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DISCUSSION: In this SECTION on this site, a hodge-podge of melanocytic lesions is available for evaluations. In the face of histologic images, real and virtual, the question is how were the lesions selected? There is no single histologic thread; the glue for this site has to do with the lack of concordance between the diagnoses of the responsible pathologists and the subsequent clinical courses. I came upon these lesions in the role of an “expert,” who had the temerity to assume the role of an expert. In my assumed role, I looked for clues in the patterns, clues that might exculpate the respective pathologists from a charge that his histologic interpretation and his interaction with clinicians represented a “deviation from the standard of care.” In this role of “expert,” I encountered adversarial experts who had taken on the mantle of the self-rightgeous; they promoted themselves as if they were unlikely to have made the same “error” as the respective and indicted pathologists; later some of these experts, in courtrooms, also would freely expressed contempt for my opinions, and even my abilities. All of the cases of this SECTION were gathered together as the result of claims of malpractice. Patients had experienced progressive disease. They, or their families had searched for, and found, a willing attorney. The attorney searched for, and found, a willing expert. The expert examined the histologic sections and then proclaimed to the attorney that the diagnosis of melanoma was obvious, a standard of care had been violated. I am not sure what exactly was violated in the above sequence of events; might conscience have suffered; might ego have taken precedence. I have enabled the reader to view these images, and to decide if the real images of the sections, and his virtual images would have sufficed to reveal the potential nature of these lesions; would his interpretations have satisfied the standard of care? Very few of the lesions in this collection can be characterized as “common melanoma.” The few “common” lesions are disguised by having unusual vertical dimensions (i.e., thin lesions), or by showing areas of regression; they might easily be assigned to a benign category.
If all the lesions of this SECTION are uncommon, or have mitigating features, should the requisites for the definition of standard of care be the same for these lesions as those for common melanomas? If these lesions, by their morphologic expressions, are difficult to assign, with a high degree of confidence, to either a benign or malignant category, is the expert, who denies the ambiguous nature of the histologic patterns, to be accepted as a fair and honest pathologist?
Clearly, the Spitz category has been misunderstood, and misrepresented in the literature. As an example, even the experts are at a loss to properly characterize many of the Spitz-like lesions. It would seem that we are faced with similar problems with regard to the pigmented epithelioid “melanocytoma.” The pigmented epithelioid “melanocytoma” probably is another lesion which could be accommodated in the much abused Spitz-like category; perhaps, some of the lesions that I have characterized as pigmented spindle cell variant or spindle cell, non-Spitz variant of MDM would belong, with different sets of virtual images, in the category of pigmented epithelioid “melanocytoma.” Some of the lentiginous melanomas in their vertical growth patterns resemble the so-called pigmented epithelioid melanocytoma.
A category of intermediate melanocytic neoplasia is required; the concept of MDM provided such a haven.
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