	Each month, Dr. Maria Flynn issues a Radiology Challenge, presenting images from one of a variety of imaging modalities and a case report. Can you diagnose the condition? Follow the link to find out whether your answer was correct, what was really wrong with the patient, and how the patient was treated. Then, come back next month to test your radiographic reading skills on a new case!

Dr. Maria Flynn is Chief of Genitourinary Imaging and Radiology Intern Program Director at the Naval Medical Center Portsmouth, as well as a Lieutenant Commander in the US Navy Medical Corps. She received her medical degree from Tulane Medical School in 1994 and completed her radiology residency at the National Capital Consortium in 2003. She is certified by the American Board of Radiology and has been appointed Adjunct Assistant Professor of Radiology and Radiological Sciences at the F. Edward Hébert School of Medicine.

	A 45-year-old woman presented to the hospital with spontaneous unilateral nipple discharge occurring for approximately 2 years. She noted the discharge to be intermittently bloody. Physical examination revealed clear discharge from the 10 o'clock position of the left nipple. No masses were palpated and no skin changes were identified. A mammogram (Figures 1 and 2) and a magnified galactography (Figures 3 and 4) were performed.

 Given the patient's history and radiology findings, the most likely cause of the nipple discharge is:

		Although the most likely cause of unilateral nipple discharge is benign intraductal papilloma, 10% to 15% of spontaneous nipple discharge is due to breast carcinoma; therefore, surgical excision of the identified lesion is warranted.

 The color of the discharge is not a significant consideration in making a diagnosis because any unilateral discharge should be investigated histologically.

 Generally, bilateral nipple discharge is due to an endocrine related disorder, such as a pituitary adenoma.

		Lesions causing unilateral nipple discharge should be investigated with galactography because they are usually not seen on mammography or ultrasonography.

 In a study of 826 women who underwent surgical excision of galactographic abnormalities, more than 40% had a solitary papilloma, 13.4 % had invasive carcinoma or carcinoma in situ, and 13.7% had extensive intraductal solid papillary or adenomatous epithelial proliferation.

		In this case, surgical resection was performed in conjunction with wire localization from a steriotactic galactogram (Figure 5). Wire localization following galactography has been proven to increase the pathologic correlation and decrease incomplete or excessive surgeries. As many as 20% of abnormalities identified on galactography (without wire localization) are missed during excision and are absent during surgical pathology review.

 Some reasons for this include nipple discharge that is intermittent and not detected during surgery, rapid periopertative methylene blue diffusion into lesions distal from the retroareolar region, and tortuous or diving ducts that are difficult to follow during surgical excision.

			Koskela A, Berg M, Pietilainen T, et al. Breast lesions causing nipple discharge: preoperative galactography-aided stereotactic wire localization. 

			Van Zee KJ, Ortega Perez G, Minnard E, et al. Preoperative galactography increases the diagnostic yield of major duct excision for nipple discharge. 

			Paterok EM, Rosenthal H, Sabel M. Nipple discharge and abnormal galactogram. Results of a long-term study (1964-1990). 

			Woods ER, Helvie MA, Ikeda DM, et al. Solitary breast papilloma: comparison of mammographic, galactographic, and pathologic findings. 

Articles

Surgical Rounds

June Challenge: Can you diagnose this breast lesion?

	? What's hot in real estate: undeveloped land

	Who would have thought that purchasing 400 acres of Illinois farmland would be a better investment than buying the cute colonial house at the end of your block? That seems to be the emerging reality in real estate. A recent article in the 

says that as the housing market has cooled, there has been a rush to snag undeveloped property, anywhere from New England to Montana. Farmland values rose 11%, their highest yearly increase since 1981, and rural land in Texas hit a historic high of nearly $1,500 an acre this past year, up about 75% since 2000. Property uses range from recreational enjoyment for deer hunters and drivers of off-road vehicles, to leasing the land to farmers. While the current market for undeveloped land is hot, the 

warns of many possible pitfalls. For example, property lines are not always well-defined, which is why it is important to have a survey conducted of any land you are considering purchasing. You also need to pay attention to how access to the land is gained. Some may require the use of makeshift roads that cross other peoples' property lines, providing illegal access to your property and the potential for lawsuits. Another consideration is mineral rights. In energy-rich Texas and the Rocky Mountain states, sellers can retain the rights to oil or minerals buried beneath the land you purchase, which allows them to drill or mine on your property, even if you object.

		? Bargain opportunities for online shoppers

		If you are a coupon cutter or a shopper who can smell a sale before you pull into a store parking lot, you won't want to miss out on the virtual blue-light specials online. 

magazine outlines various types of bargain hunters and recommends specific Web sites just for them.

 is recommended for the shopper who likes to compare prices and products. The Web site collects information from across the Web and allows consumers to view and contrast prices from a slew of retailers.

 is the Web's version of the Sunday newspaper circular, providing information on discounts being offered by various manufacturers and retailers. Sometimes you can obtain a special code to be used when you check out your online purchase.

 gives shoppers the opportunity to receive a rebate if they use their portals to access the Web sites of brand-name retailers. 

 gets a commission for referring you and, in return, sends you rebates via check or PayPal. Amounts can be for as much as 7% of an item's purchase price and include popular retailers, such as Dell Home Systems, Staples, and Brookstone.

 provides the shopper with the same opportunities as a regular outlet store, offering discounts on excess inventory, such as closeouts and overstocked goods. 

 has the broadest selection of online outlet stores and offers the best rates for shipping.

leave you scratching your head, you may be the perfect candidate for 

. This free service gives visitors a financial word of the day. To subscribe, visit 

 and enter your email address. That is all you need to do to gain access to an online financial glossary with over 6,000 terms, which you can search for by word or first letter. Recent ?Terms of the Day' include 

The site also has a subject glossary for an in-depth look at specific investing or financial topics. Currently the service has over 58,000 subscribers, and is sponsored by advertisers, including Charles Schwab, Fidelity Investments, and Morningstar.

		Life-cycle funds are a one-size-fits-all solution for retirement savings, which means that they fit no one perfectly. On the other hand, most investors will likely earn better returns over the years using life-cycle funds than by managing their own retirement portfolios. To understand why life-cycle funds may be a good choice for you, although they still may fall short of the ideal way to manage your retirement money, you must first understand what life-cycle funds are.

—Life-cycle funds are based on two tenets of retirement investing: (1) Investors can and should invest more of their retirement savings in stocks when they are young, because that is when they can afford to take more risk, but as they move closer to retirement age and after retirement, the portfolio mix of equity and fixed-income should tilt toward fixed income; and (2) Investors can increase their expected long-term investment returns significantly by keeping investment costs low, which can be done by using mostly index funds.

		It is easy to understand how life-cycle funds incorporate these two tenets by looking at the Vanguard's life-cycle funds, called Target Retirement funds. Vanguard offers target retirement dates at 5-year intervals. If you are planning to retire around year 2030, you invest in their Target Retirement 2030 fund. Right now, the money you invest in this fund will be allocated about 88% to equity and 12% to fixed income. Of the 88% allocation to equity, about 71% will be invested in domestic stocks through the Vanguard Total Stock Market Index fund, 10% will be allocated to the Vanguard European Stock Index fund, 5% to the Vanguard Pacific Stock Index fund, and 2% to the Vanguard Emerging Market Stock Index fund. The 12% allocation to fixed income will be invested in the Vanguard Total Bond Market Index fund.

		Over the years, the stock allocation is reduced gradually and fixed-income allocation increased until an allocation of 30% to equity and 70% to fixed income is reached, somewhere between 5 years and 10 years after retirement in 2030.

		Because all of the money will be invested in Vanguard's low-cost index funds, your annual investment costs will probably be around 0.3%—a very attractive, low number.

—Should you rush and shift all your retirement savings to such a life-cycle fund if you have the opportunity? Not necessarily. With these funds, you have no control over the allocation between equity and fixed income over the years. If you want to be more or less aggressive than the fund's underlying strategy, you will have to do it yourself, by allocating some of your retirement money into other funds on the side. That defeats the simplicity advantage of life-cycle funds.

		Another consideration is that, within equity, you will probably be better off allocating more money to smaller cap and value stocks, but in most life-cycle funds you will be stuck with a total market index fund, which is heavily weighted in large cap stocks and equally weighted between value and growth stocks. You may also prefer a higher allocation to international and emerging market stocks. Finally, on the fixed income side, you may prefer to keep your average maturities at about 5 years, because studies show that you generally do not get compensated for the higher risk you take by investing in longer-term bonds.

newsletter discusses a retirement option that a number of baby boomers seem to be banking on: their home. Most people plan on using this retirement strategy in a couple of ways. For example, a soon-to-be retiree who bought a house in Washington DC in the 1960s or 1970s for $50,000 now plans to sell it for upwards of $600,000, after which the retiree will relocate to a less expensive region and buy a smaller home, using only a portion of the proceeds from the sale and using the remainder to fund a large portion of his or her retirement expenses. Another example may be someone who currently owns two homes, one being a vacation home that the retiree intends to occupy during retirement. At that time, the principal residence will be sold, and the proceeds will be dedicated to retirement expenses. While these two examples seem solid and foolproof, the article warns of drawbacks and uncertainties. While the house market was booming from 2000 to 2005, it has since declined, and the market at the time of your retirement is uncertain. Prices could fall and homes could be difficult to sell. A home should not be considered a liquid asset, the way a stock or mutual fund is, and surgeon investors should not put all their eggs in that one basket.

		? Dealing with the burden of inheritance

		Today's increasingly complex tax laws can make an inheritance an additional burden for you to bear at a time of grief. Making the wrong financial decision could have irreversible effects. The 

says that an heir who makes rushed decisions on inherited assets could create devastating tax issues or financial problems. Inherited retirement accounts, in particular, can create a huge headache because of the complicated rules and potential tax bites. The 

warns against liquidating an IRA all at once, because it could lead to significant income taxes. For example, rolling over an IRA inherited from your parents into your own retirement account or withdrawing it and depositing it into a new account could lead to a big tax hit if it is not titled properly. Instead, financial advisors recommend you maintain it intact and carefully retitle the IRA as an "inherited IRA" to make it clear to tax authorities that the owner passed away and you are the beneficiary. In a worst case scenario, the 

advises turning down the inheritance altogether if you don't need the money, because an inheritance could cause your own estate to be taxable. The following is a list of some companies that offer services geared toward inheritors:

			Fidelity Investments' Inheritor Services Specialists (800-544-0003)

	? Do your homework and avoid home repair rip-offs

	Almost everyone is good at something, and that is usually why we are employed in a chosen field. Rarely, however, is anyone good at everything, and for busy surgeons, it may not be cost-efficient to do your own household repair work. So, to repair a leaky sink, you hire a plumber, and to install a new outlet, you hire an electrician. But how do you know whether you're getting a good deal when you hire an expert in the home repair field or just getting ripped off? A 

) article offers the following helpful hints for finding the right person for the job:

—The best way to find a reputable plumber is to get a referral. Real estate agents might be your best bet, because many home sales hit a snag due to interior water stains, and agents may know a reputable plumber for your needs. Before hiring, check the plumber's state license and certificate of workers' compensation insurance. Copies of these documents should be shown when you accept a bid. If you suspect a plumbing problem, seek out a plumber before it becomes an emergency-last minute service usually brings top dollar, and some plumbers charge triple on weekends.

	Also, don't buy plumbing parts on your own. You might think you're saving money, but plumbers can purchase supplies at professional discounts of up to 35%. In addition, a plumber might not warranty his work if you do the purchasing. After all, would you want someone else ordering your medical supplies?

—General contractors are your best bet for getting a recommendation on an electrician, because they see the electrician's work before it is covered over by walls and ceilings and will recommend someone they trust. When evaluating an electrician, ask if he or she has handled jobs similar to yours. If so, make certain to check with at least one reference to see whether the job was completed on time and within budget. If an electrician provides you with an estimate, make certain that repair items, such as the cost to repair holes cut in walls, are included. It is also a good idea to learn how to reset a circuit breaker or change a blown fuse yourself, because service calls can cost between $70 and $120 for the first hour.

Surgeon's bulletin board

	These questions are similar to those asked on the American Board of Surgery Recertification Examination. You can use them to prepare for the examination, fulfill learning requirements for various maintenance of competence programs, or simply improve your surgical knowledge. Answers can be seen by following the link at the end of the questions.

Patients no longer need antihypertensive agents

Diabetes improves after only modest weight loss

Quality of life improves, but life expectancy is not lengthened

Fertility is not improved in patients with polycystic ovarian syndrome

Is a branch of the pancreaticoduodenal artery

Is a branch of the superior mesenteric artery

		In a normotensive 78-year-old patient who develops oliguria immediately following a major abdominal procedure, the FIRST step is to		

Increase the rate of crystalloid infusion

		In the anesthesia care of diabetic patients, the major potential problem is		

		In adenocarcinoma of the head of the pancreas		

There is a survival advantage for a palliative Whipple procedure

Survival rates following a curative Whipple procedure average 35%

Extending the excision to include total pancreatectomy improves the survival rates

Most patients develop diabetes after a Whipple procedure

		HNPCC (hereditary nonpolyposis colon cancer)		

Accounts for 20% of carcinomas of the colon

Can be diagnosed only in patients with a strong family history

Also includes carcinomas of the endometrium, stomach, and pancreas

Should be initially treated by CT-guided drainage and antibiotics

Are generally due to infection of a contiguous structure

Are associated with mortality rates of 60% in immunocompromised patients

		Gastric stump cancers (gastric adenocarcinomas in patients who underwent gastric resection)		

		Calf claudication is symptomatic of occlusion of the		

		Characteristics of Budd-Chiari syndrome include all of the following EXCEPT		

Shifts the oxyhemoglobin dissociation curve to the right

Is directly toxic to skeletal and cardiac muscle

Has no effect on oxygen delivery until it reaches 30%

Has minimal direct central nervous system effects

		Loss of sensation in the lateral upper arm just above the elbow is indicative of injury to the		

American Board of Surgery Recertification Examination

	Your editorial on breaks was very good, but breaks should be called "delays in patient care." I have been amazed at how much time is spent on breaks by nurses and physicians, and their lounges are the site of wasted time. This is time that could be spent in the care of the patient. The people who push for breaks are the same ones who would not want a nurse or doctor on a break if one of their family members was the patient. I have noticed how in the medical profession the commandment of "love your neighbor as yourself" has disappeared. Very few health professionals treat the patient as they would like to be treated. It is a sad state of medicine to see patient care take a back seat to breaks and social time. We can start following the Golden Rule by doing away with break rooms and lounges, which are also a source of poor health practices for those in the medical profession. This is where food is served for any occasion. Look at how many nurses and physicians are overweight after years of parties, conferences, and any occasion to eat at work. Let's get back to patient care and return to practicing the Golden Rule of loving your neighbor (or patient) as yourself, which I have done in my 20 years of practice. It has been my observation that physicians speak these words but do not put them into action, and quality patient care in America has disappeared.

	I enjoyed your editorial lamenting the practice of taking breaks and the inconvenience it inflicts on all of us at one time or another. You pointed out that surgeons do not take breaks during operations, but I wonder if perhaps we should. I can think of many times when I have paused during an operation, taking a moment or two to reflect on my next move. This practice was probably not noticed by those working with me, as they saw me examining the surgical site or rearranging retractors, but in fact I was taking a "break" to try to reach a best decision.

	At other times I think a tired surgeon feels "rushed" and acts quickly instead of thoughtfully. Perhaps his (or her) taking a break at such a moment would be a break for the patient as well, allowing a mental regrouping and the formulation of a better thought-out plan of action. In this age of science-based medicine and surgery, perhaps there should be a scientific study of surgeons taking breaks, to see whether doing so benefits their patients. After all, a patient's well-being, rather than our personal comfort, is the only thing that matters.

	I have just taken a "break" between patients to tell you that I found your recent editorial especially cogent. There is little hope for bank tellers and cashiers. My concern is for tomorrow's patients and the care they will receive from today's house officers—the product of an 80-hour work week&mdash;once they have gone into practice and are no longer afforded the breaks (dual meaning) they currently experience. Once there is a critical mass of new graduates, perhaps we will have that revealed to us. As a side note, I also spent time in the United Kingdom, and I look back in astonishment at the pause that we took in the middle of a major abdominal case so that we might have a tea break with the anesthetist.

Editorial: Breaks (March 2007)

	Optimal treatment for adenocarcinoma of the gallbladder is controversial because of the poor prognosis for patients with this disease and the major liver resection and lymphadenectomy that may be necessary for local control. While these operations are relatively safe, they are often contraindicated in patients with poor hepatic reserve or multiple comorbidities. Many patients who develop gallbladder cancer are elderly and poor candidates for aggressive surgical resection. Unfortunately the outcomes for patients treated nonoperatively are extremely poor. Radiofrequency ablation (RFA) is a recently developed and well-described therapy for hepatoma and metastatic colorectal cancer that results in predictable tissue destruction.

	We present the case of an infirm, elderly woman with stage II adenocarcinoma of the gallbladder who was treated successfully with RFA of the gallbladder bed. This modality offers an alternative therapy for patients in whom liver resection would carry a substantial mortality risk.

	A 74-year-old woman with poorly controlled diabetes, hypertension, and cardiac arrhythmias presented to our institution for treatment of gallbladder cancer. She was initially worked up at an outside institution because of right upper quadrant pain. Ultrasonography revealed gallstones and slight thickening of the gallbladder wall, although the gallbladder, periportal areas, and liver appeared normal. The patient underwent an uneventful laparoscopic cholecystectomy, and no suspicious masses were observed. Pathologic evaluation of the gallbladder revealed gallstones and a 1.2-cm focus of moderately differentiated invasive adenocarcinoma with full-thickness involvement of the gallbladder wall but without invasion into the liver; it was staged a T2 NX MX tumor (Figure 1). Computed tomography (CT) scanning of the chest, abdomen, and pelvis was performed approximately 2 weeks later to stage the patient's cancer, and this revealed a 1.9-cm nodule in the right chest. A CT-guided biopsy of the right chest mass found old granulomatous disease with no evidence of malignancy.

	Following normal diagnostic laparoscopy the patient underwent exploratory laparotomy and intraoperative ultrasonography of the liver. No lesions were found during ultrasonography and palpation of the abdominal contents. RFA was performed in the gallbladder bed and the periportal, paraduodenal, and pericaval lymph nodes were resected en bloc. RFA was used twice to ablate the gallbladder bed according to radiofrequency interstitial tissue ablation (RITA) protocol, first with a 4-cm radius of thermal ablation followed by a 3-cm radius (Figure 2).

	The patient's postoperative course was uneventful, and she was discharged to home on postoperative day 6. The pathology report from her node dissection found three lymph nodes, none of which showed evidence of malignancy. Final pathologic and clinical staging of the tumor was T2 N0 M0 (stage II). The patient has undergone follow-up in our outpatient clinic on a monthly basis and is doing well with no evidence of local or distant recurrent disease 18 months postoperatively.

	Gallbladder cancer is a relatively uncommon malignancy in the United States, although its worldwide prevalence varies. It is more common in women than in men, and its incidence increases exponentially with age.

 Patients with gallbladder cancer have poor outcomes due to the disease's propensity for early dissemination, rapid growth, and often late clinical presentation.

 Additionally, the central location of gallbladder adenocarcinoma generally requires extensive liver resection and biliary reconstruction to control the operable disease. Recent reports concerning patients with gallbladder cancer have determined their overall 1- and 5-year survival rates to be at least as low as 14% and 5%, respectively.

 Patients who are not suitable candidates for surgery or those who are treated nonoperatively generally fare the worst, with a 5-year survival rate lower than 5%.

 Over the past 10 to 15 years, high-volume hepatobiliary centers have shown that major liver resection and biliary reconstruction can be performed safely in patients with gallbladder cancer, producing perioperative mortality rates of 0% to 5% and an improved 5-year rate of survival.

 The questions remain, however, as to which patients are appropriate candidates for radical surgical resection and which types of resection offer the best patient outcomes.

	The advent of laparoscopic cholecystectomy as the standard of care for non-malignant disease of the gallbladder has resulted in an increasing number of patients whose gallbladder cancer is found incidentally on histopathologic evaluation of the resected gallbladder.

 Deciding whether a more radical resection is appropriate for these patients depends on the depth of the tumor's invasion and the preoperative functional status of the patient.

Given the advanced age of many patients at diagnosis, it is not always possible to offer curative resection since this often involves extensive liver resection and regional lymphadenectomy which often confers prohibitive morbidity in this patient population.

	In recent years, destruction of liver tumors using methods such as cryoablation, ethanol injection, and RFA have been examined as alternatives to liver resection for various types of cancer. Increasingly, RFA is being investigated for this purpose, because it has been shown to be relatively safe and effective at causing tumor necrosis.

 Mortality rates following RFA of liver lesions have been reported as 0.5%, with rates of complication reported as 7% to 9%.

 Most of the current literature has evaluated the use of RFA in patients with hepatocellular carcinoma or metastatic colorectal and neuroendocrine cancer. Ablative modalities are especially useful in those patients whose significant underlying liver disease precludes hepatic resection.

 There are few randomized controlled clinical trials evaluating the long-term survival of patients whose liver tumors have been treated with RFA. A 2004 study showed limited benefit to providing RFA over chemotherapy alone for metastatic colorectal cancer.

	Navarra and colleagues authored the only report regarding the use of RFA as a treatment modality for gallbladder cancer. The patient was a 66-year-old Jehovah's Witness with a T1b tumor that was found incidentally after laparoscopic cholecystectomy

 After undergoing RFA of the gallbladder bed the patient had follow-up examinations for 9 months and remained disease-free. The patient's refusal of liver resection in the face of full-thickness tumor invasion of the gallbladder wall left few treatment options. Although 9 months is too short a follow-up to comment on the long-term success of this treatment, Navarra and colleagues' report nevertheless demonstrates a plausible alternative to surgery in patients who cannot tolerate or are unwilling to undergo definitive surgical treatment.

	Our patient's significant comorbidities convinced us that a liver resection would confer prohibitive risk. The depth of tumor invasion and the lesion's location were instrumental in helping us determine whether our patient was an appropriate candidate for RFA. We also assured ourselves intraoperatively that the structures in the porta hepatis (particularly the proximal bifurcation of the bile ducts) were located far enough away from the gallbladder bed that they would not be damaged by the probe. Biliary strictures and fistulas have been reported following RFA of liver lesions in this central portion of the liver at the confluence of segments IV and V.

	Not every patient with gallbladder cancer is a suitable candidate for treatment with RFA. Clearly, younger individuals with greater hepatic reserve should be considered for attempted curative resection, because this procedure significantly improves survival for patients with T2 and T3 cancers. RFA done in the context of oncologic principles of negative margins offers an alternative for those patients who are unable to undergo such an extensive operation. RFA is an important, evolving, adjunctive treatment for many types of cancer. Formal, prospective studies are needed to determine the long-term efficacy of this treatment modality in treating patients with gallbladder cancer.

		Misra S, Chaturvedi A, Misra NC, et al. Carcinoma of the gallbladder. 

		Michaud DS. The epidemiology of pancreatic, gallbladder, and other biliary tract cancers. 

		Shoup M, Fong Y. Surgical indications and extent of resection in gallbladder cancer. 

		Cubertafond P, Gainant A, Cucchiaro G. Surgical treatment of 724 carcinomas of the gallbladder. Results of the French Surgical Association Survey. 

		Fong Y, Jarnagin W, Blumgart LH. Gallbladder cancer: comparison of patients presenting initially for definitive operation with those presenting after prior noncurative intervention. 

		Bartlett DL, Fong Y, Fortner JG, et al. Long-term results after resection for gallbladder cancer. Implications for staging and management. 

		Donohue JH, Nagorney DM, Grant CS, et al. Carcinoma of the gallbladder. Does radical resection improve outcome? 

		Onoyama H, Yamamoto M, Tseng A, et al. Extended cholecystectomy for carcinoma of the gallbladder. 

		Romano F, Franciosi C, Caprotti R, et al. Laparoscopic cholecystectomy and unsuspected gallbladder cancer. 

		Gillams AR. Radiofrequency ablation in the management of liver tumours. 

		Scudamore CH, Lee SI, Patterson EJ, et al. Radiofrequency ablation followed by resection of malignant liver tumors. 

		Curley SA, Marra P, Beaty K, et al. Early and late complications after radiofrequency ablation of malignant liver tumors in 608 patients. 

		Mulier S, Mulier P, Ni Y, et al. Complications of radiofrequency coagulation of liver tumours. 

		Decadt B, Siriwardena AK. Radiofrequency ablation of liver tumours: systematic review. 

		Podnos YD, Henry G, Ortiz JA, et al. Laparoscopic ultrasound with radiofrequency ablation in cirrhotic patients with hepatocellular carcinoma: technique and technical considerations. 

		Abdalla EK, Vauthey JN, Ellis LM, et al. Recurrence and outcomes following hepatic resection, radiofrequency ablation, and combined resection/ablation for colorectal liver metastases. 

		Navarra G, Jiao LR, Weber JC, et al. A novel approach to gallbladder cancer in a Jehovah's Witness. 

Michele McElroy, General Surgery Resident, Department of Surgery, University of California San Diego, General Surgery Resident, Department of General Oncologic Surgery, Section of Hepatobiliary Cancer, City of Hope National Medical Center, Duarte, CA; Yale D. Podnos, Clinical Surgical Fellow, Department of General Oncologic Surgery, Section of Hepatobiliary Cancer, City of Hope National Medical Center, Duarte, CA; Lawrence D. Wagman,

Is radiofrequency ablation an acceptable alternative to resection for gallbladder cancer?

	Soft tissue sarcomas are very rare. Approximately 5,000 to 6,000 new cases are diagnosed annually in the United States, and these tumors account for 1% of adult malignancies.

 Malignant cartilaginous tumors that are not connected to bone are called extraskeletal chondrosarcomas. These lesions are extremely rare and comprise 1% to 2% of all malignant soft tissue tumors.

 This neoplasm differs from other forms of chondrosarcoma in that the preponderance of occurrences are in young adults, generally those between the ages of 15 and 35 years, with a slightly higher incidence in women.

 Although multiple predisposing factors have been identified such as genetic diseases, radiation exposure, certain chemical agents, lymphedema, and trauma, no specific etiology has been found.

	Clinical symptoms depend on the tumor's location. Distant metastases are usually observed in the lungs.

 Computed tomography (CT) scans, plain radiographs, and magnetic resonance imaging (MRI) are used to outline the mass before surgery. Angiography and bone scintigraphy may be used to determine whether bones and vessels have been affected.

	Treatment is radical wide excision of the mass and adjuvant chemotherapy.

Radiation therapy is recommended if the tumor cannot be completely removed.

Because extraskeletal chondrosarcomas are highly malignant, the 2-year rate of survival is around 50%.

	A 75-year-old woman presented with a 6-month history of a mass in her right thigh. There was no history of trauma or radiation exposure, and the patient thought the mass was a hematoma that might resolve. The lesion, however, continued to enlarge and started to cause discomfort. On clinical examination, a firm, nontender, 20 x 15-cm mass was palpated in the left medial thigh. The mass was mobile and was not fixed to the skin. There was no edema, erythema, ecchymosis, lymphadenopathy compromise in peripheral circulation, or other significant clinical findings. The patient's only symptom was minimal discomfort because of the size of the mass.

	The CT scan and MRI revealed no bony involvement (Figure 1). A CT scan of the chest showed multiple bilateral pulmonary nodules; the largest one was in the postero-basilar segment of the left lower lobe and measured 17 mm (Figure 2). These nodules were considered to be metastatic disease from the patient's primary tumor in her left thigh. Coronal and axial T1- and T2-weighted fast-spin-echo MRIs without fat suppression were taken of the lower extremities and showed a large mass in the adductor compartment of the left thigh, measuring approximately 13.4 cm and with a transverse diameter of 11 x 9.6 cm (Figure 3). Craniocaudal views, which were heterogeneous in T1 and T2 signals and showed T2 hyperintensity, suggested necrosis with no bone abnormality or involvement of the adjacent muscles in the posterior or anterior compartments of the thigh. No bone marrow signal abnormality was seen.

	Radical excision of the mass was performed with 2-cm margins all around. No breach of the tumor capsule was noted and good margins were present. Histologically, all margins were confirmed to be tumor-free. Microscopic evaluation revealed a biomorphic pattern composed of undifferentiated round or oval cells resembling embryonal mesenchyme and well-differentiated cartilaginous tissue, which is a characteristic finding of extraskeletal mesenchymal chondrosarcoma (Figure 4). Immunohistochemically the cells in the chondroid areas were positive for S100 protein, but the tumor cells were negative for cytokeratin, actin, desmin, CD34, and factor VIII. The patient did not undergo adjuvant therapy.

	Lightenstein and Bernstein first described mesenchymal chondrosarcomas in 1959, and Dowling reported the first case of an extraskeletal mesenchymal chondrosarcoma in 1964.

 Extraskeletal mesenchymal chondrosarcomas are extremely rare, fully malignant tumors with an obscure etiology. It is commonly thought that a history of trauma could be a predisposing factor for soft tissue sarcomas. Extraskeletal mesenchymal chondrosarcomas involve muscles or the central nervous system.

 These tumors usually occur intracranially in the spinal meninx and orbita. Occasionally they occur in unexpected organs, such as the abdominal wall, thyroid perineum, and heart.

Clinical symptoms depend on the tumor's location. Intracranial or spinal processes may cause vomiting, headache, and various sensory and motor symptoms. Intraorbital tumors may cause exophthalmus and visual impairment. Intramuscular processes cause a slow painless swelling.

	Diagnosis of extraskeletal mesenchymal chondrosarcomas is often delayed because these tumors are generally painless. The most common differential diagnosis includes hematoma or pulled muscle.

 The physician must consider the size of the mass and its relationship to other structures. In adults, any soft tissue mass of the extremities that is symptomatic, larger than 5 cm, or enlarging, and any new mass that persists beyond 4 weeks, should be studied carefully, preferably using imaging studies followed by incisional biopsy.

 Fine-needle aspiration biopsy has no role in diagnosis.

 True-cut core biopsies have been found to have accuracy rates of 98% for diagnosing malignancy and 94% for diagnosing sarcoma.

 Foci of calcifications of the mass typically can be seen on plain radiography and CT scans. MRI is usually performed because it provides three-dimensional images that help in planning surgical management. The lungs are the prime site for metastasis for extremity lesions, and a CT scan of the chest is useful to detect possible metastasis in the early period of the disease. Angiography is not recommended because it does not change the treatment strategy.

	The differential diagnosis of extraskeletal mesenchymal chondrosarcoma should include extraskeletal chondroma, synovial sarcoma, extraosseous osteosarcoma, and extraosseous myxoid chondrosarcoma. Currently, an extraskeletal chondrosarcoma is morphologically classified as either an extraskeletal myxoid chondrosarcoma or an extraskeletal mesenchymal chondrosarcoma. It is generally agreed that the mesenchymal variety carries a worse prognosis than its myxoid counterpart because it is metastatic in most cases.

	Pathologically, the main difference between extraskeletal myxoid chondrosarcoma and extraskeletal mesenchymal chondrosarcoma is that myxoid lesions include variable amounts of mucoid material in a myxoid stroma, and mesenchymal lesions include undifferentiated mesenchymal cells and cartilaginous tumor cells.

 Our patient's extraskeletal chondrosarcoma was the mesenchymal type. Grossly, on cut surface, the tumor will show a mixture of soft gray tissue and irregularly sized cartilage and in some cases, bone. Microscopically, it is composed of undifferentiated mesenchymal cells and well-differentiated cartilaginous tissue, usually with central calcification. Immunohistochemically, S100 protein is often found to be positive, but the tumor cells do not express desmin, actin, or cytokeratin.

	S100 protein is a calcium-binding protein and is commonly expressed in peripheral nerve tumors, such as schwannomas, neurofibromas, neurogenic sarcomas, and some carcinoid tumors. Nakajima and associates also found S100 expressed by some other tumors, including chondrosarcomas, salivary gland pleomorphic adenomas, and Langerhans cell granulomatosis. Their study shows that S100 protein is not strictly specific to nervous tissue and its associated tumors; however, S100 positivity still can be useful in diagnosing extraskeletal mesenchymal chondrosarcomas.

	Recommended treatment is complete excision of the mass and systemic chemotherapy with or without local radiotherapy. When possible, the tumor must be excised with 2- to 3-cm margins of normal tissue, and meticulous attention must be taken to avoid major neurovascular injury during the dissection. There is a high rate of local recurrence if there is a positive margin after resection.

 For extremity tumors, extrapulmonary metastases are uncommon, but regional lymph node metastasis may be observed.

 Patients should undergo thoracotomy with the intent of resecting all disease if they have controllable primary tumors, no extrathoracic disease, are medically fit for thoracotomy, and have lung disease that appears to be completely resectable.

 Patients with unresectable pulmonary metastases or extrapulmonary metastatic sarcoma are best treated with systemic chemotherapy

	Despite optimal multimodal therapy, at least one third of patients develop recurrent disease after a median disease-free interval of 18 months. Prognosis depends on several factors, including size, histological grade, and localization of the tumor; the presence of distant metastasis; and the sufficiency of the operation.

 The 10-year survival rate has been determined to be 28% with resection.

 Because local recurrence or metastases may be observed many years after a patient is rendered disease-free, long-term follow-up is necessary. It is recommended that follow-up include CT scans of the lungs and MRIs of the area of resection every 4 months for the first 3 years and then with decreasing frequency for as many as 20 years.

	Extraskeletal mesenchymal chondrosarcoma is a rare form of sarcoma that is not connected to bone, but typically involves the muscles or central nervous system. These tumors are generally painless, contributing to the frequent delays in their diagnosis. CT scanning, MRI, and plain radiographs may identify these lesions. Complete excision of the mass is recommended along with systemic chemotherapy and possible local radiotherapy. Frequent and thorough follow-up examinations are required because of the highly malignant nature of extraskeletal mesenchymal chondrosarcomas.

Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 

Philadelphia, Pa: WB Saunders; 1997:528-534.

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		Guccion JG, Font RL, Enzigner FM, et al. Extraskeletal mesenchymal chondrosarcoma. 

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		Morimura Y, Fujimori K, Sato T, et al. Imprint cytology of extraskeletal mesenchymal chondrosarcoma of the perineum: a case report. 

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		Ball AB, Fisher C, Pittam M, et al. Diagnosis of soft tissue tumors by Tru-Cut biopsy. 

Stamford, Conn: Appleton & Lange; 1998:182-183.

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		Rosenberg SA, Tepper J, Glatstein E, et al. The treatment of soft-tissue sarcomas of the extremities: prospective randomized evaluations of (1) limb-sparing surgery plus radiation therapy compared with amputation and (2) the role of adjuvant chemotherapy. 

Surgical Management of Soft Tissue Sarcoma. 

Philadelphia, Pa: Lea & Febiger; 1989:64-76.

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		Leggon RE, Munro M, Schuerch C. Thigh mass in a 52-year-old woman. 

Kadir K. Bas, Visiting Surgical Research Fellow, Department of Surgery; Anil M. Bahadursingh, Assistant Professor of Surgery, Department of Surgery, St. Louis University School of Medicine, St. Louis, MO

Extraskeletal mesenchymal chondrosarcoma of the thigh

Clean operative procedures, such as thyroidectomy, rarely result in wound infections; thus, there are no definitive guidelines or recommendations regarding antibiotic prophylaxis for such procedures. At the authors' institution, it is common practice not to administer antibiotic prophylaxis for clean cases. The authors report their experience with a patient who had multiple comorbidities and developed a surgical site infection after undergoing thyroidectomy. The authors review the current literature regarding antibiotic prophylaxis for patients undergoing such clean procedures and find that risk factors for wound infection should be considered before a decision is made.

	Wound infections after thyroidectomy are uncommon, with reports in the literature documenting an incidence that varies from 0.1% to 2%.

 Clean wounds are defined as operative wounds that have been closed primarily and in which no inflammation has been encountered. By definition, a viscus (respiratory, alimentary, and genital or urinary tract) is not entered during a clean procedure, and such wounds have an infection rate that ranges from 1.3% to 2.9%.

 Whether clean or not, the risk of infection increases when various patient-related risk factors are present, such as immunosuppression, obesity, and diabetes. Guidelines and recommendations regarding antibiotic prophylaxis for clean cases vary since no randomized trials have provided definitive answers. We report a case of a surgical site infection after thyroidectomy in a morbidly obese woman on immunosuppressive therapy.

	A 51-year-old morbidly obese woman with a history of hepatitis C, hypertension, gout, and end-stage renal disease presented with a right neck mass, which she had first noticed approximately 1 year earlier. She was asymptomatic, reporting no pain or effect on breathing, speaking, or swallowing. She had no symptoms of hyperthyroidism or hypothyroidism. She also noted no previous exposure to radiation. She was on mycophenolate and prednisone therapy because of a cadaveric renal transplant. Her family history was significant for a daughter who had a thyroidectomy for a benign nodule.

	On physical examination, the patient had a cushingoid appearance, no exophthalmos, and a firm, 3-cm mass in the right lobe of the thyroid with no palpable lymphadenopathy. Her thyroid-stimulating hormone was within the normal range at 3.5 mIU/mL (normal, 0.5-5.0 mIU/mL), and ultrasonography revealed a solid hypoechoic mass measuring 3.5 x 4.5 x 3.0 cm. A fine needle aspiration of the thyroid mass was suspicious for papillary carcinoma.

Alexander J. Greenstein, Resident, Department of Surgery; Celia M. Divino, Chief, Division of General Surgery, Department of Surgery; Kaare J. Weber, Assistant Professor of Surgery, Department of Surgery, Mount Sinai School of Medicine, New York, NY

June 2007

June Challenge: Can you diagnose this breast lesion?

Surgeon's bulletin board

American Board of Surgery Recertification Examination

Editorial: Breaks (March 2007)

Is radiofrequency ablation an acceptable alternative to resection for gallbladder cancer?

Extraskeletal mesenchymal chondrosarcoma of the thigh

Identifying preoperative risk factors for surgical wound infections in clean cases

Adenocarcinoma and high-grade dysplasia of a Brooke ileostomy decades after total proctocolectomy

Normocalcemic primary hyperparathyroidism: How new technology affects an old diagnosis

Calciphylaxis and primary hyperparathyroidism in a patient with normal renal function

The vertical hour