Retrospective analysis of 45 patients (33 females, 12 males) with cytologically-proven malignant ascites is presented. Abdominal pain was the most frequent symptom (69%). Fiftythree percent cases had low serum albumin. Ascitic fluid was haemorrhagic or serosanguinous in 48% cases, in the rest it was clear or straw-coloured. Peritoneal effusion was exudative in 84% cases. Mean glucose content of ascitic fluid was 95 mg/dl and the mean white cell count of 919 cells/cmm. Vast majority (82%) of the cases had metastatic adenocarcinomas. Primary malignancy was mostly ovarian (47%) followed by non-Hodgkin\u27s lymphoma (11%) and gall bladder carcinoma (9%). Primary site could not be identified in 13% cases. Sixty-two percent patients received systemic chemotherapy for the underlying malignancy, of these 43% had complete or partial resolution of the ascites. Of the patients whose long-term follow-up is available, 54% were alive with a median follow-up of 9 months

Abubakar, S

Alam, F

Khan, A

Malik, I

Rizvi, J

Rizwana, I

English

eCommons@AKU

eCommons@AKUSection of Cardiology Department of MedicineFebruary 1991Clinical features and management of malignantascitesI MalikAga Khan UniversityS AbubakarAga Khan UniversityI RizwanaAga Khan UniversityF AlamAga Khan UniversityJ RizviAga Khan UniversitySee next page for additional authorsFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_med_cardiolPart of the Cardiology CommonsRecommended CitationMalik, I., Abubakar, S., Rizwana, I., Alam, F., Rizvi, J., Khan, A. (1991). Clinical features and management of malignant ascites. Journalof Pakistan Medical Association, 41(2), 38-40.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_med_cardiol/69AuthorsI Malik, S Abubakar, I Rizwana, F Alam, J Rizvi, and A KhanThis article is available at eCommons@AKU: https://ecommons.aku.edu/pakistan_fhs_mc_med_cardiol/69CLINICAL FEATURES AND MANAGEMENT OFMALIGNANT ASCITESPages with reference to book, From 38 To 40 Imtiaz Malik, Saleem Abubakar, Feroz Alam, Ata Khan ( Department of Medicine, The Aga Khan University, Karachi. ) Iffat Rizwana, Javaid Rizvi ( Department of Obstetrics-Gynaecology, The Aga Khan University, Karachi. ) ABSTRACT Retrospective analysis of 45 patients (33 females, 12 males) with cytologically-proven malignantascites is presented. Abdominal pain was the most frequent symptom (69%). Fifty three percent caseshad low serum albumin. Ascitic fluid was haemorrhagic or serosanguinous in 48% cases, in the rest itwas clear or straw-coloured. Peritoneal effusion was exudative in 84% cases. Mean glucose content ofascitic fluid was 95 mg/dl and the mean white cell count of 919 cells/cmm. Vast majority (82%) of thecases had metastatic adenocarcinomas. Primary malignancy was mostly ovarian (47%) followed bynon-Hodgkin’s lymphoma (11%) and gall bladder carcinoma (9%). Primary site could not be identifiedin 13% cases. Sixty-two percent patients received systemic chemotherapy for the underlyingmalignancy, of these 43% had complete or partial resolution of the acsites. Of the patients whose long-term follow-up is available, 54% were alive with a median follow-up of 9 months (JPMA 41: 38,1991).INTRODUCTION Development of ascites is a frequently encountered clinical problem in oncologic practice. Ascites maybe the presenting feature or it may develop in the setting of prior diagnosis of cancer. In patientssuffering from cancer, ascites could develop due to many causes, both neoplastic and non-neoplastic1.The diagnosis of malignant ascites depends upon the demonstration of neoplastic cells in the peritonealfluid. Major pathogenetic mechanisms that contribute to the development of malignant ascites includeincreased capillary permeability, increased venous pressure, decreased plasma oncotic pressure due tohypoalbuminaernia and lymphatic obstruction by malignant cells2,3. Ascitic fluid in malignant ascites ismostly exudative (75%) and often bloody or serosanguinous, with a white cell count of more than 250cells/cnun and LDH content more than fifty percent of the serum values4. Most of the studies reportovarian cancer as the commonest underlying malignancy5-8. Although many studies have been reportedin the oncolop literature from European and American institutions4-8 , paucity of these data from thirdworld countries prompted us to analyze patients who had cytologically proven malignant ascites. Westudied the clinical presentation, èharacteristic of the ascitic fluid, type of underlying malignancy andthe subsequent management and survival of these patients and compared our data to those reported byothers4-8.PATIENTS AND METHODS Cases were selected from ascitic fluid analyses performed over the last two years. Only patients withcytologically proven malignant ascites were eligible for this study. On a preset format, information wascollected regarding the clinical features at the time of presentation, presence of other causes of ascites,and blood investigations including complete blood counts, LDH and serum albumin. Characteristics ofascitic fluid such as physical appearance, protein content, glucose and LDH levels and WBC countswere noted. Cytological confirmation was done in all cases. Origin of the cancer was ascertained fromreview of clinical findings and the pathological material that was available. Management, response andfollow-up were obtained from the case record.RESULTS Forty-five patients were eligible for study. The clinical features are presented in Table I.Majority of the patients were females (73%) and the median age was 50.6 years. Sixty percent hadascites as the presenting features of their disease, in the remainder it developed later on. Abdominalpain was the commonest presenting symptom (69%). Associated pleural effusion was present in 29%patients. Many patients (26%) had some other underlying disease that could have caused ascites.Haematological and biochemical profile is shown in Table II.Only 13% patients were anaemic with none having leucopenia or thrombocytopenia. Fifty three percenthad low serum albumin while majority had raised LDH levels Fluid was clear or straw-coloured in 52%cases, it was mostly exudative (84%)with a high LDH content. Cytologic analyses were suggestive ofadenocarcinoma in 82% cases.Table III indicated that ovarian cancer was the underlying cause of malignant ascites in 47% of thecases followed by adenocarcinoma of unknown primary, lymphoma and gall bladder carcinoma. Sixty-two percent of the patients received systemic chemotherapy for the underlying malignancy while resteither refused treatment or received supportive care only. Of those who received chemotherapy, 43%had complete remission or significant regression of ascites. Fifty four percent patients are still alivewith a median follow-up of nine months, 17% of them have no evidence of disease, 46% cases havedied.DISCUSSION Malignant ascites is a frequently encountered clinical problem that continues to offer considerabledifficulty in diagnosis and management. Proper diagnosis requires the demonstration of malignant cellsin the peritoneal fluid. Our study indicates that malignant ascites is more commonly observed in theelderly (mean age 50.6 years) and females (73% of all cases).The patients most often present withabdominal pain (69%) and abdominal distension (100%). In this study, 60% patients presenting withascites had no prior diagnosis of malignancy and many of them had other underlying diseases thatcould have contributed to the development of ascites. Hence, it is important to properly investigate andconsider the possibility of malignancy as the underlying cause of ascites even in the patient who mayhave some other obvious reason for developing ascites. Majority of our patients had no underlyinghaematologic abnormality except for anaemia (13%), however more than half had severehypoalbuminaemia probably suggestive of poor nutritional status as well as loss of albumin into theperitoneal space. It is important to appreciate that clear or straw-coloured appearance of ascitic fluiddoes not rule out malignancy. Almost half (52%) of the cases had clear or straw-coloured fluid. Othershave made similar observations4-8. Similarly, although uncommon, malignant ascites can betransudative in some cases. Our ascitic fluid cell counts and LDH values are comparable to thosereported elsewhere4. It was observed that high values of LDH were mostly seen in the patients who hadlymphoma as the underlying malignancy. Carcinoembryonic antigen (CEA) levels greater than 12mg/dl are reportedly pathognomonic of malignant ascites9 but such analysis was not performed on anyof our samples probably because of the cost of the test as well as lack of awareness of the significanceof CEA levels in the ascitic fluid. A variety of tumours have been associated with the development ofmalignant ascites. In more than 70% of the cases, primary tumour is intra-abdominal. Ovarian,endometrial, breast, colonic, gastric and pancreatic carcinomas account for over 80% of the cases5-8. Inone study breast cancer was the commonest cause of malignant ascites10 while in others ovarian canceris the commonest underlying neoplasm4-8. Primary site may remain unknown in 25% cases10. . In ourstudy ovarian tumour was the commonest underlying neoplasm. As compared to other studies,lymphoma and gall bladder cancer are more commonly associated with malignantascites in Pakistan6,7.Management of malignant ascites depends upon the type of underlying malignancy. If the underlyingcancer is responsive to any specific modality of treatment, such should be undertaken to control ascites.Most often it requires the use of systemic chemotherapy. Sixty-two percent of our patients receivedsystemic chemotherapy, of these 43% responded to treatment, particularly those who had ovariancancer or lymphoma. In others, disease was either very far advanced or generally unresponsive to anyspecific measures and management was purely palliative which included intra-peritonealchemotherapy11,12 insertion of peritoneovenous shunts13,14 and at times repeated paracentesis. Mediansurvival has not yet been reached and 54% of our patients are still alive with a median follow-up of 9months. This compares favourably with the results reported by others4-8.ACKNOWLEDGEMENT We thank Ms. Rozina Ameen for typing this manuscript.REFERENCES 1. Glickman, R.M. and Isselbaher, KJ. Abdominal swelling and ascites, Harrison’s principles of internalmedicine. 10th ed. London, Me Graw-Hill, 1983, p. 209.2. Fastaia, J. and Dumont, A.E. Pathogenesis of ascites in mice with peritoneal carcinomatosis. JNCL.,1976; 56: 547.3. Feldman, G.B. Lymphatic obstruction in carcinomatous ascites. Cancer Res., 1975; 35: 325.4. Baker, A.R Treatment of malignant ascites, in cancer principles and practice of oncology. Edited byDeVita, Heilman, Rosenberg, Philadelphia, Lippincot, 1989, p. 325.5. Osborne, M.P. and Copeland, B.E. Intracavitary administration radioactive colloidal gold (Au198)for the treatment of malignant effusions. N.Engl. J. Med., 1956; 225: 1122.?6. Straus, A.K., Roseman, D.L. and Shapiro, T. M. Peritoneovenous shunting in the management ofmalignant ascites. Arch. Surg., 1979;114: 489.7. Willbanks, G.D., Straus, A.K., Roseman, D.L, et al. Peri toneovenous shunting in the management ofrefractory ascites from gynecologic malignancy. Proc. Am. Assoc. Cancer Res., 1979; 20:364.8. Wolff, J.P., Vignier, M., Goldfarb, E. andPatri, N. Ascites in cancer of the ovary. Gynecologic, 1977;28: 517.9. Lowenstein, M.S., Rittgers, RA., Feinerman, A.E., et al. Car. cinoembryonic antigen assay of ascitesand detection of malignancy. Ann. Intern. Med., 1978; 88: 635.10. Twycross, RG. and Lack, S.A. Control of alimentary symptoms in far advanced cancer. Edinburgh,Churchill Livingstone, 1986, p.282.11. Paladine, W., Cunningham, Ti., Sponzo, R., Donavan, M., Olson, K. and Harton, J. Intracavitarybleomycin in the management of malignant effusion. Cancer, 1976; 38: 1903.12. Anderson, A.P. and Brincker, H. Intracavitaiy thiotepa in malig. nant pleural and peritonealeffusion. Acta Radiol., 1968; 7: 369.13. Qazi, R. and Savlov, E.D. Peritoneovenous shunt for palliation of malignant ascites. Cancer, 1982;49: 600.14. Reinhold, RB., Lokich, J.J., Tomashefski, J. and Costello, P. Management of malignant ascites withperitoneovenous shunting. Am. J. Surg., 1983; 145: 455.

Clinical features and management of malignant ascites

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Clinical features and management of malignant ascites

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