Published online: 2021-08-12 CASE REPORT CD4‑positive lymphoepithelial‑like carcinoma: Report of unusual case Luaay Aziz, Raya Saab1, Toufic Eid2, Mousa A. Al‑Abbadi3 Department of Ent and Head and Neck Surgery, Healthpoint Hospital, Abu Dhabi, United Arab Emirates, Departments of 1Pediatrics and Adolescent Medicine and 2Radiation Oncology, American University of Beirut, Beirut, Lebanon, 3Department of Pathology and Laboratory Medicine, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates Access this article online ABSTRACT Website: www.avicennajmed.com DOI: 10.4103/ajm.AJM_135_17 We are reporting an unusual case of lymphoepithelial‑like carcinoma (LELC) in an 8‑year‑old Quick Response Code: female patient where the tumor cells showed unusual CD4 expression. The lesion was found in the left submandibular neck region, in the vicinity of the submandibular gland. The salivary gland was not infiltrated by the tumor, and the tumor exhibited a classic LELC with single and clusters of tumor cells surrounded by many hematolymphoid cells. The tumor cells revealed strong positivity for Epstein–Bar virus as confirmed by the EBER: Epstein‑Barr Virus in situ hybridization (EBER‑ISH) method of staining. Interestingly, the tumor cells expressed membranous immunostaining for the T‑helper lymphocyte antibody (CD4) in addition to pan‑cytokeratin. A brief discussion about this unusual finding is offered. The patient was treated as a case of Epstein–Bar virus‑associated nasopharyngeal carcinoma with excellent response. Key words: CD4, Epstein–Bar virus, lymphoepithelial‑like carcinoma, nasopharyngeal carcinoma INTRODUCTION After obtaining the appropriate internal review board approvals and patient family consent, we present extremely Masses and swelling in the head and neck are common unusual case of lymph node enlargement in the left side presentation in children as well as adults. Many of these are neck of an 8‑year‑old female patient were the morphologic due to lesions involving the lymph nodes. Lymphadenopathy histopathological examination showed LELC in a lymph in children is commonly caused by infection, but few cases node with no known primary after thorough clinical, can be due to benign or malignant diseases. intraoperative and imaging evaluation. Moreover, the epithelial tumor cells expressed the common T‑helper Lymphoepithelial like carcinoma (LELC) are usually defined cell surface marker CD4, which we believe to be the first as any carcinoma outside the nasopharynx without evidence observation in the literature.[1,2] of definite line of cellular differentiation commonly with associated non‑neoplastic lymphoplasmacytic cell infiltrate. CASE REPORT The histological morphology is similar to nasopharyngeal carcinoma (NPC) of the non‑keratinizing undifferentiated An 8‑year old girl presented with a history of left‑sided type. Unlike NPC, not all cases of LELC are associated submandibular swelling of 1‑week duration. There was with the presence of Epstein‑Barr virus. The most common This is an open access journal, and articles are distributed under the terms of location for LELC are salivary glands, however other the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, locations such as oropharynx, sinunasal tract and larynx which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under have been reported. the identical terms. For reprints contact: [email protected] Address for correspondence: Dr. Mousa A. Al‑Abbadi, Department of Pathology and Laboratory Medicine, Sheikh Khalifa Cite this article as: Aziz L, Saab R, Eid T, Al-Abbadi MA. CD4-positive Medical City, Abu Dhabi, United Arab Emirates. lymphoepithelial-like carcinoma: Report of unusual case. Avicenna J Med E‑mail: [email protected], [email protected] 2018;8:58-62. 58 © 2018 Avicenna Journal of Medicine | Published by Wolters Kluwer - Medknow Aziz, et al.: CD4+ve lymphoepithelial carcinoma no reported fever, loss of weight or appetite, or any other The patient was admitted and was started on intravenous generalized symptoms. There was no throat pain or difficulty clindamycin and oral augmentin and dexamethasone. in swallowing. She was started on broad‑spectrum antibiotic The next day, she underwent an open drainage on the treatment with no improvement, and the swelling increased assumption of an organizing abscess. During the procedure in size. Computed tomography (CT) scan was done outside and on opening the mass, we found an inflamed firm our institution and showed a large cystic mass lesion in the tissue surrounding the wall of a cystic cavity which was submandibular area. She had an open drainage procedure attached to the submandibular gland. The salivary gland as an outpatient on the assumption of an abscess. The family appeared normal in size but with extensive adhesions to was told that the drainage was successful and no further the cystic wall mass. The cystic cavity revealed a serous information was given to the family regarding microbial fluid with no obvious pus. The tissue was found to have culture results. extensive adhesions where dissection was difficult. However, multiple representative biopsies were taken on She then presented to our outpatient clinic for further an attempt for a complete excision including the removal investigation since the mass did not change in size. On of the attached submandibular gland. The tissue was sent examination, she had a large submandibular mass measuring for histopathological examination and culture. She was discharged on oral antibiotics and advised to come back 5 cm × 5 cm which was slightly tender on palpation; she had after 1 week as an outpatient follow‑up. no evidence of fever or tachycardia. However, she was readmitted 3 days later with fever and Examination of the throat revealed normal tonsils and no serous discharge from the surgical wound. Laboratory lesions could be found in the oral cavity. No abnormalities parameters on the second admission revealed leukocytosis could be found in the nasopharynx or hypopharyngeal area. and increased inflammatory parameters. By ultrasound examination, there was a mass lesion at the left submandibular Laboratory examination showed leukocytosis with a white location measuring 4 cm × 3 cm × 5 cm with complex mixed blood cell count of 24,000 with 70% neutrophils, 20% echogenicity. lymphocytes, and 7% monocytes. The C‑reactive protein was mildly elevated at 83 mg/L. Levels of serum lactate Computerized axial tomography scan revealed a large dehydrogenase and uric acid were normal. submandibular collection and nearby multiple enlarged small lymph nodes. The right submandibular gland appeared Neck ultrasound and CT scan [Figure 1] showed a necrotic normal. Chest X‑ray was within normal limits. mass lesion in the left submandibular region, measuring 5.6 cm × 5.2 cm × 5.2 cm, suggestive of an abscess with Basic immune workup for immunodeficiency was negative. associated adjacent reactive appearing lymph nodes. The immune status screening showed mumps viral IgM, which was reported as positive IgM but with low levels of detection, Epstein–Bar virus (EBV) IgG was positive, and quantitative EBV polymerase chain reaction analysis showed 6500 copies/ml. Cytomegalovirus IgG was positive, but IgM was negative. Toxoplasma IgG and IgM were both negative. C3 and C4 serum levels were elevated. Bartonella antibodies were also negative. She was restarted Figure 1: Left image: Computed tomography scan of the neck, transverse section, showing a necrotic mass lesion in the left submandibular region measuring Figure 2: Medium‑ (left) and high‑power (right) view of the routine histological 56 × 52 × 52 mm suggestive of an abscess (arrow) with associated adjacent section showing single and clusters of large atypical cells with abundant reactive appearing lymph nodes. Right image: Positron emission tomography cytoplasm, large nucleus, and prominent nucleoli (H and E). The inset is the scan showing the large left submandibular tumor with intense positivity Epstein–Bar virus stain by the EBER ISH method revealing strong reactivity Avicenna Journal of Medicine / Volume 8 / Issue 2 / April-June 2018 59 Aziz, et al.: CD4+ve lymphoepithelial carcinoma Figure 3: Immunohistochemical stains showed immunoreactivity for pan‑cytokeratin AE1/3 (left) and the same cells were also immunoreactive for CD4 (right). The CD4 stain is membranous and is obviously lining the large atypical tumor cells in addition to the surrounding reactive T‑lymphocytes. The details of this close used are SP35, Rabbit monoclonal antibody, Ventana Medical Systems, Inc. Tucson, AZ, USA on intravenous antibiotics, ceftriaxone, and clindamycin but developed allergy to the latter; therefore, it was replaced Figure 4: Left image: follow‑up magnetic resonance imaging scan of the neck by augmentin. showing almost complete resolution of the mass after treatment. Right image: follow‑up posttreatment positron emission tomography scan demonstrating complete resolution of the tumor Histopathologic findings The histological examination revealed intensely inflamed Medical Center where advanced care for such cases would soft‑tissue fragments with mixed inflammatory cell infiltrate be available. composed of neutrophils, plasma cells, lymphocytes, and histiocytes. However, occasional large atypical cells were Treatment and follow‑up seen scattered in between these tissue fragments. These Pretreatment positron emission tomography scan showed