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doi:10.1111/jpc.12532
Letters to the Editor
References
Dear Editor, EYES THAT SEE: MIRACLES RECLAIMED I enjoyed reading your editorial ‘Miracles’1 but would challenge your conclusion – ‘Miracle is a word that should be banished from the medical lexicon’ – for the following reasons. First, your anecdote essentially highlights a clash of worldviews. On the one side, ‘atheistic scientific naturalism’ that a priori excludes supernatural causes and effects and not surprisingly is sceptical about the use of language that implies these causes and effects. On the other side, ‘rational theism’ that assumes that supernatural causes and effects are embedded into the natural worId and, not surprisingly, acknowledges these causes and effects particularly when they amaze, humble and confound us. Unless you actually want to address the worldview differences directly, wherefore this journal is probably not the most appropriate publication, your conclusion smacks of the kind of philosophical totalitarianism that religious fundamentalists are usually accused of! If census data are to be believed, the majority of parents we will deal with are theists2 of some description, and we should be cautious about dismissive attitudes to their worldviews. Second, though I agree that it would be best that the word not be used to describe new or controversial medical/surgical interventions, I would emphasise that the reason it is so frequently misappropriated in this way is because clinicians and scientists allow their activities to be deified in the public consciousness. There are benefits of course that flow from accepting such high praise, but ‘The house of God’ is not a place for men and women to dwell. Words can, of course, be so frequently misappropriated as to lose any useful semantic field, but I am reluctant to accept this diagnosis in this case. The word needs to be reclaimed! Paradoxically, one of the strengths of the word, rightly appropriated, is that it highlights the limitations of modern medicine and science. A healthy awareness of these limitations allows us to be humble about the good outcomes we occasionally see that we cannot readily explain and accept those outcomes that seem inevitable despite our best efforts. This kind of humility may in fact create more room for the involvement of palliative care. Third, I challenge the assertion that calling an event a miracle risks neglecting helpful scientific enquiry (again, you assume a scientific explanation implies an atheistic explanation). The observation of an event not readily explainable using current theories is the very trigger for more detailed observation, new hypotheses, new experiments – the practice of science. Calling an event a miracle highlights that we do not yet understand, not that we will never understand. Dr Philip N Britton Dean’s Fellow and PhD Candidate Sydney Medical School, The University of Sydney New South Wales Australia 326
1 Isaacs D. Do you believe in miracles. J. Paed. Child Health 2014; 50: 87–8. 2 Australian Bureau of Statistics. Reflecting a Nation: Stories from the 2011 Census, 2012–2013. 2012. Available from: http://www.abs .gov.au/ausstats/[email protected]/Lookup/2071.0main+features902012-2013 [updated 21 June 2013; accessed 31 December 2013].
Dear Editor, SIEGFRIED: THE ONE WHO DOES NOT KNOW FEAR I very much enjoyed reading the November issue of the journal with its focus on adolescents.1 At the time, I was enjoying Opera Australia’s first production of Wagner’s Ring Cycle, and it occurred to me that Siegfried, ‘the one who knows no fear’, is symbolic of all adolescents and young adults (AYA). Unconsciously, we see these young people as invincible and immortal, and we tend not to consider a serious diagnosis such as cancer or leukaemia when we see AYA patients. By contrast, we do consider them when faced with an unwell (and vulnerable) smaller child, despite these diseases having twice the prevalence between 15 and 30 years of age that they have in the first 15 years of life. I believe this may underlie the phenomenon of delayed diagnosis well known in teenagers and young adults with malignancy and other lifethreatening disorders. I propose that we label our tendency to see AYA patients as invincible ‘Siegfried’s syndrome’ and that we remember to teach it to our trainees. Yours sincerely, Dr Catherine H Cole Winthrop Professor Stan Perron Chair of Paediatric Haematology and Oncology School of Paediatrics and Child Health University of Western Australia Paediatric and Adolescent Haematology and Oncology Princess Margaret Hospital for Children Haematology PathWest Laboratory Medicine Perth, Western Australia Australia
Reference 1 Isaacs D. Adolescents. J. Paediatr. Child Health 2013; 49: 881–2.
Conflict of interest: None declared.
Journal of Paediatrics and Child Health 50 (2014) 326–330 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
Letters to the Editor
Dear Editor,
occurred in survivors of Hodgkin’s lymphoma (37.9%) and leukaemia (32.1%).1 The vast majority of skin cancers in childhood are identified incidentally after excision of suspect lesions. Of these, adnexal neoplasms are uncommon, and while the benign hidradenoma has been described, the malignant version, hidradenocarcinoma, has only rarely been described.2 With several pathologic subtypes described, the ‘clear cell’ variant is rarer still, with only one reported case in childhood identified on literature review. We report a case of clear cell hidradenocarcinoma, which highlights an appropriate approach to childhood skin lesions. A 7-year-old male, with a past history of acute myeloblastic leukaemia at age 2 with haematopoietic stem cell transplantation, presented with a slow-growing neck lesion for 18 months (Fig. 1 – left). Initial management with topical steroids resulted in no change. Following excision, histologic examination showed a solid and cystic tumour in the dermis and subcutis, which mainly consisted of islands of basaloid cell with some peripheral palisading (Fig. 1 – right). Prominent mitotic activity and focal necrosis were present. Occasional intracytoplasmic lumina and ducts were identified on epithelial membrane and carcinoembryonic antigen immunohistochemistry. Following external review, the features were consistent with a narrowly excised clear cell hidradenocarcinoma. A wide local excision was undertaken, with no residual tumour identified. Although malignant clear cell carcinoma is well described in adults, in childhood this tumour is exceedingly rare. In the only comparable case reported, Hernandez-Perez and CestoniParducci reported a 1-year-old infant with clear cell hidradenocarcinoma. The lesion was excised, but was multiply recurrent and presented later with metastases, and ultimately resulted in death within 6 months.3 Other authors have described a more indolent course; however, the pathology of those lesions has been considered variants such as clear cell myoepithelioma or other adnexal neoplasms.4 While rare, cutaneous malignancies in children can occur, with the potential for significant morbidity and mortality. A high index of suspicion, thorough pathologic assessment and appropriately aggressive management and follow-up are paramount.
A RARE CHILDHOOD SKIN MALIGNANCY Skin cancers in childhood are uncommon, accounting for 1% of presenting skin lesions. Risk factors for childhood skin cancer include ultraviolet exposure, hereditary factors such as dysplastic naevus or Gorlin’s syndromes, or acquired factors such as radiotherapy. Often unrecognised in clinical practice is the significant risk of developing a second nonmelanoma skin cancer (NMSC) in survivors of childhood cancer. The Childhood Cancer Survivor Study cohort found a 30-year cumulative incidence of NMSC of 6.9%, of which the largest proportion
Dr Warren M Rozen1 Dr Vikram Palit1 Dr Jessica Ng2 Dr Alenka Paddle1 Professor Anthony Penington1 1 Department of Plastic Surgery 2 Department of Anatomical Pathology Royal Children’s Hospital Parkville, Victoria Australia
Conflict of interest: The authors report no conflicts of interest. Please note: Written informed consent has been obtained from the patient’s guardian for clinical information and photographs to be used for research and publication.
Journal of Paediatrics and Child Health 50 (2014) 326–330 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
327
doi:10.1111/jpc.12532
Letters to the Editor
References
Dear Editor, EYES THAT SEE: MIRACLES RECLAIMED I enjoyed reading your editorial ‘Miracles’1 but would challenge your conclusion – ‘Miracle is a word that should be banished from the medical lexicon’ – for the following reasons. First, your anecdote essentially highlights a clash of worldviews. On the one side, ‘atheistic scientific naturalism’ that a priori excludes supernatural causes and effects and not surprisingly is sceptical about the use of language that implies these causes and effects. On the other side, ‘rational theism’ that assumes that supernatural causes and effects are embedded into the natural worId and, not surprisingly, acknowledges these causes and effects particularly when they amaze, humble and confound us. Unless you actually want to address the worldview differences directly, wherefore this journal is probably not the most appropriate publication, your conclusion smacks of the kind of philosophical totalitarianism that religious fundamentalists are usually accused of! If census data are to be believed, the majority of parents we will deal with are theists2 of some description, and we should be cautious about dismissive attitudes to their worldviews. Second, though I agree that it would be best that the word not be used to describe new or controversial medical/surgical interventions, I would emphasise that the reason it is so frequently misappropriated in this way is because clinicians and scientists allow their activities to be deified in the public consciousness. There are benefits of course that flow from accepting such high praise, but ‘The house of God’ is not a place for men and women to dwell. Words can, of course, be so frequently misappropriated as to lose any useful semantic field, but I am reluctant to accept this diagnosis in this case. The word needs to be reclaimed! Paradoxically, one of the strengths of the word, rightly appropriated, is that it highlights the limitations of modern medicine and science. A healthy awareness of these limitations allows us to be humble about the good outcomes we occasionally see that we cannot readily explain and accept those outcomes that seem inevitable despite our best efforts. This kind of humility may in fact create more room for the involvement of palliative care. Third, I challenge the assertion that calling an event a miracle risks neglecting helpful scientific enquiry (again, you assume a scientific explanation implies an atheistic explanation). The observation of an event not readily explainable using current theories is the very trigger for more detailed observation, new hypotheses, new experiments – the practice of science. Calling an event a miracle highlights that we do not yet understand, not that we will never understand. Dr Philip N Britton Dean’s Fellow and PhD Candidate Sydney Medical School, The University of Sydney New South Wales Australia 326
1 Isaacs D. Do you believe in miracles. J. Paed. Child Health 2014; 50: 87–8. 2 Australian Bureau of Statistics. Reflecting a Nation: Stories from the 2011 Census, 2012–2013. 2012. Available from: http://www.abs .gov.au/ausstats/[email protected]/Lookup/2071.0main+features902012-2013 [updated 21 June 2013; accessed 31 December 2013].
Dear Editor, SIEGFRIED: THE ONE WHO DOES NOT KNOW FEAR I very much enjoyed reading the November issue of the journal with its focus on adolescents.1 At the time, I was enjoying Opera Australia’s first production of Wagner’s Ring Cycle, and it occurred to me that Siegfried, ‘the one who knows no fear’, is symbolic of all adolescents and young adults (AYA). Unconsciously, we see these young people as invincible and immortal, and we tend not to consider a serious diagnosis such as cancer or leukaemia when we see AYA patients. By contrast, we do consider them when faced with an unwell (and vulnerable) smaller child, despite these diseases having twice the prevalence between 15 and 30 years of age that they have in the first 15 years of life. I believe this may underlie the phenomenon of delayed diagnosis well known in teenagers and young adults with malignancy and other lifethreatening disorders. I propose that we label our tendency to see AYA patients as invincible ‘Siegfried’s syndrome’ and that we remember to teach it to our trainees. Yours sincerely, Dr Catherine H Cole Winthrop Professor Stan Perron Chair of Paediatric Haematology and Oncology School of Paediatrics and Child Health University of Western Australia Paediatric and Adolescent Haematology and Oncology Princess Margaret Hospital for Children Haematology PathWest Laboratory Medicine Perth, Western Australia Australia
Reference 1 Isaacs D. Adolescents. J. Paediatr. Child Health 2013; 49: 881–2.
Conflict of interest: None declared.
Journal of Paediatrics and Child Health 50 (2014) 326–330 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
Letters to the Editor
Dear Editor,
occurred in survivors of Hodgkin’s lymphoma (37.9%) and leukaemia (32.1%).1 The vast majority of skin cancers in childhood are identified incidentally after excision of suspect lesions. Of these, adnexal neoplasms are uncommon, and while the benign hidradenoma has been described, the malignant version, hidradenocarcinoma, has only rarely been described.2 With several pathologic subtypes described, the ‘clear cell’ variant is rarer still, with only one reported case in childhood identified on literature review. We report a case of clear cell hidradenocarcinoma, which highlights an appropriate approach to childhood skin lesions. A 7-year-old male, with a past history of acute myeloblastic leukaemia at age 2 with haematopoietic stem cell transplantation, presented with a slow-growing neck lesion for 18 months (Fig. 1 – left). Initial management with topical steroids resulted in no change. Following excision, histologic examination showed a solid and cystic tumour in the dermis and subcutis, which mainly consisted of islands of basaloid cell with some peripheral palisading (Fig. 1 – right). Prominent mitotic activity and focal necrosis were present. Occasional intracytoplasmic lumina and ducts were identified on epithelial membrane and carcinoembryonic antigen immunohistochemistry. Following external review, the features were consistent with a narrowly excised clear cell hidradenocarcinoma. A wide local excision was undertaken, with no residual tumour identified. Although malignant clear cell carcinoma is well described in adults, in childhood this tumour is exceedingly rare. In the only comparable case reported, Hernandez-Perez and CestoniParducci reported a 1-year-old infant with clear cell hidradenocarcinoma. The lesion was excised, but was multiply recurrent and presented later with metastases, and ultimately resulted in death within 6 months.3 Other authors have described a more indolent course; however, the pathology of those lesions has been considered variants such as clear cell myoepithelioma or other adnexal neoplasms.4 While rare, cutaneous malignancies in children can occur, with the potential for significant morbidity and mortality. A high index of suspicion, thorough pathologic assessment and appropriately aggressive management and follow-up are paramount.
A RARE CHILDHOOD SKIN MALIGNANCY Skin cancers in childhood are uncommon, accounting for 1% of presenting skin lesions. Risk factors for childhood skin cancer include ultraviolet exposure, hereditary factors such as dysplastic naevus or Gorlin’s syndromes, or acquired factors such as radiotherapy. Often unrecognised in clinical practice is the significant risk of developing a second nonmelanoma skin cancer (NMSC) in survivors of childhood cancer. The Childhood Cancer Survivor Study cohort found a 30-year cumulative incidence of NMSC of 6.9%, of which the largest proportion
Dr Warren M Rozen1 Dr Vikram Palit1 Dr Jessica Ng2 Dr Alenka Paddle1 Professor Anthony Penington1 1 Department of Plastic Surgery 2 Department of Anatomical Pathology Royal Children’s Hospital Parkville, Victoria Australia
Conflict of interest: The authors report no conflicts of interest. Please note: Written informed consent has been obtained from the patient’s guardian for clinical information and photographs to be used for research and publication.
Journal of Paediatrics and Child Health 50 (2014) 326–330 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
327
