1. Malignant ascites is fluid accumulation in the peritoneal cavity caused by cancer. It is usually treated with paracentesis or drainage catheters to remove fluid and relieve symptoms. 2. Paracentesis involves removing fluid through needle insertion and can provide immediate relief for up to 90% of patients. Drainage catheters like pigtail or tunneled catheters allow frequent or continuous drainage without repeat needle insertions. 3. Other options include vascular shunts like peritovenous shunts or TIPS procedures to redirect fluid out of the peritoneal cavity, though response rates are generally only about 50% and many patients have a limited life expectancy of 1-3 months.

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: 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).

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
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ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2006.
WG, eds: Clinical Oncology, 3rd ed. New York: Churchill
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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: rabob@pitt.edu