Medical practices

To the Editor:Lichen planus is an autoimmune mucocutaneous inflammatory disorder. Diagnosis is often made clinically and confirmed on biopsy.1 Hypertrophic lichen planus is a distinct subtype characterised by pruritic, hyperkeratotic plaques. Histopathological findings may not have the typical features of lichen planus and can mimic squamous cell carcinoma (SCC).2 Distinguishing between hypertrophic lichen planus and SCC can be difficult for clinicians and pathologists. In our dermatology practice, we encountered three patients initially diagnosed with SCC, but on review, the cases were consistent with lichen planus. One patient was a 52-year-old woman presenting with asymmetrical, raised and violaceous lesions to her lower legs. She was referred to a skin cancer clinic that performed biopsies of these lesions, which were reported as well differentiated SCC. These lesions were excised, but they were recurrent and were excised again. The second patient was a 54-year-old man who presented with a one-year history of eruptive raised, violaceous lesions to his chest and legs. Biopsies were reported as SCC and multiple lesions were excised by a general surgeon. The third patient was a 77-year-old woman with a 2-year history of pruritic lesions to the lower legs (Box). Biopsies were reported as well differentiated SCC. Each of these patients underwent numerous excisions before being referred to our practice. The patients were reassessed and new biopsies taken, and the clinical picture was discussed with a dermatopathologist. Hypertrophic lichen planus was confirmed as the diagnosis in each of these patients, and they responded well to prednisone, acitretin and topical steroid treatment. SCC may arise in long-standing hypertrophic lichen planus, but it should be emphasised that cases of supposed SCC with atypical history should not be treated without consideration of the many mimics of SCC, including pseudoepitheliomatous hyperplasia, irritated seborrhoeic keratosis, coral reef granuloma, hypertrophic lupus erythematosus and hypertrophic lichen planus. Clinicians should provide clinical description and a list of potential differentials when referring to a pathologist. Adequate biopsy depth is important, as lichenoid activity may only be present at the tips of the rete ridges, which may be missed on a superficial biopsy. These cases highlight the difficulties in distinguishing hypertrophic lichen planus from SCC. In the cases we described, correct diagnosis was made after re-evaluation and clinicopathological correlation. Box – Figure showing violaceous hyperkeratotic patches on the patient’s lower leg, with original biopsies reported as squamous cell carcinoma (A). Histopathology showed a lichenoid inflammatory infiltrate confined to the tips of the rete processes (B)* * Infiltrate is composed of predominantly lymphocytes with few eosinophils and plasma cells. While these features are typical of hypertrophic lichen planus, superficial shave biopsies may not capture the lichenoid infiltrate at the rete processes.

Emily X Shao · Benjamin Carew · James Muir

Evidence shows that eGFR automated reporting in Australia is associated with improvements in awareness, early detection, management and referral of patients with chronic kidney disease

Marie Ludlow · Shilpa Jesudason · David W Johnson

The rates of RHD are among the highest in the world, particularly in girls and young women

Kimberly Davis · Bo Remenyi · Anthony DK Draper · Januario Dos Santos · Noel Bayley · Elizabeth Paratz · Benjamin Reeves · Alan Appelbe · Andrew Cochrane · Timothy D Johnson · Laura M Korte · Ivonia M Do Rosario · Inez T Da Silva Almeida · Kathryn V Roberts · Jonathan R Carapetis · Joshua R Francis

To the Editor: We read with interest Mendelson and colleagues’ article regarding the underutilisation of computed tomography colonography (CTC) for colorectal cancer detection in Australia.1 The authors state that “CTC is less accurate in the diagnosis of small or diminutive polyps … However, in the context of symptomatic patients, this is not relevant”.1 This overlooks the importance of detecting small adenomas as well as flat, right-sided colonic lesions such as sessile serrated polyps. It is well established that the early detection and treatment of these lesions reduces interval colorectal cancer.2 To state that these are “not relevant” in symptomatic patients is inaccurate. High definition white light with the aid of chromoendoscopy tools such as narrow band imaging in optical colonoscopy (OC) has significantly improved the ability of endoscopists to detect diminutive and subtle lesions. CTC has a markedly limited ability to detect small and flat lesions when compared with OC.3 The authors reference phase 2 data from the National Bowel Cancer Screening Program, stating that “the great majority of OCs (about nine in ten) were normal”. However, polyps were detected in 34.9% of participants.4 The authors appear to define normality as the absence of a cancer or advanced adenoma (one in ten colonoscopies). We argue that the detection of any adenoma is important and is not “normal”, as it highlights a cohort of patients at risk of colorectal cancer and requiring ongoing polyp surveillance. We also question the authors’ suggestion that a negative CTC obviates the need for OC in lower risk patients with positive faecal immunochemical test results. OC provides the opportunity to detect and treat a range of polypoid and non-polypoid colonic pathology and although a negative CTC may help exclude a cancer, it does not address the range of other potentially morbid or precancerous causes of occult faecal blood. Given these limitations, a cautious approach should be adopted if CTC is to be used as an alternative to OC in all lower risk patients.

Simon Hew · Zaid SM Ardalan

In reply

Richard M Mendelson · Tom R Sutherland · Andrew F Little

Modern digital radiological techniques include “stitching” together multiple x-ray images. This provides one overall image of the area of interest, such as the entire spine or lower limbs, for deformity assessment. Dedicated software automatically combines separate exposures and allows for overlap. Image acquisition is rapid, minimising patient motion artefact and reducing distortion.1 However, if images are inappropriately put together (digitally stitched), stitching errors may occur with this computer-driven process. If not manually corrected by the radiology technician, the supplied image may hide pathology or give the false impression of abnormality. Four cases of digital stitching error have recently occurred in our tertiary referral paediatric hospital. Digitally stitched x-rays from the lower limbs were obtained for routine assessment of a child with skeletal dysplasia, and fractures of the left tibia and fibula were apparent (Box, A). This did not correlate with the clinical findings, including the child dancing in the waiting room. The radiology department was contacted and they re-issued corrected images (Box, B). Spinal x-rays in two patients after scoliosis surgery incorrectly showed broken surgical rods. In the context of ongoing symptoms, the option of revision surgery was discussed with the family in the first case. Repeat x-rays, obtained as part of the pre-operative planning, showed the rod was in fact not broken. A stitching error was immediately recognised by the spinal surgeon when a second similar case occurred. In a fourth case, comparison of the anteroposterior and lateral views of a child’s spine showed different numbers of vertebrae in the two views (11 vertebrae on the frontal view and 12 on the lateral). Digital radiology is commonplace and allows rapid image acquisition and ease of digital measurement.2 However, technical errors — digital stitching errors — may occur. Although rarely reported, these may be relatively common, with one study identifying stitching errors in 14 out of 86 reviewed scoliosis studies.1 Despite ongoing technological refinements,3 clinicians should always carefully check digitally stitched images: look for soft tissue mismatch, correlate with source images and clinical presentation, and avoid digital stitching in certain patients, such as people with movement disorders. Box – Digitally stitched long leg images of a paediatric patient, showing the stitching error and apparent fracture (A),* and corrected image with resolution of the stitching error and no fracture (B) * Note the mismatched soft tissue shadow (A).

Clare Faurie · Nicole Williams · Peter J Cundy

To the Editor:Biobanking involves the collection, processing, storage and distribution of biospecimens and data, and, in recent years, it has rapidly evolved to become an integral component in biomedical research.1 Biobanks may range in complexity from a single researcher storing their own material to large stores of material used by multiple researchers. This diversity has complicated the standardisation of biobanking practices,2,3 sometimes compromising biospecimen quality and storage capacity4 and the security of funding. In turn, irreproducible research results, poor biospecimen access and decreased public confidence may ensue.4 Therefore, New South Wales Health Pathology — a statewide clinical diagnostic service — has adapted and launched a Biobank Certification Program in conjunction with the Canadian Office of Biobank Education and Research and the Canadian Tissue Repository Network, where the program has been operating successfully for 4 years.5 This voluntary program aims to improve the quality of biobanking practices and raise standards through the provision of education modules and document templates. To encourage participation, the program is free for NSW biobanks and associated pathology laboratories for the first year. Nominal fees will subsequently apply for non-NSW Health organisations. Certification requires the biobank or pathology leader to register details of the biobank and complete (with team members) up to nine pertinent education modules, submit a declaration of compliance to adhere to best practices and upload key documents for auditor review. Moreover, biobanks may also opt to be listed on a publically available biobank locator. The program is designed as a first step towards improving the quality of biobanks for stakeholders, including researchers, multicentre trials, ethics committees, funders and the public. Current biobank practices are diverse, making a formal accreditation system impractical for some biobanks to undertake. It is envisaged that the program — subject to evaluation and uptake of staff education modules — may provide a foundation for a future accreditation program. Further information is available at https://nsw.biobanking.org.

Jane E Carpenter · Amanda Rush · Candace Carter