During the COVID-19 pandemic, routine chest CT scans for respiratory symptoms uncovered unexpected health threats—including one case that linked a common nasal condition to a rare lung cancer.
A 48-year-old non-smoking woman from Hunan Province, China, visited her local hospital in 2020 with sneezing and a runny nose—symptoms she’d managed for 2 years due to chronic rhinitis. Fearing COVID-19, she underwent a throat swab (negative for the virus) and a mandatory chest CT scan. The scan revealed a 34mm x 32mm mass in her left upper lung—a finding that led to a diagnosis of primary pulmonary lymphoepithelioma-like carcinoma (PPLELC), a rare form of non-small cell lung cancer (NSCLC).
What Is PPLELC?
PPLELC makes up just 0.25% to 0.9% of all NSCLC cases in China, and its biggest risk factor is long-term infection with the Epstein-Barr virus (EBV)—the virus best known for causing mononucleosis but also tied to nasopharyngeal carcinoma. Diagnosing PPLELC requires two key findings:
- Pathology: Undifferentiated epithelial cells surrounded by heavy lymphocyte infiltration (visible on tissue slides).
- Viral Evidence: EBV detected in the tumor (via tests like EBER, which identifies EBV RNA).
The Case Details
For this patient, tests confirmed EBV in her nasal secretions and blood. A PET/CT scan—used to track cancer activity by measuring glucose uptake—showed:
- High tracer levels in the lung mass (SUVmax 23.9, a strong sign of malignancy).
- Abnormal uptake in her nose (SUVmax 6.6), suggesting chronic viral or bacterial infection.
Preoperative staging (8th edition of the Union for International Cancer Control [UICC] system) classified the cancer as T2aN1M0: moderate size with nearby lymph node spread but no distant metastasis.
She was referred to the General Hospital of Central Theater Command of the People’s Liberation Army in Wuhan for surgery. On May 15, 2020, doctors performed a video-assisted thoracoscopic (VATS) left pneumonectomy (complete left lung removal) because the tumor had spread to both upper and lower lobes. Postoperative results confirmed:
- PPLELC in the lung tumor.
- EBV presence in the tumor (EBER-positive).
- Lymph node metastasis in group 11 (near the lung) but not in groups 5, 7, 9, or 10.
- No mutations in 20 common lung cancer genes (e.g., EGFR, ALK, KRAS), ruling out targeted therapies.
Why This Case Matters
Most PPLELC patients present with typical lung cancer symptoms—cough, chest pain, blood-tinged sputum, or shortness of breath. But this patient’s first sign was chronic EBV-related rhinitis. Here’s why that’s significant:
- EBV’s Role: Research shows EBV drives both PPLELC and nasopharyngeal carcinoma by activating NF-κB pathways—molecular signals that help cancer cells grow and evade the immune system. This shared mechanism hints at a link between long-term EBV nasal infection and PPLELC.
- Pandemic Screening: The COVID-19 mandate for chest CT scans caught the tumor early. While the patient still needed a pneumonectomy, earlier detection could have spared more lung tissue.
Key Takeaways for Patients and Doctors
- EBV-Related Rhinitis: For patients with chronic rhinitis caused by EBV, regular follow-ups are critical. Persistent infection may increase PPLELC risk—monitor viral loads and get periodic chest CT scans.
- Screening Awareness: High-risk groups (e.g., those with chronic EBV or family history of lung cancer) should prioritize proactive screening.
- Differential Diagnosis: For lung cancer patients with EBV-positive rhinitis, rule out PPLELC (don’t assume nasopharyngeal carcinoma metastasis) to ensure proper treatment.
This case was published in the Chinese Medical Journal in 2021 by Ke Huang, Yu Zhu, Jian Zhu, Bin Huang, and Xu-Hui Gao from the Department of Thoracic Cardiovascular Surgery at the General Hospital of Central Theater Command of the People’s Liberation Army in Wuhan, China, and the First School of Clinical Medicine at Southern Medical University in Guangzhou.
doi.org/10.1097/CM9.0000000000001541
Was this helpful?
0 / 0