A 73-year-old man presented to his physician with right eyelid swelling without pain or discharge. His medical history and a review of systems were otherwise noncontributory. Physical examination showed swelling and induration of the right lower eyelid, without tenderness. The ipsilateral parotid gland and cervical lymph nodes appeared normal. Magnetic resonance imaging of the patient's face and neck showed an enhancing soft-tissue mass along the inferior right eyelid, without underlying bony abnormality or extension into the orbit (Figure 1). A biopsy specimen obtained at an outside hospital was positive for carcinoma. The patient was referred to our institution for treatment.
There was no evidence of distant disease on metastatic workup. Surgical resection of the lower eyelid and a 1-cm strip of adjoining malar skin and soft tissue was performed. Frozen-section consultation revealed diffusely infiltrating malignant single cells at all surgical margins. Some cells had a signet ring appearance (Figure 2). Additional margins were obtained and submitted as permanent sections, and the procedure was terminated. Four of the 8 additional skin margins, as well as periorbital fat, showed involvement by tumor. Immunohistochemical staining showed strong tumor cell expression of cytokeratin (CK) 7, E-cadherin, and gross cystic disease fluid protein 15 (Figure 3) and no expression of CK20, CD34, melan-A, or p63. Orbital exenteration was performed as a second-stage procedure, given the involvement of deep soft tissues. Adjuvant external beam radiation therapy was administered to the primary site and the nodal drainage basin because of concern for locoregional recurrence.
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