Peer-to-Peer, with Vijay Joshi

Pediatric pathology is among the most challenging fields of pathology and laboratory medicine. Although it spans every facet of pathology from genetics to hematology, its patients exhibit very different features and very different “normal” values to those of adults – and yet, this vital discipline is often overlooked. Megha Joshi interviewed Vijay Joshi, recipient of many awards for his achievements in pediatric pathology and in teaching, to find out what inspired his interest in diseases of childhood and to learn more about his decades-long journey to draw others into the field.

What led you to a career in pediatric pathology?
I became interested in the subject through interaction with one of my mentors, Daria Haust, the “Grand Lady of Pediatric Pathology” in Canada. She recommended me for a faculty position at Montreal Children’s Hospital in 1970. Since then, I have worked as a pediatric pathologist in nine different institutions – including children’s hospitals and teaching hospitals affiliated with medical schools. After working at the Medical College of Virginia from 1972 to 1975, I went back to India to work at the Postgraduate Institute of Medical Education and Research in Chandigarh and then at G.S. Medical College in Mumbai. It was 1980 when I returned to the USA – and I have been here ever since.

I had always wanted to further the development of pediatric pathology in India. After five years’ experience in diagnostic pediatric pathology and clinicopathologic research in North America, I thought that I had gained sufficient expertise to do that effectively – but the environment in India was somewhat different. The institutions I worked in did not require a full-time pediatric pathologist, so I also had to sign out general surgical pathology cases and there were few opportunities to do clinicopathologic research on a large scale. My desire to do more pediatric pathology and academic research prompted my return to the USA – and I truly feel that I have been able to do more for pediatric pathology in India as a result.

What goals did you set for yourself?
First, I wanted to develop expertise as a diagnostician. Pediatric pathology is vast; it encompasses the study and diagnosis of diseases of all types – congenital anomalies, inborn errors of metabolism, infections, immune and autoimmune disorders, neoplasia and iatrogenic lesions – involving all organ systems in relatively divergent groups of pediatric age. Many of these disease processes are unique or more prevalent in pediatric age groups ranging from fetus to adolescent. To gain focused expertise, I chose to concentrate on specific areas and conduct clinicopathologic research driven by my own interests and the cases that landed on my desk.

Second, I wanted to expand my scope as a pathologist, which I accomplished through several means:

• I gave my work a clinical orientation by collaborating with a variety of clinical subspecialists.
• I took on the challenge of learning electron microscopy, which I used to help examine the morphologic features of certain childhood tumors and other lesions.
• Identify an underlying systematization to explain morphologic subtypes of peripheral neuroblastic tumors. 
• In teaching, which I love, I aimed to provide a personal perspective based on my experience and my work – looking for clues to etiology, pathogenesis, and natural history in the diagnostic and morphologic features of a disease process.

Third, I wanted to make the most of insufficiently characterized or misinterpreted rare lesions. For example, I saw two cases each of glomerulocystic kidney disease, cystic partially differentiated nephroblastoma (CPDN), and atypical mesoblastic nephroma. Based on detailed study of both my own cases and the literature, I wrote articles to definitively characterize these three lesions.

Last, but not least, I wanted to assist the spread and development of pediatric pathology in India. I viewed it as an attempt to “give back” to my teachers and to the underprivileged patients being treated in inadequately equipped 1950s-era public sector hospitals. I also wished to spread the word of pediatric pathology in the USA (and other countries) because, despite the establishment of the Society of Pediatric Pathology and a certification in pediatric pathology, a number of major teaching hospitals did not have a bona fide pediatric pathologist on staff and – considering that about 70 percent of pediatric hospitalizations occur at general hospitals – pathology trainees were getting insufficient guidance in pediatric pathology.

Luckily, I happened to be in the right place at the right time – not once, but four times in my career.

In the early 1970s, I worked with Mary Ellen Avery and Leo Stern – internationally recognized pioneers of neonatology – at Montreal Children’s Hospital. Mortality and autopsy rates in premature neonates were relatively high at that time, so I got to see and study, in neonatal autopsies and surgical pathology, lesions that were previously unknown or inadequately documented. Because of that opportunity, I published a classification of primary causes of perinatal mortality and a large series of neonatal cases of iatrogenic lesions. Montreal also provided opportunities for me to become an ice hockey fan by watching live Montreal Canadiens games, and for my introduction to Western classical music by attending a Montreal Symphony Orchestra concert conducted by Zubin Mehta.

In the early 1980s, when the AIDS epidemic broke out in adults, I worked with Jim Oleske, Director of the Division of Infectious Diseases at the Children’s Hospital of New Jersey. There, on the basis of morphologic studies of autopsy and biopsy material, we recognized and documented the occurrence of AIDS in children before its etiology was known. In fact, the fresh autopsy and biopsy samples of thymus and lymph nodes we sent to the National Institutes of Health (NIH) grew HIV at a later date. I went on to publish original articles on the effects of HIV in virtually every organ system in children and eventually edited monographs on the pathology of HIV infection and on common problems in pediatric pathology. I also continued working with clinicians as an active member of the Pediatric AIDS Lymphoma Network. In 1989, the NIH designed and later carried out a prospective study of pulmonary and cardiac complications of AIDS in children based on our original articles.

In 1988, I was asked to sign out all placentas (about 1,500 each year) received in the general surgical pathology section. I studied placental pathology intensely to take on this challenge and was rewarded with the chance to turn an assignment into an opportunity. A few years later, I published a Handbook of Placental Pathology which, with the co-authorship of Ona Faye-Petersen and Debra Heller, is now in its second edition.

In the early 1990s, I was appointed Chairman of the erstwhile Pediatric Oncology Group’s Neuroblastoma Pathology Committee because of my previous work on neuroblastoma. I inherited untapped archives of histology slides and clinical data on about 800 cases of peripheral neuroblastic tumors (pNTs). After intensive study of cases with adequate pathology material for a systematic review, I came up with a new, prognostically significant classification of pNTs and clarified their terminology. Later, Hiro Shimada and I put together the International Neuroblastoma Pathology Committee.

How did you promote pediatric pathology in India while working in another country?
After returning to the USA, I began to give lectures and organize workshops both within the country and abroad. I also started visiting India once or twice a year as a volunteer teacher in its medical centers. Eventually, I parlayed that experience into giving “mini-CME courses” in different regions of India so that larger numbers of pathologists could learn about pediatric pathology and serve India’s 400 million children.

Sadashivayya Jambayya Nagalotimath and I co-founded an annual international CME course in general surgical pathology and cytology, jointly sponsored by the Association of Indian Pathologists from North America (AIPNA, founded by Megha Joshi) and the Indian College of Pathologists. I made it a point to include pediatric pathology topics in that course every year from 1996 until 2007, when other AIPNA members took over.

In 1990, I collaborated with Anand Pandit, a researcher in pediatrics, and Avinash Pradhan, a pediatric pathologist in my hometown of Pune, on two research projects in neonatology and Indian childhood cirrhosis. As an extension of that collaboration, Ashok Patwardhan (the founder of Foundation for Understanding and Enhancement) and I obtained a US$1.5 million grant from the United States Agency for International Development to upgrade the Departments of Pediatrics, Pediatric Pathology, Obstetrics, and Radiology at Pune’s KEM Research Institute.

In my 25 years of academic volunteering, I became well-acquainted with pediatric pathologists from across India. Eventually, with a generous travel grant from AIPNA and the assistance of colleagues at Children’s Hospital in Pittsburgh and Los Angeles, I arranged mini-fellowships for two senior Indian pediatric pathologists, Usha Kini and Nandita Kakkar, and got funding from AIPNA to start a pediatric pathology fellowship program at St. John’s Medical Center in Bengaluru, India. Through the combined efforts of Usha Kini, Nandita Kakkar, and other pediatric pathologists from India – along with Sarangarajan Ranganathan and Anita Gupta from Children’s Hospitals of Pittsburgh and Cincinnati respectively – India’s first International CME Course in Pediatric Pathology, sponsored by AIPNA, took place in 2016. Three more have happened since; four more are planned from 2021 onward under the leadership of Sarangarajan Ranganathan, currently of Cincinnati Children’s Hospital.

My dream has come true; pediatric pathology is now a recognized subspecialty with its own courses. In 2020, the discipline even started its own organization, the Association of Pediatric Pathologists in India. The USA’s conducive conditions for international academic work were vital to this – but the dream would not have been realized without support of AIPNA and the active participation of my colleagues in both India and the USA, so I owe all of them my thanks.

You have written both pathology texts (in English) and liberal arts books (in Marathi). How did that come about?
As a young man in India, I believed that science was the reason behind the West’s ascendancy in the world. However, after spending time in North America, I realized that a liberal arts education is just as important. This initial impression was reinforced by regular study of secular ideas of Western civilization: rationalism, humanism, liberalism, critical thinking, disciplined curiosity, the spirit of giving to society, and more. I wanted to familiarize the 110 million Marathi-speaking people in India with these secular ideas, so my wife and I wrote four books on Ideas of Modernity, as well as articles in Marathi on the importance of including classical Sanskrit and Marathi literature in the high school curriculum. Royalties from these books go to the Indian charity involved in primary education there.

You were born during the Independence movement in India. Did you meet any of the leaders of that movement – particularly Mahatma Gandhi?
Although I was born in British India during its struggle for freedom, I regret never meeting the greatest leader of that time – Mahatma Gandhi. I did, however, attend one of his regular evening prayer meetings when I was 10 years old. Even at that tender age, the sanctity of the prayer meeting had a deep impact on me and, as an adult, I read his autobiography and biographies avidly. His message of peace is still relevant today. I also read Gitanjali, the Nobel Prize-winning collection of poems by Rabindranath Tagore, and carry a copy in my briefcase to this day.

Have any professional moments made a similarly deep impression?
In 1970, in the very first week of my pediatric pathology career, I remember rushing to the pediatric surgery floor of Montreal Children’s Hospital to give a diagnosis of measles because I had spotted Warthin-Finkeldey giant cells in the resected appendix of a child. The diagnosis was confirmed when we demonstrated Kolpik spots on the buccal mucosa!

I also recall a four-year-old girl in whom I diagnosed neuroblastoma. She and her parents later established the Alex’s Lemonade Stand Foundation for Childhood Cancer, which gave a grant to one of our International Neuroblastoma Pathology Committee meetings.

My final memory is of taking the wrong set of Kodachrome slides to my workshop at an American Society for Clinical Pathology annual meeting. Thankfully, such a situation could never occur in today’s digital era!

You’ve remained healthy and active well into your 80s. What’s your secret?
I’m certainly still active… I recently gave a pediatric pathology mini-CME course in Muscat for the Oman Association of Pathologists and I intend to continue teaching pediatric pathology as widely as I can in 2020 and beyond.

How? When I look through my “retrospectroscope,” I feel that regular brisk walks, optimal amounts of food, regular reading, and “meditation” by listening to Indian classical music might have helped me in that regard!

How do you achieve a balance between professional and personal life?
I must admit that, on occasion, I have not given my family the time they deserved. I am deeply grateful to my wife and our two sons for being gracious and cooperative in enabling me to pursue my career so intensely over so many years.