ONCAlert | Upfront Therapy for mRCC

Case 1: Molecular Testing in Locally Advanced NSCLC

Targeted Oncology
Published Online:1:06 PM, Wed September 12, 2018


EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Benjamin P. Levy, MD:
So let’s go back to the case. We have a patient with unresectable stage III squamous cell disease. Greg, maybe you can provide us with some input from a pathology standpoint? I forgot to mention that this patient was tested for PD-L1 [programmed-cell death ligand 1]. It was 10%. Maybe you can talk about PD-L1 testing and whether or not to do genomic profiling in these patients?

Gregory Riedlinger, MD, PhD: One thing that I want to touch on is that pathologists, in general, always want as much tissue as possible. In this era of molecular medicine and molecular testing, it’s certainly becoming even more important that we get adequate tissue. Especially on these smaller EBUS [endobronchial ultrasound] samples and things like that, we really need to make sure that we have adequate tissue to perform all of the downstream molecular analyses.

There is another potential consideration with this patient and these smaller biopsies. There’s squamous histology on the part that was biopsied, but you need to consider whether or not this could be an adenocarcinoma squamous—a lung carcinoma. The patient doesn’t really fit the profile, being an older patient and a smoker. Generally, people would not perform the reflex molecular NGS [next-generation sequencing]-based testing, looking for EGFR, ALK, and ROS, and those types of things. In terms of PD-L1 testing, obviously it’s a very hot topic and I think there’s a real need for standardization across the field. Initially, there were a lot of different antibodies with different scoring metrics. And so, across the field, I think people are starting to kind of standardize what antibodies are used with specific drugs, as well as what specific scoring system is used based on the cancer type and whether it’s a primary versus metastatic tissue that’s tested.

Benjamin P. Levy, MD: At Rutgers, are you reflexively testing all patients no matter what their stage is for PD-L1, or is this something that the physician has to order? I’ll get to what the practice patterns are at MD Anderson Cancer Center and Memorial Sloan Kettering Cancer Center in a minute.

Gregory Riedlinger, MD, PhD: Yes. We’re reflexively doing a small kind of NGS panel for ALK, ROS, and PD-L1. For other cancers, it’s really by physician request.

Benjamin P. Levy, MD: OK.

Anne S. Tsao, MD: We actually don’t have reflexive testing. We have to order it. In general, for research purposes for early-stage disease, we test because we have molecular profiling trials open. But, I think it’s important. One of the biggest questions I get for stage III disease, and I’m sure you guys get it as well, is, “What does PD-L1 mean?” And, “Should I be doing this in the stage III setting, in light of the PACIFIC trial data?” I tell them that the PACIFIC study looked at PD-L1 and the benefit was seen across the board for all patients—the PFS [progression-free survival] benefit because we don’t have OS [overall survival] data yet.

Benjamin P. Levy, MD: This wasn’t restricted to a PD-L1-positive cohort.

Anne S. Tsao, MD: Exactly. So, in my opinion, regardless of PD-L1, I think that all patients should receive durvalumab for a year after concurrent chemoradiation.

Transcript edited for clarity.


EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Benjamin P. Levy, MD:
So let’s go back to the case. We have a patient with unresectable stage III squamous cell disease. Greg, maybe you can provide us with some input from a pathology standpoint? I forgot to mention that this patient was tested for PD-L1 [programmed-cell death ligand 1]. It was 10%. Maybe you can talk about PD-L1 testing and whether or not to do genomic profiling in these patients?

Gregory Riedlinger, MD, PhD: One thing that I want to touch on is that pathologists, in general, always want as much tissue as possible. In this era of molecular medicine and molecular testing, it’s certainly becoming even more important that we get adequate tissue. Especially on these smaller EBUS [endobronchial ultrasound] samples and things like that, we really need to make sure that we have adequate tissue to perform all of the downstream molecular analyses.

There is another potential consideration with this patient and these smaller biopsies. There’s squamous histology on the part that was biopsied, but you need to consider whether or not this could be an adenocarcinoma squamous—a lung carcinoma. The patient doesn’t really fit the profile, being an older patient and a smoker. Generally, people would not perform the reflex molecular NGS [next-generation sequencing]-based testing, looking for EGFR, ALK, and ROS, and those types of things. In terms of PD-L1 testing, obviously it’s a very hot topic and I think there’s a real need for standardization across the field. Initially, there were a lot of different antibodies with different scoring metrics. And so, across the field, I think people are starting to kind of standardize what antibodies are used with specific drugs, as well as what specific scoring system is used based on the cancer type and whether it’s a primary versus metastatic tissue that’s tested.

Benjamin P. Levy, MD: At Rutgers, are you reflexively testing all patients no matter what their stage is for PD-L1, or is this something that the physician has to order? I’ll get to what the practice patterns are at MD Anderson Cancer Center and Memorial Sloan Kettering Cancer Center in a minute.

Gregory Riedlinger, MD, PhD: Yes. We’re reflexively doing a small kind of NGS panel for ALK, ROS, and PD-L1. For other cancers, it’s really by physician request.

Benjamin P. Levy, MD: OK.

Anne S. Tsao, MD: We actually don’t have reflexive testing. We have to order it. In general, for research purposes for early-stage disease, we test because we have molecular profiling trials open. But, I think it’s important. One of the biggest questions I get for stage III disease, and I’m sure you guys get it as well, is, “What does PD-L1 mean?” And, “Should I be doing this in the stage III setting, in light of the PACIFIC trial data?” I tell them that the PACIFIC study looked at PD-L1 and the benefit was seen across the board for all patients—the PFS [progression-free survival] benefit because we don’t have OS [overall survival] data yet.

Benjamin P. Levy, MD: This wasn’t restricted to a PD-L1-positive cohort.

Anne S. Tsao, MD: Exactly. So, in my opinion, regardless of PD-L1, I think that all patients should receive durvalumab for a year after concurrent chemoradiation.

Transcript edited for clarity.
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