Training Issues for theFuture of Muscle
Pathology in the USA
Elizabeth Cochran, M.D. and Suzanne Powell, M.D.

Training in
Neuromuscular Pathology
Suzanne Powell, M.D.

Training in muscle, nerveand eye path arerequirements forneuropathology fellowship Resources“Indexes of usual and unusual cases,
course and seminar materials,
microscopic slide collections augmented
by photographs, and museum specimens
sufficient for the study of conditions anddiseases not frequently encountered inroutine necropsy and surgical specimens
should be readily available to the programfor educational purposes.”

Resources (II.D.) Fellows:(1) must demonstrate a satisfactory level ofdiagnostic competence and the ability toprovide appropriate and effective
consultation in the context of pathology
services;(2) must actively participate in the evaluationof a comprehensive body of pathologicallesions of the central nervous system,
peripheral nervous system, andneuromuscular systems

Program Requirements – Patient
Care (IV.A.5.a). (1 and 2)

(3) should have the opportunity to develop
competence in morphologic assessment ofdiseases of muscle and peripheral nerves,including morphometric analysis and teased
nerve fiber preparations, and to study neoplasms
and related lesions of peripheral nerves and thesympathetic and parasympathetic nervoussystems(4) must perform at least 200 necropsies that
include examination of the nervous system(these may include brains seen in consultation,
brains from complete autopsies, or brain onlyautopsies)

Program Requirements Patient
Care IV.A.5.a). (3 and 4)5)must examine at least 300 neurosurgical
specimens (including consultations) fromthe brain, spinal cord, pituitary gland, andeyes (including neoplastic, degenerative,infectious, and immune disorders ofsignificance in the treatment andmanagement of pediatric and adultpatients; and,6) must perform at least 50 intraoperative
neurosurgical consultations

Program Requirements IV.A.5.a.
(5 and 6)

 No specifics on muscle and/or nerve case

volumes No specifics on what constitutes“education” in these areas Vague to allow for all programs to meetthe requirements

Specifics?

 No additional specificity has been added

to the program requirements that havebeen recently posted for comment
regarding neuromuscular pathology
beyond removal of the requirement for
examination of teased nerve preparations
 Autopsy requirement is being reduced
down to 150 from 200Changes

 Variability in number of cases
 Variability in resources Variability in testing available
 Variability in participation by neurologists inthe training of neuropathologists reading
nerve and muscle biopsies Competition for these specimens withneurologists
 Joint conferences for NP and Neurology inareas where neuromuscular fellowships exist
for neurologists

Program Education Issues

Summary ofMuscle Pathology-related
Questionsfrom two AANP surveys,
Spring 2010 and Spring 2011
Elizabeth Cochran, M.D.



61% (140) do not limit practice to specific areas inneuropathology◦ 7.4% (17) limit practice to only muscle or nerveevaluations



No. of muscle & nerve biopsies range from 0 to 1250/year◦
0 to 50: 87 (38.2%)◦
51 to 250: 84 (36.8%)◦ 251 to 1250: 29 (12.8%)

69.6%(154) reported muscle & nerve biopsies are evaluatedby a neuropathologist

56.5% (125) accept muscle biopsy consults

32.1% (73) participate in muscle and/or nerve biopsy
conferences

Summary (2010 survey) Sent to NP fellowship directors
 Response: 27/35 = 77%

Survey of NP Fellowship Directors
on Training in Muscle Pathology(2011)In your department, how many muscle biopsies are evaluated byNeuropathology fellows each year?
101-250

51-1001-50

251-500

What are the responsibilities of the Neuropathology fellow in theevaluation of the muscle biopsies? Please check all that apply.
Preview slides, s/owith attending &generate report
Perform EM eval
if needed
Order & evalimmuno & molecstudies
N/A
Other, please
specifyWith whom do the Neuropathology fellows review the muscle biopsies?

Neuropathologist
Neurologist
trained inneuromusc path
BothN/AOther, please
specifyDo the Neuropathology fellows participate in research activities
in muscle pathology?

Yes

NoN/A

Do you have adequate training opportunities in muscle pathology
for Neuropathology fellows in your institution?

Yes

No

Has the training of Neuropathology fellows in muscle pathology
been impacted by Neurology colleagues at your institution?

YesNo Most comments remarked upon thepositive impact on fellow training by
Neurology colleagues:◦ Better clinical information◦ Clinico-pathological correlations◦ Educational interdisciplinary conferences◦ Frequent positive interactions between trainees& neurologists

Please explain the impact:
I think we will continue to S/O cases.
Advances in molecular/genetic testing will decrease the need forthe current morphological & histochemical studies. These will
increasingly be done at specialized academic centers.
If we are to compete with Neurologists, we have to be available forclinical consultation.
….training of NP fellows in neuromuscular pathology seems spotty,
based on my difficulty in identifying individuals with adequate
training during faculty recruitment efforts.
The role of neuropathologists in the evaluation of muscle biopsies
will likely increase…
There is still a lack of deep acknowledgement from our community
neurologists about the need and/or best practices for muscle
biopsy analysis.
Continued variations in practice patterns between institutions (assome neurologists are trained in reading biopsies).

What does the future hold?





Few training programs have the needed facilities for such complex
testing on-site. Not every institution can have state-of-art facilities& large numbers of cases.
….allowances should be made for rotations or special training atother institutions.
…ensure that histology labs in … institutions are capable ofproviding a broad range of neuromuscular histology services.
Consider rotation of fellows on a Neuromuscular clinical service
Close collaboration with neurology and neurosurgery so thatbiopsies are done correctly, & adequate clinical information &NCV/EMG results are provided. Weekly conferences withneuromuscular service.
Continued integration of & emphasis on molecular and genetic
studies so we are a resource for neurologists. More exposure offellows to interpretation of NCV, EMG, etc.
Ensure exposure of NP fellows to pediatric cases…..
Increased availability of web-based muscle pathology caseconferences, didactic courses & focused study sets with clinicopathologic correlations

How can we improve training?

Neuropathology needs to be aggressive in this area. Thereis a lot of muscle disease around and the biopsies it
generates (and will generate in the future despite moleculardiagnosis) need to be processed and interpreted properly.
NP is in the best position to do this.
 NP fellow training in muscle pathology & in fact in most of
neuropathology will have to evolve as next generation
sequencing technologies will be replacing many individual
genetic tests and eventually will replace/complement many
pathology ancillary tests. We all need to prepare for thisnew reality.
 Muscle pathology performed by Neurologists may provide
accurate diagnoses, but they may lack the infrastructure ofa path dept. in processing tissues expertly, lack training ingreater aspects of surgical pathology that regularly play arole in interpreting muscle biopsies, & represent a potential
conflict of interest when they are deciding when a muscle
biopsy should be done.
Additional Comments:

1.

Are there adequate training opportunities for NP fellows
in muscle pathology at primary sites of neuropathology
fellowship training?

2.

Are there sufficient CME/SAM opportunities in muscle
biopsy evaluation for practicing neuropathologists andother interested pathologists?

3.

How is the training of neuropathology fellows in muscle
pathology impacted by neurology colleagues?

4.

How can training in muscle pathology forneuropathology fellows be improved?

5.

What does the future hold for the role ofneuropathologists in the evaluation of muscle biopsies?

Questions for Discussion