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MG and ICI — SCE Medical Oncology MCQ

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HardImmunotherapy & Targeted TherapyMG and ICISCE Medical Oncology

A patient with metastatic driver-negative NSCLC has PD-L1 TPS 90% and pre-existing acetylcholine-receptor-positive myasthenia gravis that is clinically stable on treatment. What is the most defensible checkpoint-inhibitor risk plan?

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Correct answer: C — Prefer another option; if checkpoint therapy is justified, use one agent with neurological monitoring

Pre-existing well-controlled myasthenia is not an absolute contraindication, but potentially fatal exacerbation warrants a non-checkpoint alternative where reasonable. If checkpoint benefit justifies the risk, single-agent rather than combined therapy and coordinated neurology-oncology monitoring of bulbar and respiratory function are required. A blanket legal exclusion overstates the guidance. Combination therapy has greater immune-toxicity risk. Routine prophylactic plasma exchange before treatment is not recommended and does not replace surveillance. Creatine kinase alone cannot detect bulbar or respiratory deterioration.

Reference: International consensus guidance for management of myasthenia gravis: 2020 update (Published January 2021): https://pmc.ncbi.nlm.nih.gov/articles/PMC7884987/; West of Scotland Cancer Network immune-related adverse-events guideline (Version 4.0, March 2024; review due March 2027): https://rightdecisions.scot.nhs.uk/media/b11eeh40/woscan-immunotherapy-iraes-guideline-v40.pdf