Clinical Therapy for Cancer Related Fluid Retention and Lymphatic Edema

English
中文

Zhao Ruanjin

Abstract:

Fluid retention and lymph edema associated with cancer are important and challenging topics in clinical oncology. In Traditional Chinese Medicine (TCM), these conditions are categorized as Water-Qi disease/edema and Yin (Fluid) Syndrome, which are attributed to disruptions in water metabolism and the function of Qi. Herbal formulations and acupuncture therapies aimed at warming Yang Qi to regulate water metabolism have demonstrated efficacy in managing edema and fluid retention, including conditions such as pleural effusion and ascites. Its therapeutic principles are fully consistent and compatible with the holistic treatment of cancer and can complement modern clinical oncology therapies.

Appropriate and timely application of syndrome differentiation, management, and treatment, along with early intervention in patient care can contribute to improved quality of life and a better prognosis for individuals with cancer.

Key Words: Cancer, edema, water/fluid retention, Water-Qi disorders, Fluid-Syndromes, herbal medicine, acupuncture

Fluid retention and lymph edema associated with cancer present significant challenges in clinical oncology. These conditions frequently emerge during advanced stages of malignancy and often coincide with poor prognoses. Contributing factors may include large tumor masses compressing blood and lymph vessels, hypoalbuminemia leading to osmotic imbalances, cardiomyopathy induced by chemotherapy or radiotherapy, and various other causes resulting in water-electrolyte disturbances. Such complications can substantially impair the patient’s quality of life.

Modern medical practice employs catheters to remove fluid or diuretic medications. Currently, there are limited alternatives for this condition. For lymph edema, there have been recent advances including surgical techniques aimed at reconstructing micro-lymphatic circulation; however, these methods have significant limitations, and outcomes vary. In Traditional Chinese Medicine, there is a substantial body of clinical experience in addressing water metabolism disorders and fluid retention, particularly focusing on reducing the source of fluid accumulation and promoting its expulsion. This therapeutic approach and set of treatment methods possess certain distinct features. Applying these ideas and techniques to clinical oncology may provide potential benefits.

Although there are a wide variety of cancers, the patterns of clinical manifestation of cancer related fluid retention disorders can be explored and generalized. One group is fluid filling a body cavity. Examples would be hydrocephalus, pericardial effusion, edema of scrotum, pleural effusion, or ascites. Secondly, cardiogenic and lymph edema, characterized by fluid accumulation within the interstitial tissues of the extremities. Thirdly, visceral edema, including cerebral edema, pulmonary edema, and hydronephrosis.

Water and fluid metabolism disorders are categorized by TCM into water-Qi diseases and phlegm fluids diseases, which include edema and fluid retention subtypes. Pathogenesis is attributed to fluid accumulation and deficient Yang Qi. In this framework, insufficient Yang Qi is considered to affect processes such as the movement, transformation, evaporation, and distribution of fluids within the body. The upper burner is like a mist, the middle burner like a fermentation vat, and the lower burner like a sewer; all these activities rely on the motivating role of Yang Qi. Yang Qi may be reduced due to cancer development and progression, or as a side effect of strong therapies used in cancer treatment. This reduction can cause the circulation of fluid to stagnate, referred to as a pool of “dead water”, which is comparable to blood stasis, and may serve as an additional pathogenic factor contributing to disease.

Under normal physiological conditions, water metabolism is regulated by the Yang Qi of the heart, spleen, and kidneys, with Heart Yang Qi playing a particularly pivotal role as it governs the blood and vessels, where approximately 55% of blood content is water. Spleen Qi facilitates the transportation of water throughout the body, while Kidney Qi manages elimination via urination and the bowel. The interaction between heart fire, which descends to warm the kidney, and kidney water, which rises to temper heart fire, exemplifies the dynamic balance of fire and water. This interplay sustains homeostasis in water metabolism.

The dispersal and descent of Lung Qi, as well as the regulatory function of Liver Qi, play significant roles in water metabolism. This reflects the holistic perspective of Traditional Chinese Medicine, wherein Yang Qi is regarded as fundamental to life itself. Understanding these concepts is essential for discerning syndromes, accurately identifying the underlying causes of disease, and applying appropriate therapeutic interventions.

Deficient Yang Qi and fluid retention or phlegm-fluids are identified as significant pathomechanisms in oncology. According to the Su Wen: Discussion of Fluid Swelling, tumor formation is associated with cold energy compressing and condensing fluids outside the intestines. The development of Water-Qi disorder and fluid syndromes may indicate the emergence or progression of cancer. Water accumulating in the body’s superficial tissues can result in edema, while fluid condensation within body cavities is described as fluid syndrome.

The sage Zhong Jing Zhang classified Water-Qi disease and fluid syndromes into categories such as Feng Shui (wind-water edema), Pi Shui (skin-edema), Zheng Shui (true edema), Shi Shui (stone edema), and Huang Han (yellow sweat). Fluid syndromes were divided into Tan Yin (phlegm-fluids), Zhi Yin (thoracic fluid retention), and Xuan Yin (pleural effusion) based on pathogenic factors and the location of accumulated fluid. Additional categories include Liu Yin (lingering fluids) and Fu Yin (latent fluids), which are differentiated by the severity and progression speed of the condition. While this classification system is detailed and precise, its complexity can present challenges for practical clinical application.

The primary approach to managing cancer-associated water-Qi diseases and fluid syndromes is to integrate Chinese medicine with standard oncological therapies as early as possible. If the patient is not in a life-threatening condition, it is not necessary to achieve rapid removal of accumulated fluids. Addressing the underlying cause of fluid retention is recommended. Rapid withdrawal of fluids may lead to significant changes in osmotic balance and can result in quick recurrence of fluid retention. Cancer-related fluid accumulation is typically protein-rich, so excessive loss of protein through drainage may further weaken the patient and exacerbate fluid build-up.

For phlegm-fluids syndrome, herbal medicine with warming properties is commonly used, as these herbs are thought to stimulate Yang Qi. Fluid retention above the waist is typically addressed with diaphoresis, while fluid retention below the waist is managed using diuretics. Treatment for fluid syndrome focuses on supporting the volume of Yang Yi and facilitating the movement of Yang Qi. Smooth urination is considered important for maintaining the pathway of Yang Qi. In modern practice, diuretic medications may be effective in the early stages of water-retention and fluid syndrome, but their effectiveness can diminish over time, which is attributed to Yang Qi deficiency. When herbal medicines aimed at boosting Yang Qi are introduced, diuretic medications may become effective again.

The following will briefly discuss common water-Qi diseases and fluid syndromes related to cancer, based on the location, severity of fluid accumulation, and associated pathogenic factors.

Edema of the Head and Face, Hydrocephalus, and Cerebral Edema

These types of water retention disorder commonly occur in primary brain tumors, as well as in brain metastases from lung cancer, lymphoma, and breast cancer. It may also appear as head and facial swelling following high doses of immunosuppressants, or as cerebral edema after radiotherapy, or hydrocephalus caused by impaired cerebrospinal fluid circulation due to tumor compression.

Patients often present neuropsychiatric symptoms such as headache, vomiting, papilledema, unsteady gait, cognitive decline, and sometimes convulsions or epilepsy. In Traditional Chinese Medicine (TCM), this aligns with “water-Qi retention diseases” described as “shaking and swaying as if about to fall.”

Cerebral edema and hydrocephalus are two entirely different diseases. Hydrocephalus is caused by an obstruction in the circulation of cerebrospinal fluid, while cerebral edema involves the swelling of the interstitial tissue and neurons within the brain tissue. In TCM, both conditions fall under the category of “wind water” disorders and are treated by promoting diaphoresis to get rid of fluids, dispelling pathogenic wind, and calming internal wind. The brain is considered the highest and most delicate part of the body, and only wind can reach it. For the treatment of hydrocephalus, cerebrospinal fluid drainage procedures can be combined with TCM therapies. Cerebral edema, on the other hand, often presents as an acute condition in clinical settings and is managed in conjunction with modern medical treatments such as dehydration and decompression therapy. To control the patient’s neuropsychiatric symptoms—such as headache, convulsions, and epilepsy—acupuncture is an indispensable therapeutic method. Acupuncture points selected include Bai Hui (Du.20), Sishencong (EX-HN1), Yin Tang (EX-HN3), Shen men (HT7), and Tai Chong (Liv.3), using strong stimulation techniques.

For cases where external wind is the pathogenic factor, if the patient presents with significant facial swelling, Fang Ji Huang Qi Tang (Stephania and Astragalus Decoction) combined with Yue Bi Tang (Maid from Yue Decoction) can be used.

Internal wind, in conjunction with hyperactive liver yang, stirring up water retention, is also one of the pathological patterns. Herbal options may include Tian Ma Gou Teng Tang (Gastrodia and Uncaria Decoction), An Gong Niu Huang Wan (Calming the Palace Pill with Cattle Gallstone) combined with Wuling San (Five Ingredients Powder with Poria).

Thoracic Water and Fluid Retention Syndromes

The more common thoracic conditions include pericardial effusion, pulmonary edema, and pleural effusion. These respectively fall under the categories of “liú yǐn” (retained fluid), “fú yǐn” (hidden fluid), or “zhī yǐn” (branching fluid) and “xuán yǐn” (suspended fluid) in Traditional Chinese Medicine (TCM).

The main symptoms of pericardial effusion are difficulty breathing, chest pain or a sense of pressure that changes with body position. Tumors often cause weight loss and joint pain. These cases mostly belong to the categories of retained fluid and hidden fluid. As stated in the classics: “When there is retained fluid in the chest, a person experiences shortness of breath and thirst, pain and stiffness in the limbs, and a deep pulse—this indicates the presence of retained fluid.” Common prescriptions include Wuling Powder (Wǔ Líng Sǎn), Gua Lou Xie Bai Bai Jiu Tang (Trichosanthes Scallion and Wine Decoction) and Xue Fu Zhu Yu Tang (Expel Stasis in the Mansion of Blood Decoction).

Pulmonary edema, “water in the lungs, with frothy sputum and desire to drink water,” is one of the five organ-related water syndromes in the Jin Gui Yao Lue. The basic prescription consists of a combination of Decoction of Ling Gui Zhu Gan, Gua Lou Xie Bai Bai Jiu Decoction and Ting Li Da Zao Xie Fei Tang.

Pleural effusion, which refers to fluid accumulation in the chest cavity, is a common clinical manifestation of fluid syndromes in oncology. It appears in patients with lung cancer, as well as those with colon cancer, breast cancer, and lymphoma. Many patients must get pleural fluids surgically extracted frequently. In some instances, pleural effusion may be addressed by sealing the pleural cavity with talc powder, effectively scarring and eliminating the pleural spaces. This approach is typically considered when other treatments have not been effective, as it is destructive and irreversible.

This condition typically falls under the classic categories of “Zhi Yin” (Thoracic fluid retention) and “Xuan Yin” (suspended fluid retention) and is treated through pattern differentiation based on severity — mild or severe. For mild cases, the basic prescription is Decoction of Ting Li Da Zao Xie Fei Tang; for severe cases, Shi Zao Tang (Ten Jujubes Decoction) is prescribed.

Abdominal Fluid Retention Disorders

Common conditions include hydronephrosis (renal fluid retention) and ascites. Renal fluid accumulation is often caused by compression due to cancers such as renal cell carcinoma, lymphoma, ovarian cancer, bladder cancer, metastatic prostate cancer, ureteral cancer, colon cancer, and other metastatic tumors. Clinically, treatment often involves collaboration with urologists. During acute phases, ureteral stents are used to mechanically relieve the obstruction and allow urine to flow. Combining this with acupuncture to warm the kidneys, promote yang, and facilitate diuresis. TCM medicinals typically include a combination of Jin Gui Shen Qi and Wu Ling San.

The ascites is commonly observed as a terminal symptom in patients with advanced cancers such as liver cancer, malignant biliary tumors, pancreatic cancer, breast cancer, ovarian cancer, colon cancer, anorectal cancer, kidney cancer, and other malignancies. The pathogenesis can be highly complex, and may be summarized as follows: compression of blood circulation by the masses, obstruction of lymphatic circulation, or inflammatory exudation due to peritoneal metastasis of cancer cells. It may also result from severe impairment of liver function, leading to reduced synthesis and significant loss of albumin, causing large amounts of fluid to leak from blood vessels into the abdominal cavity. Modern medicine primarily treats ascites with high doses of diuretic drugs and procedures to physically drain the accumulated fluid.

Traditional Chinese medicine has a long history and rich experience in treating ascites. It is referred to as Gu Zhang (distension) and Ji Ju (accumulation), falling under the categories of Zheng Shui (True water) and Shi Shui (stone water) syndromes. This condition results from Yang qi deficiency, Qi obstruction, and blood stasis, which prevent fluid transformation and expulsion, causing fluid buildup in the abdomen. Treatment is difficult, and it has long been considered one of the four major complicated diseases.

Acupuncture Treatment: Select Bai Hui (Du. 20) and Sishencong (EX-HN1), to calm the spirit and lift up Yang qi; Dan Zhong (Ren.17), Zhong Wan (Res.12), Shui Fen (Ren.9), Shi Men (Ren.5), Qi Hai (Ren. 6), Kun Lun (U.B.60), and San Yin Jao (SP.6) to strengthen the spleen, promote yang, and facilitate diuresis; Qi Men (Liv.14) and Tai Chong (Liv.3) to soothe the liver and regulate Qi; Shen Men (Ht. 7) and Ye Men (S.J.2) to strengthen the heart and promote diuresis.

Basic Herbal Prescription: Chai Hu Bie Jia Tang (Bupleurum and Turtle Shell Decoction) combined with Wuling San (Five Ingredients Powder with Poria) and Tao Ren Cheng Qi Tang (Peach Kernel and Rhubarb Decoction). For severe cases, Ji Jiao Li Huang Wan (Stephania Zanthoxylum Descurainia and Rhubarb Formula) and Da Xian Xiong Tang (Major Sinking in the Chest Decoction) may also be selected.

Edema of the Limbs

This condition encompasses two forms: lymphedema and cardiac edema, both classified as Yi Yin syndrome (Overflowing Fluid Syndrome) in TCM.

Lymphedema typically results from damage to the lymphatic system, such as biopsy or surgical removal of lymph nodes in the armpit or groin, and may also occur following radiation therapy, which can obstruct lymphatic circulation. This condition is categorized as Excess Syndrome.

Lymphatic vessel circuit reconstruction surgery is a new but limited treatment option. Clinically, lymphatic massage remains the most effective method to restore subcutaneous interstitial fluid circulation.

Triple therapy—acupuncture, cupping, and herbal medicine—is viewed as the most effective TCM treatment. While it enhances blood and lymph circulation, its main effect is improving subcutaneous tissue fluid flow. Acupuncture alone can help, but its benefits are limited.

Plum blossom needling has been used as a treatment for lymphatic edema. After disinfecting the yang side of the affected limb, practitioners apply a plum blossom needle to the skin for approximately five minutes, followed by cupping. Each session may result in the withdrawal of mucus- and phlegm-like fluids. This technique often follows the path of the three yang meridians, moving from the distal portion of the limb toward the proximal end (such as the shoulder or root of the leg). When a significant amount of fluid is removed and subcutaneous interstitial pathways are cleared, it is suggested that lymphatic fluid can bypass the obstructed area and return to central circulation.

It is important for the physician to take measures to prevent acute cellulitis and reduce the risk of infection. Cancer patients are at an increased risk of infection regardless of acupuncture treatment. If needling is performed on the affected limb, it should only occur when alternative treatments have been exhausted and the patient has provided informed consent, to minimize the likelihood of medical disputes.

Basic TCM Prescription: Combine Ling Gui Zhu Gan Tang (Poria Cinnamon Twig Atractylodes and Licorice Decoction) combined with Xiao Qing Long Tang (Minor Blue Green Dragon Decoction). Among the ingredients, Ephedra (Ma Huang) may be restricted in the United States but remains a key component in the formula. Zhen Wu Tang (True Warrior Decoction) is also used in TCM practices to warm and support heart and kidney yang while promoting urination and reducing swelling.

If limb edema is due to cardiogenic causes, it typically presents as pitting edema, and diagnosis may involve assessing left ventricular ejection fraction using echocardiography. Zhen Wu Tang and Wu Ling San are used to support heart and kidney yang, aid urination, and reduce swelling.

Cardiogenic edema frequently occurs in patients with advanced cancer. When the lower limb edema progresses above the knee joint and reaches the waist, it is traditionally described as “water qi overwhelming the heart,” signifying a syndrome of heart yang exhaustion. This condition is considered to be the primary underlying cause of mortality in most cancer patients.

Limb edema in cancer patients is frequently caused by deep vein thrombosis (DVT), which can arise as a result of tumor degradation, chemotherapy, or radiotherapy, factors that predispose individuals to thromboembolic events within the circulatory system. Rapid onset of edema typically indicates DVT and is classified as fluid retention due to blood stasis; management should focus on promoting blood circulation, dispelling stasis, supporting yang, and enhancing diuresis. Commonly utilized herbal formulas include Xue Fu Zhu Yu Tang (Drive Out Stasis in the Mansion of Blood Decoction) and Zhen Wu Tang (True Warrior Decoction). Concurrently, anticoagulant therapy with heparin may be administered to resolve thrombosis and achieve swift, effective therapeutic results.

Both Water-Qi syndrome and retained fluid syndrome involve problems with water metabolism. Water-Qi leads to water overflowing into muscles and skin, while retained fluid is marked by localized stagnation. These conditions can evolve into each other as the disease advances; for instance, overflowing retained fluid may cause edema, and accumulated water may become retained fluid.

In addition to contemporary medical treatments for cancer, some integrative approaches incorporate traditional Chinese medicine modalities such as acupuncture and herbal therapies. These methods aim to support heart yang, promote yang warming to address fluid retention, facilitate the movement of Yang Qi, and assist in the elimination of dampness and water. They may also be utilized to manage symptoms or prevent complications associated with water retention and fluid accumulation syndromes.

Water metabolism disorders and electrolyte imbalances frequently arise in advanced stages of cancer, often alongside complex pathological conditions such as Qi stagnation and blood stasis, which present significant clinical challenges. Continued diuretic therapy and repeated drainage of plural and abdominal effusions can further destabilize electrolyte levels, increase fluid retention, and contribute to clinical complications. In progressive cases, patients may develop weakness in heart Yang and experience lower limb edema extending above the knees and up to the waist. Severe water accumulation affecting the heart (水气凌心) may be associated with life-threatening outcomes.

To optimize outcomes in oncology, Traditional Chinese medicine should be integrated early in cancer treatment. This approach supports heart yang, addresses fluid retention, promotes urination, and maintains fluid balance, following the principles of Spirit Fragrance Warming and Unblocking Treatment Method (神香溫通療法).

NOTES

¹Tokumoto H, Akita S, Kosaka K, Nakamura R, Yamamoto N, Kubota Y, Mitsukawa N. Differences in Transient Fluid Retention and Lymphedema With Breast Cancer Treatment for Lymphatic Microsurgery. Ann Plast Surg. 2023 Jul 1;91(1):104-108. doi: 10.1097/SAP.0000000000003623. PMID: 37450868.

²Xu H, Zheng X, Ai J, Yang L. Hemoglobin, albumin, lymphocyte, and platelet (HALP) score and cancer prognosis: A systematic review and meta-analysis of 13,110 patients. Int Immunopharmacol. 2023 Jan;114:109496. doi: 10.1016/j.intimp.2022.109496. Epub 2022 Nov 30. PMID: 36462339.

³Siddiqui MU, Yaacoub Y, Hanson HA, Junarta J, Pasha AK, Shah M. Echocardiographic predictors of symptomatic cardiotoxicity among patients undergoing chemotherapy: A systematic review and meta analysis. Medicine (Baltimore). 2022 Jul 15;101(28):e29562. doi: 10.1097/MD.0000000000029562. PMID: 35839035; PMCID: PMC11132334.

⁴Almuradova E, Cicin I. Cancer-related hypercalcemia and potential treatments. Front Endocrinol (Lausanne). 2023 Mar 22;14:1039490. doi: 10.3389/fendo.2023.1039490. PMID: 37033238; PMCID: PMC10073684.

⁵Coriddi M, Dayan J, Bloomfield E, McGrath L, Diwan R, Monge J, Gutierrez J, Brown S, Boe L, Mehrara B. Efficacy of Immediate Lymphatic Reconstruction to Decrease Incidence of Breast Cancer-related Lymphedema: Preliminary Results of Randomized Controlled Trial. Ann Surg. 2023 Oct 1;278(4):630-637. doi: 10.1097/SLA.0000000000005952. Epub 2023 Jun 14. PMID: 37314177; PMCID: PMC10527595.

⁶劉渡舟《傷寒論十四講》Pp 99-110, 人民衛生出版社 2013 年 9 月

⁷防己黃芪湯：防己 12g，黄芪 15g，甘草(炙)6g，白术 9g。

Fangji Huangqi Tang (Stephania and Astragalus Decoction): Fangji (Stephania root): 12g, Huangqi (Astragalus root): 15g, Gancao (Zhi) (Licorice, stir-fried with honey): 6g, Baizhu (White atractylodes rhizome): 9g

⁸越婢湯：麻黄六两（18g）、石膏半斤（24g [2]）、生姜三两（9g）、甘草二两（6g）、大枣三枚

Yuèbì Tāng (Maid from Yue Decoction): Máhuáng (Ephedra): 18g, Shígāo (Gypsum): 24g, Shēngjiāng (Fresh Ginger): 9g, Gāncǎo (Licorice): 6g, Dàzǎo (Jujube): 3 pieces

⁹天麻鉤藤湯：钩藤、天麻、蝉蜕、防风、人参、麻黄、僵蚕、蝎尾、甘草、川芎和麝香

Tian Ma Gou Teng Tang: Gou Teng, Tian Ma, Chan Tui, Fang Feng, Chan Tui, Ren Shen, Ma Huang, Jiang Can, Xie Wei, Gan Cao, Chuan Xiong, She Xiang.

¹⁰五苓散：猪苓（去皮）十八铢（9g），泽泻一两六株(15g)，白术十八铢(9g)，茯苓十八铢(9g)，桂枝（去皮）(6g)半两

Wu Ling San: Zhu Ling (Remove Skin) 9g, Ze Xie 15g, Bai Zhu 9g, Fu Ling 9g, Gui Zhi (remove skin) 6g

¹¹五苓散：猪苓（去皮）十八铢（9g），泽泻一两六株(15g)，白术十八铢(9g)，茯苓十八铢(9g)，桂枝（去皮）(6g)半两

Wu Ling San

¹²瓜蔞薤白白酒湯: 瓜蒌实、薤白、白酒

Gua Lou Xie Bai Bai Jiu Tang

¹³血府逐瘀湯：桃仁 12g，红花、当归、生地黄、牛膝各 9g，川芎、桔梗各 4.5g，赤芍、枳壳、甘草各 6g，柴胡 3g

Xue Fu Zhu Yu Tang

¹⁴葶藶大棗瀉肺湯：葶苈和大枣

Ting Li Da Zao Tang

¹⁵十棗湯：芫花、甘遂、大戟各等分。用法：上 3 味等分为末，或装入胶囊，每服 0.5-1g，每日 1 次，以大枣 10 枚煎汤送服，清晨空腹服。得快下利后，糜粥自养。

Shi Zao Tang (Ten Jujube Decoction)

¹⁶柴胡鱉甲湯：柴胡（去苗）、鳖甲（去裙襕，醋炙）、赤茯苓（去黑皮）各一两，黄芩（去黑心）、知母（焙）、桑根白皮（锉）各三分，甘草（炙）半两

Chai Hu Bie Jia Tang

¹⁷己椒藶黃丸：防己，椒目，葶藶子，大黃

Fang Ji Huang Qi Tang

¹⁸大陷胸湯：大黄(去皮，10 克)、芒硝(10 克)、甘遂(1 克)。上三味，以水六升，先煮大黄，取二升，去滓，内芒硝，煮一二沸，内甘遂末，温服一升。得快利，止后服。

Da Xian Xiong Tang

¹⁹小青龍湯：麻黄（去节）三两（9g），芍药三两（9g），细辛三两（6g），干姜三两（6g），甘草（炙）三两（6g），桂枝（去皮）三两（9g），五味子半升（6g），半夏（法）半升（9g）

Xiao Qing Long Tang

²⁰真武湯：茯苓三两（9g），芍药三两（9g），白术二两（6g），生姜（切）三两（9g），附子（炮，去皮，破八片）一枚（9g）

Zhen Wu Tang

癌性水液潴留與淋巴性水腫的臨證治療

赵软金

摘要

水液潴留證和淋巴性水腫是腫瘤臨床上常見的非常棘手的課題。這屬於中醫學中的水氣病和飲證的範疇。與其對應的溫陽化氣和溫陽利水中藥方劑和針灸療法,對癌症相關性的水腫和積水具有卓著的臨床效果, 包括胸水和腹水的消除。其治療法則與癌症的整體治療完全一致不悖，可與現代腫瘤臨床療法相輔相成。合理和精準的辯證施治與早期的臨床介入，將會給癌症病人較為良好的預後和生活質量的保證。

關鍵詞：癌症，水腫，水液潴留，水氣病，飲證，中藥，針灸。

癌症病人的水液潴留症和淋巴性水肿是臨床肿瘤学的一大挑战¹。这些症候群往往出现在癌症病人的較严重期和末期，多是由于肿瘤体积过大压迫血液循环和淋巴循环所致；或者由于血液中白蛋白过低令血液滲透壓改变²；亦或是在治疗过程中化療和放療使心肌损伤³ 等多种病理因素引起水液和電解質代謝障碍，是不良预后的征兆，严重影响病人的预后和生活質量⁴。现代医学除了插管引流和利尿藥的使用外，目前没有真正好的治療方法。对于淋巴性水肿虽然近期在显微外科方面有所突破⁵，有对小淋巴管重建術，但多数病例的臨床效果都不盡人意。而中医学在针对水液代謝障碍或積水的治療上，特别是止住积水

产生和将水液排除方面有其独特的治療思路和臨床優勢，所以应该把中医学治水排污的療法有机融入现代肿瘤臨床中。

虽然臨床癌症種类繁多，但出现水液潴留證的临床表现却是有规律可循。一是原本孔隙的体腔被水液充满，如腦積水、心包積液、阴囊水肿、胸水和腹水；二是机体四肢组织間質被水液充填的心因性和淋巴性水腫；三是身体内脏器官水腫，如脑水腫、肺水腫和肾脏積水等。

水液代谢障碍所产生的病證在中医学上属于水气病和痰饮病的范畴，臨床上包括了水腫和水液停積聚兩類病症。其病理根源责之于两个方面，一是水饮（液），二是阳陽氣虚衰⁶。水寒之气不能被阳气推动、气化、蒸腾和敷布，所谓的上焦如雾，中焦如沤，下焦如渎，全赖于阳气的驱动。阳气在癌症发生、发展和治疗过程中被不断地戕害，使得原本循环流动起着濡润滋养作用的陰液凝集成死水一潭，如同淤血一样潴留的液体又成为第二病理因子。

在正常的生理状态下，水液的代謝和调节主要取决于心阳和脾肾阳气，心主血脉，血脉中有 55%水分；脾主運化水濕；腎司二关。心火下降以温腎水，腎水升騰以平心火的水火既济生理机制維持着水液代謝的平衡。当然肺气的宣发肅与肝气的舒畅調達，对水道的通调起着重要作用。这其实就是中医学的整体观, 是以陽氣為生命根本的理論觀。具體的辨证论治的重点就在于找出病根所在，精准施治。

陽氣虛弱和水飲（痰飲）停滯同樣是癌症發生和發展的關鍵病理機制。在論及腸道腫瘤形成時，《素問·水脹論》明確指出，腫塊是由寒氣壓迫腸外汁沫積聚而成。水氣病與飲証的出現是癌症進一步惡化的風向標。水液停留于體表組織的，臨床表現為浮腫和水腫；水液瀦留于身體腔間隙則爲飲証。

醫聖張仲景將水氣病和飲証作了系統總結，依據病因和部位把水氣病分爲風水、皮水、正水、石水和黃汗。把飲証分爲痰飲、支飲、懸飲和溢飲,又根據病情嚴重程度和發病的機制列出留飲和伏飲證。如此分類雖然很細緻，但是臨床實用起來略嫌繁瑣。

治療癌症水氣病和飲證的核心法則：積極配合常規的癌症治療，盡早地將中醫介入臨床。在未殃及生命的情况下，不急于将潴留的水液清除，取得暂时的效应，要注重于解决引起水液潴留的根源。否则由于将水液抽出后，局部渗透压力的改变，水液潴留會很快重新出现。癌性水液中往往含有大量的蛋白，反复抽出積水会导致蛋白丢失严重，病人会更加衰弱，血液中的水液會加速溢出。

病痰飲者當以溫藥和之，溫藥能夠鼓舞陽氣。腰以上腫當發汗，腰以下腫當利小便。陽氣充足和陽氣通暢是治療水飲整的關鍵。通陽不在温而在利小便，小便的通畅与否预示着陽氣的通畅。而西藥利尿藥在疾病初期作用明顯，之後便有抗藥性，主要是陽氣不足，輔助以中藥，利尿藥就會重新起作用。

依據水飲/液體瀦留和聚集的部位，與邪氣之所結，逐一闡述癌症臨床上常見的水氣病與水液瀦留証及其治療方法。

頭面部水腫、腦積水與腦水腫

這類水氣病多發在原發性腦部腫瘤和肺癌、淋巴癌和乳腺癌腦轉移。或者大劑量使用免疫抑制劑后的頭面部腫大。以及放療后腦部水腫，或腫瘤壓迫導致腦脊液循環受阻的腦積水。臨床上病人均會產生精神神經症狀，病人會有頭痛、嘔吐、視乳頭水腫、步態不穩、智力下降，甚至抽搐和癲癇，此證即中醫學水氣病所描述的振振慾僻于地。

腦水腫和腦積水是兩種完全不同的疾病。腦積水是腦脊液的循環阻塞；腦水腫之腦組織中的間質和神經元腫脹，在中醫學上均屬於風水範疇，從發汗利水和祛外風、熄內風來論治。腦為身之巔頂，唯風可及。對於腦積水治療可以結合腦脊液引流術。而腦水腫臨床上

多爲急症表現，在結合現代醫學的脫水減壓治療。對於控制病人的精神神經症狀，如頭疼和抽搐和癲癇，針灸是不可或缺的療法，選百會、四神聰、印堂、神門和太衝。采用強刺激手法。

外風爲患者，病人面部浮腫明顯的可用防己黃芪湯⁷合越婢湯⁸。

内風與肝陽相携攪動水飲也爲病理證型之一。中藥可選天麻鈎藤湯⁹、安宮牛黃丸合五苓散¹⁰。

胸部水液瀦留証

常見的則是心包積液、肺水腫和胸水。這分別屬於中醫學的留飲、伏飲或者支飲和懸飲範疇。

心包積液主要症狀是呼吸困難、胸痛或壓迫感隨體位改變，腫瘤引起的多伴有體重下降和關節疼痛。更多屬於留飲與伏飲。“胸中有留飲，其人短氣而渴，四肢厲節痛，脈沉者，有留飲”。可以用五苓散¹¹、瓜蔞薤白白酒湯¹²和血府逐瘀湯¹³為基本方。

肺水腫，“水在肺，吐涎沫，慾飲水”。屬於《金匱要略》中五臟水證。以苓桂朮甘湯合瓜蔞薤白白酒湯合葶藶大棗瀉肺湯¹⁴為基本方。

胸水，胸腔積液則是腫瘤臨床上極為常見的飲證，多見於肺癌、結腸癌、乳腺癌和淋巴癌。很多胸水證會令人抓狂的。很多病人需要長時間抽取胸水，而有的病人則不得不選用滑石粉將胸腔封閉，那是一種沒有辦法的辦法。屬於典型的支飲和懸飲證，以輕症和重症來辨證治療。輕症治以葶藶大棗瀉肺湯為基本方；重症用十棗湯¹⁵。

腹部水液障礙病證

常見的有腎臟水液瀦留和腹水證。腎臟積水常由腎癌、淋巴癌、卵巢癌、膀胱癌症、前列腺癌轉移、輸尿管癌症、結腸癌和其他轉移癌引起壓迫。臨床經常與泌尿科醫生合作治療，急症期利用輸尿管支架，機械性的打開阻塞，讓尿液流出，同時配合針灸，溫腎通陽利水。中藥用金匱腎氣丸合五苓散。

腹水一証，則多見於肝癌、膽道惡性瘤、胰腺癌、乳腺癌、卵巢癌、結腸癌、肛門直腸癌和腎癌以及其它晚期癌症病人的臨終症狀。病機非常複雜，可總結爲腫瘤壓迫血液循環、淋巴循環受阻，或者腹膜癌症轉移后癌細胞炎性滲出，或者肝臟功能損害嚴重導致白蛋白合成低下和丟失嚴重，水液從血管大量滲出。現代醫學以大量利尿藥和腹水抽取為主要方法。

中醫學對腹水一証治療歷史悠久，經驗豐厚。以鼓脹和積聚為病名，屬於正水和石水証。由陽氣虛衰，氣機受阻，氣滯血瘀，水液無法蒸騰排出，積聚腹腔。治療起來非常困難，史上被列爲四大疑難症之一。

針灸治療：取百會和四神聰安神、通陽氣；膻中、中脘、水分、石門、氣海、昆侖和三陰交健脾通陽利水，期門和太衝疏肝理氣，神門和液門强心利水。

中藥基本處方：柴胡鱉甲湯¹⁶合五苓散合桃仁承氣湯，重症也可選用己椒藶黃丸¹⁷和大陷胸湯¹⁸。

四肢水腫證

包括淋巴性水腫和心性水腫兩類，均屬溢飲証。淋巴性水腫多是由腋窩部淋巴結和大腿根部淋巴結的活檢、手術切除中和放療中損傷，導致淋巴液循環受阻，屬於實證範疇。目前的最新治療嘗試是淋巴管回路重建術，但是適應範圍較窄。臨床上有肯定療效的是淋巴按摩術，來打通皮下組織液循環通路。

中醫治療，最爲有效的是針灸、拔罐和中藥三聯療法，能夠增加血液和淋巴管循環,而最主要的是改變皮下組織液的流通。傳統的針灸療法有效果但不顯著。

對淋巴性水腫治療是使用的梅花針。在患肢陽側經過嚴格消毒后用梅花針擊打皮膚五分鐘后拔罐，每次吸出粘液痰飲，沿著三陽經路綫逐漸由遠端移向近端（肩部或腿根部）。在吸出大量的粘液和痰飲后，皮下組織液通路暢通后，淋巴液體會越過阻塞地帶返回中心循環。醫生必須要注意防止急性蜂窩組織炎發生、防止染發。很多癌症病人即使不予針刺治療仍然會發生感染的幾率非常高。如果在病人患肢扎針時，一定是病人在沒有別的治療辦法，無條件同意醫生針刺治療時，才可以施針，避免可能的醫療糾紛。

中藥基本方：苓桂朮甘湯合小青龍湯¹⁹。其方中的麻黃在美國使用有些困難，但又是必須之藥。也常用真武湯²⁰溫補心腎陽氣，利水消腫。

如果是心因性的四肢水腫，水腫往往是凹陷性水腫，可以同時參照超聲心動圖左心室射血分數作出判斷。中藥以真武湯和五苓散溫補心腎陽氣，溫陽利水消腫。癌症晚期病人心因性水腫常見，一旦水腫越過膝關節達到腰部，就成爲典型的水氣凌心，心陽衰竭之證候。這也是絕大部分癌症病人死亡的真正原因。

另外，四肢水腫在癌症臨床上也常由深部靜脈血管栓塞引起，由於癌腫破潰、化療和放療導致血液循環系統栓塞多見。如果水腫發生迅急，多由深部靜脈栓塞引起。屬於血瘀引起的水液潴留證，當以活血化瘀溫陽利水來治療，以血府逐瘀湯和真武湯為基本方，同時可以配合肝素消栓療法，共臻速效。

總之，水氣證與飲證均為水液代謝障礙證，水證是泛溢與肌表，飲證停留與局部。二者可隨著病情相互轉化，如飲證泛溢可成水腫。水液積聚可成飲證。

在利用現代醫學手段積極治療癌症的同時，儘早將中醫針灸中藥等手段融入，保護心陽，溫陽化飲，通陽氣，利水溼，既能夠幫助癌症的治療，又能防止水氣病和飲証的發生和加劇。水液代謝障礙和電解質失衡的病症幾乎都在癌症的嚴重期或晚期，常伴隨著氣滯血瘀等多種複雜病例，臨床上極為難治，常有捉襟見肘的感。長期使用利尿劑和抽取胸水和腹水使得電解質平衡更加破壞，液體潴留惡化，陽氣被阻遏加劇，最後病人心陽衰微，下肢水腫蔓延過膝，上及腰部水氣凌心，生命消失。所以中醫治療要在第一時間介入癌症病人的治療。從始至終要顧護心陽，溫陽化飲，通陽利水，保證水液的氣化和流動。理論上這與神香溫通療法是一脈相承的。