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Dermatopathology: Practical & Conceptual

July – September 2010 | Volume 16, No. 3

A letter to the editor not published in a well-known pathology journal, Dysplastic Nevus—Voices of Dissent! A response to Dr. Elder

François Milette; Hurt, Mark A.

To the Readers of <i>Dermatopathology: Practical and Conceptual:</i>

We recently sent the following letter to the editor of a well-known pathology journal in hopes of bringing attention to our profound disagreement with their publication of a recent review article titled: “Dysplastic naevi: an update” by D.E. Elder. [1]

The next section shows our letter in full.

Dysplastic nevus - Voices of Dissent! A response to Dr. Elder

Sir:

We disagree profoundly with Elder [1] on so many levels that we are compelled in this missive to point out the most fundamental flaw in his article: “dysplasia” has never been defined in any rational way [2], and it, therefore, has no practical utility. It serves only to confuse and impair understanding of any lesion melanocytic (or non-melanocytic) to which it is applied. This figures prominently in Elder’s article where “dysplastic” nevus is, alternatively, a benign melanocytic nevus defined both histologically and clinically, a “simulant” of melanoma, a precursor of melanoma, a risk marker for melanoma, an intermediate between common acquired nevi (left undefined because it is indefinable) and melanomas, etc. In short, it is anything, everything – and nothing!

Consequently, no melanocytic nevus can be “dysplastic”!

A melanocytic nevus is a benign proliferation of melanocytes; its natural history is benign, not “intermediate” between a nevus and a melanoma, whether morphologically or biologically. Of course a nevus can “look like” a melanoma and vice versa, but a “look-alike” is not an “intermediate”; it is a mimic. If a “look-alike” sooner or later behaves like a melanoma (by generating metastases and causing death) then that melanocytic proliferation is a melanoma, not a nevus. There is no “intermediate” in nature, whether morphological or biological. There are only specific things with specific natures that must be understood and defined clearly.

All of the photographs in Elder’s article are of melanocytic nevi. Figure 1 is a superficial congenital melanocytic nevus (its junctional component is detailed in Figure 2). Figure 3 is also a congenital melanocytic nevus, likely also a superficial congenital melanocytic nevus. The patterns of these lesions are so distinct, even from the photographs, that melanoma is excluded. None of these lesions is morphologically “intermediate,” a precursor of, or a risk marker for melanoma.

Of course this “update” is stuffed with molecular and genetic considerations that serve well to obnubilate the issues so as to pound the reader into submission. But, in fact, it is no “update”; it is only reiteration of senescent and meaningless articles of Faith. In our eyes, it verges on superstition!

It baffles us why Elder continues to perpetuate the myth of the “dysplastic” nevus without referring even once to a demonstration by us (together with the late Bernard Ackerman) of the irrationality of the concept. An update even minimally serious should refer to the existence of controversies centered on “dysplasia” in general and “dysplastic” nevus in particular to relate all published viewpoints of it. (3, 4) Intellectual honesty requires writers to elaborate on and readers understand that there is a different point of view about the concept of the “dysplastic nevus,” and that this difference needs to be stated repeatedly and often for all clinicians and dermatopathologists who evaluate these lesions and formulate diagnoses on them.

Mark A. Hurt, M.D.

François Milette, M.D.

Follow-up

The editor of that well-known pathology journal agreed to publish our letter only if it were edited to remove the “unscientific hyperbole” and “insult” that was “unacceptable” to the journal.

To these conditions we could not agree, and indicated so in this manner:

“Thank you for your candor. I have corresponded with my coauthor, Dr Milette, on this letter, and we are in complete agreement that the letter should be published as we wrote it – or not at all. With all due respect to you, we are not interested in your edits of our letter. We are delighted to receive comments and criticisms from Dr. Elder; we welcome them – but only if he responds to the letter as we wrote it.

Because this will not be acceptable to you, and because we respect your position as Editor . . . , we have but a single request upon the withdrawal of our letter. It is this: we request your permission to publish your letter to us along side our letter in the journal Dermatopathology: Practical and Conceptual. If you refuse this request, we will simply acknowledge the facts of what happened here, but not the actual language of your letter to us and not your name.

With respect to you from

Mark A. Hurt, M.D.

cc: François Milette, M.D.”

As the Editor did not grant us permission to publish his correspondence to us, you cannot read it here.

Comment

As final comment, there are a few words that need to be defined:

“Scientific” is defined as: conducted or systematized after the manner of science or according to results of investigation by science: practicing thoroughness or systematic methods approximating those of scientists or devised by scientists: applying expert knowledge or technical skill. [2]

In our letter of criticism, we pointed out the lack of scientific rigor about the “dysplastic” nevus because the entire concept is based on a false premise: the validity of “dysplasia.” How is our criticism unscientific? It is not.

“Insult” is defined as: to treat with insolence, indignity, or contempt by word or action: affront wantonly. [3]

Here, we grant that we intended to insult the concept of dysplastic nevus, but not the article’s author, whom neither of us knows and on whom we have no need or desire to press an ad hominem attack. Our criticism was to the thing, the “dysplastic” nevus; it was ad rem.

“Hyperbole” is defined as: extravagant exaggeration that represents something as much greater or less, better or worse, or more intense than it really is or that depicts the impossible as actual. [4]

The only hyperbole that has occurred in relation to the concept of the “dysplastic” nevus is the concept itself; the comments in our letter pale in comparison to the hype about this so-called “type” of nevus and the “syndrome” of which is it is supposedly a part. It has now been 32 years since that concept first appeared in the literature, first as the “B-K mole syndrome” [5] and later as the “dysplastic” nevus and the putative “syndrome.” [6] Tens of millions of dollars have been granted by the government to researchers to study it. We conclude, after all of this, that it is a fallacy, based on a false premise: the premise that dysplasia is a term that has a specific meaning. It does not. [7]

We challenge the readers to re-examine the literature and their souls about whether our criticisms are too harsh. We do not believe they are. We believe, rather, that they are just.