Microbial and Immune Landscape of Malignant Ascites: Insights from Gut, Bladder, and Ascitic Fluid Analyses

Malignant ascites frequently arises in advanced cancers with peritoneal metastasis and is associated with poor outcomes. Known mechanisms include lymphatic obstruction by tumor cells, increased vascular permeability, and sodium retention via the renin-angiotensin-aldosterone system; however, the pathogenesis remains not fully understood. We investigated whether gut and bladder microbiomes correlate with malignant ascites development or progression and whether the immune microenvironment in ascitic fluid is altered.

We enrolled 66 histologically confirmed cancer patients, dividing them into malignant ascites (n = 20) and non-ascites (n = 46) groups. Stool, urine, and ascitic fluid samples were analyzed using 16S rRNA next-generation sequencing. Immune cell subsets in ascitic fluid were characterized using flow cytometry.

In 19 of the 20 malignant ascites samples, the bacterial load was too low for reliable 16S rRNA sequencing, suggesting that malignant ascites is largely sterile. The overall gut microbiome diversity did not differ significantly by ascites status, although a trend emerged in patients with peritoneal metastasis, including the enrichment of class Clostridia and Gammaproteobacteria. Bladder microbiome analysis also showed no significant differences in ascites or metastasis status. Flow cytometry revealed reduced T-cell (CD3+, CD4+, CD8+) and NK cell (CD56+) populations compared to data from cirrhotic ascites.

Malignant ascites exhibit minimal bacterial biomass, making comprehensive microbiome analysis challenging. Although no major global changes were noted in gut and bladder microbiomes, specific taxa were linked to peritoneal metastasis. These findings highlight an immunosuppressive ascitic environment and suggest that larger-scale or multi-omics approaches may help elucidate the role of microbiota in malignant ascites.