Lymphoepithelioma-like carcinoma of the lung is an Epstein-Barr virus-associated undifferentiated carcinoma that presents primarily in young non-smoking Asians. The histology of this carcinoma is indistinguishable from lymphoepithelioma of the nasopharynx. We describe a patient who presented with massive hemoptysis, and was found to have lymphoepithelioma-like carcinoma of the lung with coexistent culture-negative pulmonary tuberculosis.
A 35-year-old Chinese man presented to the emergency department with 2 weeks of intermittent hemoptysis. Outpatient work-up was significant for normal platelets, coagulation studies, renal function and a negative tuberculin skin test. He denied any weight loss, fever or night sweats. He had a 10 pack-year history of tobacco, having quit 10 years previously. He immigrated to the United States from China 8 years ago, and worked in construction and restaurants prior to admission. A chest x-ray revealed a left hilar mass and contrast-enhanced computed tomography scan of the thorax showed a 1.9 cm by 2.6 cm mass in the left hilum, surrounding the lingular bronchus. On hospital day one, he developed large volume hemoptysis and underwent bronchoscopy and embolization of the left bronchial artery. Cytology and acid-fast bacilli stain from a bronchoalveolar lavage were negative. One week later, he had worsening hypoxia, and was found to have a pulmonary embolus in the right main pulmonary artery. An inferior vena caval filter was placed. Four days later, he had recurrent large volume hemoptysis. He underwent embolization of his internal mammary artery which failed to control the bleeding; pulmonary angiography showed no residual pulmonary embolus and he underwent emergent left pneumonectomy. Pathology showed a poorly differentiated squamous cell carcinoma involving the left pulmonary artery and surrounded by an extensive lymphohistiocytic reaction, consistent with a lymphoepithelioma-like carcinoma. Serum was Epstein-Barr virus IgG positive, IgM negative. Positron Emission Tomography and Computed Tomography scan of the head and neck and fiberoptic laryngoscopy did not show evidence of a primary nasopharyngeal carcinoma. Pathologic staging was IIIB and he received four cycles of cisplatin and vinorelbine. Numerous necrotizing granulomas were also noted on pathology and he was treated for culture-negative pulmonary tuberculosis. He is currently doing well five months after completing chemotherapy.
Primary lymphoepithelioma-like carcinoma of the lung is a rare malignancy, first reported in the literature in 1987. From the limited case reports in the literature, lymphoepithelioma-like carcinoma of the lung has a highly variable clinical presentation. It is predominately described in young, non-smoking Asians. There is no gender predilection. It is an Epstein-Barr virus-associated undifferentiated carcinoma, and the histology of this carcinoma is indistinguishable from lymphoepithelioma of the nasopharynx. It is thus important to exclude nasopharyngeal origin of the cancer. Experience with systemic chemotherapy is limited. There were no case reports found describing lymphoepithelioma-like carcinoma of the lung presenting with co-existent pulmonary tuberculosis.
Primary lymphoepithelioma-like carcinoma of the lung is a rare lung malignancy with variable clinical presentations reported in the literature. We describe a patient who presented with massive hemoptysis and coexistent culture-negative pulmonary tuberculosis.
Paru Patrawalla, No Financial Disclosure Information; No Product/Research Disclosure Information