Once a local perforation is established, rapid invasion of fascial planes may track along the path of least resistance, most commonly the urogenital tract and perineal tissues. Interestingly, our patient had scrotal invasion extending through the left inguinal canal manifesting as an inguinal lump, which could have been mistaken for an incarcerated inguino-scrotal hernia.Operative intervention in the acute setting involves extensive debridement of necrotic tissues with subsequent staged debridement and delayed wound closure or graft repair. Despite the extensive tissue necrosis, testicular involvement is uncommon due to the gonadal vascular supply. 5 Faecal diversion via a defunctioning colostomy is recommended during initial surgery to aid with wound healing. 6 In this case, laparoscopy was performed to assess intraabdominal involvement prior to scrotal debridement and loop colostomy formation in anticipation of potential obstruction due to his advanced circumferential rectal cancer and need for down-staging neoadjuvant chemo-radiotherapy. Purulent discharge from the deep inguinal ring, in the absence of a hernia, unmasked a large inguinal collection tracking along the canal down to the scrotum that had originated from the perforated rectal cancer.The COVID-19 pandemic is almost certain to have contributed to the severity of this case and it is very likely that any similar delayed presentation, with other medico-surgical pathologies, will continue to cause significant collateral damage.

Background: Spiradenocarcinoma is a rare skin adnexal neoplasm that may behave aggressively. It is often associated with a benign slow-growing spiradenoma that has undergone malignant transformation. Given the paucity of cases in the literature, there is a lack of consensus on treatment. Methods: The terms 'malignant spiradenoma' or 'spiradenocarcinoma' were systematically used to search the PubMed, MEDLINE and Google Scholar databases. A total of 182 cases of spiradenocarcinoma were identified as eligible for this comprehensive literature review. Results: Spiradenocarcinoma was commoner in older age and Caucasian race. In most cases, surgical excision for local disease is the mainstay of treatment. Lymph node dissection is usually reserved for those with suspected or confirmed lymph node metastases. High rates of local recurrence (20.8%), metastasis (37.4%) and mortality (19.1%) were identified, prompting some authors to suggest regular follow up including chest X-rays and liver function tests. Conclusions: Patients with spiradenocarcinoma may benefit from a magnetic resonance imaging and fluorodeoxyglucose-positron emission tomography/computed tomography to establish the extent of disease. We recommend wide local excision as the treatment of choice to achieve surgical margins of ≥1 cm, with node resection to be determined on a case-to-case basis. Regular follow up is important given the high rate of local recurrence, metastasis and mortality. This should include an examination of the regional lymph nodes. Further research is required to refine an evidence-based approach to spiradenocarcinoma.

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Chylothorax caused by blunt trauma is extremely rare. We present a case of bilateral massive chylothorax post blunt trauma and a review of the literature regarding the identification and management of this rare diagnosis. An eighteen-year-old male was involved in a motor vehicle crash where he sustained multiple injuries including a right, moderate to large, haemopneumothorax, a small left haemopneumothorax, left T8, T9, L1 and L2 acute transverse process fractures and fractures of bilateral 11th ribs. An intercostal catheter was inserted on the right side which initially drained blood-stained fluid however milky colour fluid was noted to be draining 11 h post insertion. Further imaging revealed a left pleural effusion causing a mediastinal shift where, once drained, also revealed a chylothorax. The patient was managed conservatively with bilateral intercostal catheters and a no fat/low-fat diet. The patient was discharged day seven post removal of bilateral intercostal catheters.

that revealed marked dilatation of the caecum and ascending colon, with intestinal pneumatosis and patent mesenteric vessels. The colonoscopy showed normal mucosa with atonic right colon. A colon decompression tube was inserted. Unfortunately, his clinical conditions progressively worsened and the patient deceased after 2 days. The clinical manifestations of COVID-19 are multiform, and patients with abdominal symptoms should be thoroughly evaluated with bowel sonography, followed by CT scan and colonoscopy if necessary, because the abdominal examination often underestimates the severity of the eventual underlying disease. Moreover, when COVID-19 patients need abdominal surgery, we encourage surgeons to investigate the intestinal blood flow intraoperatively (i.e. using fluorescence imaging), to look for intestinal vascular damage in surgical specimens and to perform microbiota and peritoneal fluid analysis whenever possible, to gain new significant data.

An inaugural Roundtable on Breast Reconstruction Practice in Australia was held on the Gold Coast in October 2019 to discuss this inequity in BR access. It involved 40 participants from all mainland states and territories. Attendees included breast oncoplastic surgeons, plastic reconstructive surgeons, breast care nurses, cancer policy representatives, consumers, medical and radiation oncologists and industry representatives. While GP representatives were invited, none were available to attend. Practical strategies to address inequities in BR access were discussed and different models of care across Australia were examined. No quick fixes were identified, with changes required on a system level, hospital level and individual surgeon level. Potential solutions included organized referral pathways from primary care to specialized cancer centres, promotion and wider dissemination of existing BR information resources specifically tailored for GPs and patients and the introduction of a formal 'mentor system' between hospitals to provide inexperienced surgeons with advice on patient selection for specific BR procedures, access to multidisciplinary team discussion and the establishment of regular inter-hospital referral patterns (supported by telemedicine). The results of the roundtable are expected to be released in early 2020.

Background: Medullary thyroid cancer (MTC) is rare, with poorer outcomes than differentiated thyroid cancer. We aimed to identify areas for improvement in the pre-operative evaluation of patients with possible MTC in a high-volume endocrine surgery unit in accordance with current practice guidelines. We hypothesised that the selective use of serum calcitonin (sCT) as a biomarker for possible MTC could guide the extent of initial surgical management. Methods: We recruited MTC patients between 2000 and 2020 from the Monash University Endocrine Surgery Unit database. Demographics, tumour characteristics, pre-operative evaluation, operative management, and outcomes were analysed. Results: Of 1454 thyroid cancer patients, 43 (3%) had MTC. Pre-operatively, 36 (84%) patients with MTC confirmed on cytology (28, 65%), elevated sCT (6, 14%) or RET mutation (2, 4%). Of these 36 patients, 31 (86%) had optimal extent of thyroidectomy and lymph node dissection (LND). Five (14%) had less than total thyroidectomy due to nerve injury. Thirty-four patients had compartmental LND. In the 12 (27%) patients with indeterminate or non-diagnostic cytology, 5 had elevated sCT and were managed as above. None of the remaining seven had LND, thus potentially suboptimal surgery. Conclusion: Our findings reflect the rarity of MTC, and the challenges of pre-operative diagnosis. The addition of sCT may improve surgical planning in patients with indeterminate cytology.

Spiradenocarcinoma is a rare skin adnexal neoplasm that may behave aggressively. It is often associated with a benign slow-growing spiradenoma that has undergone malignant transformation, characterised by rapid growth and tenderness. They often present as solitary skin nodules and are classified as low-grade or high-grade tumors. We report a case of a high-grade spiradenocarcinoma in association with a benign spiradenoma, measuring 3.2 x 3 x 2.8 cm, situated on the chest wall of a 63-year-old male. The lesion had been enlarging over 20 years but recently became painful, prompting treatment. Preoperative ultrasound revealed a complex vascular lesion suggestive of a dermoid cyst. Excision of the tumor under general anaesthesia was performed. Histopathology confirmed a high-grade spiradenocarcinoma cleared of margins by 1 mm. Wide local excision of the scar, with a 1 cm margin, confirmed no further malignancy. An FDG PET-CT showed no evidence of distant metastases. The patient recovered well and has had no evidence of tumor recurrence at the 3-month follow-up. Given the rarity of this neoplasm and the paucity of cases in the literature, there is a lack of consensus on treatment. In most cases, surgical excision with adequate margins is the mainstay of treatment, with lymph node dissection reserved for those with suspected or confirmed lymph node metastases.