Neuropathology

Goals and Objectives

Level: two consecutive blocks in PGY-3 or PGY-4 and PGY-5 (elective)

In the CBD cohort, junior residents are considered to be PGY-1 and PGY-2 while senior residents are considered to be PGY-3 and PGY-4.  PGY-5 CBD residents are also considered to be senior residents within the CBD curriculum. The ultimate goal is to allow for independence in the form of independent final report creation, intraoperative consultations and supervision of junior residents and pathologist assistants.

Neuropathology rotations are designed to be undertaken by senior residents (PGY3-PGY5).

PGY-3 and/or PGY-4: The aim of the rotation in Neuropathology is to provide the resident with the knowledge, skills, and attitudes that will allow him or her to deal effectively with the nervous system component of an autopsy, and with neurosurgical specimens. The resident is expected to identify the limits of his or her diagnostic ability, and to consult appropriately.

PGY-5 year is one of senior leadership and the resident should be able to assume responsibility for organizing the service and supervising junior residents and students. The resident should have mastery of the information contained in standard texts and be prompt in using the literature to solve specific problems. The resident will be responsible for presentations at conferences and for teaching junior residents and students on a routine basis. The PGY 5 should begin to have an understanding of the role of the practitioner in an integrated health care delivery system and to be aware of the issues in health care management facing patients and physicians.

For surgical sign out in Anatomical Pathology residency training, there is no separation of cases based on complexity.  Due to the nature of Anatomical Pathology (all cases are ultimately reviewed and finalized by a supervising staff), a resident in any training level can participate/observe brain cutting, intraoperative consultations, review the glass slides and write up a preliminary report on any neuropathology case.

  • Ordering of any ancillary studies (histochemical stains, immunohistochemical stains, molecular testing) will initially be done under staff supervision for residents rotating in their first neuropathology block.  This is done in order to conserve tissue and prevent tissue waste that may limit the staff pathologist's ability to render a diagnosis. 
    • Based on the resident's experience and abilities they will eventually be permitted to order additional ancillary stains for straightforward, routine cases without consulting the staff neuropathologist.
    • Regardless of training level, any challenging case for which the resident is unsure of cell lineage or is unable to formulate a differential diagnosis that would be resolved by ancillary testing, the resident must consult the staff neuropathologist before ordering any ancillary stains.
    • Regardless of training level, any biopsy with limited tissue, the resident must consult the staff neuropathologist before ordering any ancillary stains.
    • It is expected that senior residents would be able to initiate a preliminary panel of ancillary studies for routine cases.  This is ultimately at the discretion of their supervising staff.

It is expected that the first neuropathology rotation will result in the mastery of normal histology, knowledge of the various surgical procedures encountered and the ability to diagnose common entities. 

It is also expected that the resident will review the gross report and correct any typographical errors, assess the completeness of the grossing and correctly report the specimen site, laterality and procedure in the diagnostic section of the surgical pathology report.

Subsequent neuropathology rotations will be built upon the above foundation and include the ability to formulate reasonable differential diagnoses as well as to work up challenging cases.  A senior resident in their second or third neuropathology rotation, should be able to produce a draft surgical pathology report that includes the elements listed above, along with the appropriate diagnosis, completion of a synoptic report (if indicated) and an appropriately completed microscopic description and/or comment field.  This draft report should also be free of typographical errors.

Staff pathologists are required to be present at all multidisciplinary rounds during which a resident is presenting.

There are a variety of Multidisciplinary rounds that the resident will encounter during their neuropathology rotations (see below).  The resident is responsible for reviewing the clinical history and neuropathologic reports for cases to be discussed at rounds.  Depending on level of expertise, the resident may be asked to prepare a case, under staff supervision and appropriate for their level of training.

Medical Expert

Specific Goals And Objectives

Neurovascular Examination – Postmortem Examination

  • Residents should be able to summarize the clinical history from a chart and identify the specific questions to be answered by the autopsy (EPA: F#4).
  • Residents should be able to remove the brain, spinal cord, eyes, peripheral nerves, and muscles by themselves; promptly and without causing damage (EPAs: C#6, C#7, C#8, TTP#1).
  • Residents should be able to name every grossly visible structure of the brain and spinal cord and their major vessels. They should be able to indicate the general function of the different parts of the brain (EPAs: C#6, C#7, C#8).
  • Residents must be aware of circumstances (such as a subarachnoid hemorrhage) in which special procedures are called for before fixation of the brain, and be prepared to act accordingly. They should be familiar with the risks associated with conventional infectious agents and prions, and with the procedures used to reduce this risk (EPAs: C#6, C#7, C#8).
  • Residents should be able to select and take appropriate samples for histological examination (EPAs: C#6, C#7, C#8, TTP#1).
  • Residents must be able to recognize the histological appearance of all parts of the brain or spinal cord (EPAs: C#6, C#7, C#8).
  • Residents must be able to obtain a diagnosis in all common lesions and to classify less common lesions in the appropriate group (EPAs: C#6, C#7, C#8, TTP#1).
  • Residents must be able to correlate pathological findings with clinical signs and symptoms, and to write a brief summary explaining how the autopsy results relate to the clinical history (EPAs: C#6, C#7, C#8, TTP#1).

Surgical Pathology

  • Residents must be able to handle neurosurgical specimens appropriately, including obtaining smears, frozen sections, preparing tissue for culture or flow cytometry, and fixing samples for electron microscopy (EPA: C#1).
  • Residents must be able to provide an appropriate gross and microscopic description of surgical specimens (EPAs: C#2, C#3, C#4, C#5, TTP#1).
  • Residents must be familiar with the technical principles involved in ancillary stains in neuropathology, as well as their diagnostic significance (EPAs: C#9, C#10).
  • Residents should be able to identify the use and pitfalls of the different antigenic markers utilized in immunoperoxidase and immunofluorescence procedures (EPAs: C#10, C#15, TTP#3).
  • Residents should be able to interpret the microscopic findings in light of clinical and radiological information, and to incorporate this process into a written comment (EPAs: C#4, C#5, TTP#1).
  • Residents must be able to achieve an appropriate diagnosis in all common conditions, and to recognize uncommon conditions (EPAs: C#4, C#5, TTP#1).
  • Residents should be familiar with normal and abnormal CSF cytology (EPA: C#12).
  • Residents should be able to obtain high quality photographs of gross and microscopic specimens (EPAs: C#2, C#3, C#4, C#5, TTP#1).
  • Acquire proficiency in the morphologic diagnosis, immunohistochemical work-up and staging of the spectrum of glial tumours (germ cell, surface-epithelial, sex-cord- stromal and others) (EPAs: C#4, C#5, TTP#1).
  • Acquire proficiency in the morphologic diagnosis, immunohistochemical work-up and staging of the spectrum of meningeal disease and related lesions (EPAs: C#4, C#5, TTP#1).
  • Acquire proficiency in the morphologic diagnosis, immunohistochemical work-up and staging of the spectrum of dementia (EPAs: C#4, C#5, TTP#1).
  • Acquire proficiency in the morphologic diagnosis, immunohistochemical work-up and staging of the spectrum of neuromuscular disorders (EPAs: C#4, C#5, TTP#1).
  • Acquire proficiency in the morphologic diagnosis, immunohistochemical work-up and staging of the spectrum of CNS infections (EPAs: C#4, C#5, TTP#1).
  • Acquire proficiency to prepare well-organized, comprehensive reports that convey the appropriate staging and prognostic information in common neuropathology oncology specimens (EPAs: F#2, C#4, C#5, TTP#1).
  • Acquire knowledge in the use and interpretation of immunohistochemistry pertinent to neuropathology (EPAs:  C#10, TTP#1)

Communicator/Collaborator

  • Obtain a relevant clinical history, including relevant laboratory and imaging results and interpreting this information in light of the clinical information and providing a summary to the supervising staff pathologist (EPA: TTD#2)
  • Demonstrate the ability to function at a junior staff pathologist level at various neuropathology rounds by previewing cases to be presented, appropriately choosing histology slides to present, presenting the pertinent pathological features, and responding to questions regarding the cases (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)
  • Demonstrate the ability to teach aspects of neuropathology at teaching sessions including gross rounds, neuropathology seminars and other teaching sessions. (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)
  • Gain an understanding of clinical aspects of neuropathologic disease, the management of CNS tumours, CNS infections, neuromuscular disorders and dementia (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)

Manager

  • Become aware of tissue handling, transport and storage issues in neuropathology.  Understand the importance of quality control and quality assurance measures for immunohistochemical markers used in the diagnosis of neuropathology lesions including preanalytical, analytical and postanalytical variables (EPAs: F#1, F#2, C#15, TTP#3)
  • Understand the value of proficiency testing for immunohistochemistry (EPAs: C#15, TTP#3).

Health Advocate/Professional

  • Maintain collegial relationship with peers and staff.
  • Be aware of infectious disease control in neuropathology (EPAs: C#15, TTP#3).
  • Understand the importance of turn-around time for diagnostic biopsies due to the high level of stress experienced by patients with symptomatic CNS disease (EPA: TTD#1B)
  • Understand the implication of a diagnosis of CNS tumours, neuromuscular disorders and dementias and gestational and trophoblastic disease (EPAs: C#4, C#5, TTP#1).
  • Understand the physical and emotional difficulties related to aggressive CNS tumour treatment (EPAs: C#4, C#5, TTP#1).
  • Know when to appropriately consult in neuropathology (EPAs: C#5, TTP#1)
  • Demonstrate an increasing ability to handle more of the clinical workload of the staff pathologist.  It is expected that by the second neuropathology rotation, residents are able to handle the full clinical workload of the staff pathologist each day on service (EPAs: TTP#1, TTP#5, TTP#6)

Scholar

  • Consider conducting a case report, case series or more in-depth project on neuropathology material (EPAs: C#16, C#17, TTP#4)
  • Review the pertinent recent literature regarding advances in investigative techniques in neuropathology, including the molecular pathogenesis of these CNS tumours and other CNS diseases (EPAs: C#9, C#10, C#15, C#16, TTP#4).

Instructional Tools

The resident will meet with the Neuropathology subspecialty Lead and go over this document and the overall aspects of the rotation the day before the rotation starts.

Expectations will be assigned and assessed based on the resident's level of training and performance.

Neuropathology Sign-Out (EPAs: C#4, C#5, TTP#1)

The resident is expected:

  • Attend daily sign-out with the neuropathologist on service.
  • Maintain a log of cases encountered during your rotation.
    • Include a summary of clinical and pathological case data with clinic-pathological correlation, as well as recording any questions or learning points that arose, to act as guides for further study.

In discussion with the neuropathologist on service, take responsibility for assigned cases; this will be based on the resident's level of training and performance.

Assigned tasks may include:

  • Obtaining relevant history and imaging (EPA: TTD #2)
  • Review all of the slides prior to attending sign-out and be able recognize normal histology and areas with lesional pathology (EPAs: C#4, C#5).
  • Provide a diagnosis (provisional) or a differential diagnosis of the identified lesion (EPAs: C#4, C#5, TTP#1)
  • Based on the differential diagnosis, be able to provide an ancillary testing panel to work through the proposed differential diagnosis (EPAs: C#5, C#10, TTP#1)
  • Showing cases to off-service residents and medical students (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)
  • Triaging cases (EPAs: C#4, C#5, TTP#1)
  • Writing up reports (including synoptic reporting when appropriate) (EPAs: C#4, C#5, TTP#1)
  • Obtaining intra-departmental consultations*.   (EPAs: C#5, TTP#1)                                   (* Always check with the neuropathologist on service prior to performing this task independently)

Prognostic Markers

  • Learn how to properly interpret routinely used neuropathology immunohistochemical markers (EPAs: C#4, C#5, C#10, C#15)
  • Learn indicators for molecular testing in neuropathology (EPAs: C#5, C#9)
  • Learn how to interpret molecular tests in neuropathology (EPAs: C#5, C#9, C#15)

Neuropathology Frozen Sections (EPA: C#13)

The resident is expected to:

  • Attend all neuropathology frozen sections.
  • Prior to the start of frozen sections, review the daily O.R schedules each morning, anticipate which neurosurgical cases will likely require frozen sections and obtain relevant history and imaging for those cases.
  • Observe and subsequently assist (when appropriate) the preparations of smears and frozen sections and participate in the process of formulation of intra-operative consultative diagnoses.

Grossing (EPAs: F1, C2, C3, TTP#2) and Neurovascular Examination of Postmortem Exam (EPAs: C#6, C#7, C#8, TTP#1).

  • Gross select neuropathology cases, so as to become familiar with:
    • General grossing principles as they relate to common neuropathological specimens (such as brain biopsies of neoplastic and non-neoplastic entities; resections of gliomas, meningiomas, metastases, peripheral nerve sheath tumours, vascular malformations)
  • Attend brain cutting sessions:
    • This can include hospital autopsy brains (at TOH and CHEO) and forensic autopsy brains. For TOH cases, the resident will be responsible for reviewing and documenting the clinical history, including brain/spine imaging as well as for preparing the materials for the brain cutting session in collaboration with the Pathology Assistant.

Rounds (EPAs: C#14, C#18, if presenting à TTP#1, TTP#2, TTP#5, TTP#6)

  • Attend weekly Neuropathology QA rounds (Tuesday mornings 9 am)
  • If unknown cases provided in advance of a teaching session, preview the cases.
  • Attend multidisciplinary neuro-oncology rounds at TOH and CHEO, when feasible.
    • If provided with the list of cases to be discussed, review the pathology reports for these patients ahead of time.
  • Attend conferences involving neuropathologists as opportunities arise.
    • Examples could include Muscle Biopsy rounds, select Neuroscience rounds, Neuropathology rounds for Pediatric Neurology Academic Half-Day.
  • Present select cases encountered during your rotation at academic half-day (Black Box rounds)

Evaluation

  • Mid-rotation evaluation (end of the first neuropathology block) to be completed by the neuropathology section head with input from other neuropathologists.
  • Final evaluation to be completed by the neuropathology section head following evaluations completed by all neuropathologists encountered during the rotation.
  • Expectations will be graded according to the level of training

Recommended Reading

A minimal reading list would include a neuroanatomy textbook, such as:

  • Most recent edition of Kiernan and Barr, The Human Nervous System
  • Most recent edition of Nieuwenhuys R, Voogd J, van Huijzen C: The human central nervous system, a synopsis and atlas.

A neuropathology textbook, such as:

  • Most recent edition of Gray F, Duyckaerts C, de Girolami U; Escourolle and Poirier's manual of basic neuropathology
  • Most recent edition of Ellison D and Love S: Neuropathology, A reference text of CNS pathology
  • Most recent edition of Hilton, Davi, Shivane and Aditya: Neuropathology Simplified: A Guide for Clinicians and Neuroscientists

A surgical neuropathology textbook, such as:

  • Most recent edition of  WHO Classification of Tumours of the Central Nervous System
  • Most recent edition of Burger P et al: Diagnostic pathology - Neuropathology

Updated April, 2022

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