In 2005, Howard et al., in Dermatology Online Journal [12], lent credence to the concept of pigmented epithelioid melanocytoma. From the outset a contradiction bald was stated by the authors, seemingly unaware of their own failure of logic and oblivious to the need of the reader. This is the first statement: "Because [emphasis ours] of indolent course without mortality the term "pigmented epithelioid melanocytoma" has been suggested"

The sentence just quoted means that it is prognosis favorable that justifies the title "pigmented epithelioid melanocytoma." But, just a few lines later, referring to the very same lesion, a second statement, contrary to the first, appears thus: ". . . . heavily pigmented melanocytic tumors with an indolent but sometimes aggressive behavior [emphasis ours]"

Dear reader, what is a patient to intuit when informed that his lesion is "indolent but sometimes aggressive"? Should he not ask what, precisely, "aggressive behavior" is, to which Howard et al. might respond that . .." in 2004, a clinicopathological analysis of 41 cases revealed no aggressive behavior . . ."

Very good! BUT "lymph node metastases were detected in 46% of patients who underwent sentinel lymph node biopsy (and) liver metastasis occurred in a single patient . . ." If that is "no aggressive, behavior," the patient might then query, "What, exactly, qualifies as aggressive behavior?" Howard et al. then would reply: "There were no reported deaths in the series."

A person logical would understand this to mean that "aggressive behavior" denotes causing death! And therefore the initial statement that the lesion is "indolent but sometimes aggressive," would be translated as follows: "the lesion will probably not kill you, but it may!" All of this is unilluminating about what is requisite for a diagnosis of cancer, is of no use in coming to a decision about therapy, and certainly does not justify coining a new category diagnostic.

Howard et al. also wrote that "The concept of 'animal type' melanomas was not widely accepted because (emphasis ours) there were no large series of the entity and because (emphasis ours) definitive histologic criteria were not developed."

For those very same "because," twice, the term and the concept pigmented epithelioid melanocytoma must be rejected. The "large" series of 41 cases published by Zembowicz et al., as we have demonstrated earlier, describes a mixture of poorly defined lesions benign and malignant and not of a group of patients homogeneous. Moreover, nowhere can "definitive histologic criteria" be found for diagnosis with specificity of it. The only criteria, even vaguely approaching ones diagnostic to be found in this article, or anywhere to our knowledge, are cited from a "comment" of Mihm in a Consultation Report at a time when pigmented epithelioid melanocytoma was called "animal-type" melanoma by him. This is the comment of Mihm: ". . . . this rare variant of melanoma 'is identifiable by the large cells with prominent nucleoli that are consistently present throughout the lesion. The densely pigmented cells were noted to have similar nuclear characteristics allowing one to separate them from macrophages. There was no maturation as the cellular infiltrate of epithelioid and spindle cells extended to the base of the biopsy specimen.'"

With such criteria so indefinite, it is no wonder that benignancy/malignancy cannot be resolved definitively! No mention is made either of asymmetry of the lesion as it is assessed at scanning magnification or of polymorphism of nuclei as judged at high power magnification, those being two aspects crucial in determining a particular nature biologic of a certain proliferation of melanocytes.

Nevertheless, on the basis of what are asserted to be "definitive histological criteria" of the time, Patient 1 of Howard et al., a young 27 year-old man, was subjected to a re-excision in which 2 cm of normal skin was taken around a pigmented epithelioid melanocytoma located on the scalp, radical lymph node dissection of the posterior neck was performed, radiotherapy was given, and treatment with interferon was instituted, only for her to learn, through her physicians, a few years later that her lesion was "indistinguishable from a benign nevus" and that the presence of a positive lymph node biopsy did not imply character malignant.

This story would be a cruel joke on pathology as a discipline serious were it not for the consequences catastrophic for the patient.

All this notwithstanding, however, Mihm and his acolytes continue to advise "lymph node biopsy" for what they now call "pigmented epithelioid melanocytoma." Toward what end? This is their answer: "To define better the biological potential of these lesions." But once a lymph node is positive, they contend that that neither indicates metastasis of melanoma nor spread of pigmented epithelioid melanocytoma. So much for defining potential biologic of lesions! And even if the proponents of "lymph node biopsy" understood the meaning of findings histopathologic in the particular nodes harvested, their reason for recommending the procedure is fine for purposes of research, but not so fine for the patient. Fortunately, some colleagues seem to have had the good sense, as in the case of Patient 2 of Howard et al. Despite Mihm's advice of sentinel lymph node sampling, "no node sampling [should have] occurred"---and it did not.

In our view, the article by Howard et al. not only is incoherent, but also servile (the coworkers accepting uncritically each and every letter encyclical by Mihm) and an example stereotypical of failure of thought critical. On the basis of the photographs clinical and the photomicrographs presented in the article by Howard et al., it is not possible to establish in their patients a diagnosis with surety; that being so, the diagnosis we would render is "We don't know." But what we do know is that the diagnosis is not "pigmented epithelioid melanocytoma," but either metastatic melanoma or congenital nevus of the "blue" type (with lymph node "implants" in Patient 1) or melanoma in a nevus (Fig. 4). In any event, there is no justification for the overtreatment vast of Patient 1.