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Introduction Breast cancer is the most common female cancer in India, and 30–60% of patients present with locally advanced breast cancer. Level III clearance is routinely performed in India in locally advanced breast cancer following neoadjuvant chemotherapy, even in clinical complete response. We analysed our data of patients with locally advanced breast cancer post-neoadjuvant chemotherapy who have undergone level III clearance to identify any subgroup in which level III dissection can be avoided. Material and methods This is a retrospective study of female patients with locally advanced breast cancer who received neoadjuvant chemotherapy and underwent breast surgery including level III nodal clearance between June 2016 and May 2018. Data collected included age, menopausal status, TNM stage at presentation, grade, estrogen, progesterone, human epidermal growth factor receptor 2 status, response to treatment, post-chemotherapy stage and final histopathology. Uni- and multivariate analysis was undertaken. Results Data from 200 patients was analysed. The level III positivity rate was 15.5%. The clinical complete response rate was 43%, of which 41% had pathological complete response. A significant association was present between level III node positivity and pathological T stage (p=0.03). No association was seen between level III positivity and any other studied variables. In the subset of patients with cT3N1 and cT2N2, level III positivity was seen in only 3/49 (6.1%) and 1/31 (3%), respectively. Conclusion Level III positivity rate is high and so cannot be avoided in locally advanced breast cancer following neoadjuvant chemotherapy. None of the preoperative factors predict for level III positivity. Level III positivity in cT3N1 and cT2N2 is low and these subgroups require further studies.

Repair of inguinal hernia is one of the commonest surgical procedures worldwide. Since the era of tension free repair using synthetic mesh, the basic tenets of hernia repair has changed little. Currently there are two methods of mesh placement: open method or laparoscopic method. Although a number of clinical studies have explored the potential benefits and drawbacks of open and laparoscopic repair for inguinal hernia, no one procedure has emerged as having a clear benefit over the other. This study endeavors to reach a clear conclusion as to which is the most suitable procedure, with a special emphasis on the influence of the surgeon's experience on the outcome. A combined Prospective and retrospective Cohort study was carried out in KMC Hospitals, Mangalore. The sample size was two hundred for each arm; patients aged 18 and above without factors pre-disposing to recurrence were included in the study. The subjects were followed up for a period of one year at the end of which primary outcome assessed was recurrence. A number of secondary outcomes such as hematoma, persistent pain and return to regular activity were also assessed. The study concluded that the rate of recurrence in the laparoscopic arm was higher (5%) compared to the open arm (2.5%). However, we observed that 90% of the recurrences in the laparoscopic arm were at the hands of surgeons with less than five years experience in laparoscopic surgery which was statistically highly significant (P value = 0.00). In the open arm however, the surgeons' experience did not alter the outcome significantly (P value = 0.341). Thus, laparoscopic repair for inguinal hernia is a safe alternative in the hands of experienced laparoscopic surgeons.

A 65-year-old asymptomatic female patient was referred to the Department of Surgical Oncology; Bangalore Institute of Oncology, for thyroidectomy for a FNAC diagnosed follicular neoplasm of the left lobe of the thyroid. She was a known case of neuroendocrine tumour of the pancreas, having undergone a Whipple's procedure, elsewhere 5 years back. She had no comorbidities and family history was negative. The histopathology of the Whipple's procedure was reported as well differentiated endocrine carcinoma, with negative circumferential margins (R0). The tumour was Neuron Specific Enolase (NSE), synaptophysin and chromogranin A positive on immunohistochemical studies.On the sixth month of follow-up her chromogranin A levels were elevated (825ng/ml, Normal <100 ng/ml), but subsequent endoscopic USG did not show any recurrence. The patient was followed up with annual abdominal CT. On the fifth year, follow-up CT showed nodular lesions in segment 4b, 7 and 8. Subsequent PET CT showed increased tracer uptake in heterogeneously enhancing lesion measuring 2.8x3.9x3.3cm in the region of inferior left lobe of thyroid [ ABSTRACTWith the increasing use of 18F-Fluro-Deoxyglucose (FDG) Positron Emission Tomography (PET) the number of thyroid incidentalomas is on the rise. Focal thyroid incidentalomas identified by FDG-PET have been reported to have a high incidence of malignancy. Neuroendocrine tumours of the thyroid are rare entities. The most common neuroendocrine tumour of the thyroid is medullary carcinoma. A thyroid nodule in a patient with a known neuroendocrine tumour must be differentiated from a primary medullary carcinoma which can present as a diagnostic challenge to the clinician.A 65-year-old female patient was referred for thyroidectomy for a FNAC diagnosed follicular neoplasm of the left lobe of the thyroid, detected on FDG PET follow up. She was a known case of neuroendocrine tumour of the pancreas with no features suggestive of familial Multiple Endocrine Neoplasia (MEN) syndrome. The patient had undergone Whipple's procedure elsewhere, 5 years back. Following total thyroidectomy, the final histopathology report was suggestive of a primary neuroendocrine tumour.We present this case to highlight the clinical dilemma in diagnosing a thyroid incidentaloma as a second primary neuroendocrine tumour versus a solitary metastatic nodule in the background of metastatic gastroentero pancreatic neuroendocrine tumour. Although clinically, a metastatic nodule should have been the obvious diagnosis, the histopathological and immunohistochemical features were in favour of a primary non-medullary Neuroendocrine Tumor (NET) of the thyroid.

Ovarian cancer is one of the most common gynecological cancers worldwide. It is the third leading cause of cancer among women in India. Metastatic disease to the visceral organs from ovarian cancer occurs as a terminal event in the natural history of the disease. In particular, spread to the bone and large bowel is infrequently described. The risk of distant metastasis increases in a recurrent setting. We describe a case of a 77-year-old lady, who was diagnosed for ovarian carcinoma in 2007 and underwent primary cytoreductive surgery, stage IIIc. She presented to us with asymptomatic rising cancer antigen (CA) 125 levels during follow-up. On evaluation she was found to have sternal and colonic deposits. She underwent left hemicolectomy and biopsy of sternal deposit. Histopathology revealed metastasis from the carcinoma ovary to the colon and sternum. This case report highlights the rare synchronous metastatic disease in a metachronous setting from ovarian carcinoma.