My Empirical Formula for Treating Pleural and Ascitic Fluid in Cancer Patients

Pleural and ascitic effusion is a common complication when cancer reaches the middle-to-late stages, and it is relatively difficult to treat. Refractory pleural or ascitic fluid in particular rarely responds to conventional diuretics, and Western medicine mostly relies on draining the fluid to relieve symptoms. For such patients, a large compound TCM formula (da fu fang) can sometimes be effective. I have previously published one relatively effective regimen I use for treating pleural and ascitic effusion. In recent years this regimen has been steadily refined in clinical practice, and I am now publishing its improved version for readers' reference.

Huangqi 30 g, Han Fangji (Stephaniae Tetrandrae Radix) 20 g, Chao Baizhu (stir-fried Atractylodis Macrocephalae Rhizoma) 20 g, Fuling (Poria) 30 g, Zhuling (Polyporus) 10 g, Tinglizi (Descurainiae Semen) 15 g, Sangbaipi (Mori Cortex) 15 g, Digupi (Lycii Cortex) 15 g, Mudanpi (Moutan Cortex) 10 g, Dangshen (Codonopsis Radix) 30 g, Huangjing (Polygonati Rhizoma) 30 g, Chaihu (Bupleuri Radix) 10 g, Huangqin (Scutellariae Radix) 10 g, Guizhi (Cinnamomi Ramulus) 10 g, Baishao (Paeoniae Alba Radix) 10 g, Fuxiaomai (Tritici Levis Fructus) 30 g, Duan Muli (calcined Ostreae Concha) 30 g, Tianhuafen (Trichosanthis Radix) 10 g, Zhi Gancao (honey-fried Glycyrrhizae Radix) 10 g, Cheqianzi (Plantaginis Semen) 15 g, Huainiuxi (Achyranthis Bidentatae Radix) 15 g, Yimucao (Leonuri Herba) 30 g, Cheqiancao (Plantaginis Herba) 30 g, Yiyiren (Coicis Semen) 30 g, Zhi Mahuang (honey-fried Ephedrae Herba) 6 g, Xingren (Armeniacae Semen) 6 g, Zisuzi (Perillae Fructus) 6 g, Shengjiang (Zingiberis Rhizoma Recens) 7 slices, Dazao (Jujubae Fructus) 7 pieces.

This formula is formed by combining and modifying three classical formulas: Huangqi Fangji Tang, Chaihu Guizhi Tang, and Ma Xing Yi Gan Tang. Huangqi Fangji Tang originates from the Jin Gui Yao Lue (Essential Prescriptions of the Golden Coffer) written by Zhang Zhongjing in the Han dynasty; it is one of the commonly used TCM formulas for treating edema and is designed as a water-disinhibiting, detumescent formula suitable for patients with weak constitutions. Chaihu Guizhi Tang comes from Zhang Zhongjing's Shang Han Lun (Treatise on Cold Damage); it is the representative formula for the combined disease of the Taiyang and Shaoyang channels marked by alternating chills and fever, limb pain, and fullness and oppression in the chest and hypochondrium caused by externally contracted disease. Ma Xing Yi Gan Tang also comes from the Shang Han Lun and principally treats generalized body pain caused by the contest of wind-dampness.

Why choose these three formulas as the core? Because most middle-to-late-stage cancer patients are weak, and using harsh and toxic formulas such as Shi Zao Tang, Peng Zheng Wan, or Zhou Che Wan carries great risk. Although a few patients may obtain a lucky effect, after taking toxic herbs such as Daji (Euphorbiae Pekinensis Radix), Gansui (Kansui Radix), Yuanhua (Genkwa Flos), or Shanglu (Phytolaccae Radix), most patients deteriorate sharply and are difficult to manage afterward.

By contrast, Huangqi Fangji Tang is a formula that supports the righteous qi (fu zheng) while dispersing pathogen, and its water-disinhibiting herbs such as Fangji, Fuling, and Baizhu are all mild in nature. On this basis, adding water-disinhibiting herbs such as Zhuling, Yimucao, Cheqiancao, Cheqianzi, and Niuxi gives a good diuretic, detumescent effect that does not readily damage the righteous qi. Further adding Dangshen and Huangjing to support the righteous and secure the root makes the side effects even smaller. Adding Sangbaipi, Digupi, and Mudanpi has the effect of draining heat and disinhibiting water.

When pleural or ascitic effusion appears in middle-to-late-stage cancer patients, inflammation is usually also present, and there may additionally be cancer pain and cancer fever. The subtlety of using Chaihu Guizhi Tang is that it can simultaneously address these problems in the patient; thus using it to assist Huangqi Fangji Tang in disinhibiting water and reducing swelling achieves twice the result with half the effort. The rationale for using Ma Xing Yi Gan Tang is similar to that for Chaihu Guizhi Tang. Once these two formulas are applied, they often not only resolve the patient's pleural and ascitic effusion but also resolve the cancer pain and cancer fever.

It should be noted that in summer, or when treating patients allergic to Mahuang, the Zhi Mahuang in the formula should be replaced by Xiangru (Moslae Herba), and the dose should be above 30 g. Xiangru is similar in nature to Mahuang: both can disinhibit water and reduce swelling as well as drain the lung and calm wheezing. But Xiangru is milder and less likely to cause adverse reactions. Mahuang has certain side effects; a few patients are allergic to it and may develop spasms and pain reactions after use. Patients with poor cardiac function are more likely to develop tachycardia when using Mahuang. One must understand the patient's condition before using Mahuang.

If the patient has hepatic ascites, Muxiang (Aucklandiae Radix) 10 g and Houpo (Magnoliae Cortex) 10 g should be added on the basis of this formula. If cancer embolus or thrombosis is also present, Dilong (Pheretima) 10 g, Shuizhi (Hirudo) 3-10 g, Taoren (Persicae Semen) 10 g, Honghua (Carthami Flos) 3-6 g, Sanqi (Notoginseng Radix et Rhizoma) 6 g (ground powder, taken infused), Ezhu (Curcumae Rhizoma) 10 g, Sanleng (Sparganii Rhizoma) 10 g, and Jianghuang (Curcumae Longae Rhizoma) 10 g should be added to activate blood and resolve stasis. In the case of liver cirrhosis or primary or secondary liver tumors, Biejia (Trionydis Carapax) 30 g and Shuihonghuazi (Polygonum Orientalis Fructus) 30 g should be added to soften hard masses and disperse nodulation.

Using the above approach, I have treated pleural and ascitic effusion in patients with mesothelioma, lung cancer, liver cancer, hepatic metastatic tumors, lymphoma, and pancreatic cancer, and there have been effective cases in each. The clinical efficacy of this formula can be reproduced across different patients, which shows that its composition rationale is practical.