Primary pulmonary lymphoepithelioma-like carcinoma in Singapore

Development of a nomogram based on the clinicopathological and CT features to predict the survival of primary pulmonary lymphoepithelial carcinoma patients

BACKGROUND

The aim of this study was to develop a nomogram by combining chest computed tomography (CT) images and clinicopathological predictors to assess the survival outcomes of patients with primary pulmonary lymphoepithelial carcinoma (PLEC).

METHODS

113 patients with stage I-IV primary PLEC who underwent treatment were retrospectively reviewed. The Cox regression analysis was performed to determine the independent prognostic factors associated with patient's disease-free survival (DFS) and cancer-specific survival (CSS). Based on results from multivariate Cox regression analysis, the nomograms were constructed with pre-treatment CT features and clinicopathological information, which were then assessed with respect to calibration, discrimination and clinical usefulness.

RESULTS

Multivariate Cox regression analysis revealed the independent prognostic factors for DFS were surgery resection and hilar and/or mediastinal lymphadenopathy, and that for CSS were age, smoking status, surgery resection, tumor site in lobe and necrosis. The concordance index (C‑index) of nomogram for DFS and CSS were 0.777 (95% CI: 0.703-0.851) and 0.904 (95% CI: 0.847-0.961), respectively. The results of the time‑dependent C‑index were internally validated using a bootstrap resampling method for DFS and CSS also showed that the nomograms had a better discriminative ability.

CONCLUSIONS

We developed nomograms based on clinicopathological and CT factors showing a good performance in predicting individual DFS and CSS probability among primary PLEC patients. This prognostic tool may be valuable for clinicians to more accurately drive treatment decisions and individualized survival assessment.

Pathogenesis and therapeutic implications of EBV-associated epithelial cancers

Epstein-Barr virus (EBV), one of the most common human viruses, has been associated with both lymphoid and epithelial cancers. Undifferentiated nasopharyngeal carcinoma (NPC), EBV associated gastric cancer (EBVaGC) and lymphoepithelioma-like carcinoma (LELC) are amongst the few common epithelial cancers that EBV has been associated with. The pathogenesis of EBV-associated NPC has been well described, however, the same cannot be said for primary pulmonary LELC (PPLELC) owing to the rarity of the cancer. In this review, we outline the pathogenesis of EBV-associated NPC and EBVaGCs and their recent advances. By drawing on similarities between NPC and PPLELC, we then also postulated the pathogenesis of PPLELC. A deeper understanding about the pathogenesis of EBV enables us to postulate the pathogenesis of other EBV associated cancers such as PPLELC.

Prognostic significance of circulating Epstein-Barr virus DNA in pulmonary lymphoepithelioma-like carcinoma: A meta-analysis and validation study

In small-scale studies, circulating Epstein-Barr virus (EBV) DNA levels have prognostic value in patients with pulmonary lymphoepithelioma-like carcinoma (LELC). Therefore, we performed a comprehensive meta-analysis to evaluate the prognostic significance of circulating EBV DNA levels in patients with pulmonary LELC. Studies that discussed the prognostic significance of circulating EBV DNA detection in pulmonary LELC were eligible for inclusion in this study. The overall survival (OS) and progression-free survival (PFS) were the primary outcomes. Pooled hazard ratio (HR), 95% confidence intervals (CIs), and p value were calculated to estimate the prognostic significance of EBV DNA levels. Additionally, we conducted a further observation using an independent cohort. The pooled HR and 95% CI of pretreatment EBV DNA levels for OS and PFS were 3.63 (95% CI: 2.90-4.55) and 2.88 (95% CI: 1.90-4.38), respectively. The pooled HR and 95% CI for Posttreatment EBV DNA levels for OS and PFS were 3.77 (95% CI: 2.96-4.80) and 3.52 (95% CI: 1.91-6.51, p < 0.001), respectively. The independent cohort showed similar results that patients with high pretreatment EBV DNA or positive posttreatment EBV DNA had significantly inferior PFS. Circulating EBV DNA levels provide prognostic values of survival and treatment response in pulmonary LELC patients.

Anti-PD-1 antibodies, a novel treatment option for advanced chemoresistant pulmonary lymphoepithelioma carcinoma

Background

Pulmonary lymphoepithelioma-like carcinoma (LELC) exhibits a unique immune microenvironment, including high PD-L1 expression and abundant infiltrating-immune cells. However, the availability of PD-1/PD-L1 inhibitors in patients with LELC is still not determined.

Methods

A total of 36 cases of pulmonary LELC treated with PD-1/PD-L1 inhibitors were reviewed, including 10 cases from our institute and 26 cases included from the literature. The Kaplan-Meier method and log-rank test were utilized to analyze the survival outcomes of LELC patients receiving immunotherapy, and the factors related to immunotherapy response were further examined.

Results

Of the 10 patients from our institute, the median age was 53.5 years, adrenal glands and distant lymph nodes were the most common metastatic sites, and 4 of 8 (50%) patients had a PD-L1 TPS ≥50%. The median progression-free survival and overall survival in patients from our institute and from the literature were 11.6 and 27.3 months, 17.2 months and not reached, respectively. In all 36 patients, the objective response rate was as high as 57.6%. Patients with higher PD-L1 expression were more likely to have a tumor response, but the association of PD-L1 expression with survival time remains to be determined.

Conclusions

PD-1/PD-L1 inhibitors in patients with pulmonary LELC demonstrated a promising efficacy in retrospective cohorts, and deserve further validation in prospective studies administrating in front-line setting.

Tumor infiltrating lymphocytes-based subtypes and genomic characteristics of EBV- associated lymphoepithelioma-like carcinoma

Tumor infiltrating lymphocytes (TILs) offer a key for morphological diagnosis of lymphoepithelioma-like carcinoma (LELC) and are the foundation of onco-immunology. To date, no reports have found a specific risk stratification value of TILs and related it to genomic variation in LELC. Based on the stromal TILs (str-TILs) ratio, we classified 105 EBV-associated LELC cases into two subtypes: patients with ≥ 60% str-TILs area ratio in tumor were classified as subtype I, and otherwise as subtype II. Subtype I patients had significantly better progression-free survival (PFS) and overall survival (OS). We also explored genomic characteristics of EBV-associated LELC within different involved organs. We performed whole-exome sequencing for 51 patients with enough tissue and analyzed genomic characteristics of EBV-associated LELC. Overall, EBV-associated LELCs were characterized by low somatic mutation rate and copy number variations; the enriched genetic lesions affected RTK-RAS, PI3K and cell cycle pathways. Moreover, EBV-associated LELCs from different organs were more similar to each other genetically as compared with other traditional carcinomas of the same sites -as evidenced by unsupervised clustering based on the quantitative data from both mutation signature and chromosomal aneuploidies. Notably, EBV-associated LELC patients with oncogenic driver alterations showed a worse prognosis compared with patients without such alterations. This article is protected by copyright. All rights reserved.

A Rare Subtype of Non-small Cell Lung Cancer: Report of 159 Resected Pathological Stage I-IIIA Pulmonary Lymphoepithelioma-Like Carcinoma Cases

Background: The current study analyzed resected stage I–IIIA pulmonary lymphoepithelioma-like carcinoma (LELC) cases to define the clinical characteristics, prognosis and long-term outcomes of resected LELC, with the purpose of guiding clinical management for this rare tumor.

Methods: Resected stage I–IIIA LELC, adenocarcinoma (ADC) and squamous cell carcinoma (SCC) cases from our center were enrolled. Propensity score matching (PSM) was applied to minimize the selection bias. Overall survival (OS) and disease-free survival (DFS) were compared between groups. Multivariate analyses were performed to identify the prognostic factors, and a nomogram was developed.

Results: A total of 159 LELCs, 2,757 ADCs, and 1,331 SCCs were included. LELC, dominated among younger patients and non-smokers. LELC was a poorly differentiated disease that lacked driver gene mutations and was positive for immunohistochemistry indicators of squamous cell lineage. Survival analyses revealed that OS was significantly better for LELC than for other common non-small cell lung cancers (NSCLCs) both before PSM (all P < 0.001) and after PSM (all P < 0.05). Further analyses revealed that early pathological node stage and preoperative albumin level ≥35 were identified as independent prognostic factors favoring OS and DFS.

Conclusions: LELC, dominated among younger and non-smoking populations, lacked driver gene mutations and was positive for immunohistochemistry indicators of squamous cell lineage. The survival outcome of LELC was better than other common NSCLCs.

Pulmonary Lymphoepithelioma-Like Carcinoma Treated with Immunotherapy or Chemotherapy: A Single Institute Experience

Background

Lymphoepithelioma-like carcinoma (LELC) is a rare malignant tumor of the lung. It is related to EB virus infection. Epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) are rarely found in this disease, while high level programmed cell death ligand 1 (PD-L1) expression is observed. Here a series of patients with advanced LELC treated with immunotherapy were summarized.

Methods

This retrospective, observational study was conducted in patients who were pathologically confirmed, metastatic or recurrent LELC patients. Patients were prescribed with either chemotherapy or immunotherapy, according to treating physicians’ discretion.

Results

A total of 27 patients were included in our study, 10 with immunotherapy (ICI group) and 17 with chemotherapy (Chemo group). The objective response rates (ORR) of the two groups were 80.0% and 70.5% (p=0.678), and disease control rates (DCR) were 100% and 88.2% (p=0.516). However, the response depth was better in the ICI group. Although the cohort of patients in the ICI group was in a disadvantageous state (both up-front and salvage), the progression-free survival (PFS) was much longer (15.0 and 7.9 m, p=0.005). The 1-year PFS rate in the ICI group was also much higher (40% and 5.9%, p=0.047).

Conclusion

This study implicated the high efficiency of ICI therapy in this disease.

Pulmonary lymphoepithelioma-like carcinoma: A case report with emphasis on computed tomography findings

RATIONALE

Pulmonary lymphoepithelioma-like carcinoma (PLELC) is a rare type of primary malignant lung tumor characterized by Epstein-Barr virus infection, with, to the authors' knowledge, a total of only 500 reported cases during the past 30 years worldwide. Histologically, PLELC is similar to undifferentiated nasopharyngeal carcinoma and poorly differentiated squamous cell carcinoma. However, although PLELC accounts for <1% of all lung cancers, it has a better prognosis and is usually detected in non-smokers and individuals of Asian ancestry.

PATIENT CONCERNS

The patient presented with chest distress of no apparent cause, dizziness, headaches, and a feeling of disequilibrium without remission, as well as a pulmonary nodule incidentally detected on contrast-enhanced computed tomography (CT).

DIAGNOSIS

PLELC was confirmed histopathologically rather than on preoperative CT; nevertheless, CT findings still contributed to the diagnosis.

INTERVENTIONS

The patient underwent thoracoscopic wedge resection of the affected lung.

OUTCOMES

The patient recovered after the lung nodule was completely removed, and was discharged. No evidence of recurrence or metastasis was found at the latest follow-up appointment 2 months after the operation.

LESSONS

PLELC is a rare bronchogenic carcinoma associated with lymphatic tissue with a favorable prognosis in most cases. With nonspecific clinical symptoms, specific radiological findings may facilitate an early diagnosis in some cases, followed by timely surgical intervention.

Chronic Cough With Non-Resolving Mass-like Consolidation

CASE PRESENTATION

A 72-year-old Chinese man presented with a 5-month history of chronic dry cough, weight loss, and progressive dyspnea. There was no associated hemoptysis, hoarseness, epistaxis, or fever on systemic review. He was a nonsmoker and had no family history of malignancy. He was treated for pulmonary TB 40 years ago. A chest radiograph (Fig 1) showed mass-like consolidation in the right midzone with loss of the right hilar border, a small right pleural effusion, and bi-apical scarring. On physical examination, he was afebrile and normotensive, and he had pulse oxygen saturation of 97%. Examination of the chest was remarkable only for reduced breath sounds over the right chest. He did not have digital clubbing, distended neck veins, or cervical lymphadenopathy.

Surgical treatment of Epstein-Barr virus-associated lymphoepithelioma-like carcinoma occurring in both the posterior mediastinum and liver: Case report

RATIONALE

Lymphoepithelioma-like carcinoma (LELC) is a rare malignant tumor that can occur in many areas of the body. The pathogenesis of LELC remains unknown, but Epstein-Barr virus (EBV) has been shown to be strongly correlated with LELC at several anatomic sites, including the lungs and thymus. To the best of our knowledge, EBV-associated LELC has never been reported in both the posterior mediastinum and liver. Herein, we report the case of a 41-year-old female diagnosed with LELC in both the posterior mediastinum and liver and discuss whether it is beneficial to perform surgery on advanced LELC when resectable metastases are found.

PATIENT CONCERNS

The patient was a 41-year-old woman who had been suffering from intermittent pain in the upper right quadrant for 3 months without obvious cause and was admitted to our hospital with occasional nausea without vomiting.

DIAGNOSIS

Her cancer antigen 125 and cytokeratin 19 fragment levels were elevated, whereas alpha-fetoprotein and alanine aminotransferase were normal. Computed tomography (CT) and magnetic resonance imaging revealed a mass in the S6 segment of the liver. Whole-body positron emission tomography/computed tomography (PET/CT) revealed a 3.2-cm mass in the posterior mediastinum and a 6.7-cm mass on the right side of the liver. We made a diagnosis of LELC based on the histological and immunohistochemical findings of specimens obtained by operation. However, it was difficult to determine the primary origin of the tumor.

INTERVENTIONS

The patient underwent mediastinal tumor resection, hepatectomy, and diaphragmatic repair. Thereafter, she was administered paclitaxel and cisplatin as adjuvant chemotherapy.

OUTCOMES

The postoperative course was uneventful, and the patient was discharged 10 days later. Although she was administered paclitaxel and cisplatin as adjuvant chemotherapy, we noted recurrence during the 4-month follow-up examination. Then, the patient passed away 5 months after surgery.

LESSONS

We present the first case of LELC found in both the posterior mediastinum and liver and describe the functionality of PET/CT for finding occult carcinomas and identifying their primary tumor origin. Additional studies are urgently needed to discover whether it is beneficial to perform surgery on advanced LELC when resectable metastases are revealed by PET/CT.

Computed tomography-based differentiation of primary pulmonary lymphoepithelioma-like carcinoma and small-cell lung cancer

BACKGROUND

Primary pulmonary lymphoepithelioma-like carcinoma (LELC) is a rare subtype of lung cancer. Both small-cell lung cancer (SCLC) and LELC often manifest as a centrally located tumor with lymphadenopathy. This retrospective study investigated and compared the initial computed tomography (CT) features and subsequent survival outcomes of LELC and SCLC.

METHODS

A total of 50 patients with a confirmed diagnosis of LELC were enrolled and matched at a ratio of 1:1 with patients with SCLC according to the tumor stage. Utilizing a consensus approach, two radiologists reviewed pretreatment CT images. Survival outcomes were analyzed.

RESULTS

Well-defined tumors were significantly more common in the LELC group (LELC: 42% vs SCLC: 24%, p = 0.005). Based on the comparisons of the primary tumor with the muscles, LELC tumors exhibited a significantly higher percentage of attenuation on contrast-enhanced CT scans (21.6% ± 29% vs -14.2% ± 37%, p < 0.001). The prevalence of vascular or bronchial encasement (18% vs 40%, p = 0.028), background emphysematous changes (10% vs 60%, p < 0.001), and tumors located in upper lobes (18% vs 64%, p < 0.001) was significantly lower in the LELC group. Female gender (70% vs 12%, p < 0.001), younger age (57.6 ± 12.0 years vs 68.0 ± 11.0 years, p < 0.001), and without a history of smoking (16% vs 88%, p < 0.001) were factors more commonly found in the LELC group. The patients with LELC had a better prognosis with significantly longer median survival than did the patients with SCLC (23.4 months vs 17.3 months, p = 0.01).

CONCLUSION

Because SCLC demonstrated a more aggressive disease progression, differentiating LELC from SCLC is crucial. In Epstein-Barr virus-endemic areas, the diagnosis of LELC should be considered when approaching a patient with the above-mentioned CT and clinical features.

Partial absence of PD-1 expression by tumor-infiltrating EBV-specific CD8+ T cells in EBV-driven lymphoepithelioma-like carcinoma

Objectives

Lymphoepithelioma‐like carcinoma (LELC) is an uncommon lung cancer, typically observed in young, non‐smoking Asian populations. LELC is associated with Epstein–Barr virus (EBV) infection of lung tumor cells of epithelial origin, suggesting a carcinogenic role of EBV as observed in nasopharyngeal carcinoma (NPC). Here, we studied the antigen specificity and phenotype of EBV‐specific CD8⁺ T cells in blood and tumor of one LELC patient positive for EBV infection in lung tumor cells.

Methods

Using multiplex MHC class I tetramers, mass cytometry and mRNA sequencing, we studied EBV‐specific CD8⁺ T cells at the transcriptomic and phenotypic levels in blood and tumor tissues of the LELC patient.

Results

Lymphoepithelioma‐like carcinoma lung tumor cells were positive for EBV infection. In both blood and tumor tissues, we detected two populations of EBV‐specific CD8⁺ T cells targeting the EBV lytic cycle proteins: BRLF1 and BMLF1. Transcriptomic analyses of these two populations in the tumor, which can be considered as tumor‐specific, revealed their distinct exhausted profile and polyclonal TCR repertoire. High‐dimensional phenotypical analysis revealed the distinct phenotype of these cells between blood and tumor tissues. In tumor tissue, EBV‐specific CD8⁺ TILs were phenotypically heterogeneous, but consistently expressed CD39. Unexpectedly, although the LELC tumor cells expressed abundant PD‐L1, these tumor‐specific CD8⁺ tumor‐infiltrating lymphocytes (TILs) mostly did not express PD‐1.

Conclusion

Epstein–Barr virus‐specific CD8⁺ TILs in EBV‐driven tumor are heterogeneous and partially lack PD‐1 expression, suggesting that anti‐PD1/PD‐L1 immunotherapy may not be an appropriate strategy for disinhibiting EBV‐specific cells in the treatment of LELC patients.

Pulmonary Lymphoepithelioma-Like Carcinoma: A Mini-Review

Pulmonary lymphoepithelioma-like carcinoma (PLELC) is a rare and distinct subtype of non-small-cell lung carcinoma associated with Epstein–Barr virus (EBV) infection. We systematically reviewed the recent research that expands our knowledge about PLELC, with main focus on its genetic profile, tumor-infiltrating environment, PD-L1 expression, circulating EBV-DNA, clinical utility of 18F-FDG PET/CT, and treatment strategy. A low frequency of typical driver mutations and widespread existence of copy number variations was detected in PLELC. Persistent EBV infection may trigger intense infiltration of lymphocytes, representing enhanced tumor immunity and possibly resulting in a better prognosis. Circulating EBV-DNA in the plasma of patients with PLELC may predict disease progression and response to therapy. PLELC is 18F-FDG avid, and 18F-FDG PET may help refine palliation strategies and subsequently improve the prognosis. Most of the reported patients present at early and resectable stage, and surgical resection with curative intent is the preferred approach. There is currently no consensus on the regimen of chemotherapy for patients with advanced stages. EGFR-targeted therapies seem to have no therapeutic effect, and the clinical impact of PD-1/PD-L1 therapy is uncertain but worthy of further research.

Epstein-Barr Virus-Associated Pulmonary Carcinoma: Proposing an Alternative Term and Expanding the Histologic Spectrum of Lymphoepithelioma-like Carcinoma of the Lung

Lymphoepithelioma-like carcinoma (LELC) of the lung is a rare Epstein-Barr virus (EBV)-associated carcinoma. It is histologically characterized by a syncytial growth pattern with marked lymphocytic infiltration that is indistinguishable from the histology observed in undifferentiated nasopharyngeal carcinomas. However, it has been noted that LELC can display nonclassic morphology and lack significant lymphocytic infiltration. In this study, we conducted a comprehensive clinicopathologic analysis of 61 patients with pulmonary LELC and performed automatic quantification of the lymphocytic infiltrate using the IHC Profiler software. We demonstrated that pulmonary LELCs have a morphologically continuous spectrum, ranging from classic poorly differentiated tumors with intense lymphocytic infiltration to nonclassic morphology with little lymphocytic infiltration. These EBV-associated tumors represent a distinct entity and usually occur in female and nonsmoking patients. Tumors with low lymphocytic infiltration can closely resemble nonkeratinizing squamous cell carcinoma and tend to be larger in size, have higher maximum standardized uptake values on radiography, and exhibit shorter times to recurrence than those with high lymphocytic infiltration. Through detailed pathologic examination, we observed several distinct morphologic features in pulmonary LELCs, including granulomatous inflammation, focal keratinization, spread through alveolar spaces, and lepidic spreading pattern. We also found that patients with tumors exhibiting granulomatous inflammation have favorable outcomes; however, spread through alveolar spaces did not significantly correlate with prognosis. As many of these "LELCs" do not resemble undifferentiated nasopharyngeal carcinoma or lymphoepithelioma, we propose using an alternative term, EBV-associated pulmonary carcinoma, to encompass the entire morphologic spectrum of this distinct disease entity.

Thorough survey and analysis of pulmonary lymphoepithelioma-like carcinoma in Macau and multimodality treatment for advanced disease

OBJECTIVE

Pulmonary lymphoepithelioma-like carcinoma (LELC) is a rare type of non-small cell lung cancer. The clinical course and prognosis of advanced LELC are largely unknown. Few reports have discussed multimodality treatment for LELC.

MATERIALS AND METHODS

This retrospective study identified records from 2007 to 2018 of pulmonary LELCs and other lung cancer subtypes from hospital information systems and collected demographic, treatment, and survival data.

RESULTS

In this cohort of 69 LELCs (median age: 55.4), more female, non-smokers, and fewer right upper lobe tumors (4.3%) were observed in the LELC subgroup compared with others. The median overall survival (OS) of LELCs was 40 months, superior to other subtypes (p < 0.05), except adenocarcinoma (p = 0.062). Patients with early stage disease and primary tumor resection tended to have better OS in univariate analysis, but surgery was the independent predictor in multivariate analysis (0.042). The median OS of 52 advanced LELCs was 22.7 months. Platinum-based chemotherapy and radiotherapy with curative purpose were independent predictors for OS of advanced LELCs (p = 0.004 and 0.003, respectively). For patients who received multimodality treatment in advanced setting, the median line of treatments was two. The overall response and disease-control rates were 61.8% and 80.6%, respectively. There were no differences in response or survival between patients receiving taxane-combined and non-taxane-combined chemotherapy. However, patients treated with radiotherapy in upfront settings had significantly favorable response and progression-free survival compared with those without. One case with PD-L1 positivity had pembrolizumab in the 4^th line and achieved tumor shrinkage and stable disease for 12 months.

CONCLUSION

Patients who underwent radical resection of primary tumors had better prognoses. Patients with advanced LELC could achieve satisfactory survival by receiving multimodality treatment, including platinum-based chemotherapy and/or radiotherapy. Immune checkpoint inhibitors may be part of future therapies. A well-organized clinical trial should be performed to determine the optimal treatment regimen.

First-line platinum-based chemotherapy and survival outcomes in locally advanced or metastatic pulmonary lymphoepithelioma-like carcinoma

OBJECTIVES

Pulmonary lymphoepithelioma-like carcinoma (LELC) is a rare subtype of primary lung cancer. Due to the lack of prospective studies, the optimal first-line chemotherapy regimens and survival outcomes remain unclear.

MATERIALS AND METHODS

This real-world, retrospective study enrolled consecutive patients with unresectable pulmonary LELC. The survival outcomes, prognosis, and comparative efficacy of different chemotherapy regimens were investigated.

RESULTS

In total, 127 patients were included in the analyses. The first-line chemotherapy regimens included gemcitabine plus platinum (GP, n = 19 [15.0%]), taxanes plus platinum (TP, n = 70 [55.1%]) and pemetrexed plus platinum (AP, n = 38 [30.0%]). 25 (19.7%) patients underwent palliative thoracic radiotherapy. 60 (47.2%) patients had detectable baseline Epstein-Barr virus (EBV) DNA. For the entire cohort, objective response was obtained in 41 patients (32.3%). Median progression-free survival (PFS) and overall survival (OS) were 7.7 months (95% CI, 6.6-8.8) and 36.7 months (95% CI, 30.9-42.5), respectively. Among the three chemotherapy regimens, GP achieved the highest response rate (GP, 63.2% vs. TP, 30.0% vs. AP, 21.1%; p = 0.005). Median PFS in the GP group (8.8 months) was also significantly longer than that in the TP group (7.9 months) and AP group (6.4 months) (p = 0.031). In the multivariate model, cycles of first-line chemotherapy (p < 0.001), palliative thoracic radiotherapy (p < 0.001), and chemotherapy regimens (p = 0.031) remained independent prognostic factors for PFS; while cycles of first-line chemotherapy (p = 0.002), baseline EBV DNA (p = 0.033) and palliative thoracic radiotherapy (p = 0.041) were significantly associated with OS.

CONCLUSION

Gemcitabine-based chemotherapy and palliative thoracic radiotherapy are active in pulmonary LELC. These data provide added evidence for the similarity between pulmonary LELC and nasopharyngeal carcinoma in endemic area. Randomized controlled studies are needed to further define the standard-of-care for patients with advanced pulmonary LELC.

Clinical silence of pulmonary lymphoepithelioma-like carcinoma with subcutaneous metastasis: a case report

BACKGROUND

Dissemination of lung cancer to cutaneous sites usually results in a poor prognosis. Pulmonary lymphoepithelioma-like carcinoma (PLELC) is a rare tumor, and no therapeutic strategy for it has yet been established. We present herein an extremely rare case of a long-term surviving patient with PLELC showing subcutaneous metastasis.

CASE PRESENTATION

A 76-year-old woman was diagnosed unexpectedly as having PLELC based on a nodule on her back. After surgical resection of the primary and metastatic lesions, she has remained alive with no recurrence for over 5 years without any additional therapy.

CONCLUSION

Even in the case of PLELC with subcutaneous metastasis, surgical management may afford a prognosis of long-term survival.

Prognostic Value and Clinical Impact of Pretreatment FDG PET in Pulmonary Lymphoepithelioma-Like Carcinoma

PURPOSE

Compared with other forms of non-small cell lung cancer, pulmonary lymphoepithelioma-like carcinoma (LELC) is rarer and portends better outcomes. We sought to investigate the prognostic role and clinical impact of pretreatment F-FDG PET in pulmonary LELC.

METHODS

A total of 71 patients with pulmonary LELC were identified through a retrospective review of clinical records. Of them, 41 underwent F-FDG PET for primary staging. Outcomes were assessed using the Kaplan-Meier method and Cox regression models with a forward stepwise selection procedure. Staging changes served as the main outcome measure for assessing the impact of F-FDG PET. For the purpose of analyses, all patients were restaged according the American Joint Committee on Cancer Staging Manual eighth edition.

RESULTS

Stage and pretreatment F-FDG PET were significantly independent predictors of overall survival (OS) on multivariate analysis. Five-year OS rates for patients with stages I-II, III-IVA, and IVB were 92.3%, 70.4%, and 20.0%, respectively. The use of F-FDG PET for staging purposes was associated with a better OS (P = 0.003). Specifically, the 5-year OS rates for patients who were staged with and without F-FDG PET were 85.4% and 49.7%, respectively (P = 0.012). F-FDG PET resulted in a disease upstage in 28.6% of patients with CT-defined stages III-IVA; of them, 14.3% were upstaged to IVB disease.

CONCLUSIONS

The American Joint Committee on Cancer eighth edition stage and pretreatment F-FDG PET were independent prognostic factors for OS in patients with pulmonary LELC. F-FDG PET imaging resulted in a better disease staging with a corresponding optimization of therapeutic interventions, which ultimately improved survival outcomes.

Clinical Features and Prognosis of Pulmonary Lymphoepithelioma-like Carcinoma: Summary of Eighty-five Cases

BACKGROUND

Pulmonary lymphoepithelioma-like carcinoma (PLELC) is a rare subtype of lung cancer that is less reported and not well-understood.

MATERIALS AND METHODS

We investigated the clinical features of 85 patients with PLELC to determine the prognostic factors.

RESULTS

PLELC preferentially affected the young (71.8%) and nonsmokers (72.9%), without a significant difference in gender. Most (50.6%) patients were at the early stage with opportunity for operation, and patients at advanced stages mainly received multimodality treatment. The median follow-up duration was 17 months (range, 1-39 months) for the whole group, and the 3-year overall survival rate for patients in the early stage was 100%, whereas the 1-year and 2-year overall survival rate for patients in the advanced stage were 93% and 77%, respectively. The tumor stages (P = .031), distant lymph node metastasis (P = .035) and performance status (P = .008) were associated with progression-free survival in the univariate analysis, whereas performance status was an independent prognostic factor in the multivariate analysis (P = .016). The median progression-free survival in the paclitaxel plus platinum (12 months) group and gemcitabine plus platinum (10 months) group were significantly longer than that in the pemetrexed plus platinum (5 months) group (P = .001).

CONCLUSION

PLELC had a better prognosis compared with other types of non-small-cell lung cancer and was sensitive to radiotherapy and chemotherapy. Gemcitabine plus platinum and paclitaxel plus platinum should be used as first-line treatment of PLELC, whereas the second-line treatment, if necessary, was always decided by the managing oncologist. The tumor stages and performance status were predictive in the prognosis of patients with PLELC.

Immunotherapy for LELC: Case Report and a Focused Review

Lymphoepithelioma-like carcinoma of the lung (LELC) is a rare, Epstein-Barr virus-associated tumor. LELC occurs mostly in young, Asian nonsmokers. A few hundred cases have been reported, mostly from retrospective Asian studies. Optimal treatment has not been clearly established. Treatment options are based on surgery for early stage and on cisplatin-based chemotherapy as first-line therapy for metastatic disease. Prognosis may seem better than for other types of non-small-cell lung cancer, but it remains poor in advanced disease, with a median survival of 24 months, and new treatments options are still warranted. Immunotherapies are now key players in the treatment of non-small-cell lung cancer. However, few data are available for this rare histologic subgroup. We have reviewed the available data on LELC with a focus on the first few cases reported with a response to a programmed cell death 1 inhibitor.