Thoracic perfusion of recombinant human endostatin (Endostar) combined with chemotherapeutic agents versus chemotherapeutic agents alone for treating malignant pleural effusions: a systematic evaluation and meta-analysis

Malignant pleural disease

Malignant pleural disease represents a growing healthcare burden. Malignant pleural effusion affects approximately 1 million people globally per year, causes disabling breathlessness and indicates a shortened life expectancy. Timely diagnosis is imperative to relieve symptoms and optimise quality of life, and should give consideration to individual patient factors. This review aims to provide an overview of epidemiology, pathogenesis and suggested diagnostic pathways in malignant pleural disease, to outline management options for malignant pleural effusion and malignant pleural mesothelioma, highlighting the need for a holistic approach, and to discuss potential challenges including non-expandable lung and septated effusions.

Current status and future of anti-angiogenic drugs in lung cancer

Lung cancer, as a malignant tumor with both high incidence and mortality in China, is one of the major causes of death in our population and one of the major public health problems in China. Effective treatment of lung cancer is a major public health task for all human beings. Angiogenesis plays an important role in the development of tumor, not only as a basic condition for tumor growth, but also as a significant factor to promote tumor metastasis. Therefore, anti-angiogenesis has become a vital means to inhibit tumor development, and anti-angiogenic drugs can rebalance pro- and anti-angiogenic factors to inhibit tumor cells. This article reviews the mechanism of blood vessel formation in tumor tissues and the mechanism of action of different anti-angiogenic drugs, the combination therapy of anti-angiogenic drugs and other anti-tumor drugs, and the mechanism of anti-angiogenic drug resistance.

Comparison between different treatment regimens of vascular targeting drug to malignant pleural effusion in patients with lung cancer: A Bayesian network meta-analysis

BACKGROUND

The presence of malignant pleural effusion in lung cancer patients often suggests a poor prognosis. We plan to investigate which regimen of vascular targeting drug is preferable to control the malignant pleural effusion in such patients.

METHODS

Two investigators dependently searched and screened for randomized controlled trials in PubMed, Embase, Web of Science and China National Knowledge Infrastructure from the database inception to August 2022. R software was applied to build a network model in Bayesian method. Objective response rate of malignant pleural effusion is the primary outcome measure. Besides, the incidence of 3 adverse events were compared, including gastrointestinal reaction, leukopenia and hypertension. Due to the disconnection of network, we analysis and discuss the short-term treatment (3-4 weeks) and long-term treatment (6-12 weeks) respectively.

RESULTS

31 studies with 2093 patients were identified. Four targeting drugs contain bevacizumab (Bev), anlotinib, apatinib and Endostar. Two administration routes include intracavity perfusion (icp) and intravenous injection. Based on the current evidence, for short-term treatments, compared with single-agent chemotherapy (CT), Bev_icp + CT, anlotinib + CT, Bev_icp and anlotinib + endorstar_icp present better objective response, and no statistical significance was found in objective response between Bev_icp + CT, anlotinib + CT and Bev_icp. For long-term treatments, compared with doublet or triplet chemotherapy (2CT or 3CT), Bev_icp + 2CT, apatinib + 2CT, Bev_icp + 3CT, and Bev_intravenous injection + 2CT are more effective option, but no statistical significance was found in objective response between the 4 combination regimens with chemotherapy.

CONCLUSION

Our findings suggest that no statistical significance between above vascular targeting regimens. Pathological type of lung cancer may affect the effect of bevacizumab intracavity infusion plus chemotherapy. The influence of different administration routes of vascular targeting drugs on efficacy remains to be investigated. There are some concerns with the quality of the studies, and some limitations should be considered when interpreting these results, which includes limited geographical region and sample size of studies. Despite these limitations, this study may inform vascular targeting therapy choice in such a patient population.

Intrapleural Anticancer Therapy for Malignant Pleural Diseases: Facts or Fiction?

Malignant pleural diseases involves both primary pleural malignancies (e.g., mesothelioma) as well as metastatic disease involving the pleura. The management of primary pleural malignancies remains a challenge, given their limited response to conventional treatments such as surgery, systemic chemotherapy, and immunotherapy. In this article, we aimed to review the management of primary pleural malignancy as well as malignant pleural effusion and assess the current state of intrapleural anticancer therapies. We review the role intrapleural chemotherapy, immunotherapy, and immunogene therapy, as well as oncolytic viral, therapy and intrapleural drug device combination. We further discuss that while the pleural space offers a unique opportunity for local therapy as an adjuvant option to systemic therapy and may help decrease some of the systemic side effects, further patient outcome-oriented research is needed to determine the exact role of these treatments within the armamentarium of currently available options.

Factors Affecting Rate of Pleural Fluid Accumulation in Patients with Malignant Pleural Effusions

Purpose of Review

Malignant pleural effusions (MPEs) are initially treated with thoracocentesis but usually reaccumulate. There is wide variation in the rate of recurrence. Those with rapid recurrence could benefit from early definitive treatment, whilst those with slower recurrences may not. Here, we discuss pleural fluid homeostasis, MPE pathophysiology, and factors associated with reaccumulation.

Recent Findings

Few studies have investigated markers of MPE reaccumulation. Suggested features of rapid reaccumulation include lactate dehydrogenase, effusion size, positive cytology, and dyspnoea. Vascular endothelial growth factor (VEGF) correlates with MPE size and treatment response, but its association with reaccumulation rate is unknown. Some anti-VEGF therapies have shown promise in MPE management.

Summary

Further work is needed to validate hypothesised biomarkers of rapid recurrence and to characterise other biomarkers, such as VEGF. The Reaccumulation rate of Malignant Pleural Effusions After Therapeutic Aspiration (REPEAT) study aims to address these gaps in the literature and is currently in recruitment.

Current status of and progress in the treatment of malignant pleural effusion of lung cancer

Malignant pleural effusion (MPE) is a common complication in the late stage of malignant tumors. The appearance of MPE indicates that the primary tumor has spread to the pleura or progressed to an advanced stage. The survival time of the patients will be significantly shortened, with a median survival of only a few months. There are a variety of traditional treatments, and their advantages and disadvantages are relatively clear. There are still many problems that cannot be solved by traditional methods in clinical work. The most common one is intrapleural perfusion therapy with chemotherapy drugs, but it has a large side effect of chemotherapy. At present, with the development of medical technology, there are a variety of treatment methods, and many innovative, significant and valuable treatment methods have emerged, which also bring hope for the treatment of refractory and recurrent MPE patients. Several clinical trials had confirmed that drug-carrying microparticles has less adverse reactions and obvious curative effect. However, there is still a long way to go to completely control and cure MPE, and the organic combination of clinical work and scientific research results is needed to bring dawn to refractory MPE patients.

Efficacy of Intrapleural or Intrapericardial Injection of Single Bevacizumab in the Treatment of Lung Cancer-Mediated Malignant Effusion

The usage of bevacizumab for malignant pleural effusion (MPE) or malignant pericardial effusion (MPCE) has attracted increasing interest from researchers, but the precise ways of bevacizumab administration remain unknown. Patients with histologically or cytologically confirmed non-small-cell lung cancer (NSCLC) with MPE or MPCE were enrolled in the study and treated with a low dose of single bevacizumab (100 mg) intrapleurally or intrapericardially injected after the drainage of the effusions. The Lung Cancer Symptom Scale (LCSS), efficacy, and safety of drug administration were used as evaluation parameters in this study. The results indicated that lung cancer-related symptoms were significantly improved following treatment, compared with symptoms before the treatment (LCSS, score 494 ± 78 vs. score 377 ± 77, mean ± SD) (P < 0.001). Malignant effusions were well controlled, and the median time to progression (TTP) was 91 days and 111 days in MPE and MPCE, respectively. In addition, no severe side effects were observed, except in one patient with mild dizziness. In summary, the low dose of single bevacizumab (100 mg) with intrapleural or intrapericardial injection is effective and safe in the treatment of lung cancer-mediated malignant effusion, rapidly improving the malignant effusion-related symptoms and quality of life in patients with NSCLC.

Intraperitoneal infusion of recombinant human indentation improves prognosis in gastric cancer ascites

Objective: To investigate the efficacy and safety of intraperitoneal administration of recombinant human indentation in gastric cancer with malignant ascites. Methods: Clinical data of 90 patients (37 in an Endostar^® combined with cisplatin group and 53 in a cisplatin group) were retrospectively analyzed. The primary end point was overall survival, and the secondary end points were objective response rate (ORR), disease control rate (DCR) and so on. Results: Median overall survival was longer in the combination group (9.7 vs 8.1 months; p = 0.01). ORR and DCR were higher in the combination group (ORR: 75.7% vs 54.7%; p = 0.04; DCR: 94.6% vs 75.5%; p = 0.02). There were no significant differences in adverse effects between the two groups. Conclusion: Intraperitoneal administration of recombinant human indentation improved efficacy and survival for gastric cancer with ascites.

Better effect of intrapleural perfusion with hyperthermic chemotherapy by video-assisted thoracoscopic surgery for malignant pleural effusion treatment compared to normothermic chemoperfusion of the pleural cavity

Objective

The aim of this study was to assess the efficacy and safety of intrapleural perfusion with hyperthermic chemotherapy (IPHC) in treating malignant pleural effusion (MPE) compared to normothermic chemoperfusion of the pleural cavity (NCPC), and to investigate the better treatment to control MPE.

Methods

Malignant pleural effusion patients were enrolled in the study and treated with NCPC or IPHC under video‐assisted thoracoscopic surgery (VATS). The chest drainage duration, clinical characteristics, and recurrence time of pleural effusion of patients were collected for statistical analysis. The chi‐squared test and the Fisher's exact test were applied to compare the distribution differences in categorical variables. Progression‐free survival (PFS) was estimated by the Kaplan–Meier method and was compared by the log‐rank test. The survival analysis was performed using the Cox proportional hazards method.

Results

A total of 37 MPE patients were enrolled in this study. Twenty‐seven patients received NCPC and 10 patients received IPHC under VATS. Significant differences were found in pathological types (p = 0.011), chest drainage duration (p = 0.005), and remission rate (p = 0.009) between two different treatment groups. The chest drainage duration of IPHC under VATS was shorter than the NCPC group (t = 2.969, p = 0.005). The remission rate of MPE in IPHC group was better than the NCPC one (OR = 0.031, 95% CI: 0.002–0.507, p = 0.015). The result of the Kaplan–Meier method showed that IPHC group could significantly prolong the PFS of patients with MPE compared to NCPC group (log‐rank p = 0.002). Univariate cox regression analysis showed that patients with MPE in the IPHC group presented significant longer PFS than the NCPC group (HR = 0.264, 95% CI: 0.098–0.713, p = 0.009). Multivariate cox regression analysis further verified this conclusion (HR = 0.268, 95% CI: 0.096–0.753, p = 0.012).

Conclusion

Compared to the NCPC, the IPHC under VATS presents a better control effect on MPE, shorter tube placement time, and longer complete remission time. For this reason, we recommend IPHC under VATS as the first‐line treatment for patients with MPE those who can tolerate minimally invasive surgery.

Intrapleural Administration With Rh-Endostatin and Chemical Irritants in the Control of Malignant Pleural Effusion: A Systematic Review and Meta-Analysis

INTRODUCTION

A modified and recombinant human endostatin (Rh-endostatin) is often used in the control of malignant pleural effusion (MPE) through intrapleural infusion.

OBJECTIVES

To demonstrate the clinical response, survival, and safety of Rh-endostatin plus chemical irritants, their optimal combinations, treatment threshold, and optimal usage, we performed a new systematic review and meta-analysis.

METHODOLOGY

All randomized controlled trials (RCTs) were collected from Chinese and English electronic databases (from inception until August 2020). We pooled the data using a series of meta-analyses and summarized the evidence quality following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

We included 75 RCTs recruiting 4,678 patients, which reported six combinations for Rh-endostatin plus chemical irritants. Among the six combinations, only Rh-endostatin plus cisplatin (DDP) with enough trials might improve the complete response [2.29 (1.93, 2.71)] and quality of life [3.01 (2.49, 3.63)] and reduce treatment failure [0.29 (0.25, 0.33)] and progressive disease [0.27 (0.22, 0.34)]. It might not increase the risk of adverse drug reactions. For patients with lung cancer, moderate to massive effusion, initial treatment, Karnofsky Performance Status (KPS) score ≥60, or anticipated survival time ≥3 months, Rh-endostatin (30-45 mg each time, once or twice a week 3-4 times) plus DDP (30-60 mg/m2) obtained a significant improvement in clinical response and a reduction of failure and progressive disease. Most results had good robustness and moderate quality.

CONCLUSIONS

Current evidence suggests that Rh-endostatin with DDP may be an optimal combination, which may improve clinical response and reduce failure and progressive disease with good safety. Rh-endostatin (30-40 mg each time, once or twice a week 3-4 times) with DDP (30-40 mg/m2) may be an optimal usage for achieving an ideal response.

Thoracic perfusion of recombinant mutant human tumor necrosis factor (rmhTNF) can be considered as a good adjunct in the treatment of malignant pleural effusion caused by lung cancer

BACKGROUND

Tumor necrosis factor (TNF) has been investigated to be correlated with the occurrence and progression of lung cancer. This investigation was to assess the efficacy and safety of recombinant mutant human tumor necrosis factor (rmhTNF) for controlling malignant pleural effusion (MPE) through thoracic perfusion.

METHODS

Through searching from MEDLINE, Web of Science, EMBASE, Cochrance Library, OVID and China National Knowledge Infrastructure (CNKI), a total of 12 studies with 694 patients were included in this study. A series of meta-analysis methods were used to analyze the extracted data.

RESULTS

Thoracic perfusion of rmhTNF combined with cisplatin promoted the objective response rate (ORR) (P < 0.001; odds ratio = 4.49) and the quality of life (QOL) of patients with MPE (P < 0.001; odds ratio = 10.33), as compared with cisplatin alone. Although the participation of rmhTNF increased the incidence of fever (P < 0.001), it seemed to relieve the adverse reactions in the digestive tract (P = 0.017).

CONCLUSIONS

Thoracic perfusion of rmhTNF contributes to the treatment of MPE and improves the QOL of MPE patients.

The Safety and Exploration of the Pharmacokinetics of Intrapleural Liposomal Curcumin

Background

Malignant pleural effusion (MPE) is the accumulation of fluid in the pleural cavity as a result of malignancies affecting the lung, pleura and mediastinal lymph nodes. Curcumin, a compound found in turmeric, has anti-cancer properties that could not only treat MPE accumulation but also reduce cancer burden. To our knowledge, direct administration of curcumin into the pleural cavity has never been reported, neither in animals nor in humans.

Purpose

To explore the compartmental distribution, targeted pharmacokinetics and the safety profile of liposomal curcumin following intrapleural and intravenous administration.

Methods

Liposomal curcumin (16 mg/kg) was administered into Fischer 344 rats by either intrapleural injection or intravenous infusion. The concentration of curcumin in plasma and tissues (lung, liver and diaphragm) were measured using ultra-performance liquid chromatography-mass spectrometry (UPLC-MS). Blood and tissues were examined for pathological changes.

Results

No pleural or lung pathologies were observed following intrapleural liposomal curcumin administration. Total curcumin concentration peaked 1.5 hrs after the administration of intrapleural liposomal curcumin and red blood cell morphology appeared normal. A red blood cells abnormality (echinocytosis) was observed immediately and at 1.5 hrs after intravenous infusion of liposomal curcumin.

Conclusion

These results indicate that liposomal curcumin is safe when administered directly into the pleural cavity and may represent a viable alternative to intravenous infusion in patients with pleural-based tumors.

Evaluation of Efficacy and Safety for Lentinan in the Control of the Malignant Pleural Effusions via Intrapleural Injection

BACKGROUND

Many studies have investigated the efficacy and safety of lentinan combined with cisplatin versus cisplatin alone for controlling malignant pleural effusion (MPE). This study is a meta-analysis of available evidence.

MATERIALS AND METHODS

Seventeen studies reporting lentinan combined with cisplatin versus cisplatin alone for controlling MPE were reviewed. Pooled odds ratios and hazard ratio with 95% confidence intervals were calculated using the fixed effects model of meta-analysis.

RESULTS

The overall response rate (ORR) of lentinan combined with cisplatin for controlling MPE was significantly higher than that of cisplatin alone (P < 0.001). In addition, lentinan combined with cisplatin showed a better benefit of quality of life (QOL) compared with cisplatin alone (P < 0.001). The main adverse effects (AEs) found in the control plan were hematological reactions, nausea/vomiting, chest pain and fever. However, the presence of lentinan did not have an extra influence on the incidence of AEs (P > 0.05).

CONCLUSIONS

Intrapleural injection of lentinan combined with cisplatin had a better benefit of ORR and QOL for controlling MPE, compared with cisplatin alone. Moreover, lentinan combined with cisplatin had a similar incidence of AEs with cisplatin alone.

Well-controlled pleural effusion indicated pseudoprogression after immunotherapy in lung cancer: A case report

Squamous cancer (SqCC) of the lung has a poor prognosis. With the advent of immunotherapy, prognosis has tended to improve; however, pseudoprogression poses a challenge to the management of immunotherapy. Herein, we discuss the case of a 47‐year‐old heavy smoker with advanced SqCC. The patient had recurrent disease after initial successful control of the tumor by concurrent radiochemotherapy, together with ample pleural effusion. Pleural effusion was well controlled with systematic nivolumab and intra‐thoracic recombinant endostatin; however with simultaneous deterioration of performance and tumor progression. Nivolumab was maintained with the addition of nab‐paclitaxel. The combination soon led to a partial response and rapid improvement of the patient's performance. During treatment of this case, we advocated the early control of pleural effusion as an indicator for pseudoprogression. Our experience might be helpful to identify pseudoprogression for the clinical management of immunotherapy.

Thoracic injection of low-dose interleukin-2 as an adjuvant therapy improves the control of the malignant pleural effusions: a systematic review and meta-analysis base on Chinese patients

BACKGROUND

Interleukin-2 (IL-2) is an important immunotherapy cytokine for various diseases including cancer. Some studies reported the efficacy and safety on cisplatin combined with IL-2 versus cisplatin alone for treating malignant pleural effusion (MPE) through thoracic injection.

METHODS

We searched these studies from medical electronic database. A total of 18 studies that met the inclusion criteria were recruited in this meta-analysis. Pooled odds ratios (OR) with 95% confidence intervals (CI) were determined by the fixed effects model of meta-analysis.

RESULTS

The objective response rate (ORR) and disease control rate (DCR) of cisplatin plus IL-2 for controlling MPE was significantly higher than that of cisplatin alone (p < 0.001). In addition, compared with cisplatin alone, the presence of IL-2 improved the quality of life (QOL) of patients with MPE (p < 0.001). Although the use of IL-2 seemed to increase the probability of fever in patients (p = 0.001), it did not lead to extra other side effects (AEs) including myelotoxicity, nausea/vomiting and chest pain (p > 0.05).

CONCLUSIONS

The low-dose IL-2 improved the ORR, DCR and QOL of patients in the treatment of MPE. Although it may cause fever in patients, it did not increase other AEs.

A Retrospective Study to Compare Five Induction Chemotherapy Regimens Prior to Radiotherapy in the Reduction of Regional Lymph Node Size in Patients with Nasopharyngeal Carcinoma

BACKGROUND Combined chemotherapy and radiation therapy are used to treat nasopharyngeal carcinoma (NPC). Previous studies have shown that induction chemotherapy, given before radiotherapy, is beneficial in patients with local lymph node metastases. The aim of this study was to evaluate regional lymph node size in patients with NPC and the efficacy of five induction chemotherapy regimens given before radiotherapy. MATERIAL AND METHODS Between December 2007 and June 2011, 190 patients were included in this study, who had regionally advanced NPC (Stages II-IV). Five induction chemotherapy regimens were given prior to radiation: 98 patients (51.6%) received the TPF regimen (docetaxel, cisplatin, and fluorouracil); 56 patients (29.5%) received PF regimen (cisplatin and fluorouracil); 26 patients (13.7%) received the TP regimen (cisplatin and docetaxel); seven patients (3.7%) received combined nimotuzumab with TPF; three patients (1.6%) received a combination of the novel modified recombinant human endostatin (Endostar) with PF. The length and width of the regional lymph nodes were measured using neck B-mode (high-resolution grey scale) ultrasonography before chemotherapy and on the second day following completion of chemotherapy. Gastrointestinal tract and bone marrow suppression were also monitored during and after chemotherapy. RESULTS The TPF chemotherapy induction regimen resulted in an improved early response of lymph node size reduction, compared with the PF and TP chemotherapy induction regimens. The combined use of nimotuzumab with the TPF regimen improved efficacy by 15%. The combined use of Endostar improved the efficacy of the PF regimen by 56% (P<0.05). CONCLUSIONS In a retrospective study in patients with NPC, different induction chemotherapy regimens had different effects on lymph node size before radiation therapy.

Evaluation of efficacy and safety for Brucea javanica oil emulsion in the control of the malignant pleural effusions via thoracic perfusion

Background

Brucea javanica oil emulsion (BJOE) is traditional Chinese medicine with implicated anti-tumor activity, which has been used for treating lung cancer in China. The aim of this investigation was to evaluate the effects and safety of intrapleural injection of BJOE in treating malignant pleural effusion (MPE).

Methods

The randomised controlled trials (RCTs) on the effects and safety of BJOE in treating MPE were searched from electronic medical database including MEDLINE, SCI, EMBASE, Cochrance Library and CNKI. A total of 14 RCTs with 1085 patients were involved in this meta-analysis.

Results

The overall response rate (ORR) of traditional chemotherapy drugs plus BJOE was higher than that of traditional chemotherapy drugs alone (p = 0.001; odds ratio = 1.39). Meanwhile, the combination of BJOE and traditional chemotherapy drugs improved the quality of life (QOL) of patients with MPE (p < 0.001; odds ratio = 1.56) compared with traditional chemotherapy drugs alone. Moreover, the participation of BJOE reduced the myelotoxicity and digestive reactions caused by traditional chemotherapy drugs (p < 0.05).

Conclusions

The efficacy and safety of traditional chemotherapy drugs plus BJOE was superior to traditional chemotherapy drugs alone via intrapleural injection in controlling MPE, which suggested that BJOE can be used to treat MPE.

Evaluation of efficacy and safety for bevacizumab in treating malignant pleural effusions caused by lung cancer through intrapleural injection

Some clinical investigations have assessed the efficacy and safety of bevacizumab combined with platinum anti-cancer drugs versus platinum drugs alone in treating malignant pleural effusion (MPE) caused by lung cancer through intrapleural injection. This report is a meta-analysis of independent research conclusions. Eleven controlled trials with 769 MPE patients were included in this report. Pooled odds ratios and standardized mean difference with 95% confidence intervals were estimated using the fixed or random effects model of meta-analysis. For treating MPE through intrapleural injection, bevacizumab combined with platinum chemotherapy drugs increased the overall response rate (p = 0.003), decreased the incidence of chest pain (p < 0.001) and relieved the dyspnea of patients with MPE (p = 0.002), as compared with platinum chemotherapy drugs alone. In addition, intrapleural injection of bevacizumab participation decreased the expression of vascular endothelial growth factor in MPE (p < 0.001). The main adverse effects of two groups were myelotoxicity, hypertension, digestive reaction and damage of liver and kidney. However, the presence of bevacizumab did not show an extra influence on the incidence of adverse effects (p > 0.05). In summary, bevacizumab combined with platinum chemotherapy drugs for treating MPE caused by lung cancer through intrapleural injection has a better benefit of overall response rate and quality of life. And, the participation of bevacizumab did not increase adverse effects.

Antitumor activities of Liver-targeting peptide modified Recombinant human Endostatin in BALB/c-nu mice with Hepatocellular carcinoma

In our previous study, a liver-targeting peptide CSP I-plus modified recombinant human Endostatin (rEndostatin, endostar) (rES-CSP) was constructed and showed potent antiangiogenic capability and could specifically bind to human hepatocellular carcinoma cells to make a direct inhibition in vitro. In this study, the biological activities of rES-CSP in vivo were evaluated by subcutaneous and orthotopic xenograft nude mice model of human hepatocellular carcinoma cells HepG2. We found that rES-CSP significantly decreased tumor volume to 54.9% in the nude mice with subcutaneous xenograft compared with the control. In orthotopic xenograft model, rES-CSP not only decreased tumor volume (to 39.6% compared with the control) and tumor weight, it also increased its biodistribution in the liver tissue and hepatoma tissue. Moreover, lower microvessel density (MVD) and higher apoptotic index (AI) were also observed in the tumor tissues. It had no significant side-effects on the heart, liver, spleen, lung and kidney of mice. Results indicated CSP I-plus modified Endostar may be a potential candidate for a targeting therapy on hepatocellular carcinoma.