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case_images: Skin adnexal carcinoma affecting the right eye (pre-treatment appearance).
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case_images: A 70-year-old male with fair skin presented to Smart Health Tower (Sulaymaniyah, Iraq) in December 2023 with swelling and redness around the right eye, extending to cover the eye, along with skin desquamation (Fig. 1).
case_images: Hematoxylin and eosin-stained images of the tumor biopsy. (A) The tumor cells were arranged in sheets and nests underneath the ulcerated epidermis (magnification, x40). (B) Sheets and nests of large tumor cells infiltrated deeply around the benign adnexal structures (magnification, x40). (C) The tumor cells were arranged in nests and had an abundant lightly eosinophilic to clear cytoplasm with markedly pleomorphic, large nuclei that had vesicular chromatin, prominent eosinophilic nucleoli and irregular nuclear outlines. There was brisk mitosis with atypical (tripolar) mitotic figures (magnification, x400). (D) The tumor cells were predominantly arranged in nests with occasional pseudoglandular structures (magnification, x400).
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case_images: The cells were large and had an abundant lightly eosinophilic to clear cytoplasm, with markedly pleomorphic, large nuclei that had vesicular chromatin, prominent eosinophilic nucleoli and irregular nuclear outlines. There was brisk mitosis with atypical (tripolar) mitotic figures. There was no squamous, apocrine, sebaceous or any other form of distinct histogenetic differentiation in any area of the tumor in the incisional biopsy (Fig. 2).
case_images: Pre-treatment imaging revealing a significant right periorbital mass. (A) An axial contrast-enhanced computed tomography scan of the face and skull exhibited a large, well-defined mass (arrow) and the optic nerve (arrowhead). (B) A sagittal T2-weighted image revealed a large cystic-solid lesion (yellow arrow) with orbital (white arrow), periorbital and intraorbital extension. The optic nerve appeared free of any invasion (yellow arrowhead). (C) Post-contrast axial T1 fast suppression imaging showed a large, enhanced lesion (arrow) with foci of cystic degeneration represented by non-enhancing areas and the optic nerve (arrowhead). (D) Pre-treatment axial fat-suppressed T1-weighted images revealed two oval-shaped lymph nodes within the parotid gland, exhibiting peripheral enhancement and central necrosis (yellow and red arrows).
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case_images: Tower included a computed tomography (CT) scan of the head and neck, revealing an ill-defined, heterogeneously enhancing soft-tissue mass occupying the skin, lateral canthus, right lacrimal gland, lower eyelid and preseptal space, measuring 44x54x32 mm (Fig. 3A). This mass extended to the medial canthus and intraconal space, infiltrating the lateral and inferior recti muscles of the right eye. Furthermore, multiple right intraparotid lymph nodes with rounded contours and central necrosis, the largest measuring 16x15 mm, were noted, indicative of lymph node infiltration (Fig. 3D). Magnetic resonance imaging (MRI) of the neck and base of the skull with contrast revealed the presence of a large, well-defined heterogeneous mass involving the right orbit and periorbital tissue, measuring 62x38x43 mm (Fig. 3).
case_images: A coronal reformatted computed tomography scan revealed a large, thick-walled subcapsular cystic lesion (arrows) with multiple thin internal septations (arrowhead), located at the liver dome just beneath the right hemidiaphragm.
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case_images: These lesions appeared multilocular, containing multiple enhanced septa suggestive of multiple hydatid cysts (Fig. 4).
case_images: Decreased swelling and ulceration around the affected eye during treatment.
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case_images: The radiation was focused on the primary target volume (PTV)1, encompassing the right cervical regions 2 and 3 and the entire parotid gland, with a cumulative dose of 5,940 cGY delivered over a total of 33 fractions spanning 33 days; this led to a reduction in swelling and ulceration around the affected eye (Fig. 5).
case_images: Post-treatment results after combining chemotherapy and radiotherapy, followed by additional chemotherapy cycles. A notable reduction in tumor size was observed, shrinking from an initial 62 to 8 mm in diameter.
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case_images: Upon follow-up, 1 month after the last chemotherapy (Fig. 6), an MRI revealed a small, linear-shaped focal enhancing lesion measuring 8x4 mm in the inferior segment of the right orbital cavity.
case_images: Post-treatment magnetic resonance imaging showing a significant reduction (~90%) in the tumor size. (A) A sagittal T2-weighted image showing a shrunken intraorbital mass (arrow) with atrophy of the right orbit, resulting in phthisis bulbi, which contained a hemorrhagic component (arrowhead). (B) A sagittal post-contrast fat-suppression T1-weighted image showing an infraorbital linear enhancing component measuring 8x4 mm, with the intraorbital homogenous component appearing hyperintense (arrowhead). (C) A sagittal subtraction sequence showing an enhancing infraorbital linear focus (arrow), representing residual tumor after chemotherapy, with the intraorbital hemorrhagic component showing no post-contrast enhancement (arrowhead). (D) Post-treatment axial fat-suppressed T1-weighted images demonstrated a significant reduction in the size of both lymph nodes (yellow and red arrows).
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case_images: This lesion showed a significant reduction from its initial size of 62x43x38 mm, indicating 90% post-treatment shrinkage (Fig. 7). The enlarged lymph nodes in the right cervical region, previously displaying suspicious imaging features, exhibited a reduction in size of ~40% relative to their prior assessments (Fig. 7).