THE REED PATCH
(A NEGLECTED GARDEN)
by Richard J. Reed, M.D.; New Orleans
Table of Headings
WHITHER IN THE GARDEN (PART 1)
REAL AND VIRTUAL IMAGES
SPONTANEOUS AND IMPOSED IMAGES
IMAGES AND THEIR MODIFIERS
THE ROLE OF NUMMERATIONS
THE STUFF OF PATHOLOGY
AN ILLUSORY BOUNDARY
THE IMPOSITION OF PARCELS
MINIMAL DEVIATION IN EITHER SIZE, or CYTOLOGY and PATTERNS
Pathologists’ thoughts are pathological. This observation is open to various interpretations, some complimentary, some not. I have known some fairly pathological pathologists; those who choose the specialty may be inherently pathological. For one to find the other, stars must be properly aligned. When I was a young man, the mystique of disease made the specialty of pathology attractive. That mystique seems to have been dispelled, but this may only be the perspective of an old man. Perspectives on the nature of images, and the influence of politics and society on perspectives and on how images are managed, are basic to the nature of this site.
Politicians are ambitious; their thoughts are societal. I mean no compliment in this characterization. I have hardly known a politician. How can you know them? Those with the bent are inherently covert. A combination of politics, greed, and the "needs" of society have impacted on the practice of medicine. Most of the insults have been first leveled at pathologists and their endeavors.
Taxonomy, as an end in pathology, has given way to societal concerns; biologic import is the required information. At one time, diseases outnumbered designations. Now, with many of the applicable designations having been molded to accommodate the empiricism of oncology, there are more designations than diseases.
Oncology and pathology are intertwined. The new empiricism (currently, there are few findings so pressing as to require an autopsy) of oncology is legitimatized by the old empiricism of pathology (pathologists are comfortable with low autopsy rates). The empiricism of oncology is guilt-ridden. Each new recruit to an oncological regimen is viewed as someone else’s failure; fault-finding and finger-pointing make the rigors of chemotherapy, radiation, etc., easier to bear.
In part, the maelstrom of modern pathology is an outgrowth of the economic pressures of the 60's. Clinical pathology was at one time the preserve of practicing pathologists; the financial rewards of the practice of clinical pathology far overshadowed those of anatomic pathology. The practice of anatomic pathology was almost a hobby. Clinical pathology provided the political strength of hospital-based pathologists; contracts were negotiated on the basis of the revenue generated by the clinical laboratory. Pathologists, adept in the workings of the clinical laboratory, had to be good politicians, if they were to successfully interact with administrators. They came to think of themselves as leaders. In the latter role, they also seemed to have the time to function as politicians in our major societies. From my experience, they thought themselves exceptional politicians, above the common herd, but they were functioning in a protected forum. Their abilities were tested as soon as they began to interact with other specialties. Just how good they were as politicians can be measured by the relative give and take of the decision by Boards of Pathology and Dermatology in the mid ‘70's to conjointly examine for competency in dermatopathology; from my perspective of the results of the decision to jointly conduct examinations, this pathological few would appear to be politicians in name only. In fact, in the respective negotiations, they were snookered. Although these "representatives" (they were not democratically elected officials of any society) in spirit were clinical pathologists, in their role as politicians, they presumably should also have been representing anatomic pathologists. Despite the latter responsibility, they were more than willing to compromise on a number of issues, all affecting anatomic pathology. They did so in a manner that would have been unacceptable to them, if the prize had been some portion of clinical pathology. At least one of these same politicians, boldly encouraging others to resist the incursions of the business world into the practice of pathology, was among the first to yield the control of his laboratory to big business for monetary gain.
At the time of the agreement to hold a joint examination, anatomic pathology in its various guises was quite simply less precious to the politically powerful (i.e., laboratory directors) with the exception of the pathological few who had truly answered a call. Unfortunately those truly dedicated to anatomic pathology generally were not of a political bent.
The forces, ambitions, and relationships were such that parts of anatomic pathology were considered to be dispensable; pathologists who favored clinical pathology found themselves in a position to dispense. They found one powerful anatomic pathologist with a vested interest in the joint examination; they nominated him as the sole representative of the body politic of anatomic pathology. With his encouragement, they then concluded that a portion of anatomic pathology could be dispensed to another discipline with little threat of financial compromise. They did so with little hesitation and with no input from, and very little interaction with, the body politic. The favors received, in return for surrendering dermatopathology, have yet to be revealed. I would think embarrassment would have by this time prompted one of the former Board members to disclose the nature of a barter. If nothing was received in return, the political shortcomings are overwhelming. In the absence of knowledge regarding an exchange, there is no way to measure the potential of the pathological politicians’ share of what appears to me to have been a bad deal.
The discipline of pathology has changed (as has life). However modified by the decision of the respective Boards to examine conjointly for competence in dermatopathology, the decision was merely symptomatic of the economic vectors of the time. It was symptomatic of a pathologically changing economy. Apparently few of the politicians, who lost, or purloined, a part of anatomic pathology, accurately appreciated the extent to which the practice of medicine would be altered. The attitude at the time of the decision was: "Why bother with dermatopathology?" At the time, it was not a big source of income for a hospital laboratory but did supplement the income of dermatologists who had been told by their Board that, with two years of training in dermatology, they were competent to read histologic sections of lesions removed by them from their patients.
The decision to sponsor a joint examination for competency in dermatopathology was followed by significant events, all more indicative of a changing social and political milieu than of an adverse effect of an influx of non-pathological dermatologists into a pathological population. On the other hand, a compromise in the quality of training in pathology had been accepted; a discipline had been polluted. From my perspective, something of importance was lost in the deal.
Perspectives will be important in the presentations on this site. The designation of this site as a garden in which new growths can be freely moved about, trimmed, manipulated, and categorized is based on perspectives. In these endeavors, perspectives are required, if we are to distinguish between weeds and flowers. On this site, perspectives carry with them a healthy respect for the basic discipline of anatomic pathology without concerns for the reaping of financial rewards from having shared this garden.
As a chief perspective, histopathology, particularly the dermal branch, has integrity. The lack of respect sometimes demonstrated in the actions of its "representatives" reflects on the representatives, not the discipline. In the late 50's in the face of competition from an evolving specialty of electron microscopy, it was microscopic morphology which persevered; electron microscopy is ancillary. In the late 50's and early 60's, challenged by histochemistry, microscopic morphology remained the mainstay. Biochemistry was, and is, no challenge to pathology. Pathology has been greatly altered by the proliferation and availability of immunohistochemical reactions. In spite of all the technology, the morphologic approach of common, old histopathology has not been displaced; attempts to supplant the common morphologic approach by batteries of immunohistochemical reactions have proved to be an expensive failure. The old specialty with the old techniques remains basic; anatomic pathology is a human endeavor mediated cerebrally; it is a “cerebralness” rather than a technicalness; the laboratory, with only the exception of pathologists’ accommodations for oncology’s obligations to society, is subsidiary. In the socialization of medicine, sameness in the nature of histologic interpretations can only be justified as an accommodation for the empiricism of oncology. Sameness is sometimes disguised as "evidence-based medicine." If ever there was an oxymoron, here it is. Hidden in it is managed medicine’s search for sameness (and ordinariness).
This site is dedicated to the old techniques. Any shortcomings are those of an old pathologist rather than those of a respected discipline. Herein, an understanding of, rather than accommodations for, disease will be the focus. The search for understanding will be our garden, and, like "Mary," how it grows will reflect on the abilities of the gardener ("Mary, Mary, how contrary. How does your garden grow - Silver bells, and cockleshells, and one g-- d--- petunia"). Why a petunia and how did it get there is our premise? In this garden, the growths will be images, some real, some virtual, and some of human sorts known as thought, perspective, intuition, and even concern.
WHITHER IN THE GARDEN (PART 1)
REAL AND VIRTUAL IMAGES
(THEIR RELATIONSHIPS TO PERSPECTIVES)
Pathology is a discipline. In a sequence, firstly static images are observed. Then, in turn, static images of dead tissue are translated into vital interpretations. In practice, images captured through the oculars of a microscope, not the tools for the projections of the images, are the materials of pathologists. They are fairly predictable and repeatable, if, on all occasions, the same observer views the histologic sections. Images embodied in histologic sections are real images. Those projected through the optics of the eye onto the retina are spoken of as virtual images - more precisely, they qualify as retinal virtual images. The images at the level of the retina, although spoken of being virtual, have a physicality that is embodied in the phenomena of light. The points of the histologic section have a one to one correspondence with the points that comprise a virtual image of the histologic section on the retina. Eventually, after repeated observations of the same section, an observer, with only the briefest attention to the real images, can turn away from the microscope to cite the details; he has acquired a store of post-retinal virtual images that are independent of those of the actual section; the store of images includes primalities, which make easy what otherwise might be a difficult task, as well as extraneities, which may lead a pathologist astray. The post-retinal virtual images are less physical than the images of either a histologic section, or the optically projected virtual images on the surface of the retina; words are required for a pathologist to roughly convey to another the nature of post-retinal images. For another, who has not actually viewed the real images, post-retinal virtual images exist only in approximate words of a pathologist, whether written or spoken.
Repeat the experience with a new observer for each viewing of the sections. If the problems relative to the nature of the common sections are complex, it is likely that the several new observers, each viewing the sections in a sequence with all the others, will not agree (after the viewing session has closed) as to the patterns, or the significance of the images. They will use different words. Some will "see" more (more complex virtual images) and some less; some will "see" what others do not. Many will have difficulty in finding words to give his images to another. On the other hand, some observers, on their initial examination of the sections and with only the briefest attention to the patterns (real images), will be able to supply details (mobilized, in-transit virtual images) and discuss the nature of the process without a need to return to the microscope for detailed examinations of the real images; they will have seen other similar patterns, or will have encountered them in the literature, and will have the means and the words to give the images and their significance to another. They will have access to a store of relevant central, or stored, virtual images; they will have retained virtual images from the examination of other lesions, and will have structured and stored them in parcels.
Access to the parcels of stored virtual images, and the ability to select relevant virtual images from the parcels will impact on the observers’ responses to certain new histologic sections. The images mobilized from the central store of parcels (first as in-transit virtual images, and then as structured and imposed virtual images) will influence not only the manner in which the new real images are described but also the observers’ interpretation of the nature of the new real images; something will have been added to the post-retinal (central) virtual images; individuality will have been introduced. Point to point correspondence of real and virtual images is established only as long as an observer maintains an image of a histologic section on his retina. If the observer walks away, what he retains of his observations has no point to point correspondence with the real images of the original section. Beyond the retina, on the tract leading away from the image of the actual section, and extending to the occipital lobes of the brain, the individuality of the observer is introduced; the post-retinal images of each individual observer are unique.
In all this, the experienced observer will have, along the way, captured the tools to put his images into words. The tools to manage the words distinguish a pathologist. The vocabularies of dermatology and dermatopathology - even if the words of the two seem mostly the same - are unique for each discipline; the similar words are distinguished by their context. The distinguishing context of those with a pathological bent has been imparted by a pathological few. As much as any quality, vocabularies distinguish clinicians (especially dermatologists) from pathologists, even pathologists with expertise in diseases of the skin. Dermatological dermato- pathologists, who do not recognize the differences, have not truly made the transition.
Post-retinal virtual images have a fluid quality; they may swish here and there, and may even spill over into other parcels of stored virtual images. The parcels may then become heterogeneous. Only a portion of the in-transit virtual images from central parcels will actually have had their origin in the observation of real images of a specific histologic section of a representative disorder. Point to point correspondence as a guide to interpretations can become a moot relationship. An experienced observer may impose as much as, or even more than, he "sees." Intransit virtual images, having been imposed on real images, become intensions (attributes embodied in words).
SPONTANEOUS AND IMPOSED IMAGES
Pathologists can take from their parcels of stored images what they know about one organ system and utilize some of the respective, mobilized (in-transit) virtual images for the interpretation of new real images of an unrelated disease in a different organ system. The ability to mobilize, and apply (impose), relevant virtual images to new encounters must be distinguished from the random imposition of irrelevant virtual images; the distinctions between the two may not be evident to an observer at the time of the impositions. In the act of histologic interpretations, false virtual images can be imposed in the absence of a conscious acknowledgment of the intrusion; in the accident of such an imposition, the relativity of imposed virtual images, in and of itself, then becomes relative.
IMAGES AND THEIR MODIFIERS
Immediacy characterizes the in-transit virtual images evoked spontaneously during the observation of a histologic section. In structuring an interpretation (here, we are in the garden), the mixture of real and virtual images, all relevant to histologic sections of a single lesion, might be characterized as compost. How we then spread the compost forms the basis, and constitutes the nature, of histologic interpretations. Intuition (insight) has a role in histologic interpretations; in importance, it may even supplant intellect, if a pathologist is sensitive to its impulse. Such a quality is akin to the naturalness expressed in the adage that it is smart not to shovel manure into the wind (a guideline often emphasized by the late Herb Lund).
Stored central virtual images are not confined to their respective compartments. In swishing about in fluid-like fashion, some of the images may spill over and contaminate neighboring parcels. The mental state of an observer impacts greatly upon the selection of parcels of virtual images; they impact not only on the integrity of the selected parcels but also on the purposefulness of the respective histologic interpretation. In the act of making an histologic interpretation, what on an initial review might seem to be an appropriate diagnosis, may, on later evaluations with retrospection, be recognized as most inappropriate. Emotions and fatigue are among the factors which make waves; they often influence the purity of the parcels, and can even affect the selection of an appropriate parcel. Intruders (extraneities) don’t belong in the contaminated parcels but, to an pressured observer, their subtle foreignness may be unobtrusive; such an observer might unwittingly accept them as if they were primalities. Such intruders in our central stores, once recognized for what they are, and then categorized as extraneities, can be swished back to appropriate parcels.
THE ROLE OF NUMMERATIONS
The distinctions between primality and extraneity, attributes seemingly as distinct as the differences between flowers and weeds, are often a matter of perspective. Individuality and perspectives are obstacles which must be managed in attempting to make pathology an exercise in numerations (and surely the aesthetics of flowers would contradict an effort to simply identify the variants by the assignment of numbers). The current immersion of histopathology in a pile of immunoreactions is nothing more than an exercise in numerations. An exercise in assigning 0 or 1, or + or - is hardly the stuff of pathology; it is the business of the clinical laboratory and statisticians.
THE STUFF OF PATHOLOGY
Real images, and projected "virtual" image of the retina, are the stuff of microscopy. Post-retinal (central) virtual images and in-transit virtual images, of the type described, and evoked in response to new real images, are the stuff of pathology (and of controversies).
Controversies in pathology are mostly contrived. They, in part, relate to individual variations in the structuring of post-retinal virtual images. It is possible to train groups of observers in the structuring of post-retinal virtual images (and has been accomplished). To stifle individuality in this manner reflects on the nature of the susceptible population. The susceptible acolytes are not pathologically bent; they have not been called to the specialty. If a large enough audience has been biasedly trained, then the trainees in such a group can be provoked into confrontations with other groups of a different background and with other parcels of virtual images.
During histologic examinations, real images are likely to become incidental to the manipulation of virtual images. A perspective, as the focus of the training of a biased observer, can be mistakenly equated with a exposition of the nature of disease when, in fact, such a trained response is merely a man-made relativity among a host of relativities, most of which are native. Post-retinal virtual images, in their profusion and confoundedness, can be distorted into abessentials. In the face of a host of relativities, all being nothing more than a measure of the inexactness of the human response to real images, it is expedient to carefully examine the patterns of neoplastic systems, to document the histologic findings, and to then structure parcels of virtual images which are congruent with the recorded histologic findings.
Post-retinal virtual images clearly are more complex than the virtual images of the retina. They embody intellectual as well as emotional and intuitive contributions. Their nature and complexity are reflections of the basic nature of each observer. Each observer has the responsibility of weeding his own patches; in the process, individuality is imprinted on interpretations. It is dumbness to relinquish individuality to charisma.
Individually, pathologists’ stores of parcels of virtual images, all related to the interpretation of histologic sections, might be characterized as patches; they are relatively neglected gardens, most often carelessly tended. For the manipulation of virtual images, neoplastic cells might be characterized as seeds, and stroma and retinaculum as soil. In this approach, not only the soil but also the nature of the seeds (those that in the course of events will be sown into the soil) become the stuff of pathology.
A sowing of seeds bespeaks of the movement of cells without significant change in their nature, and with only minimal change in the relationships between seeds and soils, other than the movement of one to the domain of the other. "Taking root" introduces new phenomena in which the seeds and the soil interact in a symbiotic manner.
Congruence between certain phenomena of the soil, such as either the density and acidophilia of the fibrous mat which is inlaid in accretive patterns in the domain of the papillary dermis, or the intensity of the lymphoid infiltrates and the degree of cytologic atypia ("hybridness") is such that, for the melanocytic system, there would seem to be utility in the structuring of post-retinal virtual images in a manner to relate the mild dysplasias and the marked dysplasias in a sequence, not only to each other, but also to melanoma. Certainly, this is not the only approach; it is possible to structure virtual images so as to supplant, or by-pass, an entire sequence of neoplastic progressions - a sequence which, in the stores of others, would be a cornerstone in the structuring of steps of neoplasia..
AN ILLUSORY BOUNDARY
In the melanocytic neoplastic system, the definition of a boundary beyond which it become possible to speak of a neoplasm as a melanoma is a basic problem; the definition is not simply the act of defining anatomic boundaries and then identifying a neoplastic cell or cluster of cells beyond a proscribed boundary. Boundaries, and other problems, were addressed in the contribution on desmoplastic melanoma (see (Fig. 1). Prospectively (i.e., prior to the documentation of a metastasis), a universal, conceptual boundary between melanoma and precursor (dysplasia) will always remain indefinite. The only definable, universal boundary is not a dimensionality which would have application for all examples of progressive melanocytic neoplasia; it is a phenomenality which is unique for each example of a particular neoplasm. It can be established as a fact only after the fact. The phenomena which define melanoma have relevance to age of neoplasia, and age of neoplasia is roughly correlated with size of the neoplasm. The one histologic pattern which most closely relates to a competence for metastasis is that of vertical growth - specifically typical vertical growth. Even in typical vertical growth components, the relativity of size and prognosis compromises the utility of the designation, melanoma, if the latter is to be considered appropriate for lesions in the most limited portion of the spectrum of sizes (see Fig.1 & Fig. 2).
Some patterns of melanocytic neoplasia are so common, so documented, and of such bulk that, in their presence, there is little controversy in regard to the appropriateness of the designation, "melanoma." These common examples include superficial spreading melanoma, lentigo maligna melanoma, acral lentiginous melanoma, and "nodular" melanoma. These variants are readily accepted, if only examples in the size range greater than 1.5 mm in vertical dimensions are considered. The documentation of these variants is extensive and, in turn, their acceptance is widespread. For the most part, nay-sayers, who would question the legitimacy of even the common melanomas, constitute members of a group, who, quite simply, by the very nature of their training form an opposition; they have been trained to confront the notions of others.
The significance of bulk as a measure of the appropriateness of the designation, "melanoma," extends beyond the contentiousness of those trained to contend. With the simple recognition of bulk as a measure of malignancy, degrees of malignant potential can then be utilized to study the appropriateness of a variety of treatment regimens. Until recently, injurious and rigorous forms of treatment were options only for patients whose lesions were beyond a certain range in size; bulk was a measure of the likelihood for metastasis and, in turn, a determinant, justifying the use of certain forms of treatment. On the other hand, such restrictions at an oncologic level were not translated into a restructuring of the criteria (i.e., parcels of virtual images) for the diagnosis of melanoma. Recently, at the oncologic level, there has been an extension of the use of adjuvant treatment to include lesions at little risk for metastasis (i.e., lesions for which the risk is less than 10%). The oncologic restructuring is for the most part a willingness on the part of oncologists to coerce patients, at little risk for metastatic disease, into treatment regimens using the premise that the treatment regimen will ferret out and even eliminate the most occult deposits. In part, this aggressiveness is based upon technological advances in which the "smell" of tumor (DNA) is the equivalent of having discovered demonstrable deposits of tumor cells (presumably, and always presumably for thin lesions, tumor cells, if they were to be left undisturbed, would compromise the future of the affected patient).
THE IMPOSITION OF PARCELS
(MINIMAL DEVIATION IN EITHER SIZE, or CYTOLOGY and PATTERNS)
One available parcel of central virtual images, if mobilized and then imposed, is both selective and restrictive. In it, images, the congruence of which all pointing to stages of neoplastic progressions, can, by fiat, be negated with the exception of those images in which neoplastic cells migrate upward into the epidermis. For followers who have endorsed this negation (and, for a problem lesion, have identified the relevant real images), the related neoplasm is a melanoma without regard for the relativity of bulk to prognosis, a multitude of histologic variations in patterns, variations in degrees of cytologic atypia, or the opinions of others that another boundary might be more appropriate.
Parcels of central virtual images, other than those of the above negation, in which attention is given to patterns in the dermis, are a requisite for the characterization of typical vertical growth (at least level III invasion). With the proposition, that the combination of typical vertical growth and cytologic atypia, particularly if manifested in a lesion also showing a remnant of one of the "nevi," defines the basic features identifying problematic lesions as a melanoma, the concept of minimal deviation melanoma (MDM) provided parcels of virtual images which greatly extended the spectrum of malignant melanoma. Variants were defined but biologic implications were constrained; the variants were evaluated on their own merits, not those of the common melanomas. Implicit in the definition was the proposition that the variants of MDM might not have the same relationship between bulk and biologic potential as the common melanomas. On the other hand, within the confines of rigidly defined boundaries (i.e., boundaries relative to bulk), even the thin, common melanomas should be qualified.
With these generalities as guidelines, we can return to a consideration of real and virtual images. Clearly, central (and, in turn, in-transit) virtual images may greatly simplify the interpretation of patterns on a newly encountered histologic section. On the other hand, a great reliance on central virtual images, to the relative exclusion of a careful examination of histologic sections, eventually may lead to the imposition of inappropriate virtual images. Real images, that are truly foreign and new, if encountered during the course of a review of a heavy workload of histologic sections, may be subjected to an imposition of parcels of inappropriate central virtual images. Such an exercise is likely to result in the production of a misleading report, and an incorrect diagnosis. In such an event, and all because parcels of central virtual images are manipulatable, melanoma, or a borderline lesion, might be dismissed as a nevus. Often, such offenses, resulting from the intrusion of divergent virtual images, can be altered favorably, if the section, following a period of reflection, is reviewed at leisure at a later date. The offense however may be lost to the observer in his rush, or under undue pressure. Central virtual images must be handled with care and respect.
That there is a Reed Patch says something about the gardener. Surely, there are more respected gardeners, and more respected vehicles by which to spread compost (convey perspectives and concepts). This produce, on which the gardener has labored for so long, is of a nature that would find limited display along the common avenues. In addition, the products of this garden have been so systematically and repeated demonized that they, like Little Boy Blue’s things, lie alone, covered with dust, and "awaiting."
The early efforts on this site will be a conceptualization of melanocytic neoplasia; it will be concerned with basic tenets from the concept of minimal deviation melanoma. Some will be so disguised as to possibly slip by the attention of the self-appointed guardians of all "foreign" concepts. The concept of MDM has been much abused; the attitude of some critics has been so biased that, on occasions, the gardener has felt that his critics expected a public apology from him for having promoted deceit. "Crust" is a distinguishing feature of many of the critics of the concept of MDM. Some of the criticism of the concept of MDM may relate to a stumbling use of English. For the latter fault, there is little chance for improvement. If I could bring words to life, I would gently, repentantly, and forever write "---".
It would not be possible to find a forum as open as the World Wide Web. There is the opportunity to present material in a form that might facilitate the conceptualization of the nature of the melanocytic neoplastic system. Peer review is not a safeguard on the web but, on the other hand, there are no compunctions about not adhering to what all others are doing; a-- kissing is not a requisite.
I am an old pathologist, perhaps too old to be undertaking a new endeavor. I have nurtured the concept of MDM too long to abandon it near the end. Recently, a friend, an acquaintance from the early days of my training in pathology, chided me with a copy of an announcement of the creation of yet another "Institute of Pathology" with a cryptic message about CV’s and my prospects for a festschrift in my name. Such a memorial has not been my search in life.
This Site will be dedicated to discussions of pathology; emphasis will be on dermatopathology.
In part, the presentations will build on a conceptual base. They will be progressive with emphasis on a particular aspect (i.e., melanocytic neoplasia). Both text, photomicrographs, and diagrams will be utilized in the development of concepts, and in the elaboration of histologic patterns. References will be included in accordance with the personal whims. The conceptualization of disease is not always a static recitation of gross and histologic patterns. On the other hand, to build on concepts without constant renewal of virtual images, and without recourse to relevant real images would likely lead both the contributors and the readers far afield. The concepts may be open to criticisms; The reader is asked to keep an open mind, and to reinforce or negate new principles by reference to valid real images rather than merely dismissing them out of hand as being something other than what the reader has been taught, or may currently believe or endorse.
The three Parts entitled "Whither in the Garden" will be devoted to the philosophical side of pathology. In them, the nature of both the practice of histopathology and the related interpretative processes will be examined and discussed. Pages dedicated to "Variants" will broadly discuss melanocytic neoplasia, and document particular variants, some of which are mostly ignored in current practice. All this would appear to be suitable material for a book, but if restricted to book-form, it would not be so universally available. There will be a section entitled Weeds and Wildflowers. Presentations in the latter section will be mostly in the nature of medico-legal cases. A separate section with presentations of individual cases will not be restricted to discussions of skin pathology.
The soil of melanomas, with attention to the patterns in which nests of cells are arranged in the dermis, will be examined and evaluated; distinctions will be made between a "seeding of soil" and "taking root." The density in which nests of cells (i.e., seeds) are arranged in the dermis allows for the definition of several patterns of vertical growth; not all of the patterns in which nests of neoplastic cells are regularly spaced in the soil of the dermis clearly equate with "taking root." Seeds (nests of neoplastic cells) may be regularly but loosely spaced in the dermal component; the resultant patterns may be characterized as variant vertical growth. In the act, some caution is required, if the tendency is to equate all "vertical growth" patterns with "taking root." Size, intensity of the immune response, and degree of atypia become relativities in the prognostic evaluations of some of the variant patterns. These variables and others will be dealt with in subsequent contributions. Hopefully, some of what is "spread" about on these pages on this site will "take root" in soil away from this site.
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