De novo intraepidermal epithelioid melanocytic dysplasia, a unique observation in a complex...
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J Cutan Pathol 2009: 36: 1029 Copyright © 2009 John Wiley & Sons A/S John Wiley & Sons. Printed in Singapore Journal of Cutaneous Pathology Letter to the Editor De novo intraepidermal epithelioid melanocytic dysplasia, a unique observation in a complex discipline To the Editor, In reading Dr. Milette’s ‘Letter to the Editor’ with regard to the concept of ’de novo intraepidermal epithe- lioid melanocytic dysplasia’ (DNIEMD) (Milette F. De novo intraepidermal epithelioid melanocytic dys- plasia? J Cutan Pathol 2008; 35: 1148), it becomes clear that Dr. Milette’s concern relates to a matter that is more fundamental than the concept in ques- tion; specifically, the issue of terminology that seeks to communicate diagnostic uncertainty, and perhaps the concept of diagnostic uncertainty itself. Dr. Milette calls for an abandonment of phrases such as ‘atypical,’ ‘dysplastic,’ and ‘unknown significance.’ It is appro- priate to criticize the practice of introducing terms to the diagnostic lexicon for matters academic insofar as they fail to contribute to our understanding of a given biologic process. However, to dismiss the con- cept of biologically indeterminate or morphologically equivocal lesions is frankly na ¨ ıve. Does Dr. Milette truly believe that a ‘black and white’ approach is justified given our current level of understanding of this complex field of investigation? Specifically with regard to the concept of DNIEMD, I believe that it merits due consideration for the following reasons. Firstly, I have encountered this lesion many times in my own practice and, as such, I find it to be quite reproducible. A pattern consisting of atypical epithelioid melanocytes within the epidermis that demonstrate a haphazard pattern of upward scatter in the absence of nesting, lentig- inous growth, or confluence set within a preserved epidermal architecture is indeed a unique histologic profile. Many, if not most, of the instances in which I have encountered this lesion have been those in which the patient has harbored the atypical mole phe- notype/dysplastic nevus syndrome and/or has had a personal/family history of malignant melanoma. Second, to report this process complete with its clin- ical significance and relatively unique histologic fea- tures is appropriate in that it raises the awareness of a histologic pattern that carries with it a definable clini- cal association. Naturally, as is the case with histomor- phology as a whole, there is some degree of ‘threshold variability,’ so to speak, with regard to these features, particularly in those cases in which they occur along- side a dysplastic nevus. Even in these cases, it is identifiable as the cytomorphology and architecture appear distinct from those of the adjacent features of dysplastic nevus. I personally do not find the his- tologic profile of this lesion to be as nebulous and ‘arbitrary’ as Dr. Milette seems to imply. The indis- criminate classification of a lesion with this histologic profile as melanoma in situ is, in my opinion, a consid- erable overinterpretation of the features. Further, this prospect would do a disservice to patients, who would have to suffer the unnecessary stigma of malignant melanoma. Rather, identifying the lesion as atypi- cal with subsequent excision would spare the patient the unnecessary insurance implications that are asso- ciated with malignant melanoma, while receiving appropriate therapeutic intervention in the process. I will summarize by stating that the use of terms such as ‘atypical’ and ‘unknown significance,’ and the introduction of designations such as DNIEMD are not so much a proclamation of a lesion’s biologic nature as they are an admission of diagnostic uncertainty. Dr. Milette concludes by stating ‘It is long past due that acronyms of unknown significance that result in ignorance significantly be abandoned and the mentality that spawns them be forsaken.’ I would contend that such acronyms are, in fact, a direct result of our ignorance and that the mentality that spawns them represents a robust attempt at navigating what is at its core an intricate and abstruse discipline. Kapil Gupta, MD Dermatopathologist, Dermatology Group of the Carolinas, Concord, North Carolina, USA e-mail: [email protected] 1029
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Transcript of De novo intraepidermal epithelioid melanocytic dysplasia, a unique observation in a complex...
J Cutan Pathol 2009: 36: 1029 Copyright © 2009 John Wiley & Sons A/S
John Wiley & Sons. Printed in SingaporeJournal of
Cutaneous Pathology
Letter to the Editor
De novo intraepidermal epithelioidmelanocytic dysplasia, a uniqueobservation in a complex disciplineTo the Editor,
In reading Dr. Milette’s ‘Letter to the Editor’ withregard to the concept of ’de novo intraepidermal epithe-lioid melanocytic dysplasia’ (DNIEMD) (Milette F.De novo intraepidermal epithelioid melanocytic dys-plasia? J Cutan Pathol 2008; 35: 1148), it becomesclear that Dr. Milette’s concern relates to a matterthat is more fundamental than the concept in ques-tion; specifically, the issue of terminology that seeks tocommunicate diagnostic uncertainty, and perhaps theconcept of diagnostic uncertainty itself. Dr. Milettecalls for an abandonment of phrases such as ‘atypical,’‘dysplastic,’ and ‘unknown significance.’ It is appro-priate to criticize the practice of introducing terms tothe diagnostic lexicon for matters academic insofaras they fail to contribute to our understanding of agiven biologic process. However, to dismiss the con-cept of biologically indeterminate or morphologicallyequivocal lesions is frankly naı̈ve. Does Dr. Milettetruly believe that a ‘black and white’ approach isjustified given our current level of understanding ofthis complex field of investigation?
Specifically with regard to the concept ofDNIEMD, I believe that it merits due considerationfor the following reasons. Firstly, I have encounteredthis lesion many times in my own practice and, assuch, I find it to be quite reproducible. A patternconsisting of atypical epithelioid melanocytes withinthe epidermis that demonstrate a haphazard patternof upward scatter in the absence of nesting, lentig-inous growth, or confluence set within a preservedepidermal architecture is indeed a unique histologicprofile. Many, if not most, of the instances in whichI have encountered this lesion have been those inwhich the patient has harbored the atypical mole phe-notype/dysplastic nevus syndrome and/or has hada personal/family history of malignant melanoma.Second, to report this process complete with its clin-ical significance and relatively unique histologic fea-tures is appropriate in that it raises the awareness of a
histologic pattern that carries with it a definable clini-cal association. Naturally, as is the case with histomor-phology as a whole, there is some degree of ‘thresholdvariability,’ so to speak, with regard to these features,particularly in those cases in which they occur along-side a dysplastic nevus. Even in these cases, it isidentifiable as the cytomorphology and architectureappear distinct from those of the adjacent featuresof dysplastic nevus. I personally do not find the his-tologic profile of this lesion to be as nebulous and‘arbitrary’ as Dr. Milette seems to imply. The indis-criminate classification of a lesion with this histologicprofile as melanoma in situ is, in my opinion, a consid-erable overinterpretation of the features. Further, thisprospect would do a disservice to patients, who wouldhave to suffer the unnecessary stigma of malignantmelanoma. Rather, identifying the lesion as atypi-cal with subsequent excision would spare the patientthe unnecessary insurance implications that are asso-ciated with malignant melanoma, while receivingappropriate therapeutic intervention in the process.
I will summarize by stating that the use of termssuch as ‘atypical’ and ‘unknown significance,’ andthe introduction of designations such as DNIEMDare not so much a proclamation of a lesion’sbiologic nature as they are an admission of diagnosticuncertainty. Dr. Milette concludes by stating ‘It is longpast due that acronyms of unknown significance thatresult in ignorance significantly be abandoned andthe mentality that spawns them be forsaken.’ I wouldcontend that such acronyms are, in fact, a direct resultof our ignorance and that the mentality that spawnsthem represents a robust attempt at navigating whatis at its core an intricate and abstruse discipline.
Kapil Gupta, MDDermatopathologist,
Dermatology Group of the Carolinas,Concord, North Carolina, USA
e-mail: [email protected]
1029
