What first drew you to neuropathology, and how has your focus evolved over the years?
I was drawn to pathology – specifically neuropathology – fairly late in medical school. I’ve always been interested in the brain; my PhD was in neurobiology, focused on how neurons and their axons become dysfunctional. I was considering fields like neurology, neurosurgery, or psychiatry, but hadn’t decided. Then a mentor at the Mayo Clinic suggested I try a rotation in neuropathology.
Within a few days, I knew it was the right fit. The people, the work – it all felt right. Neuropathology lets me study the brain and neurological diseases while also doing meaningful clinical and research work. It’s a field that combines intellectual depth, high data intensity, and strong clinical impact. It’s a very special field for those who are drawn to it.
In your view, what are the most pressing diagnostic challenges in surgical neuropathology today?
We've made great progress in providing reliable and clinically meaningful diagnoses by combining molecular diagnostics, immunohistochemistry, and traditional morphology. One of the biggest challenges now is making sure these standards are adopted globally. We still need to be skilled at diagnosing disease under the microscope, but these additional tools have greatly improved what we can do.
In central nervous system tumors, some diagnoses are very complex and require advanced tests like methylation profiling. Unfortunately, not all institutions – or countries – have access to these tools. That creates a gap in diagnostic ability between high- and low-resource settings.
Each time a new WHO classification is released, it reflects advances in the field – most of which rely on molecular techniques. So we’re in a tough spot: we can offer the best diagnoses when we have access to these technologies, but many places still don’t. We need better ways to help all pathologists, regardless of location, reach the same diagnostic standards.
How has the growing integration of molecular pathology impacted the traditional morphologic framework of neuropathologic diagnosis?
We still begin with the morphologic evaluation of the specimen. It's important to understand how the tumor interacts with the brain – is it infiltrative or solid? What is the grade? Most molecular tests don’t determine the grade directly; that’s still mostly based on morphology.
That said, our field has advanced a lot over the past 20 years. We now use molecular diagnostics in nearly every surgical neuropathology case, especially with diffuse gliomas, pediatric brain tumors, and meningiomas. It’s becoming a standard part of care.
Every lab should either be able to do molecular testing on-site or have a reliable way to send it out. Good patient care in neuropathology depends on combining molecular results with immunohistochemistry and traditional morphology.
How have you approached the challenge of teaching such a complex and morphologically nuanced subspecialty to learners at different levels?
We have different expectations for trainees depending on their level of experience, and we also teach medical students who rotate with us. One key point we emphasize early on is that morphology alone isn’t enough to make a diagnosis today – you need to integrate molecular diagnostics and immunohistochemistry. Our trainees are used to this approach because it’s common in other areas like bone, soft tissue, and lung pathology.
For those not planning to specialize in neuropathology, I aim for them to leave the rotation with a solid understanding of the diagnosis and workup of common tumors like meningiomas, diffuse gliomas, and pituitary adenomas. They’re usually already familiar with metastatic brain tumors like breast, lung, melanoma, and renal cell cancers from other specialties. They also need a basic understanding of pediatric brain tumors – like medulloblastomas, ATRTs, ependymomas, and pilocytic astrocytomas – as well as common cerebral tumors.
For those going into neuropathology, they need to start with the basics and build up their knowledge to include rare tumors – the so-called "zebras" – which might only appear a handful of times a year nationwide. But it’s still important to know them to make accurate diagnoses.
If you were to redesign training in neuropathology from the ground up for today’s learners, what would it look like?
I think there could be an option to offer a one-year surgical neuropathology track for those more focused on clinical practice than academics. Right now, most people who go into neuropathology are interested in academic careers. The standard fellowship is two years and very intensive, covering everything from neurodegenerative diseases to eye pathology, nerve and muscle, pediatric cases, and even forensic work.
In some countries, like Germany, Canada, and parts of Europe, neuropathology is a separate specialty and requires very in-depth training due to the field’s wide scope. That level of training is great for someone planning to work in an academic setting, but it may not suit everyone.
There’s a real need for pathologists who can do both general surgical pathology and neuropathology in a community setting. Right now, the two-year academic focus of the fellowship might discourage some from choosing the specialty.
If we could offer a more targeted training program – combining surgical and neuropathology for clinical practice – it might attract more people. And for those pursuing academic careers, we really need to build in protected time for research. In some programs, the second year allows fellows to focus more on research, but clinical demands often get in the way. Giving trainees more support and time to build an independent research path would be a big improvement.
What advice would you give to early-career anatomic pathologists interested in pursuing neuropathology?
You’ve already made a great decision by choosing pathology. Now within that field, choose something you’re truly passionate about – you’ll be doing this for decades, so it should be something you enjoy and care about deeply. If the brain interests you, go for neuropathology. It’s the organ that defines who we are, and studying it is incredibly rewarding.
The field is evolving quickly. In the next 10 years, neuropathology will look very different. We’ll see more digital pathology, AI tools, expanded molecular profiling, and possibly even non-invasive approaches like liquid biopsies or CSF sampling. These changes will make the field even more exciting.
People who go into neuropathology are usually very passionate. You rarely hear someone say they regret it. In fact, many people transfer into pathology, not away from it. That’s because choosing this path often requires deep thought and commitment – especially since it doesn’t always match the typical image of a doctor that students have early on.
For many, deciding to go into pathology or neuropathology means stepping outside the mainstream of medical careers. It can feel like a bold move, but once you make that decision, it’s freeing. You get to spend your career doing work you love. So if it feels right to you, don’t hesitate – go for it.
What do you hope your legacy will be – as a diagnostician, teacher, and leader in the field of neuropathology?
I hope people see me as someone who had a real passion for neuropathology and wanted to share that passion and strive for excellence with everyone – students, trainees, colleagues, and faculty. I also hope that impact is recognized nationally and internationally.
I’d like to be remembered as someone who contributed, even in a small way, to advancing the field – especially in surgical neuropathology and the diagnosis of diffuse gliomas in adults. I’ve been lucky to work with great teams in pushing that forward.
Teaching is also a big part of who I am. I truly care about training residents and fellows, and I wouldn’t want to be at an institution without them. I often joke that I started academic life at age four and never left – and I don’t plan to. It’s more than just work to me.
I recently watched the show Severance, where people split their work and personal lives completely. That’s not me. I’m the same person in and out of work. My identity is tied to what I do, and I hope others can see and value that.
Any expectations or hopes for the future of neuropathology, or the pathology field as a whole?
I hope people continue to recognize how clinically important pathology – and especially neuropathology – is. Too often, it's seen as a "black box" that people don’t fully understand, which leads to efforts to cut costs or treat it as separate from the rest of care.
I want there to be more awareness of what pathologists, neuropathologists, and our labs actually do every day. I often hear concerns about the rising cost of molecular testing, but when you look at the full picture – everything a patient with a brain tumor goes through, from imaging and doctor visits to surgery, radiation, and chemotherapy – the cost of molecular diagnostics is actually very small. In fact, most of those steps are leading up to one thing: getting a diagnosis. And that’s our job. So whatever it takes to get the most accurate diagnosis is worth it – because everything that follows depends on it.
We shouldn’t feel the need to apologize for the cost of doing high-quality diagnostic work. Instead, we should be proud of the value we bring and advocate for the tools we need to do our job well. The cost is modest, and the impact is huge.
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