year the society has recognized a neuropathologist -- Kenneth Aldape, MD from the University of Texas MD Anderson Cancer Center -- as recipient of the Victor Levin Award in Neuro-Oncology Research. I'll be in attendance on Friday when Dr. Aldape receives the Levin Award and delivers a plenary session on tumor genetics. SNO has further recognized neuropathology by including "pathology" among the nine Young Investigator Round Table career interest luncheons. Finally, in reviewing the abstracts from the meeting, I see that several posters include neuropathologists among the authors. Although most of these authors are placed in other specialty categories in the abstract book, there is actually a distinct section devoted specifically to pathology. The senior author of one of the posters in the pathology section is a neuropathologist whom I have described previously in this blog as a "rising star in the neuropathology firmament": Craig Horbinski, MD, PhD.  Dr. Horbinski's abstract is  entitled Glioblastoma Survival Varies According to Degree of EGFR Amplification.

The outgoing president of SNO, Frederick F. Lang, MD, writes in the latest issue of SNO News that one of the goals of his presidency has been to "extend a cooperative hand to other like-minded organizations in the USA and internationally. The wisdom of SNO is its inclusion of multiple disciplines, and I have always thought that other organizations should benefit from this wisdom."  In the spirit of this multidisciplinary approach, SNO has partnered this year with the Section of Tumors of the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS). I would urge the American Association of Neuropathologists (AANP) to consider partnering with SNO to create a joint meeting. A productive cross-pollination would undoubtedly result.

Keep reading this blog over the next couple of days as I report on the interesting educational and research presentations that will occur as SNO comes sunny Southern California!

Thursday, November 10, 2011

MD/PhD Student Seeks Advice About a Career in Neuropathology


I recently received an inquiry from a medical student named Stephen Briggs. Rather than pontificate on this topic myself, I am posting, with his permission, Stephen's email with hope that the readership of this blog might offer some advice to this young man in the comment section of this post. Thanks in advance to anyone who would like to put in their two cents' worth.

Stephen Briggs
Dear Dr. Moore,
  I have been avidly following your blog for a while now, and I would like to ask you a few questions about the field of neuropathology. I am an MD/PhD student, currently in the PhD phase of my training. I am researching neurological disease, and I want to continue in this field. I am still relatively early in the program (I just finished the first year of my PhD), but I would like to start thinking about possible future directions. Neuropathology seems to be a great fit based on my interests, but I would like to discuss some of the details with you.
  First, you have mentioned in some posts that a neurology residency followed by neuropathology is no longer the standard pathway (September 2010 guest post). Is it actually a disadvantage? If I want to do neuropathology work, should I plan to go through pathology? The guest poster (Dr. John Donahue) seemed to think that the neurology to neuropathology was a long shot for new students, because most departments want a more general pathologist instead of a total specialist in neuropathology.
  Second, I was interested in your take on research in neuropathology. To an outsider, it seems particularly well suited: it includes predictable work hours, access to human tissue, and a generally academic mindset. Is the actual practice different? Are there any challenges to pathology research that I may not be aware of? If I chose to do research in neurology instead, would it be substantially different?
  Finally, I am interested in the long-term prospects of the field. I count fully 20 openings posted on your blog, which certainly seems hopeful. However, from searching on Google I have seen horror stories about how difficult it can be to get into the field of pathology in general. Some pathologists report taking fellowship after fellowship to avoid being unemployed while waiting for a position to open up. Also, some residents were worried about the field as a whole, as it is easier to computerize or outsource than other fields of medicine. Are these concerns justified?
  Thank you for maintaining your blog. I am glad that there is a resource for students to find out a little about neuropathology, and to feel connected to the field as it evolves.
  Stephen Briggs

Sunday, November 6, 2011

Best Post of May 2011: The Timeless Dr. Adelman

The next in our "Best of the Month" series comes from May 20, 2011:

Lester S. Adelman, MD
I was recently sent this 1992 essay written by Dr. Lester S. Adelman, retired neuropathologist at Tufts New England Medical Center. It amusingly illustrates the anonymity in which we pathologists toil:

Pathologists spend their time in the figurative,
and sometimes literal bowels of the hospital.
Even those of us who specialize in the pathology
of the brain occupy this nether region. The
patients who benefit from our brilliant diagnoses
are often as little aware of us as they are of
the hospital laundry.
This life of anonymity has its rewards. Frozen sections
are only rarely done on nights and weekends, and straightforward
cases are disposed of quickly. The intellectual and
visual pleasures of the job are great. Every once in a while,
however, we are reminded of the fact that we have given up
a part of doctoring, the part that has to do with knowing the
gratitude of the patients whom we help.
Some years ago, in the era before CT scans and MRIs,
a patient was admitted to our hospital with a brain tumor.
Preoperative radiologic diagnoses in those days were based
on angiography, and this patient's angiogram strongly suggested
a glioblastoma multiforme. The patient was given the
bad news, and a biopsy was done to confirm the diagnosis.
The surgeons also thought the tumor was a glioblastoma,
but when I looked at the frozen section, I discovered the
tumor was clearly a meningioma. With this diagnosis, the
surgeons were able to find a plane of dissection around the
tumor and remove it completely.
I was happy with the outcome and thought I had accepted
the fact that the patient would never know my part .
in it. It was not long after that I was to come face-to-face
with the shortcomings of my chosen medical specialty.
A week later I was at a conference with the neurosurgeons
when I noticed that one of the residents was wearing
an expensive new wristwatch. A moment later I noticed that
a senior neurosurgeon had a similar watch on his wrist. A
quick check of the audience revealed that they all had new
watches!
"What's going on?" I asked.
"You remember Mr. X, the patient with the meningioma?
He's a jeweler, and he was so happy he didn't have
a glioblastoma that he gave us all new watches."
"How about me?" I whined. "I'm the one who cured
him. If it weren't for me, you would have quit, thinking he
had a glioblastoma."
The physicians smiled graciously and conceded this was
probably the case.
Years have passed, and despite the advances in imaging,
my neurosurgical colleagues continue to consult me about
diagnoses. But when I want to know what time it is I still
consult my Timex.