A Vision for Pathology

What inspired you to enter (ophthalmic) pathology?

My father was a medical oncologist and my mother was a nurse, so I grew up with “medical speak” over the dinner table – it became second nature to me. After graduating from medicine in Sydney, I moved to Berlin and began a PhD in ophthalmology. I examined the immune mechanisms involved in corneal rejection, which meant performing corneal transplants in rats followed by histological and immunohistological examination of their eyes. And that’s how I rediscovered my enthusiasm for the morphological understanding of disease mechanisms.

After completing my PhD, I did a three-month elective with William Lee in Glasgow – a period during which I finally made the decision to specialize in histopathology. I then spent seven years training in general pathology with Harald Stein at the Charité Benjamin Franklin – at that time a referral center for lymphomas, head and neck surgery and ophthalmic tumors – and emerged with a number of pathology subspecialties under my belt.

You make it sound straightforward, but there were a few “bumps in the road”…

I’ve not encountered what I would consider true adversity, but I have experienced a number of challenges along the way. Learning German in my mid-twenties to a sufficient standard to work as a pathologist, write complicated medical reports, and teach students was particularly demanding. To complicate things further, human anatomy in the German medical system is still described in Latin, so I had to learn that as well!

The most dramatic (and literal) bump in the road was my pregnancy with triplets near the end of my pathology training. Unfortunately, my contract was due to end during my maternity leave, and there was a strong prevailing opinion that I was unlikely to return to work – so there was considerable doubt that I would have a job to return to at all! Luckily, I was able to organize a phased return to work. I completed my training two years after the children’s birth (despite the complication of HELLP syndrome, which put us all in intensive care for a few weeks!) and then submitted my Associate Professor thesis, becoming the first female “Privat Dozent” from the Stein lab.

What is unique about ophthalmic pathology?

As an ophthalmic pathologist concentrating on ocular oncology, I interact closely with clinical teams. Ophthalmological diagnoses are very reliant on morphology and images. The beauty of the eye – and the surrounding structures – is the ability to see many pathologies in situ in the patient, which can allow for easier interpretation of the samples. That being said, many cases are difficult because the samples are tiny! For example, intraocular biopsies of the choroid or vitreous can be very demanding; one is expected to squeeze out as much information as possible: morphology, immunophenotype, and genotype.

My favorite aspect of the work is making a difficult diagnosis in a timely manner to improve a patient’s outcome. The typical scenario would be a vitreous biopsy for suspected vitreoretinal lymphoma. These are notorious for the fragility of the tumor cells and the relatively high rate of non-diagnostic samples. By working closely with the vitreoretinal surgeons, we have been able to make recommendations with respect to how the sample is taken, transported, and processed in the lab to improve the diagnostic yield. And that is essential because vitreoretinal lymphomas are high-grade tumors where diagnostic delays must be avoided.

How are advances in fields like molecular pathology influencing your work?

My training in hematopathology has meant that I have always incorporated molecular pathology into my diagnoses. I co-founded our Hemato-Oncology Diagnostics Service (HODS) here in Liverpool, and also established the Royal Liverpool University Hospital’s molecular pathology laboratory. I no longer lead HODS or the lab, but am actively involved in national molecular pathology initiatives.

Molecular pathology is a broad and rapidly developing field; it is not essential in all cases, but is often integral for diagnostic, predictive or prognostic purposes. The new generation of pathologists must be trained in the available tests, as well as the strengths and weaknesses of the differing molecular pathology platforms and how to integrate and interpret the results. Unfortunately, parts of the UK are really behind the curve in this area. Molecular pathology is not the future; it is already here and should be widely available.

If you could change one aspect of your field, what would it be?

I was taught that the pillars in the understanding of medicine are the “three Ps”: pathology, physiology and pharmacology. If we are to make progress in the understanding of the pathogenesis, prevention and treatment of disease, we have to invest in these cornerstones of scientific medicine. Academic pathology is one of the most fragile subspecialties in medicine at present, and we have to increase awareness of its importance and create initiatives to make it attractive and prevent its complete disappearance.

If you could go back in time to give yourself some advice, what would you say?

Pick your battles. Don’t waste time on things that take you away from science. And don’t spend too much time writing long emails!