Intrapleural Perfusion With Staphylococcal Enterotoxin C for Malignant Pleural Effusion: A Clustered Systematic Review and Meta-Analysis

Abstract

IntroductionThe staphylococcal enterotoxin C (SEC), a commercially available bio-product from Staphylococcus aureus (S. aureus), has been widely used to control MPE.ObjectivesWe designed and performed a new systematic review (SR) and meta-analysis to clarify the perfusion protocols with SEC, determine their clinical effectiveness and safety, and reveal the indication and optimum usage for achieving the desired responses.MethodologyAll randomized controlled trials (RCTs) about SEC for MPE were collected from electronic databases (from inception until July 2021), and clustered into multiple logical topics. After evaluating their methodological quality, we pooled the data from each topic using the meta-analysis or descriptive analysis, and summarized the evidence quality using the grading of recommendation assessment, development, and evaluation (GRADE) approach.ResultsAll 114 studies were clustered into SEC perfusion alone or plus chemical agents. The SEC alone showed a better complete response (CR), a lower pleurodesis failure, and adverse drug reactions (ADRs), and a higher fever than cisplatin (DDP) alone. The SEC and chemical agents developed 10 perfusion protocols. Among them, only SEC and DDP perfusion showed a better CR, a lower failure, disease progression and ADRs, and a higher fever than DDP alone. The SEC (100–200 ng per time, one time a week for one to four times) with DDP (30–40 mg, or 50–60 mg each time) significantly improved clinical responses for patients with moderate to large volume, Karnofsky performance status (KPS) scores ≥40, ≥50, or ≥60, and anticipated survival time (AST) ≥2 or 3 months. Most results were moderate to low quality.ConclusionCurrent pieces of evidence indicate that super-antigen SEC is a pleurodesis agent, which provides an attractive alternative to existing palliative modalities for patients with MPE. Among 10 protocols, the SEC and DDP perfusion is a most commonly used, which shows a significant improvement in clinical responses with low ADRs. These findings also provide a possible indication and optimal usage for SEC and DDP perfusion.

Pleurodesis

“…Chambers [7]. Multiple substances or interventions on the pleura have been used to achieve pleurodesis, all with the purpose of generating fibrosis and adhesion between pleurae, starting with talc [8][9][10], iodized talc [7,11], silver nitrate [12], iodine [13], extending to the use of antimicrobials such as tetracycline [14,15], doxycycline [16][17][18][19][20], minocycline [18,21] tigecycline [22,23], quinacrine [24], mepacrine [25], cytotoxics such as bleomycin [18,19], mitomycin [26,27], mitoxantrone [28,29], platinum derivatives [30,31], bacterial agents such as Corynebacterium parvum [32], OK-432 (a derivative of Streptococcus) [26,33], Staphylococcus superantigens [26,34,35], lipoteichoic acid [36], reaching haematic patches [37][38][39], hypertonic glucose [40][41][42], mistletoe-derived substances such as Viscum album [43][44]…”