Patient Scenario 2: 1L Management of ES-SCLC Positive for Synaptophysin With a Ki-67 Score of 90%

Transcript:
Taofeek K. Owonikoko, MD, PhD: I think we've spent a lot of time on what we do for newly diagnosed patients, whether they have limited-stage or extensive-stage. I think we should switch gears now and talk about other approaches to this disease and for that, I will pass it on to Dr [Anne] Chiang to take us through the next case illustration.

Anne Chiang, MD, PhD: This patient is actually still a patient at diagnosis so we're going to talk about that. It's my patient, a 65-year-old African American woman, with a 40-pack-a-year tobacco history and she presented with weight loss over several months. She had worsening shortness of breath on exertion and abdominal discomfort. Her physical exam, she had shoddy neck adenopathy, a right axillary lymph node, or an enlarged lymph node. And the PET scan showed a very large, right-lower low mass. There's an additional satellite nodule. She had extensive regional nodal involvement in the right hilar mediastinal and axillary lymph node areas. Her brain MRI was negative, and a biopsy of the lymph node revealed small-cell carcinoma positive for the neuroendocrine marker synaptophysin. And as I said before, the Ki-67 was very high at 90%. So, how would you treat this patient?

Taofeek K. Owonikoko, MD, PhD: [What are your] impressions of this case vs was the first one? What would be different in terms of our approach? Dr [Konstantinos] Leventakos, do you want to tackle that? This patient has no brain met [metastases], for instance, but a lot of adenopathies.

Konstantinos Leventakos, MD, PhD: I think that adenopathy with axillary lymph nodes [means] additional tumor nodules. So, I don't think that would be a case someone would feel comfortable calling limited-stage as an extensive-state patient. I think that this is a patient that will be treated with standard first-line using chemotherapy-immunotherapy.

Taofeek K. Owonikoko, MD, PhD: Our first patient was treated with durvalumab. This could be a patient that you treat with atezolizumab. Have you noticed any differences in terms of toxicity profile between these 2 regimens?

Konstantinos Leventakos, MD, PhD: I have not been able to identify any in practice but I'm happy to hear your opinions of any differences. I feel patients still initially get better because of their symptoms, and this patient seems to have symptoms and I have not been able to identify differentiating adverse events between the 2 immunotherapies. So, this is a patient that I could have treated with any of these agents.

Anne Chiang, MD, PhD: This patient had a great response to the 4 cycles of carboplatin, etoposide, and atezo [atezolizumab], and she continued on monthly atezo, and it was tolerated very well. She did have a rash that was controlled with steroid cream, and she's on cycle 9 of maintenance of atezo. And then this comes up. How long do you continue that maintenance immunotherapy?

Jacob Sands, MD: It's a great question, and it's one that I think most of us kind of hide behind, saying we need a biomarker, which frankly, we do. I think it's a compelling scenario where you get some blood-based testing at 2 years, at 1 year. This would be an area of important research. I kind of continue them until there's a reason to not. And I have a few patients who are now around 5 years or even a little longer out from their initial diagnosis. They don't happen to still be on their maintenance therapy, and there were just reasons to stop. I'll also just add, I’ve had some patients who ended up with brain metastases alone, and I radiate those and then continue immunotherapy with, in some cases, years of ongoing control.

One patient I think about is someone who actually treated the brain on a trial that our radiation oncologists have with SRS [surgery and stereotactic radiosurgery]. She ended up getting SRS 3 different times for brain metastases and I continued the immunotherapy throughout. She’s one of those patients who is now more than 5 years out. Now she’s not on the treatment anymore but still doing well, still without any evidence of progression on small-cell. So, there’s not a clean great answer but if someone’s starting to have toxicities and they’re beyond 2 years, I’ve had others where there ended up being something else that showed up so then I’m more inclined to continue if it’s just that 1 site with otherwise control. There’s no standard for every patient. [There is no] “Here's how long I give [maintenance therapy].”

Transcript edited for clarity.