Elsewhere in this issue of the American Journal of Ophthalmology , my esteemed teacher, mentor, and colleague, Dr Frederick (Fred) Jakobiec, presents the case for changing the naming convention applied to conjunctival melanoma precursors by the ophthalmologist and pathologist.

It is worthwhile comparing what Dr Jakobiec says in his current review with what he said in another comprehensive review article more than 25 years ago (I was a co-author):

“The term primary acquired melanosis, favored by the World Health Organization, can be used by both the clinician and the pathologist: primary means that the lesion is not the result of generalized dark pigmentation (“racial”), system disease, or local topical factors; acquired means that the lesion is not congenital and usually does not even date from childhood; and melanosis indicates that the condition results from the production of melanin rather than another pigment or drug deposit…”

“Although the term primary acquired melanosis may be used by the clinician and pathologist alike, only the pathologist, using the histologic criteria described below, can distinguish between those lesions likely to remain stable and those likely to progress to malignant melanoma. This distinction is made by first determining if melanocytic hyperplasia is present. If melanocytic hyperplasia is identified, the pathologist must look for two features: the pattern of intraepithelial growth and the presence or absence of cytologic atypia.”

“The pathologist will designate a lesion as PAM without atypia under two conditions: (1) there is overproduction of melanin without melanocytic hyperplasia … (2) melanocytic hyperplasia is present … but the melanocytes lack atypia… Patients who have a patch of conjunctival pigment removed and who are given the diagnosis of PAM without atypia are at extremely low risk of melanoma developing.”

“If the pathologist encounters PAM with cytologic atypia, it is important to examine the specimen for two features: (1) the presence or absence of epithelioid cells; and (2) the pattern of intraepithelial growth.”

In the table that Dr Jakobiec developed for the paper in this issue, one notices that primary acquired melanosis (PAM) without atypia has been subdivided into 2 entities—“intraepithelial nonproliferative melanocytic pigmentation” (IMP) and “intraepithelial melanocytic proliferation without atypia”—and that PAM with atypia has been renamed “intraepithelial melanocytic proliferation with atypia.” Aside from the name changes, the histologic criteria applied across the names to diagnosis are identical.

Why does Dr Jakobiec now advocate for the name change? He states in his current review : “There is no reason, however, why clinical and pathologic diagnoses should rely on the same vocabulary” and “… an argument is simultaneously made for the adoption of what is regarded as more appropriate diagnostic nosology based on the vocabulary that is frequently employed today for cutaneous precursor lesions.”

The phrase “primary acquired melanosis” used in the clinical context by ophthalmologists provides a diagnostic algorithm, word by word. For example: “The lesion that I see in my patient involves the conjunctiva and I have determined that this condition is not secondary to systemic disease, topical medication, or a dark skin tone (it is primary condition); the lesion is in the conjunctiva (not in the sclera) and is not congenital (it is acquired) and I am visualizing brown or black pigment (melanin). My patient clinically has primary acquired melanosis and if I take a biopsy, the pathologist will either refute the diagnosis (eg, no, your patient’s lesion is a nevus) or will confirm it. The pathologist will never use the term “primary acquired melanosis” in a report to me without qualification.”

The pathologist examining the biopsy sample will add language to guide therapy based on outcomes: if the pathologist sees histologic evidence of atypia, the lesion is diagnosed as primary acquired melanosis with atypia and the ophthalmologist then knows that the patient requires therapy to ablate the lesion. If the pathologist does not detect atypia, then the lesion is designated as primary acquired melanosis without atypia and no further treatment is indicated. After the biopsy, the pathologist has only 2 diagnostic options, not 3 or more, and both options guide management.

If the criteria for identifying atypia in new nomenclature proposed by Dr Jakobiec are identical to what is conveyed in the PAM naming system, should ophthalmologists choose a different name for the clinical condition of conjunctival pigmentation suspicious of being a melanoma precursor so that pathologists may use a term that is “frequently employed today for cutaneous precursor lesions”? How does changing the name of a lesion to conform with the conventions of some dermatopathologists benefit the patient in the ophthalmologist’s office?

The histologic classification of PAM with and without atypia was built upon a statistical analysis of patient outcomes. There is evidence to support the validity of this nomenclature. Where is the evidence that the proposed new nomenclature results in a more accurate diagnosis, and where is the evidence that this new nomenclature is more precise in guiding outcomes?

If evidence should guide practice, then where is the evidence to support Dr Jakobiec’s additional conclusion that “All pre- and postoperative biopsies of flat conjunctival melanocytic disorders should be evaluated immunohistochemically if there is any question regarding atypicality”? Does this mean that if, as a pathologist, I observe atypia on a tissue section stained by hematoxylin-eosin, I must order a battery of immunohistochemical stains? Dr Jakobiec’s review would seem to require this as a standard of care.

In a shift of medical practice to a value-based paradigm, pathologists are being held accountable for ordering special stains (including immunohistochemistry) to support diagnoses. Some patients who carry insurance policies with very high deductibles may not be able to afford to pay for a battery of immunohistochemical stains. We pathologists could justify ordering these test if there were evidence to show that the cost of 3 immunohistochemical stains adds to the precision of identifying atypia. Where is the evidence?

In the end, it matters not what Bob Folberg says or what Fred Jakobiec says. Changes in our practices, including the words that we use to transmit information between ophthalmologists and pathologists, should be based on evidence of improved patient outcomes.