| 본문 : A 47 year old female presented with painless swelling of the right eyelid for the past 3 months, on February 2009. Orbit MRI revealed 3cm sized enhanced lesion in the right lacrimal gland with bony invasion. Biopsy confirmed the diagnosis of adenoid cystic carcinoma. After neoadjuvant intracarotid adriamycin and cis-platinum, followed by intravenous regimen, orbital exenteration was performed. Pathology report verified T4bN0M0 stage adenoid cystic carcinoma of cribriform type with lymphovascular invasion. As the resection margins were positive for carcinoma, additional lateral zygoma bone was removed and postoperative 59.4Gy radiotherapy was done. MRI taken after 1 year revealed approximately 7mm, focal enhancing lesion in the right anterior maxilla bone, suggestive of tumor recurrence. PET-CT did not show increased uptake of FDG. Bone biopsy was recommended, which the patient refused. Repeat MRI a year later demonstrated progression of the lesion, but still no increased FDG uptake was observed in the PET-CT. The patient insisted on not having bone biopsy. PET-CT 1 year later once more showed stable disease, however, the patient presented with elevated pigmented lesion over exenterated floor in December 2012, 3.5 years after the treatment. MRI revealed markedly increased infiltrating mass along the entire maxillary sinus wall with perineural spread to cavernous sinus. At that time, PET-CT finally showed consistent findings of high FDG uptake. Excisional biopsy confirmed pathology as recurred adenoid cystic carcinoma. Salvage operation was planned, but the patient did not return until she presented to the emergency room in confused mental status with blindness of her left eye in January 2014. CT scans revealed increased right maxillary sinus mass with intracranial extension, brain edema, and infiltration into the left orbital apex.
This case of aggressive local recurrence which even involved the contralateral eye despite multimodality treatment of neoadjuvant chemotherapy, surgery and postoperative radiotherapy and the inconsistent radiologic findings which did not show increased FDG uptake on PET-CT scans in the lesions which seemed suspicious of recurrence on MRI highlight the need for serial MRI follow up for monitoring of disease progression, for prompt biopsy when recurrence is suspicious, and for radical local control of disease .
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