Good Doctor·Hyperthermic Perfusion | The Hazards of Malignant Ascites and a Core Analysis of Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Cancerous ascites, also known as malignant ascites, is a pathological condition in which malignant tumors invade intra-abdominal organs and metastasize to the retroperitoneum, leading to an abnormal increase and accumulation of fluid within the peritoneal cavity. It is a common complication of advanced malignancies, such as gastric cancer, colorectal cancer, ovarian cancer, and pancreatic cancer. Cancerous ascites severely impairs patients’ quality of life, accelerates disease progression, and serves as a significant indicator of poor prognosis in patients with advanced cancer. According to clinical data, approximately 15%–20% of patients with advanced malignancies develop cancerous ascites, with the highest incidence observed in ovarian and gastric cancer—ranging from 50%–70% and 30%–40%, respectively. Among patients with advanced cancer complicated by cancerous ascites, the median survival is typically less than six months.

Combined Cytoreductive Surgery (CRS) followed by Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Intraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Patients with Massive Ascites

Part 01: Major Adverse Effects of Malignant Ascites

The harms of malignant ascites are multifaceted, encompassing both physical dysfunction and significant psychological burden. Moreover, the severity of these harms progressively increases with greater fluid accumulation and disease progression, primarily manifesting in the following four aspects:

01 Compression of intra-abdominal organs, leading to severe physical discomfort

The abdominal cavity is a vital body cavity that houses several important organs, including the liver, spleen, stomach, and intestines. When fluid accumulates within the abdominal cavity and continues to increase, it leads to sustained intra-abdominal hypertension, which compresses adjacent organs and impairs their normal function. Compression of the gastrointestinal tract results in symptoms such as abdominal distension, abdominal pain, nausea, vomiting, and decreased appetite; in severe cases, patients may even be unable to eat or have bowel movements, leading to malnutrition and electrolyte disturbances. Compression of the diaphragm restricts diaphragmatic movement, compromising pulmonary ventilation and gas exchange, and causing chest tightness, shortness of breath, dyspnea, and even orthopnea, thereby severely impairing respiratory function and sleep quality. Compression of the kidneys can reduce renal blood flow, resulting in decreased urine output, lower-extremity edema, and other manifestations of impaired renal function, which further increases the burden on the body.

02 Worsens malnutrition and weakens the body’s immune defenses.

Malignant ascites is rich in proteins, particularly albumin and other nutrients (with protein concentrations as high as 2–4 g per 100 mL of fluid). Prolonged accumulation of large volumes of ascitic fluid, combined with symptomatic interventions such as paracentesis or drainage, leads to substantial protein loss from the body, resulting in hypoproteinemia. Hypoproteinemia not only exacerbates the formation of ascites—creating a vicious cycle of “increased fluid accumulation → protein loss → hypoproteinemia → further fluid accumulation”—but also causes symptoms such as wasting, fatigue, anemia, and impaired immune function. Under these circumstances, the patient’s overall resistance is severely compromised, making them highly susceptible to complications such as pulmonary infections and intra-abdominal infections; these infections, in turn, further aggravate the underlying disease, perpetuating the vicious cycle and posing a serious threat to life.

03 Promotes tumor metastasis and accelerates disease progression

Malignant ascites is not merely a “fluid accumulation”; the effusion contains abundant tumor cells, pro-inflammatory cytokines, growth factors, and chemokines. Within this tumor microenvironment, tumor cells freely disseminate and implant throughout the peritoneal cavity, invading additional intra-abdominal organs—such as the peritoneum, mesentery, and liver surface—thereby giving rise to extensive peritoneal metastasis and increasing the complexity of treatment. Meanwhile, the pro-inflammatory mediators in the ascitic fluid can trigger chronic inflammation of the peritoneal tissues, leading to symptoms such as peritoneal adhesions, pain, or intestinal obstruction, which further compromise patients’ quality of life.

04 Causes psychological stress and reduces the will to survive

Patients with advanced cancer already endure tremendous psychological stress; the persistent discomfort caused by malignant ascites—such as abdominal distension, abdominal pain, and dyspnea—combined with the palpable sense that their condition is worsening, further undermines their psychological resilience. Patients often experience negative emotions such as anxiety, depression, and hopelessness, leading to a loss of confidence in treatment and a diminished will to live, and may even refuse subsequent therapies, thereby indirectly accelerating disease progression. Moreover, the prolonged course of treatment imposes a heavy financial burden and significant caregiving demands on both patients and their families, further exacerbating psychological distress.

Part 02: Core Analysis of Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Multiple clinical studies have demonstrated that HIPEC is highly effective in preventing peritoneal surface implantation metastases following radical surgery for abdominal malignancies and in controlling the recurrence of microscopic residual disease after cytoreductive surgery (CRS). Owing to its unique therapeutic mechanism—the synergistic interplay of perfusion, hyperthermia, and chemotherapy—HIPEC overcomes the limitations of conventional treatments that address only the symptoms rather than the root cause, making it the most effective modality currently available for managing malignant ascites.

HIPEC effectively eliminates free cancer cells (FCCs) and eradicates microscopic lesions that cannot be removed during surgery, thereby reducing the risk of postoperative peritoneal metastasis and tumor recurrence. Chemotherapeutic agents selected based on the primary tumor cell type and drug sensitivity, when combined with hyperthermia, not only penetrate cancer cells more readily but also reach deep into the tumor lesion—up to 5 mm—resulting in an exponential increase in therapeutic efficacy. Local intraperitoneal administration of chemotherapeutic agents ensures that the drugs accumulate within the abdominal cavity and exert direct antitumor effects, while simultaneously maintaining significantly lower systemic blood concentrations compared with those achieved with systemic chemotherapy (intravenous or oral administration). Consequently, the severity and incidence of systemic adverse effects, such as nausea and vomiting, are markedly reduced.

Indications for Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Primary Peritoneal Tumors: Appendiceal Cancer; Pseudomyxoma Peritonei (PMP); Malignant Peritoneal Mesothelioma (MPM)

Secondary peritoneal tumors: peritoneal metastases from colorectal cancer; peritoneal metastases from gastric cancer; peritoneal metastases from ovarian cancer; other peritoneal metastatic cancers.
 

Clinical Data and Expert Consensus Recommendations for Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

“Clinical Application of Isothermal Circulating Hyperthermic Perfusion Chemotherapy in the Prevention and Treatment of Cavity Metastatic Cancer” — Modern Oncology — 2009:

There were 127 cases of ascites, with the following characteristics: hemorrhagic in 43 cases, yellow in 69 cases, chylous in 11 cases, gelatinous in 3 cases, and infectious in 1 case. There were 28 cases of pleural effusion, with hemorrhagic in 22 cases and yellow in 6 cases. The number of treatment responses varied depending on the nature of the effusion: generally, hemorrhagic ascites responded 1–3 times, yellow ascites 3–6 times, and chylous ascites 6–9 times; after two courses of treatment, the overall effective rate was 91.2%.
 

“Observation of the Efficacy of Circulating Hyperthermic Perfusion Chemotherapy in the Treatment of Malignant Ascites” — Modern Oncology — 2009:

A total of 56 patients receiving treatment were all pathologically confirmed to have malignant ascites, including 33 males and 23 females, with a median age of 55 years (54 ± 16 years). All patients had an expected survival of more than 3 months and no encapsulated ascitic fluid had formed within the peritoneal cavity. Among them, 17 had gastric cancer, 12 had hepatocellular carcinoma, 15 had colorectal cancer, and 12 had ovarian cancer. The treatment regimen was as follows: the observation group (n = 29) underwent 60-minute intraperitoneal hyperthermic perfusion chemotherapy (HIPEC), while the control group (n = 27) received only conventional hyperthermic perfusion chemotherapy. Results: the overall response rate in the observation group was 93.1%, compared with 66.7% in the control group. Conclusion: Intraperitoneal hyperthermic perfusion chemotherapy is effective for treating malignant ascites, is simple to perform, is associated with few adverse reactions, is well tolerated by patients, and offers distinct advantages.
 

“Clinical Study on Continuous Constant-Temperature Circulating Hyperthermic Perfusion Therapy for Malignant Ascites” – Journal of the Bethune Military Medical College – 2009:

A total of 22 patients, aged 39–65 years, were included: 8 with gastric cancer, 5 with colorectal cancer, 6 with ovarian cancer, and 3 with other malignancies. In the observation group, a conventional puncture needle was used to establish a circulating dual-channel system; first, the peritoneal cavity was irrigated and drained to remove malignant ascitic fluid, followed by continuous hyperthermic intraperitoneal chemotherapy (HIPEC). In the control group, conventional drainage combined with intraperitoneal infusion of chemotherapeutic agents was employed. The overall response rate in the HIPEC group was 86.3%, significantly higher than that in the control group (P<0.05). Conclusion: Compared with traditional catheter-based drainage and thermal perfusion chemotherapy, continuous constant-temperature circulating hyperthermic intraperitoneal chemotherapy markedly improves the efficacy of treating malignant ascites and also significantly reduces the recurrence of malignant effusion, thereby enhancing the quality of life in patients with advanced cancer.

Chinese Expert Consensus on the Diagnosis and Treatment of Peritoneal Metastasis from Colorectal Cancer (2025 Edition)

Peritoneal metastasis of colorectal cancer refers to the direct shedding of cancer cells from the primary tumor and/or their dissemination via the bloodstream and lymphatic system to implant on the peritoneum, thereby forming new lesions. At initial diagnosis, 7%–15% of patients with colorectal cancer already have peritoneal metastases, and 4%–19% develop such metastases after curative surgery. Patients with peritoneal metastasis from colorectal cancer have a poor prognosis; without aggressive treatment following diagnosis, their median overall survival (OS) is only 6–9 months. The more extensive the peritoneal involvement, the poorer the prognosis and the shorter the survival.

Recommendation 9: Common intraperitoneal chemotherapy approaches primarily include hyperthermic intraperitoneal chemotherapy (HIPEC) and normothermic intraperitoneal chemotherapy (NIPEC). (Evidence quality: A; Recommendation strength: Strong recommendation)
Expert Consensus on the Clinical Application of Drugs in Intraperitoneal Hyperthermic Perfusion Therapy for Gynecologic Oncology (2024 Edition)

Hyperthermic intraperitoneal chemotherapy (HIPEC) is an important modality for the eradication of disseminated intraperitoneal malignancies. High-level evidence has demonstrated that HIPEC can improve outcomes in patients with ovarian cancer, peritoneal pseudomyxoma, and metastatic ovarian cancer.
 

Chinese Expert Consensus on the Diagnosis and Treatment of Peritoneal Metastasis from Gastric Cancer (2023 Edition)

Gastric cancer is a common malignant tumor of the digestive tract in China, ranking third among all malignancies in both incidence and mortality. In China, early-stage gastric cancer accounts for only about 20% of cases, with the majority of patients presenting at intermediate or advanced stages. The peritoneum is the most frequent site of recurrence and metastasis in advanced gastric cancer; epidemiological data estimate that in 2020, there were 523,937 cases of peritoneal metastasis from gastric cancer in China. Approximately 20% of patients are diagnosed with peritoneal metastasis preoperatively or intraoperatively, and more than 50% of patients with T3 or T4 disease develop peritoneal metastasis after curative surgery. Among advanced patients with peritoneal metastasis, the median survival is only 3 to 6 months, and the 5-year survival rate is less than 2%. Peritoneal metastasis exhibits distinct characteristics compared with metastasis to other organs, often leading to specific complications such as ascites and malignant bowel obstruction.

Recommendation 13: For patients at high risk of peritoneal metastasis, intraoperative or early postoperative prophylactic intraperitoneal chemotherapy—including HIPEC and normothermic intraperitoneal chemotherapy (NIPEC)—may be considered. (Evidence quality: moderate; recommendation strength: strong; expert panel consensus rate: 98.2%)
 

Expert Consensus on Cytoreductive Surgery Combined with Intraperitoneal Hyperthermic Perfusion Chemotherapy for Pseudomyxoma Peritonei (2019)

Peritoneal pseudomyxoma (PMP) is a malignant clinical syndrome characterized by the accumulation and redistribution of mucinous fluid produced by mucinous tumor cells within the peritoneal cavity, with clinical manifestations including mucinous ascites, peritoneal implantation, omental cake formation, and ovarian involvement. The incidence of PMP is approximately 2 to 4 per million; the male-to-female ratio is about 1:1.2 to 1:3.45; and the median age at diagnosis ranges from 43 to 63 years, classifying PMP as a rare disease.

The theoretical basis for CRS+HIPEC treatment of PMP includes pharmacokinetic advantages, thermal effects, large-volume lavage, and the synergistic effect of hyperthermic chemotherapy.

Good Doctor is dedicated to the field of continuous constant-temperature, circulating hyperthermic perfusion chemotherapy.

The intraoperative or postoperative combined application of Good Doctor hyperthermic intraperitoneal chemotherapy (GD-HIPEC) in radical surgery for abdominal tumors (such as gastric cancer, colorectal cancer, ovarian cancer, etc.) can effectively prevent the implantation and metastasis of free cancer cells (FCC) shed during CIS on the peritoneal surface.

The intraoperative or postoperative combined application of GD-HIPEC during cytoreductive surgery (CRS) for peritoneal surface tumors can effectively eradicate FCC and micrometastatic lesions, significantly improving therapeutic efficacy and preventing recurrence.

The standalone application of GD-HIPEC can effectively control malignant ascites caused by primary or metastatic advanced tumors, fundamentally preventing postoperative tumor metastasis and the recurrent “recurrence” of malignant ascites.

Good Doctor Hyperthermic Perfusion is committed to its original aspiration, focusing on the clinical application and technological R&D of HIPEC (Hyperthermic Intraperitoneal Chemotherapy), and has been deeply engaged in the treatment of malignant ascites for many years, bringing new hope for diagnosis and treatment to patients with peritoneal metastasis and malignant ascites.