“Mitogenicity”—the latest and mosthilarious episode in the slapstick comedy of melanoma management

In his “Essay on Comedy” in 1877, George Meredith noted, “the test of true Comedy is that it shall awaken thoughtful laughter.” [1] This does not necessarily mean that a comedy must be funny. Laughter can also be provoked by matters serious or sad. Most psychologists agree that the predominant characteristics connected with the phenomenon of laughter are incongruity or contrast in the object creating it and shock or emotional seizure on the part of the subject. Freud pointed out that laughter is a sign of relief from tension. René Descartes emphasized the suddenness of laughter evoked by circumstances that “cause the lungs suddenly to inflate” so that “the air they contain is forced out through the windpipe with impetuosity,” whereas Thomas Hobbes related laughter to feelings of superiority, to a “sudden glory arising from sudden conception of some eminency in ourselves by comparison with the infirmity of others, or with our own formerly.” [2] All those feelings can be provoked if one starts to think about concepts in the management of melanoma. Sad in many ways because misconceptions may come to bear severely on patients, the history of melanoma management is also rivetingly funny because it possesses all ingredients of a good comedy. First, many concepts pertaining to melanoma are replete with incongruities that truly are breathtaking. As a novice, one may neglect them and adhere obediently to established standards of care, but if one’s intellectual faculties are not benumbed completely, the question will sooner or later arise, “What’s wrong with my brain that I simply cannot get it?” That is the moment of shock or despair, an important element of good comedy, and then comes the moment of relief, to wit, the sudden awareness that nothing is wrong with one’s brain but only with the premises of melanoma management, a moment of alleviation and laughter that leads to what Hobbes called “sudden glory,” a feeling of superiority in comparison with acolytes of such concepts, including one’s former self. Examples are legion. A particularly striking one is recommendations concerning margins of excision. For decades, huge excisions necessitating free transplants of skin were required for melanomas that already had been removed completely. The fable was spread, and believed throughout the world, that excision of a scar and a chunk of healthy skin could prevent death from melanoma. When in the 1970s margins of excision were reduced for thin melanomas, basic principles of logic were violated even more flagrantly. Margins of excision were adjusted to the risk of nodal and visceral metastases, rather than the risk of persistence of the neoplasm at the primary site, as if excision of some skin around the site of a primary cutaneous melanoma of the leg or trunk could have any effect on metastases in the groin, lung, or liver. Moreover, the horizontal margin of excision “Mitogenicity”—the latest and most hilarious episode in the slapstick comedy of melanoma management