Peer-to-Peer: Ivan Damjanov Interviews Syed Ali

Syed Ali serves as Professor of Pathology and Radiology at the Johns Hopkins University School of Medicine as well as the Director of the Division of Cytopathology at The Johns Hopkins Hospital. He received his pathology residency training at North Shore University Hospital/Cornell University in New York, with fellowships in oncologic surgical pathology at Memorial Sloan-Kettering Cancer Center in New York and cytopathology at The Johns Hopkins Hospital in Baltimore.

Known globally as an innovative educator, Ali collaborates with international societies and universities to direct several annual major cytopathology tutorials  – delivering lectures, keynote speeches, and visiting professorships across the world. He is also extensively published, with over 330 peer-reviewed articles in scientific journals, over 35 books, and electronic media. In particular, his monograph on “The Bethesda System for Reporting Thyroid Cytopathology” (now in its third edition) has been translated into eight languages and is used in medical practices worldwide. 

Ali is also a fellow of both the UK’s Royal College of Pathologists and the International Academy of Cytology, with many awards to his name, including the American Society of Cytopathology’s “Warren R. Lang Award” in 1996, “Excellence in Education Award” in 2015, and “Papanicolaou Award” in 2023.

Ivan Damjanov sat down with Ali to find out what makes him tick – and how he’s upheld such an exemplary profile in pathology education.

What was your “aha” moment in becoming a pathologist and devoting yourself to cytopathology in particular?
 

I was instantly fascinated with pathology in medical school – in my opinion, it offered the best combination of patient care through early diagnosis and the opportunity to do innovative research. The idea of “detective work” through examining and evaluating cells and tissues through the lens of a microscope had me hooked. It is often said that all good pathologists have a hidden artist within them, whether it's visual art, writing, music, or something else. As an avid photographer who often posts on X (@sza_jhcyto), I was naturally attracted to pathology with its visual, artistic, and colorful nature. To my medical student mind, pathology seemed to be an intellectually stimulating career path – something I took great interest in – and once I signed up for residency, I never looked back.

As far as cytopathology is concerned, I have to give credit to my mentor, Steve Hajdu, for pushing me into this subspecialty. Even as an intern, I was drawn to the challenges and excitement of diagnosing neoplastic disease by fine needle aspiration (FNA). Steve identified this enthusiasm and always invited me to join him in FNA procedures in radiology, even when I was on alternate clinical rotations. It was just a matter of time until I realized that cytopathology was what I wanted to do for the rest of my professional life.

This passion was further cemented when I moved to the John K. Frost Cytopathology Laboratory at Johns Hopkins, which has a stellar reputation for producing eminent leaders in the field. During my time there, I worked with some of the best and thoroughly enjoyed the pivotal role that a cytopathologist plays in patient management through disease diagnosis – interacting with both the patient and other physicians. 

You spent most of your professional life at Johns Hopkins Hospital. What was the attraction?
 

This July, I will have spent 29 years at Johns Hopkins Hospital and what a pleasure it has been. Juan Rosai once said, “It all started from Johns Hopkins,” when discussing surgical pathology in his book Guiding the Surgeon’s Hand. It has been a competitive, exciting, and stimulating environment filled with wonderful colleagues, true leaders, and role models.

What’s more, as a history enthusiast, there’s no end to the joy of walking through the hallways of the hospital lined with portraits of pathology pioneers that transformed American medicine – including Welch, Osler, Halstead, Kelly, Billings, and so many more. 

How has the cytopathology field changed since you started your journey at Johns Hopkins?
 

We’ve seen a considerable influence of ancillary testing – particularly molecular markers – in cytopathology. Although cytomorphology is still the cornerstone for cytologic diagnosis, we’re witnessing an ever increasing and important impact of molecular testing performed on cytologic samples for personalized medicine and targeted therapies. This shift presents new challenges, with FNA cases becoming more intricate, and requiring more than simple morphological interpretation.

Additionally, the increased use of HPV genotyping for cervical cancer screening has led to a notable decrease in traditional GYN PAP tests. Recent years have also seen molecular classifications of various tumor types – reshaping how we approach reporting in routine cytology.

And finally, as technology continues to progress, we’ve seen an introduction of automated screening systems, some incorporating AI/CAD technology, and a gradual integration of digital pathology and AI software algorithms to enhance cytopathologic evaluation.

What are your daily responsibilities as Director of the Cytopathology Division?
 

My daily routine involves varying administrative and leadership responsibilities, clinical service, teaching, and mentorship, as well as regulatory and technical QA/QC assignments in the lab. When time permits, I also pursue my own scholarly and academic activities. Clinical diagnostic work takes up about 65 percent of my professional time.

Do you take rotations signing out routine cases or do you see only complex cases?
 

I am indeed involved with the signing-out of general cytopathology cases, including in-house medical (non-GYN) cases, PAP tests, consults, and FNAs. However, I’ll never turn away from a junior colleague who wants my opinion on difficult or complex cases, whether they are in my division or another area of surgical pathology. 

You’ve also worked in thyroid cytopathology – could you tell us more about your experience there?
 

Absolutely. Thyroid cytopathology, in my opinion, is one of the most fascinating areas of pathology. I find that thyroid FNAs are my favorite cases to look at – they’re challenging, intriguing, and especially clinically relevant in patient disease management. The Bethesda System for Reporting Thyroid Cytopathology, a book I co-edited in 2009, has reached audiences worldwide and has been translated into several languages. It’s this reach and my expertise in thyroid cytopathology that allows me to lecture on this topic across the globe – something I’m incredibly grateful for.

Could you tell us more about the lectures you’ve given during your career?
 

I’m afraid the number of lectures I have delivered thus far is quite extreme. Over the years, I’ve lectured in over 350 conferences, workshops, CME courses, and invited lectureships – comprising well over 750 individual lectures!

One of the most exciting aspects of my career in academic medicine is having the ability to forge educational relationships on a national and international level. I’m incredibly lucky to have networked with like-minded educators, pathology organizations, and universities across the world. Almost half of my invited talks have been overseas in East Asia, which remains one of my most traveled and favorite destinations for work. I often call my global outreach efforts “Cytopathology Beyond Borders”.

What paper are you most proud of?
 

I worked on an article with my colleagues in the Division of Cytopathology many years ago that addressed the concept of introducing cytopathology to our second year medical students (1). This study was based on an innovative interactive online educational tool and image atlas created with an educational grant from the dean of our school of medicine. You can find it online if you’re interested in learning more.

In November 2023, you received the Papanicolaou Award – the highest award given yearly by the American Society of Cytopathology (ASC). What does receiving this award mean to you?
 

The ASC’s Papanicolaou Award was established in 1958 and is essentially the “Oscar” equivalent in our field. Receiving this award was truly a moment of epiphany. The Papanicolaou Award overshadows every other award that I’ve been lucky enough to receive over the years. It's a particularly significant and momentous life event to see my name in the company of my great mentors and previous awardees – Steve Hajdu, Patricia Saigo, Yener Erozan, and Dorothy Rosenthal – who taught me all I know in cytopathology and took me under their wings during my training years and beyond. I’m most humble and appreciative of how lucky I’ve been that my life was touched by the absolute best in the field.

What words of advice do you have for our junior colleagues considering cytopathology as a career?
 

I would most strongly recommend cytopathology to the next generation!

Despite current workforce challenges, cytopathology has a very bright future. Cytopathologists are well acknowledged as versatile generalists who handle diverse clinical specimens from various anatomical sites. We adapt to new tests and technologies while emphasizing efficiency and minimal invasiveness. Cytologic samples – both liquid and FNA tissue – are ideal for molecular testing and enhancing diagnostic accuracy. We’re seeing exponential growth in oncologist requests for these tests in diagnostic, predictive, prognostic, and therapeutic purposes, which fuels the field's growth.

I must emphasize to my junior colleagues that cytopathology is crucial for early disease detection, accurate and timely diagnosis, personalized treatment and planning, and monitoring treatment response. We play a vital role in improving patient outcomes, reducing morbidity and mortality, and advancing medical knowledge. I hope my enthusiasm for the work we do highlights cytopathology in the most positive light.

^{Image Credits: Supplied by Interviewee}