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23]

Original Article

A metaanalysis of elemene versus DDP

intrapleural injection in the treatment of
malignant pleural effusion caused by lung
cancer
ABSTRACT Xiaolong Wang,
Objective: The objective of this study was to evaluate the clinical efficacy of elemene versus DDP intrapleural injection in the treatment Haojie Wang,
of malignant pleural effusion caused by lung cancer by metaanalysis. Li Li1
Materials and Methods: PubMed(1960~2016.4), EMBASE(1980~2016.4), and CNKI(1979~2016.4) databases were Department of
searched to identify the clinical studies of elemene intrapleural injection in the treatment of lung cancer malignant pleural effusion. The Thoracic Surgery,
odds ratio(OR) was used to evaluate the clinical efficacy of elemene in the treatment of pleural effusion compared to cisplatin(DDP). Huaihe Hospital of
Henan University,
Results: Seven hundred and Thirtytwo subjects with 14 studies were finally included in this metaanalysis. Metaanalysis 1
Nursing College of
demonstrated that the objective response rate in elemene group was much higher than that in DDP group(OR=1.34, 95% confidence Henan University,
interval: 1.07~1.69, P<0.05). The Beggs funnel plot and Eggers line regression test showed no statistical publication bias. Kaifeng, PR China
Conclusion: High clinical efficacy of elemene in the treatment of lung cancer malignant pleural effusion was found compared to DDP. For correspondence:
Mrs. Li Li,
Nursing College of
KEY WORDS: Elemene, lung cancer, metaanalysis, pleural effusion Henan University,
Kaifeng, 475000, PR
China.
Email:77371692@
INTRODUCTION accordance with each other. Therefore, to further qq.com
evaluate the clinical efficacy of elemene intrapleural
Lung cancer is the most diagnosed malignant injection in the treatment of malignant pleural
carcinoma clinically. The epidemiology study effusion caused by lung cancer, we performed this
showed that about 1 million people were dead of metaanalysis by pooling the open published data.
lung cancer in the year of 2012, and lung cancer
has become the first cause of cancerrelated MATERIALS AND METHODS
death.[1] Pleural effusion caused by pleural cavity
metastasis was often observed in advanced stage Publication searching strategy
lung cancer patients. Huge pleural effusion can PubMed(1960~2016.4), EMBASE(1980~2016.4),
cause respiratory and circulatory failure which and CNKI(1979~2016.4) databases were
need urgent treatment.[2] In most of the cases, searched to identify the clinical studies of elemene
the treatment procedure was closed drainage of intrapleural injection in the treatment of lung X i a o l o n g Wa n g
an d H aojie Wang
thoracic cavity and chemotherapy drugs pleural cancer malignant pleural effusion. The searching
contributed equally
cavity injection which can reduce the pressure items were elemene, lung cancer/nonsmall cell to this work.
on the lung tissue and the heart.[3] The most used lung cancer, pleural effusion, and elemene. The
drug, intrapleural injection, was DDP which can searching languages were restriction to English Access this article online
kill the metastatic lung cancer cell and reduce the and Chinese. Website: www.cancerjournal.net
pleural effusion.[4] However, the pleural adhesion DOI: 10.4103/0973-1482.200748
effects were poor. Several studies have reported the This is an open access article distributed under the terms of the Creative Commons PMID: ***
AttributionNonCommercialShareAlike 3.0 License, which allows others to remix,
efficacy of elemene intrapleural injection for the tweak, and build upon the work noncommercially, as long as the author is credited Quick Response Code:

treatment of malignant pleural effusion caused by and the new creations are licensed under the identical terms.
lung cancer. However, the conclusion was not in For reprints contact: reprints@medknow.com

Cite this article as: Wang X, Wang H, Li L. A meta-analysis of elemene versus DDP intrapleural injection in the treatment of
malignant pleural effusion caused by lung cancer. J Can Res Ther 2016;12:C244-7.

C244 2017 Journal of Cancer Research and Therapeutics | Published by Wolters Kluwer -Medknow
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Wang, etal.: Elemene versus DDP in treatment of malignant pleural effusion

Inclusion and exclusion criteria
Inclusion criteria
(1) The study design was clinical controlled trials with or
without blindness;(2) the patients included in the study were
diagnosed of lung cancer with pleural effusion;(3) the patients
were treated with DDP or elemene;(4) the original study can
provide enough data to calculate the odds ratio(OR);(5) paper
published in English or Chinese.
Exclusion criteria
(1) Retrospective study or case report or review;(2) the
original study cannot provide enough data to calculate the
OR;(3) repeat published literature;(4) pleural effusion caused
by other disease such as infection.
Data extraction
The data of original included studies were extracted by two
reviewers independently. The extracted information or data
included the title of the papers, the first author, the journal
of publication, the year of publication, the treatment period,
the treatment drugs and dosage, and the number of patients
with response. The extracted data or information were
crosschecked by the two reviewers.
Statistical analysis
The data were analyzed by the statistical software Stata
12.0(Stata Corporation, College Station, TX, USA) using a
fixed or random effects model according to the heterogeneity
analysis. The results of discontinuous data were reported as OR
with 95% confidence interval(CI), P<0.05 was considered to
indicate a statistically significant difference. The publication
bias was evaluated by Beggs funnel plot and Eggers line
regression test.
RESULTS
General characteristics of included publications
Through searching the PubMed and Wanfang databases, we
initially find 126 publications. After reading the title and
abstract, 96 studies were excluded for not some reasons.
Moreover, 16 papers were excluded after reading the whole
paper. Finally, 14 studies[515] were included in the present study
with 371cases in the elemene group and 361 subjects in the
DDP group. The general characteristics of the 14 studies are
demonstrated in Table1.
Metaanalysis
Because of no significant statistical heterogeneity was
found(I2=0.00%, P=0.99), the effect size of OR was pooled
by fixed effect model. Metaanalysis demonstrated that the
objective response rate in elemene group was much higher
than that in other drugs group(OR=1.34, 95% CI: 1.07~1.69,
P<0.05)[Figure1].
Sensitivity analysis
The sensitivity analysis was taken by excluding each of the
included studies. The pooled OR ranged from 1.17 to 1.21 which
was still more than 1. The sensitivity indicated that the
pooled results were not sensitivity to each of the included
14 publications[Figure2].
Publications
We use Beggs funnel plot and Eggers line regression test
to evaluate the publications. The Beggs funnel plot was
left and right symmetric without publication. The Eggers
line regression test showed the t = 0.74, P=0.47 which
indicated no significant publication bias[Figure3].
DISCUSSION
Huge pleural effusion can cause respiratory and circulatory
failure which needs urgent treatment. The prognosis was poor
for patients with huge malignant pleural effusion, and the
median survival was less than 12months.[16] The traditional
Chinese medicine believe that the malignant pleural effusion
belonged to Xuanyin category, and it was the results of body
toxin and other factors, such as disorder of lung, spleen and
kidney dysfunction, Sanjiao channel obstruction, obstruction
of lung qi descending and documented and etal. The main
reason of malignant pleural effusion was metastasis of disease of

Table1: The general characteristics of included publications

Author Publication Elemene DDP Treatment time
Effective Total Effective Total
Zhang Wanling[5] 1996 16 19 7 9 1 month
Lin Shuntong[6] 1996 9 11 7 10
Wang Fengyue[4] 1998 11 13 9 13
Hongxin etal.[7] 1998 26 35 27 34
Yang Boquan[2] 2000 28 30 21 30 1 month
Ye Aihe[1] 2001 40 46 28 50 1 month
Wang Ping[8] 2002 25 30 17 30 1 month
Gu Lixin[9] 2003 18 20 11 20 1 month
Bai Xianli[10] 2005 17 24 17 23 1 month
Shi Guoqiang[11] 2007 19 25 15 25 1 month
Li Ming[12] 2008 22 26 16 26 1 month
Sun Junzhong[13] 2009 29 30 17 29 1 month
Wu Haisong[14] 2011 20 30 12 30 4weeks
Sun Lanying[15] 2013 27 32 18 32 4weeks

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Wang, etal.: Elemene versus DDP in treatment of malignant pleural effusion
Figure 1: The forest plot of clinical effect for elemene intrapleural
injection
Figure3: The funnel plot of evaluation of the publication bias
pleura. In general, the pleural effusion should be firstly drainage
and then injected by chemotherapy drugs into the pleural cavity
which can reduce the pressure on the lung tissue and the heart
and made the visceral and parietal pleural adhering together.[10]
The most used drug, intrapleural injection, was DDP which
can kill the metastatic lung cancer cell and reduce the pleural
effusion.[17] Another drug elemene was also widely used for the
treatment of malignant pleural effusion. Several studies[4,13] have
reported the clinical efficacy of elemene intrapleural injection
in the treatment of malignant pleural effusion caused by lung
cancer. However, the results were not in accordance with each
other. Therefore, to further evaluate the clinical efficacy of
elemene intrapleural injection in the treatment of malignant
pleural effusion caused by lung cancer, we performed this
metaanalysis by pooling the open published data.
In the present metaanalysis, we included 14 papers with
732 subjects. The pooled results showed that objective
response rate in elemene group was much higher than that
in DDP group(OR=1.34, 95% CI: 1.07~1.69, P<0.05). The
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Figure2: The forest for sensitivity analysis
pooled results indicated that patients who received elemene
intrapleural injection have more chance to gain complete or
partial response compared to DDP.The sensitivity indicated
that the pooled results were not sensitivity to each of the
included 14 publications, which means the results were
stable and cannot be affected by a single study. Moreover, the
publication bias evaluation showed no significant publication
bias in this metaanalysis. Hence, we believe that the clinical
efficacy of elemene was superior to DDP in the treatment of
malignant pleural effusion caused by lung cancer.
Financial support and sponsorship
Foundation: Key project of science and technology
research, department of education, henan province In 2015
(No.15A320044).
Conflicts of interest
There are no conflicts of interest.
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