Palliative treatment of malignant ascites #177


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Palliative treatment of malignant ascites #177

  1. 1. 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: 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).
  2. 2. FAST FACTS AND CONCEPTS 1029 References 7. Pockros PJ, Esrason KT, Nguyen C, Duque J, Woods S: Mobilization of malignant ascites with diuretics is dependent 1. Thomas J, von Gunten CF: Diagnosis and management on ascitic fluid characteristics. Gastroenterology 1992;103: of ascites. In Berger AM, Von Roenn J, Schuster J, eds. Prin- 1302–1306. ciples and Practice of Palliative Care and Supportive Oncology, 3rd 8. Abeloff M, Armitage J, Niederhuber J, Kastan M, McKenna ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2006. WG, eds: Clinical Oncology, 3rd ed. New York: Churchill 2. Adam RA, Adam YG: Malignant ascites: Past, present, and Livingstone; 2004: 1199–1205. future. J Am Coll Surg 2004;198:999–1011. 9. Covey AM: Management of malignant pleural effusions and 3. Spratt JS, Edwards M, Kubota T, et al: Peritoneal carcino- ascites. J Support Oncol 2005;3:169–173. matosis: Anatomy, physiology, diagnosis, management. Curr Probl Cancer 1986;10:553–584. 4. Becker G, Galandi D, Blum HE: Malignant ascites: Systematic Address correspondence to: review and guideline for treatment. Eur J Cancer 2006;42: Robert M. Arnold, M.D. 589–597. Division of Internal Medicine 5. Aslam N, Marino CR: Malignant ascites: New concepts in University of Pittsburgh pathophysiology, diagnosis, and management. Arch Intern 200 N. Lothrop Street Med 2001;161:2733–2737. Pittsburgh, PA 15213 6. Smith EM, Jayson GC: The current and future management of malignant ascites. Clin Oncol 2003;15:59–72. E-mail: