Practical Approaches to Immune-Related Adverse Events in SCLC

Long-term immunotherapy toxicity management in small cell lung cancer (SCLC) requires systematic monitoring and prompt recognition of immune-related adverse events, with pneumonitis representing the most significant pulmonary concern. Dr Leal emphasizes the importance of imaging surveillance and symptom monitoring, particularly the challenge of distinguishing radiation-induced from immunotherapy-induced pneumonitis in limited-stage patients. Collaboration with pulmonology, radiology, and radiation oncology teams helps determine whether pneumonitis appears localized to radiation fields or represents diffuse immunotherapy-related inflammation, guiding appropriate treatment decisions.

Early recognition and treatment of pneumonitis prevent progression to chronic fibrosis and preserves lung function and quality of life. The management approach includes prompt corticosteroid initiation when indicated, with attention to supportive care including prophylactic antibiotics for patients requiring prolonged steroid courses. The experts emphasize the importance of aggressive early intervention to prevent complications while attempting to salvage the opportunity to complete the full durvalumab treatment course when safely possible.

Beyond pneumonitis, the panel discusses other long-term immunotherapy toxicities including hypothyroidism requiring chronic thyroid hormone replacement and adrenal insufficiency necessitating hydrocortisone replacement therapy. Recognition of adrenal insufficiency requires high clinical suspicion in patients with unexplained fatigue and appropriate cortisol testing. For long-term survivors, the experts note that prophylactic cranial irradiation can cause significant neurocognitive effects, adding another layer of long-term toxicity considerations beyond the immunotherapy itself, requiring comprehensive survivorship planning and monitoring.