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Dr. Jack West is a medical oncologist and thoracic oncology specialist, and Executive Director of Employer Services at the City of Hope Comprehensive Cancer Center in Duarte, CA.

SCLC with Pleural Effusions: Is there Benefit to Adding Radiation?
Wed, 07/09/2008 - 22:32
Howard (Jack) West, MD, Associate Clinical Professor, Medical Oncology, Executive Director, Employer Services, Founder, President and CEO of GRACE

In my earliest introductory post about SCLC, I described the typical staging breakdown used clinically, which is essentially divided into limited disease SCLC (LD-SCLC), which is typically treated with chemo and chest radiation together, with curative intent, and extensive disease SCLC (ED-SCLC), which is typically treated with chemo alone and is not considered conventionally curable. But one of the murky areas in SCLC staging is the situation of what is limited disease except for a pleural effusion on the same side as the main tumor (called an "ipsilateral" pleural effusion) . In some trials and at some centers, this situation is considered ED-SCLC, while at others, it's considered LD-SCLC. On the diagram below, an ipsilateral pleural effusion is designated as a controversial staging question:

SCLC staging

A recently published report from Japan (abstract here) describes the experience of 63 patients with LD-SCLC and an ipsilateral pleural effusion. This retrospective review of patients over several years who were all treated at the same center compared the outcomes of patients who initially received chemotherapy and then received chest radiation if their effusion had resolved to the experience of patients who didn't receive radiation after their effusion resolved. They also compared the results for these groups to outcomes in the patients whose effusions didn't resolve after chemo.

There were several take-home messages. One is that the patients who had an effusion but otherwise stable disease had a prognosis between that of patients with otherwise completely limited disease and ED-SCLC:

SCLC survival by status

Importantly, there were long-term survivors with LD-SCLC and a pleural effusion, and the survival was better in the patients who had an effusion that resolved compared with an effusion that didn't. This result wasn't surprising, because we have always seen that the people who have more of a response tend to do better than the people who have less of a response. But more important was the finding that of the patients who had their effusion resolve after chemo, the ones who received chest radiation did better than the ones who didn't get radiation:

SCLC survival with RT for effusion

This might suggest that patients with pleural effusions have a greater chance of being cured by receiving radiation along with chemo. While that may be true, only a minority of these patients (42%) had their effusions drained and evaluated for cancer cells. None of the patients who had confirmed cancer cells had an especially prolonged survival, and the patients who did best were the ones who had a confirmed negative tap for cancer cells. The 58% who didn't have their effusions evaluated had a survival in between, likely because they harbored a mix of true malignant effusions and some with effusions for other reasons that didn't actually have cancer in them.

Overall, it may be that patients with true effusions from SCLC (cancer cells in the fluid) could do better with radiation, but since the best survivors were the ones with no malignant cells in their fluid, these patients may have really been LD-SCLC patients without a true malignant effusion and just had inflammation or some other cause. This study suggests that the patients with LD-SCLC and a pleural effusion that isn't confirmed as positive, and who have a good response after chemo, may do better by being presumed to have true LD-SCLC and should get radiation with chemo (and other evidence says to add the radiation earlier rather than later, preferably with the first or second cycle of chemo). But with the results with a confirmed malignant effusion looking decidedly worse than in the cytology-negative and unknown groups, it's not clear to me that radiation is really providing a benefit to people who actually have malignant effusion. Instead, I interpret these results as saying that if someone has an ambiguous effusion, it makes sense to give them the benefit of the doubt and treat it as LD-SCLC, with curative intent, which means adding chest radiation to chemo.

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