Neoadjuvant Therapy Before Resection of Primary Pulmonary Lymphoepithelial Carcinoma

Primary lymphoepithelial carcinoma (LEC) of the lung is an extremely rare subset of non-small cell lung cancer (NSCLC) with less than 500 documented cases since its identification in 1987. A vast majority of these cases occur in east or southeast Asia and have been associated with Epstein-Barr Virus (EBV). While localized disease has been managed via surgical resection or resection followed by adjuvant chemotherapy, there is no current consensus on definitive treatment strategy.A 64-year-old patient who had immigrated from Vietnam 35 years ago presented with intermittent cough and was found to have a left lower lobe mass on chest computerized tomography. Positron emission tomography revealed this mass to be hypermetabolic with potential mediastinal and perihilar lymph node activity, suggestive of cT4N2M0 or stage IIIB disease. Immunohistochemistry from transbronchial needle biopsy performed under endobronchial ultrasound demonstrated poorly differentiated EBV-associated LEC. In addition, 90% of the tumor cells were found to have positive programmed death-ligand 1 (PDL1) expression. The patient was started on neoadjuvant chemo-immunotherapy with cisplatin/docetaxel and nivolumab and completed 3 cycles before reassessment. The patient's primary pulmonary LEC mass demonstrated 40% reduction after 3 cycles of neoadjuvant therapy. The patient underwent left lower lobectomy with lymph node sampling. Pathology showed significant down staging to ypT1N0 disease and patient is doing well post-operatively.This represents the first documented case of neoadjuvant therapy being used in primary pulmonary LEC. Here, neoadjuvant chemotherapy plus checkpoint immunotherapy was shown to be a viable alternative to previously attempted strategies for pulmonary LEC, broadening options for effective management. Furthermore, additional discussion details the state of current research into pulmonary LEC.