Clinical Significance of Cell-free and Concentrated Ascites Re-infusion Therapy for Advanced and Recurrent Gynecological Cancer

Background: The management of malignant ascites is critical for the treatment of patients with advanced gynecological cancer. The purpose of this study was to assess the clinical significance of cell-free and concentrated ascites re-infusion therapy (CART). Patients and Methods: Adverse events, alterations in Eastern Cooperative Oncology Group performance status, serum albumin, body weight and abdominal circumference, and overall survival were examined in 22 patients with advanced gynecological cancer which were treated with CART. Results: Most of the adverse events were grade 1 or 2 fever. CART treatment had little effect on ECOG performance status and on levels of serum albumin. There was a significant decrease in body weight and in abdominal circumference post-treatment with CART, relative to pre-treatment (p<0.01). The overall survival rate was significantly prolonged in 14 patients after CART plus chemotherapy, as compared with eight patients after CART alone (p<0.01). Conclusion: CART may contribute to the improvement of quality of life and of survival in patients with advanced gynecological cancer. In advanced gynecological cancer, especially in the case of ovarian, peritoneal and endometrial cancer, cancer cells spread extensively in the abdominal cavity, resulting in massive refractory ascites (1). Such refractory ascites when associated with peritonitis carcinomatosa cause severe abdominal distension, dyspnea, appetite loss and circulatory failure. Even a transient removal and re-infusion of refractory ascites leads to relief from severe symptoms, facilitation of oral intake, circulatory improvement and renewed determination of the patient to continue living and fight their disease (2). In addition, the subsequent chemotherapy can potentially eliminate the ascites and enable discharge of the patient from the hospital. The management of malignant ascites is a significant challenge in medical oncology. Current treatment strategies include diuretic therapy, paracentesis, peritoneal drains and venous shunts (3-5). However, there are no established evidence- based guidelines. Cell-free and concentrated ascites re-infusion therapy (CART) for refractory ascites is carried out in the following four ways: i) Ascitic fluid is collected by abdominal paracentesis; ii) bacteria and malignant cells in the fluid are filtered off; iii) the autologous proteins are concentrated; and iv) the filtered and concentrated autologous ascitic fluid is re- infused into the patient's vein. Britton first reported the efficacy of CART for patients with liver cirrhosis (6). Since then, CART has been applied to the treatment of refractory ascites in patients with conditions such as liver cirrhosis, congestive heart failure, nephrotic syndrome and malignancies (7-12). Nevertheless, CART has not been used widely for the treatment of refractory ascites in patients with cancer and there have been few reports concerning its safety and clinical efficacy (13, 14). Accordingly, the best treatment of cancer patients with refractory ascites using CART still needs to be established. Advanced gynecological cancer and its recurrence frequently results in peritoneal carcinomatosis with refractory ascites. Therefore, the management of refractory ascites in the treatment of advanced gynecological cancer remains a key problem. The purpose of this retrospective study was to evaluate the safety and efficacy of CART and to assess the clinical significance of CART plus chemotherapy in patients with refractory ascites.