Different approaches to caudate lobectomy with ＂curettage and aspiration＂ technique using a special instrument PMOD： A Report of 76 cases

AIM: To study different approaches to caudate lobectomy with “curettage and aspiration“ technique using Peng‘‘s multifunctional operative dissector (PMOD). The surgical procedure of isolated complete caudate Iobectomy was specially discussed. METHODS: In 76 cases of various types of caudate lobectomy, three approaches were used including left side approach, right side approach, and anterior approach. Among the 76 cases, isolated complete caudate Iobectomy was carried out in 6 cases with transhepatic anterior approach. The surgical procedure consisted of mobilization of the total liver, ligation and separation of the short hepatic veins, splitting the liver parenchyma through the Cantlie‘‘s plane, ligation and division of the caudate portal triads from the hilum, dissection of the root of major hepatic veins, detachment of the caudate lobe from liver parenchyma. RESULTS: The mean operative time was 285±51 min, the mean blood loss was 1 600 ml. No severe complications were observed. Among the 6 cases receiving isolated complete caudate Iobectomy with transhepatic anterior approach, one case died 17 months after operation due to disease recurrence and liver failure, the other 5 cases have been alive without recurrence, with one longest survival of 49 months. CONCLUSION: The choice of approach is essential to the success of caudate lobectomy. As PMOD and “curettageand aspiration“ technique can delineate intrahepatic or extrahepatic vessels clearly, caudate lobe resection has become safer, easier and faster.     

Resection of hepatic caudate lobe hemangioma: experience with 11 patients

BACKGROUND:Caudate lobectomy is now considered to be the most appropriate surgical treatment for benign tumors in the caudate lobe.But how to resect the caudate lobe safely is a major challenge to current liver surgery and requires further study.This research aimed to analyze the perioperative factors and explore the surgical technique associated with liver resection in hepatic caudate lobe hemangioma.METHODS:Eleven consecutive patients with symptomatic hepatic hemangiomas undergoing caudate lobectomy from November 1990 to August 2009 at our hospital were investigated retrospectively.All patients were followed up to the present.RESULTS:In this series,9 were subjected to isolated caudate lobectomy and 2 to additional caudate lobectomy(in addition to left lobe and right lobe resection,respectively).The average maximum diameter of tumors was 9.65±4.11 cm.The average operative time was 232.73±72.16 minutes.Five of the 11 patients required transfusion of blood or blood products during surgery.Ascites occurred in l patient,pleural effusion in the perioperative period in 1,and multiple organ failure in l on the 6th day after operation as a result of massive intraoperative blood loss,who had received multiple transcatheter hepatic arterial embolization preoperatively.The alternating left-right-left approach produced the best results for caudate lobe surgery in most of our cases.All patients who recovered from the operation are living well and asymptomatic.CONCLUSIONS:For large hemangioma of the caudate lobe,surgery is only recommended for symptomatic cases.Caudate lobectomy of hepatic hemangioma can be performed safely,provided it is carried out with optimized perioperative management and innovative surgical technique.     

A new approach to the surgical treatment of parasitic cysts of the liver： Hepatectomy using the liver hanging maneuver

AIM： To review 11 patients with parasitic cysts of the liver, who were treated by hepatic Iobectomy using the liver hanging maneuver （LHM）.
METHODS： Between January 2003 and June 2006, we retrospectively analyzed patients who underwent surgical treatment due to parasitic cysts of the liver, at the Ege University School of Medicine, Department of General Surgery. Of these, the patients who underwent hepatic lobectomy using the LHM were reviewed and evaluated for surgical treatment outcome.
RESULTS： Over a three-year period, there were 102 patients who underwent surgical treatment for parasitic cysts of the liver. Of these, 11 （10%） patients with parasitic cysts of the liver underwent hepatic Iobectomy using the LHM. Presenting symptoms were abdominal pain, dyspepsia, and cholangitis. Cyst locations were as follows： right lobe filled with cyst, 7 （63%）; segmental location, 2 （18%）; and multiple locations, 2 patients （18%）. All patients underwent hepatic Iobectomy with an anterior approach using the LHM. The intraoperative blood transfusion requirement was one unit for 3 patients and two units for one patient. Postoperative complications included pulmonary atelectasy （2, 18%） and pleural effusion （2, 18%）. No significant morbidity or mortality was observed.
CONCLUSION： We concluded that hepatic Iobectomy using the LHM should be considered, not only for hepatic tumors or donor hepatectomy, but also to treat parasitic cysts of the liver.     

Hepatectomy after primary repair of ruptured liver cancer

BACKGROUND: Spontaneous rupture of liver tumor is often considered a potentially life-threatening situation. The aim of the present study was to assess re-operation after emergency repair of ruptured liver cancer. METHODS: We reviewed retrospectively five patients who had been admitted within a one-year period and undergone a second operation after emergency repair of primary liver cancer rupture. RESULTS: Five patients (4 males and 1 female) underwent emergency repair of ruptured liver cancer in local hospitals; three of them received transarterial chemoembolization (TACE). The tumor was in the right hepatic lobe in 2 patients, middle lobe in 1, left median lobe (segment Ⅳ) in 1, and caudate lobe (segment Ⅰ) in 1. Operative methods included right hemihepatectomy in 2 patients, left partial lobectomy or wedge resection in 1, caudate lobe resection in 1, and middle lobctomy+cho-lecystectomy+abdominal implant resection in 1. Intra-abdominal chemotherapy was given to all 5 patients. Follow-up showed that one patient died from intrahepatic metastasis and hepatic failure six months after re-operation and that two patients died from extensive intra-abdominal metastases six months later. The remaining two patients have been surviving for 28 months. CONCLUSIONS: Re-operation is indicated for patients with primary liver cancer rupture whose liver function is good and whose foci are localized and operable. Apart from removing the primary foci, it is necessary to clearabdominal metastatic foci, irrigate the abdomen and administer chemotherapy to prolong the patient's life.     

Addition of hepatectomy decreases liver recurrence and leads to long survival in hilar cholangiocarcinoma

AIM： To evaluate hepatic recurrence and prognostic factors for survival in patients with surgically resected hilar cholangiocarcinoma in a single institution over the last 13 years. METHODS： From 1994 to 2007, all patients with hilar cholangiocarcinoma referred to a surgical clinic were evaluated. Demographic data, tumor characteristics, and outcome were analyzed retrospectively. Outcome was compared in patients who underwent additional liver resection with resection of the tumor. RESULTS： Of the 69 patients submitted to laparotomy for tumor resection, curative resection （Ro resection） was performed in 40 patients, and palliative resection in 29. Thirty-one patients had only duct resection, and 38 patients had combined duct resection with liver resection including 34 total or part caudate lobes. Curative rates with the combined hepatectomy were significantly improved compared with those without additional hepatectomy （27/38 vs 13/31; X^2 = 5.94, P 〈 0.05）. Concomitant liver resection was associated with a decreased incidence of initial recurrence in liver one year after surgery （11/38 vs 23/31; X^2 = 13.98, P 〈 0.01）. The 3-year survival rate after Ro resection was 30.7% and was 10.5% for palliative resection. R0 resection improved the 3-year survival rate （30.7% vs 10.5%; X^2 = 12.47, P 〈 0.01）.CONCLUSION： Hepatectomy, especially including the caudate lobe combined with bile duct resection should be considered standard treatment to cure hilar cholangiocarcinoma.     

Technical note on ALPPS for a patient with ad-vanced hepatocellular carcinoma associated with invasion of the inferior vena cava

Patients with hepatocellular carcinoma have a very short life expectancy if they receive no surgical interven-tion. A relatively new surgical technique termed “Associating Liver Partition and Portal Vein Ligation for Staged Hepa-tectomy” (ALPPS) has been employed for inducing rapid hypertrophy of the future liver remnant for patients waiting for hepatectomy. As portal vein embolization may not result in satisfactory hypertrophy before tumor progression occurs, ALPPS can be an alternative for patients with advanced hepa-tocellular carcinoma. Herein we describe an ALPPS procedure with tumor thrombectomy for a patient who had a small left liver lobe and a large hepatocellular carcinoma involving the whole right liver lobe and the middle hepatic vein and extend-ing into the inferior vena cava. In the ifrst-stage operation, the right portal vein was controlled and divided with a Hemolock. The right hepatic artery was well protected. Hepatic transec-tion was performed with a 1-cm margin from the tumor. The middle hepatic vein trunk was preserved. Ten days afterwards, there was signiifcant hypertrophy of the left lateral section of the liver, and the second-stage operation was conducted. Ex-tended right hepatectomy and tumor thrombectomy were per-formed under sternotomy and total vascular exclusion. The patient had good recovery and was free of disease 10 months after the operation. ALPPS may be a good treatment option even for patients with advanced disease if carried out at high-volume centers.     

Extrahepatic collaterals and liver damage in embolotherapy for ruptured hepatic artery pseudoaneurysm following hepatobiliary pancreatic surgery

AIM： To evaluate the effects of extrahepatic collaterals to the liver on liver damage and patient outcome after embolotherapy for the ruptured hepatic artery pseudoaneurysm following hepatobiliary pancreatic surgery.
METHODS： We reviewed 9 patients who underwent transcatheter arterial embolization （TAE） for the ruptured hepatic artery pseudoaneurysm following major hepatobiliary pancreatic surgery between June 1992 and April 2006. We paid special attention to the extrahepatic arterial collaterals to the liver which may affect post-TAE liver damage and patient outcome.
RESULTS： The underlying diseases were all malignancies, and the surgical procedures included hepatopancreatoduodenectomy in 2 patients, hepatic resection with removal of the bile duct in 5, and pancreaticoduodenectomy in 2. A total of 11 pseudoaneurysm developed： 4 in the common hepatic artery, 4 in the proper hepatic artery, and 3 in the right hepatic artery. Successful hemostasis was accomplished with the initial TAE in all patients, except for 1. Extrahepatic arterial pathways to the liver, including the right inferior phrenic artery, the jejunal branches, and the aberrant left hepatic artery, were identified in 8 of the 9 patients after the completion of TAE. The development of collaterals depended on the extent of liver mobilization during the hepatic resection, the postoperative period, the presence or absence of an aberrant left hepatic artery, and the concomitant arterial stenosis adjacent to the pseudoaneurysm. The liver tolerated TAE without significant consequences when at least one of the collaterals from the inferior phrenic artery or the aberrant left hepatic artery was present. One patient, however, with no extrahepatic collaterals died of liver failure due to total liver necrosis 9 d after TAE.
CONCLUSION： When TAE is performed on ruptured hepatic artery pseudoaneurysm, reduced collateral pathways to the liver created by the primary surgical procedure and a short postoperative interval may lead to an unfavorable ou     

Efficacy of multislice computed tomography for gastroenteric and hepatic surgeries

AIM: To determine the efficacy of multislice CT for gastroenteric and hepatic surgery. METHODS: Dual-phase helical computed tomography was performed in 50 of 51 patients who underwent gastroenteric and hepatic surgeries. Twenty-eight, eighteen and four patients suffering from colorectal cancer, gastric cancer, and liver cancer respectively underwent colorectal surgery (laparoscopic surgery: 6 cases), gastrectomy, and hepatectomy. Three-dimensional computed tomography imaging of the inferior mesenteric artery, celiac artery and hepatic artery was performed. And in the follow-up examination of postoperative patients, multiplanar reconstruction image was made in case of need. RESULTS: Scans in 50 patients were technically satisfactory and included in the analysis. Depiction of major visceral arteries, which were important for surgery and other treatments, could be done in all patients. Preoperative visualization of the left colic artery and sigmoidal arteries, the celiac artery and its branches, and hepatic artery was very useful to lymph node dissection, the planning of a reservoir and hepatectomy. And multiplanar reconstruction image was helpful to diagnosis for the postoperative follow-up of patients. CONCLUSION: Three-dimensional volume rendering or multiplanar reconstruction imaging performed by multislice computed tomography was very useful for gastroenteric and hepatic surgeries.     

Surgical management in biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury

AIM: To discuss the surgical method and skill of biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury. METHODS: From November 2005 to December 2006, eight patients with biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury were admitted to our hospital. Their clinical data were analyzed retrospectively. RESULTS: Bile duct injury was caused by cholecys- tectomy in the eight cases, including seven cases with laparoscopic cholecystectomy and one with mini- incision choleystectomy. According to the classification of Strasberg, type E1 injury was found in one patient, type E2 injury in three, type E3 injury in two and type E4 injury in two patients. Both of the type E4 injury patients also had a vascular lesion of the hepatic artery. Six patients received Roux-en-Y hepaticojejunostomy for the second time, and one of them who had type E4 injury with the right hepatic artery disruption received right hepatectomy afterward. One patient who had type E4 injury with the proper hepatic artery lesion underwent liver transplantation, and the remaining one with type E3 injury received external biliary drainage. All the patients recovered fairly well postoperatively. CONCLUSION: Roux-en-Y hepaticojejunostomy is still the main approach for such failed surgical cases with bile duct injury. Special attention should be paid to concomitant vascular injury in these cases. The optimal timing and meticulous and excellent skills are essential to the success in this surgery.     

Resection of a locally advanced hilar tumor and the hepatic artery after stepwise hepatic arterial embolization： A case report

We herein report a case of a hilar tumor with extensive invasion to the proper hepatic artery, which was successfully treated with a radical resection in a 57-year-old female patient after a stepwise hepatic arterial embolization. She underwent right colectomy and partial hepatectomy for advanced colon cancer two years ago and radiofrequency ablation therapy for a liver metastasis one year ago, respectively. A recurrent tumor was noted around the proper hepatic artery with invasion to the left hepatic duct and right hepatic artery 7 mo previously. We planned a radical resection for the patient 5 mo after the absence of tumor progression was confirmed while he was undergoing chemotherapy. To avoid surgery-related liver failure, we tried to promote the formation of collateral hepatic arteries after stepwise arterial embolization of the posterior and anterior hepatic arteries two weeks apart. Finally, the proper hepatic artery was occluded after formation of collateral flow from the inferior phrenic and superior mesenteric arteries was confirmed. One month later, a left hepatectomy with hepatic arterial resection was successfully performed without any major complications.     

Isolated resection of the caudate lobe: indications, technique and results

BACKGROUND/AIMS: This paper reports a series of 24 isolated caudate lobe resections (ICLR), performed for 13 benign tumors (10 hemangiomas, 2 focal nodular hyperplasias, 1 adenoma) and 11 malignant tumors (3 hepatocarcinomas, 1 peripheral cholangiocarcinoma and 7 metastatic - 5 colorectal carcinomas, 1 breast carcinoma, 1 adrenal carcinoma). Klatskin tumors were excluded. METHODOLOGY: There were 10 hemangioma enucleations, 7 Spiegel lobe resections and 7 high dorsal resections. Total vascular exclusion was performed in 7 cases. Vascular resection with reconstruction was necessary in 5 cases. RESULTS: Complications occurred in 7 cases (3 bile leaks, 3 abdominal fluid collections and one liver failure leading to death). From the 10 patients with malignant tumors who survived the operation, 7 developed recurrences: 2 intrahepatic, 1 retroperitoneal, 4 systemic. Five patients are alive (3 without recurrence). One patient died of multiple complications after a repeat hepatectomy and colectomy. Three patients died from generalized disease. Another patient, with generalized disease, was lost from follow-up. CONCLUSIONS: ICLR is a difficult operation, especially with malignant tumors. Total vascular exclusion of the liver is routinely recommended in high dorsal resection. Malignant tumors located in the caudate lobe have a poor prognosis; local and, especially, distant metastases are frequent. Aggressive chemotherapy and follow-up are recommended.     

Extracorporeal bypass using a centrifugal pump during resection of malignant liver tumors.

BACKGROUND/AIMS: Total hepatic vascular exclusion (THVE) during extracorporeal bypass is used for hepatic resection in patients with malignant liver tumors. The aim of this study was to determine the efficacy of hepatectomy during total hepatic vascular exclusion using a centrifugal pump (Bio-pump). METHODOLOGY: Fourteen patients with malignant liver tumors who underwent hepatectomy during total hepatic vascular exclusion using the Bio-pump were studied retrospectively. RESULTS: In 3 of 14 patients, insufficient hepatic vascular exclusion was achieved. Six patients underwent tumor resection during total hepatic vascular exclusion, without extracorporeal bypass. In the remaining 5 patients, flow exclusion averaging 1500 ml was achieved with the Bio-pump, and hepatectomy was performed during the procedure. In these 5 patients, the mean operative time and blood loss were 11 hours 38 minutes and 6850 +/- 2451 ml. The Bio-pump bypass time, the excluded blood flow and the mean blood pressure were 82 minutes, 1650 ml and 108/53 mmHg, respectively. The arterial ketone body ratio (AKBR) decreased from a pre-operative value of 1.85-0.32 during total hepatic vascular exclusion. CONCLUSIONS: Total hepatic vascular exclusion was useful for hepatectomy in patients with tumor invasion into the hepatic vein and inferior vena cava, or tumor thrombus in the inferior vena cava and right atrium. However, this technique did not decrease blood loss or improve outcome in patients undergoing hepatectomy.     

Laparoscopic extended right hepatectomy for posterior and completely caudate massive liver tumor (with videos)

<正>To the Editor: Liver tumor may occur in any hepatic segment or lobe, and thus the liver resection is individualized as per the location and size of the tumor. In addition, the resection of the posterior and caudate lobes of the liver is especially difficult amongst all types of hepatectomy. Kawaguchi et al. believed that the laparoscopic resection of right posterior liver lobe was a difficult surgical procedure [1].     

肝断面血流阻断器在肝癌切除术中的应用

目的:比较不同的肝血流阻断方法在肝切除术中应用的有效性及安全性.方法:回顾性分析我院2004-2009年117例行肝切除术的肝癌患者的相关资料.A组:自制肝断面血流阻断器局部血流控制(n=42);B组:解剖性半肝血流阻断(n=35);C组:第一肝门阻断(Pringle法,n=40).比较3组患者术中出血量和手术时间、术后肝功能的恢复以及术后并发症的发生率.结果:术中出血量和手术时间A组均明显少于B(P=0.026,P<0.001)、C(P<0.001,P<0.001)组.A组术后第3、7天肝功能(TB、ALT)的明显好于C组(TB:P=0.014,=0.009;ALT:P<0.001,P<0.001).C组术后有29例出现不同程度的腹水,术后腹水发生率显著高于A组(P<0.001);2例发生肝功能衰竭,1例出现胃肠道出血,死亡1例.结论:肝切除术中采用肝断面血流阻断器能有效控制出血、缩短手术时间,对肝功能影响小,是一种简便、安全有效的方法.     

Hepatic resection for colorectal metastases in the caudate lobe of the liver

Although hepatic resections for colorectal metastases have become established procedures, there is still only a small number of reports of hepatic resections for such metastases in the caudate lobe. From 1993 to 2001, seven patients underwent eight hepatic resections for colorectal metastases in the caudate lobe at our department. The patients were five men and two women, and their ages were from 53 to 73 years. The ratio of synchronous to metachronous liver metastases was 2?:?5. Solitary metastasis was observed in one patient. One patient with a metastasis in the Spiegel lobe and three patients with metastasis in the caudate process underwent partial resection of the site. The other patients underwent resection of the Spiegel lobe (two times), resection of the right-sided caudate lobe, and total caudate lobe resection. The mean (±SE) operative time was 315.9 ± 30.6?min. Mean intraoperative blood loss was 1325.9 ± 421.1?ml, and mean postoperative hospital stay was 21 ± 3.7 days. One patient, who underwent sigmoidectomy and hepatectomy as an emergency operation due to ileus, experienced wound infection. No patient died within 12 months after the surgery. Five patients were alive at 24 months, and three at 36 months. The outcome of these patients encourages us to continue performing hepatic resection for colorectal metastases in the caudate lobe, as it is assumed to be a safe and effective procedure.     

Two-step hepatectomy with right portal branch ligature for a right lobe metastasis

AIMS/BACKGROUND: Hepatic resection is the only treatment with possible curative effect both for primary and secondary tumors. An increase of the rate of resectability for tumors considered inoperable at first and a decrease of the postoperative morbidity and mortality can be realized by right portal branch ligature and two-step hepatectomy. METHODOLOGY: This paper presents the case of a patient with left bowel cancer with a hepatic metastasis. A right portal branch ligature was performed followed by systemic postoperative chemotherapy. RESULTS: The right portal branch occlusion was followed by right lobe atrophy and left lobe hypertrophy, confirmed by CT scan. Three months after the portal occlusion a right lobe hepatectomy was performed. The postoperative evolution was favorable; eight days of hospitalization were necessary. CONCLUSIONS: Portal branch ligature can be performed in certain cases of hepatic tumors to increase the resectability rate.     

常温下全肝血流分步阻断行肝左尾叶切除术

采用常温下全肝血流分步阻断法对３例左肝尾叶原发性肝癌患者行肝左尾叶切除,其中１例肿瘤侵及左肺内叶者同时行左半肝切除术。结果手术顺利,疗效满意。认为该术式的优点为：（１）对全身血流动力学影响不大。（２）提高了切除率。（３）可在直视下显示和切除肝左尾叶及肿瘤,并可修复大血管损伤。     

Right liver necrosis: complication of laparoscopic cholecystectomy

Although bile duct injuries are common among the complications of laparoscopic cholecystectomy, hepatic vascular injuries are not well described. Between January 1990 to December 1999, 83 patients with bile duct injuries have been referred to our clinic. Two of them had liver necrosis due to hepatic arterial occlusion. These two women had laparoscopic cholecystectomy for symptomatic cholelithiasis in district hospitals 4 and 15 days prior to their referral to our clinic. Serum aspartate aminotransferase and alanine aminotransferase levels were found to be 30 to 40-fold higher than normal levels. Ultrasonography, computed tomography and Doppler sonography showed necrosis in the right liver lobe and no flow in the right hepatic artery. Patients were also complicated with liver abscess and biliary peritonitis, respectively. Emergency right hepatectomy was performed in both cases and one of them needed Roux-Y-hepaticojejunostomy (to the left hepatic duct). One patient died of peritonitis in the postoperative period. The other one has no problem in her third postoperative year. The earliest and the simplest method for diagnosis or ruling out hepatic arterial occlusion is detecting the blood biochemistry and Doppler ultrasonography. In some cases emergency hepatectomy can be necessary. Postoperative complications should be expected higher than elective cases.     

Heat shock protein 70 induction in hepatocytes after right portal vein embolization

BACKGROUND/AIMS: Preoperative right portal vein embolization enhances remnant liver function following massive hepatectomy. Several studies have reported an increase in the volume of the left hepatic lobe after right portal vein embolization, but little information exists regarding heat shock protein induction in hepatocytes after right portal vein embolization. The objective of this study is to determine whether heat shock protein is induced in hepatocytes after right portal vein embolization in patients who underwent extended right hepatic lobectomy. METHODOLOGY: Four patients with gallbladder cancer and one patient with intrahepatic cholangiocellular carcinoma who underwent extended right hepatic lobectomy combined with caudate lobectomy and resection of the extrahepatic bile duct after right portal vein embolization were enrolled in this study. Operation was performed 21-36 days after right portal vein embolization. At operation, small liver specimens were taken immediately after laparotomy from both the right anterior segment (embolized lobe) and lower part of the left medial segment (non-embolized lobe) and heat shock protein 70 was induction in these specimens was measured by Western blotting. RESULTS: Heat shock protein 70 was induced in the left lobe relative to the right lobe in four patients, three of whom had an uneventful postoperative course. CONCLUSIONS: This paper is the first report to show the induction of heat shock protein 70 in the non-embolized hepatic lobe after right portal vein embolization in the clinical cases.     

Long-term survival of intrahepatic cholangiocarcinoma with hilar lymph node metastasis and portal vein involvement

We report the case of a very rare 6-year disease-free survivor of intrahepatic cholangiocarcinoma with hilar lymph node metastasis and portal vein involvement. A 76-year-old female with liver dysfunction was referred to our institution. Contrast-enhanced computed tomography showed a 5-cm low-density tumor with irregular marginal enhancement in the left and caudate lobes of the liver. Cholangiography revealed complete obstruction of the left hepatic bile duct. Angiography showed obstruction of the left branch of the portal vein. Metastasis to the hilar lymph nodes was disclosed at surgery. The patient underwent left hepatectomy with caudate lobectomy, resection of the extrahepatic bile duct, and lymphadenectomy. The total vascular exclusion of the liver was used for hepatectomy and reconstruction of the portal vein. Microscopically, the tumor was a poorly differentiated adenocarcinoma with many infiltrating lymphocytes, and extensive necrosis was present within the tumor. The experience gained in the present case suggests that aggressive surgery may be a potential approach to provide a hope of long-term survival for patients with intrahepatic cholangiocarcinoma despite the presence of regional lymph node metastasis and vascular invasion.