Neuropathology in Low- and Middle-Income Countries: A Narrative Review of Capacity, Barriers, and Pathways Forward

Neuropathology underpins accurate diagnosis, prognostication, and treatment selection in neuro-oncology, particularly following the adoption of integrated histomolecular classification in the 2021 WHO classification of CNS tumors. However, the implementation of contemporary neuropathology standards remains highly uneven across low- and middle-income countries (LMICs). This review aims to characterize the current landscape of neuropathology services in LMICs, identify key barriers to diagnostic equity, and summarize scalable strategies to strengthen capacity. This narrative review synthesizes the published literature on neuropathology workforce capacity, laboratory infrastructure, immunohistochemical and molecular diagnostic availability, and educational and collaborative initiatives across LMICs. Evidence was integrated from multiple geographic regions, including Africa, South Asia, Latin America, and the Middle East, with emphasis on CNS tumor diagnostics in the context of the WHO 2021 classification. Marked disparities were identified in neuropathology service availability across LMICs, driven by severe shortages of trained neuropathologists, limited laboratory infrastructure, restricted access to immunohistochemistry panels, and minimal availability of molecular diagnostics. As a result, many CNS tumors cannot be fully classified according to current WHO standards, leading to diagnostic uncertainty and limited access to risk-adapted therapies. Emerging solutions include institutional twinning programs, telepathology and digital pathology platforms, regional centers of excellence, and tiered diagnostic frameworks that adapt molecular testing to resource availability. Neuropathology capacity in LMICs remains insufficient to meet the growing demands of modern neuro-oncology. Coordinated investment in workforce development, infrastructure, digital solutions, and resource-stratified diagnostic strategies is essential to reduce diagnostic disparities and enable equitable access to precision cancer care globally.