Edit concept Question Editor Create issue ticket

Malignant Ascites

Malignant ascites is defined as the abnormal accumulation of fluid in the peritoneal cavity of patients with malignancies of the ovaries, breast, colon, lung, pancreas, stomach or liver. The prognosis of this disease is poor as the patients often succumb within four months after the diagnosis.


Presentation

Malignant ascites accounts for only 10% of all cases of ascites [1]. 80% cases of malignant ascites are secondary to epithelial malignancies of the breast, ovaries, endometrium, colon, stomach, and pancreas while 20% cases are due to unknown malignancies [2]. Chylous ascites is encountered in lymphomas. Peritoneal carcinomatosis and malignant ascites are not synonymous as is often believed [3] and some patients can have two causes for the development of malignant ascites e.g. cirrhosis and peritoneal carcinomatosis.

As malignant ascites typically develops in advanced or recurrent cancers, the patients may be severely debilitated at presentation. Symptoms may include dyspnea, anorexia, as well as early satiety, vomiting, nausea, pain, poor exercise tolerance with weight gain, especially an increase in abdominal girth (pants do not fit). The patients may complain of bloating sensation or feeling of heaviness in the abdomen along with generalized abdominal discomfort. Increase in the intra­abdominal pressure due to the ascites can lead to symptoms of esophageal reflux, delayed gastric emptying with indigestion, nausea, and vomiting.

Several factors may cause this disease [2] and the primary tumor determines the location of the abdominal metastases, as well as, the cause of the ascites [2].

Orthopnea
Abdominal Distension
  • Clinical findings Abdominal distension, weight gain, indigestion, dyspnea, orthopnea, tachypnoea, intestinal obstruction with nausea, vomiting.[medical-dictionary.thefreedictionary.com]
  • Case contributed by Dr David Cuete Diagnosis almost certain Diagnosis almost certain Presentation Stomach cancer diagnosed, Cachexia and abdominal distension Patient Data Age: 60 Gender: Male From the case: Malignant ascites on a background of gastric[radiopaedia.org]
  • One month after this regime of treatment, patient presented with 10 days history of abdominal distension and found to have gross ascites. A diagnostic and therapeutic paracentesis was conducted and removed 1,500 mL straw colored fluid.[jcmtjournal.com]
  • Presentation Abdominal distension. Weight gain as a result of water retention. Discomfort: tense ascites is very uncomfortable but prior to this stage there is simply abdominal distension with only very mild discomfort.[patient.info]
Increased Abdominal Girth
  • Patients can complain of increasing abdominal girth, generalized abdominal pain and shortness of breath. Weight loss is a relatively non-specific symptom, but may be more common in those with an underlying malignancy.[cancertherapyadvisor.com]
  • abdominal girth, bulging flanks, shifting dullness Investigations to consider are ultrasound, diagnostic paracentesis (cytology, albumin, bacterial culture), serum electrolytes and albumin Malignant ascites may be caused by liver disease/metastases leading[inctr-palliative-care-handbook.wikidot.com]
Flushing
  • The Denver Shunt has a miter valve which is less likely to become occluded by fibrinous and cellular debris, and manual compression of the pumping chamber allows flushing and control of flow.[ncbi.nlm.nih.gov]

Workup

The workup of malignant ascites starts by obtaining a detailed patient history which, in most cases, will provide information about the underlying malignancy. Physical examination may reveal bulging flank along with flank dullness (with fluid accumulation >1.5 liters). A fluid wave and shifting dullness may also be seen. Serial measurements of abdominal girth at the level of the umbilicus help to note down the fluctuations in ascites volume. Routine laboratory tests like complete blood count, liver function tests, serum proteins are obtained. As physical examination and radiology cannot differentiate between benign and malignant ascites, cytological analysis of ascites fluid has become the gold standard for the diagnosis of this condition [4].

A plain abdominal radiograph may show a “ground-glass” or hazy appearance. Ultrasound or computed tomography helps to detect the free fluid. The presence of ascites can be confirmed through paracentesis of 10 to 20 ml of fluid. The calculation of serum-ascites albumin gradient (SAAG) is done by subtracting the albumin concentration in the ascitic fluid from the albumin concentration in serum [5]. SAAG <1.1 g/dl excludes portal hypertension from the differential diagnosis. Microscopic, chemical and cytological analysis of the ascitic fluid is essential to differentiate between various etiologies of this disease. Cytologic analysis has a sensitivity of 97% when detecting peritoneal carcinomatosis [2] [6], but has a low sensitivity in diagnosing other types. The ascitic fluid in peritoneal carcinomatosis has raised levels of proteins and a low SAAG [7]. The location of the carcinoma can be detected by biochemical markers in conjunction with cytologic studies, immunohistochemical staining [8]. Ascites can be caused by various factors and so the diagnostic value of tumor markers may be questionable [9]. So far, no tumor markers with high sensitivity and specificity have been reported [10].

The primary source of the malignancy can be detected by various tests. In female patients, laparoscopy or laparotomy can be advised to obtain tissue diagnosis as malignant ascites secondary to an ovarian malignancy is responsive to chemotherapy and tumor debulking and has better survival outcomes. But in males, it is not helpful to pursue further investigations as detecting the site of the primary tumor may not influence the management or the outcome.

Treatment

  • The combined treatment group demonstrated 13 cases of complete remission and 22 cases of partial remission. Thus, the rate of efficacy was significantly higher in the combined treatment group (85.36 %; p 0.05 vs. control group).[ncbi.nlm.nih.gov]
  • Therefore, precise assessment of initial state of ascites, repetitive evaluation of treatment efficacy, selection of suitable treatment, and swift transition to other treatment options as needed are paramount to maximizing patient benefit.[ncbi.nlm.nih.gov]
  • The treatment was performed safely without major side-effects except for transient pyrexia. A significant reduction of ascites was noted 1 month after the treatment without subsequent re-accumulation.[ncbi.nlm.nih.gov]
  • In addition, cecropinXJ treatment normalized the hematological and biochemical phenotypes, induced tumor cell apoptosis in ascites and improved the survival of mice bearing malignant ascites when compared with Dox treatment.[ncbi.nlm.nih.gov]
  • Therefore, quality of life (QoL) assessment is of particular importance to demonstrate new treatment value.[ncbi.nlm.nih.gov]

Prognosis

  • It is associated with distressing symptoms and poor prognosis. Treatment may be aimed at the underlying cancer but is rarely successful. Therapeutic success for the available symptomatic treatment options for ascites is often limited.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Although the prognosis of pancreatic cancer patients with MA remains poor, selected patients may be candidate for chemotherapy, regardless of the timing of appearance of MA.[ncbi.nlm.nih.gov]
  • The latest prognosis statistics give you a realistic picture of the survival possibilities for your patients so you can provide the most appropriate nursing care and patient education.[books.google.de]
  • BACKGROUND: Malignant ascites (MA) is associated with poor prognosis and limited palliative therapeutic options. Therefore, quality of life (QoL) assessment is of particular importance to demonstrate new treatment value.[ncbi.nlm.nih.gov]
  • […] cancer (P 0.001), no chemotherapy (P 0.001), an albumin level less than 30 g/L (P 0.013), an ascites volume greater than 2,000 mL (P 0.019), Helicobacter pylori infection (P 0.010), and metastases to other organs (P 0.037) were associated with poor prognosis[ncbi.nlm.nih.gov]

Etiology

  • Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[icd10coded.com]
  • It is necessary to bear in mind that malignancies may not only be the underlying etiology for paraneoplastic glomerular injuries, but also can be an independent pathogenic process, regardless of their nephrotic status during the overall management of[ncbi.nlm.nih.gov]
  • MATERIALS AND METHODS: We performed a retrospective study of 102 CT scans in adults, distributed into two groups based on the cirrhotic or malignant etiology of their ascites.[ncbi.nlm.nih.gov]
  • Microscopic, chemical and cytological analysis of the ascitic fluid is essential to differentiate between various etiologies of this disease.[symptoma.com]

Epidemiology

  • Austria. 3 Oncotyrol - Center for Personalized Cancer Medicine, Innsbruck, Austria. 4 European Competence Center for Ovarian Cancer, Charité Berlin, Berlin, Germany. 5 Haemato-Oncological Day Hospital, Hospital of Merano, Merano, Italy. 6 Evaluative Epidemiology[ncbi.nlm.nih.gov]
  • Coverage of each cancer includes pathophysiologic mechanisms, epidemiology and etiology, risk profile, prognosis, professional assessment criteria (PAC), nursing care and treatment, evidence-based practice update, patient teaching, nursing diagnoses or[books.google.de]
  • Carcinoma of the Vulva 1528 Cancer of the Uterine Body 1543 Chemoprevention 609 1545 Uterine Sarcomas 1557 Gestational Trophoblastic Diseases 1564 Colon Cancer 1232 1574 Epothilones 455 1586 Genetic Predisposition 1390 1595 Epidemiology 1232 1604 Malignant[books.google.de]
Sex distribution
Age distribution

Pathophysiology

  • This article uses a clinical case to highlight the problem, then reviews these new concepts in the pathophysiology of malignant ascites formation.[ncbi.nlm.nih.gov]
  • Each chapter includes a new section on pathophysiology to help you understand the physiologic processes associated with each oncologic complication.[books.google.de]
  • Several pathophysiological mechanisms are implicated in the development of malignant ascites. Management should be aimed at maximising patient comfort and quality of life.[spcare.bmj.com]
  • They are more likely to be effective if portal hypertension is contributing to the pathophysiology of the ascites.[handbook.ggcmedicines.org.uk]
  • Cavazzoni E, Bugiantella W, Graziosi L et al (2013) Malignant ascites: pathophysiology and treatment. Int J Clin Oncol 18:1–9 PubMed CrossRef Google Scholar 11. Covey AM (2005) Management of malignant pleural effusions and ascites.[link.springer.com]

Prevention

  • The P-32 CP instillations reduced the frequency of paracentesis for almost 1 year, until disease progression prevented palliation.[ncbi.nlm.nih.gov]
  • The acute adverse effets of the PV shunt (fever, fluid overload, and fulminant disseminated intravascular coagulation) may be prevented or minimized by preoperative fluid removal to obviate a major intravascular infusion of colloid and biologically active[ncbi.nlm.nih.gov]
  • When the mesothelial cells were protected against oxidative stress, both deterioration of junctional proteins and intensification of cancer cell invasion in response to ascites from serous and undifferentiated tumors were effectively prevented.[ncbi.nlm.nih.gov]
  • The principal of treatment for GC patients with ascites is palliation and prevention of ascites-related symptoms.[ncbi.nlm.nih.gov]
  • Malignant ascites is a known consequence of vascular dysfunction, but current approved treatments are not effective in preventing fluid accumulation.[ncbi.nlm.nih.gov]

References

Article

  1. Runyon BA, Montano AA, Akriviadis EA, Antillon MR, Irving MA, McHutchison JG.The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites.Ann Intern Med. 1992;117(3):215.
  2. Runyon BA, Hoefs JC, Morgan TR. Ascitic fluid analysis in malignancy-related ascites. Hepatology. 1988;8(5):1104.
  3. Smith EM, Jayson GC. The current and future management of malignant ascites. Clin Oncol (R Coll Radiol). 2003;15(2):59.
  4. Liu F, Kong X, Dou Q, et al. Evaluation of tumor markers for the differential diagnosis of benign and malignant ascites. Ann Hepatol. 2014; 13: 357-63.
  5. Hoefs JC. Serum protein concentration and portal pressure determine the ascitic fluid protein concentration in patients with chronic liver disease. J Lab Clin Med. 1983;102:260-273.
  6. Parsons SL, Watson SA, Steele RJ. Malignant ascites. Br J Surg. 1996;83:6–14
  7. Nagy JA, Herzberg KT, Dvorak JM, Dvorak HF. Pathogenesis of malignant ascites formation: initiating events that lead to fluid accumulation. Cancer Res. 1993;53:2631–2643.
  8. Tangkijvanich P, Tresukosol D, Sampatanukul P, et al. Telomerase assay for differentiating between malignancy-related and nonmalignant ascites. Clin Cancer Res. 1999;5:2470–2475.
  9. Wang X, Li J, Han Y. Prognostic significance of preoperative serum carcinoembryonic antigen in non-small cell lung cancer: a meta-analysis.Tumor Biol. 2014; 35: 10105-10.
  10. Zhu FL, Ling AS, Wei Q, Ma J, Lu G. Tumor markers in serum and ascites in the diagnosis of benign and malignant ascites. Asian Pac J Cancer prev. 2015; 16(2): 719-722

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2018-06-22 07:20