Evaluation of malignant ascites #176
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Evaluation of malignant ascites #176 Evaluation of malignant ascites #176 Document Transcript

  • JOURNAL OF PALLIATIVE MEDICINE Volume 13, Number 8, 2010 Fast Facts and Concepts ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2010.9800 Evaluation of Malignant Ascites #176 Karen LeBlanc and Robert M. Arnold, M.D. Background draining lymphatics, portal vein thrombosis, elevated portal venous pressure from cirrhosis, congestive heart failure, M alignant ascites is the accumulation of abdominal fluid due to the direct effects of cancer. This Fast Fact reviews the causes and diagnosis of malignant ascites. Fast constrictive pericarditis, nephrotic syndrome, and peritoneal infections. Depending on the clinical presentation and expected sur- Fact #177 will review its treatment. vival, a diagnostic evaluation is usually indicated, as it will affect both prognosis and treatment approach. Key tests in- Pathophysiology clude the serum albumin and protein level and a simulta- neous diagnostic paracentesis, checking ascitic fluid white The pathophysiology of malignant ascites is incompletely blood cell count, albumin, protein, and cytology. understood. Contributing mechanisms include tumor-related obstruction of lymphatic drainage, increased vascular perme- Classification ability, over-activation of the renin-angiotensin-aldosterone system, neoplastic fluid production, and production of me- The old classification of exudative versus transudative as- talloproteinases that degrade the extracellular matrix. Portal cites has been updated using the serum-ascites albumin gra- venous compression can also occur from metastatic invasion of dient (SAAG). the liver, leading to peritoneal fluid accumulation. SAAG = (the serum albumin concentration) – (ascitic fluid albumin concentration) Natural History A SAAG 1.1 g/dl indicates ascites due to, at least in part, The most common cancers associated with ascites are ad- increased portal pressures, with an accuracy of 97%. This is enocarcinomas of the ovary, breast, colon, stomach, and most commonly seen in patients with cirrhosis, hepatic con- pancreas. Median survival after diagnosis of malignant ascites gestion, CHF, or portal vein thrombosis. is in the range of 1–4 months; survival is apt to be longer for A SAAG < 1.1 g/dl indicates no portal hypertension, with ovarian and breast cancers if systemic anti-cancer treatments an accuracy of 97%; most commonly seen in peritoneal carci- are available. nomatosis, an infectious process of the peritoneum, nephrotic syndrome, or malnutrition/hypoalbuminemia. Presentation and Diagnostics Cytological evaluation is approximately 97% sensitive in Symptoms include abdominal distension, nausea, vomit- cases of peritoneal carcinomatosis, but is not helpful in the ing, early satiety, dyspnea, lower extremity edema, weight detection of other types of malignant ascites due to massive gain, and reduced mobility. Physical exam findings may in- hepatic metastasis or malignant obstruction of lymph vessels. clude abdominal distention, bulging flanks, shifting dullness, and a fluid wave. Plain abdominal x-rays are not specific, but References may show a hazy or a ‘‘ground glass’’ appearance. Ultrasound 1. Thomas J, von Gunten CF: Diagnosis and management of or CT scanning can confirm the presence of ascites and ascites. In Berger AM, Von Roenn J, Schuster J, eds. Principles demonstrate if the fluid is loculated in discrete areas of the and Practice of Palliative Care and Supportive Oncology, 3rd ed. peritoneal cavity. Philadelphia, PA: Lippincott, Williams & Wilkins; 2006. There are many potential causes of ascites in the cancer 2. Adam RA, Adam YG: Malignant ascites: Past, present, and patient: peritoneal carcinomatosis, malignant obstruction of future. J Am Coll Surg 2004;198:999–1011. Fast Facts and Concepts are edited by Drew A Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information, write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu. Version History: Current version re-copy-edited in May 2009. Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. LeBlanc K, Arnold RA. Evaluation of Malignant Ascites. Fast Facts and Concepts. March 2007; 176. Available at: www.eperc.mcw.edu/fastfact/ ff_176.htm. Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used. 1027
  • 1028 FAST FACTS AND CONCEPTS 3. Spratt JS, Edwards M, Kubota T, et al: Peritoneal carcino- Address correspondence to: matosis: Anatomy, physiology, diagnosis, management. Curr Robert M. Arnold, M.D. Probl Cancer 1986;10:553–584. Division of Internal Medicine 4. Becker G, Galandi D, Blum HE: Malignant ascites: Systematic University of Pittsburgh review and guideline for treatment. Eur J Cancer 2006; 42:589–597. 200 N. Lothrop Street 5. Aslam N, Marino CR. Malignant ascites: New concepts in Pittsburgh, PA 15213 pathophysiology, diagnosis, and management. Arch Intern Med 2001; 161:2733–2737. E-mail: rabob@pitt.edu DOI: 10.1089/jpm.2010.9799 Palliative Treatment of Malignant Ascites #177 Karen LeBlanc and Robert M. Arnold, M.D. Background extended duration (peritonitis, accidental removal, leakage, occlusion). T he natural history, presenting signs/symptoms, and diagnostic approach to the patient with malignant ascites are discussed in Fast Fact #176; readers are encouraged b. Tunneled catheter: A catheter that prevents infection by promoting scarring around an antibiotic-impregnated Dacron cuff in subcutaneous tissue. Used convention- to read this Fast Fact to review the important role of deter- ally for peritoneal dialysis, it is placed with ultrasound mining the serum-ascites albumin gradient (SAAG) as a diag- or fluoroscopic guidance and has lower risks of infec- nostic and treatment aid. This Fast Fact will review treatment tion and leakage than the pigtail catheter. Complica- approaches. tions are reduced by daily drainage for the first 2 weeks of cuff healing. The Pleurx catheter is FDA approved 1. Diuretics for malignant ascites, and features a one-way rubber valve to prevent leaks between draining sessions. Malignant ascites (SAAG < 1.1) generally does not re- Tunneled catheters are used in patients with a life ex- spond to diuretic treatment, although no randomized trials pectancy of at least 1 month. have been completed. Patients with evidence of portal hypertension (SAAG > 1.1) are more likely to respond to diuretics. 4. Vascular Shunts 2. Paracentesis a. Peritovenous shunt (PVS) systems are designed to channel peritoneal fluid and proteins in benign as- Paracentesis can provide immediate relief of symptoms cites back into the circulation via the superior vena in up to 90% of patients. Drainage of uncomplicated large- cava. PVS has not been shown to have clinically volume ascites (4–6 L/session) can be done safely and quickly significant risk of disseminating tumor cells in in the outpatient setting—including the home—or at the malignant ascites. A PVS is placed by interventional hospital bedside; ultrasound guidance is necessary only when radiology under conscious sedation, and patients there is loculated fluid. typically require 24 hours of monitoring with a central venous line after the procedure. The best 3. Drainage catheters response to PVS (only about 50%) is in ovarian and breast cancers. PVS is recommended only in patients For patients who require frequent paracentesis, external with a life expectancy of 1 to 3 months. drainage catheters placed through the abdominal wall allow b. Transjugular Intrahepatic Portosystemic Shunt (TIPS) is a frequent or continuous drainage of ascites fluid without re- shunt between the portal vein and hepatic vein, de- petitive needle insertions. Patients or caretakers may perform signed to reduce portal hypertension and improve the drainage, reducing visits to medical clinics. Several types sodium balance. Most patients with malignant ascites of catheters are available including: do not have portal hypertension although TIPS might a. Pigtail catheter: A simple, temporary all-purpose cath- be helpful in the occasional cancer with evidence of eter; prone to complications when used over an increased portal pressures (SAAG > 1.1).