Malignant ascites. Clinical and experimental observations

Management of non-ovarian cancer malignant ascites through indwelling catheter drainage

Backgrounds

Intra-abdominal placement of the Central Venous Catheter (CVC) was conducted to manage the ascites-related symptoms of non-ovarian cancer patients. The aim of this study is to document the efficacy of symptom relief and conduct survival analysis of non-ovarian cancer patients with malignant ascites who received paracentesis and indwelling catheter drainage.

Methods

Seventy eight patients received paracentesis and drainage. All patients who met the inclusion criteria were included in this study. The overall survival (OS) was defined as the interval between initial diagnosis and death. Since-paracentesis survival (SP-Survival) was defined as the interval between initial paracentesis and death.

Results

Hepatic cancer was the most frequent original cancer in this study. Peritoneal catheters remained in situ for a median of 13 days. No immediate complications, such as perforation of a viscus or excessive bleeding, were encountered during placement. All ascites-related symptoms improved after drainage compared with the baseline. There was a statistically significant improvement in the mean score for abdominal swelling (p < 0.001), anorexia (p = 0.023) and constipation (p = 0.045). Cancer type was shown to be an independent prognostic factor for overall survival length (p = 0.001). Serum albumin was an independent prognostic factor for SP-survival (p = 0.02).

Conclusions

Paracentesis and indwelling catheter drainage through CVC set is a useful method for improving painful symptom. Further research is needed to validate the findings.

Surgical technology and pharmacology of hyperthermic perioperative chemotherapy

Although cytoreductive surgery (CRS) and hyperthermic perioperative chemotherapy (HIPEC) have not been shown to be effective by themselves, as a combined treatment they are now standard of care for peritoneal metastases from appendiceal cancer and from colorectal cancer as well as peritoneal mesothelioma. The timing of the HIPEC in relation to the CRS is crucial in that the HIPEC is to destroy minimal residual disease that remains following the CRS and prevent microscopic tumor emboli within the abdomen and pelvis from implanting within the resection site, within fibrinous clot, or within blood clot. Proper selection of chemotherapy agents is crucial to the long-term benefit of CRS and HIPEC. One must consider the response expected with the cancer chemotherapy agent, its area under the curve (AUC) ratio indicating the amount of dose intensity within the peritoneal space, and the drug retention within the peritoneal space for a prolonged exposure. Hyperthermia will augment the cytotoxicity of the cancer chemotherapy agents and improve drug penetration. Irrigation techniques should not be overlooked as an important means of reducing the cancer cell burden within the abdomen and pelvis. Multiple technologies for HIPEC exist and these have advantages and disadvantages. The techniques vary from a totally open technique with a vapor barrier over the open abdominal space to a totally closed technique whereby the HIPEC is administered at the completion of the surgical procedure. The open techniques depend on a table-mounted retractor for suspension of the skin edges allowing a reservoir to occur within the abdomen and pelvis. There are nearly a dozen commercially available hyperthermia pumps, all of which seem to perform adequately for HIPEC although there is a variable degree of convenience and documentation of the HIPEC procedure. As the management of peritoneal metastases has progressed over three decades, early cases are now seen in which a laparoscopic CRS and HIPEC may be appropriate. Also, prophylactic use of laparoscopic HIPEC with perforated appendiceal malignancies and T4 colon cancers may be appropriate.

Diagnostic and prognostic value of SHOX2 and SEPT9 DNA methylation and cytology in benign, paramalignant, and malignant ascites

BACKGROUND

Cytology remains the gold standard for the detection of malignant cells in ascites. However, its sensitivity is limited. The aim of this study was to evaluate DNA methylation biomarkers for the differential diagnosis of benign (ascites in patients without malignancy), malignant (ascites in cancer patients directly caused by malignancy), and paramalignant (ascites in cancer patients caused by comorbidities but not by malignancy) ascites.

METHODS

A cohort of 283 patients (134 cancer patients, 149 patients with benign diseases) presenting with ascites was prospectively enrolled. Ascites was evaluated by means of cytopathological investigation and DNA methylation of SHOX2 and SEPT9 in the cell-free and cellular fraction. DNA methylation in bisulfite-converted DNA was determined using quantitative methylation specific real-time PCR. Cytopathological and DNA methylation results were evaluated with regard to diagnosis and overall survival (OS).

RESULTS

Patients with positive DNA methylation had a poor overall survival compared to methylation-negative patients (hazard ratio: HR = 1.97, p = 0.001). In multivariate survival analysis, DNA methylation was an independent prognostic parameter (p = 0.003) together with age (HR = 1.03, p < 0.001) and the presence of malignant disease (HR = 1.87, p < 0.001). The combination of methylation with cytopathological analyses led to a 42 % increase in the detection rate of malignant ascites, resulting in 37 % positively diagnosed cancer patients and a specificity of 97 %. Among cancer patients, patients with DNA methylation-positive ascites showed an adverse clinical course (HR = 1.63, p = 0.039).

CONCLUSIONS

DNA methylation testing adds diagnostic and prognostic information and might constitute an effective ancillary method for the differential diagnosis of malignant, paramalignant, and benign ascites.

A specimen volume of ≥80 mL improves cytologic sensitivity for malignant ascites: a retrospective analysis of 2665 cases

INTRODUCTION

Although paracentesis simultaneously allows cytologic evaluation of peritoneal fluid and symptomatic relief, its utility is limited by a paltry 50% to 60% sensitivity for malignancy. Specimen volume has recently been shown to affect cytologic diagnosis in other body fluids, but its role has never been examined in ascites. This study evaluates how specimen volume impacts cytologic diagnosis of malignant ascites.

MATERIALS AND METHODS

We identified 2665 consecutive paracentesis specimens with documented numeric volumes collected at our institution between 1994 and 2013. We separated the cases into 10 bins of roughly equivalent sample size and compared the percentage of cases that received malignant diagnoses across each cutoff volume. When follow-up pathology was available, we also compared the sensitivity of cytology with the gold standard of surgical pathology.

RESULTS

The peritoneal fluids had a mean volume of 760.2 mL (range: 1-10,000). Just 11.3% of specimens with volumes <80 mL were diagnosed as malignant, while 20.1% were malignant at volumes ≥80 mL (P < 0.001, OR = 0.51, 95% CI = 0.39-0.64). Lower volume specimens also had more indeterminate and nondiagnostic results. Cytologic sensitivity increased from 56.7% for specimens <80 mL to 75.4% for volumes ≥80 mL (P = 0.03, OR = 0.43, 95% CI = 0.19-0.94).

CONCLUSIONS

A specimen volume of ≥80 mL is associated with increased cytologic sensitivity for malignant ascites and a higher rate of malignant diagnoses. The disparate sensitivity at lower volumes likely stems from inadequate sampling of larger specimens. Although fluids should not be summarily rejected based on volume, a specimen volume of ≥80 mL minimizes the influence of specimen size on diagnostic adequacy in paracentesis specimens.

Tissue invasion and metastasis: Molecular, biological and clinical perspectives

Cancer is a key health issue across the world, causing substantial patient morbidity and mortality. Patient prognosis is tightly linked with metastatic dissemination of the disease to distant sites, with metastatic diseases accounting for a vast percentage of cancer patient mortality. While advances in this area have been made, the process of cancer metastasis and the factors governing cancer spread and establishment at secondary locations is still poorly understood. The current article summarizes recent progress in this area of research, both in the understanding of the underlying biological processes and in the therapeutic strategies for the management of metastasis. This review lists the disruption of E-cadherin and tight junctions, key signaling pathways, including urokinase type plasminogen activator (uPA), phosphatidylinositol 3-kinase/v-akt murine thymoma viral oncogene (PI3K/AKT), focal adhesion kinase (FAK), β-catenin/zinc finger E-box binding homeobox 1 (ZEB-1) and transforming growth factor beta (TGF-β), together with inactivation of activator protein-1 (AP-1) and suppression of matrix metalloproteinase-9 (MMP-9) activity as key targets and the use of phytochemicals, or natural products, such as those from Agaricus blazei, Albatrellus confluens, Cordyceps militaris, Ganoderma lucidum, Poria cocos and Silybum marianum, together with diet derived fatty acids gamma linolenic acid (GLA) and eicosapentanoic acid (EPA) and inhibitory compounds as useful approaches to target tissue invasion and metastasis as well as other hallmark areas of cancer. Together, these strategies could represent new, inexpensive, low toxicity strategies to aid in the management of cancer metastasis as well as having holistic effects against other cancer hallmarks.

Laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) for refractory malignant ascites in patients unsuitable for cytoreductive surgery

INTRODUCTION

Malignant ascites (MA) is the abnormal accumulation of fluid in the peritoneal cavity of patients with intraperitoneal dissemination of their disease and is associated with a short life expectancy. The most common clinical feature is a progressive increase of abdominal distention resulting in pain, discomfort, anorexia and dyspnoea. Currently, no treatment is established standard of care due to limited efficacy or considerable toxicity. The objective was to examine the efficacy of laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) in the palliation of refractory MA in patients who were unsuitable for cytoreductive surgery.

METHODS

From May 2009 to June 2015, 12 patients with MA due to their peritoneal malignancy were treated with laparoscopic HIPEC. The time between operation and repeat paracentesis, in-hospital data, and the proportion of patients that did not require repeat paracentesis was analyzed.

RESULTS

One patient (8%) was admitted to ICU for 1 day. The mean operating time and hospital stay was 149.3 min (range 79-185) and 4.6 days (range 2-11) respectively. Neither high-grade morbidity nor mortality was observed. The median OS was 57 days. In our experience, a complete and definitive disappearance of MA was observed in 83% of patients. Two patients (17%) developed recurrent MA 124 days and 283 days post-HIPEC.

CONCLUSION

Laparoscopic HIPEC is a beneficial treatment for the management and palliation of refractory MA and results in an excellent clinical and radiological resolution in patients with a complete resolution observed in selected patients.

The clinical significance of vascular endothelial growth factor in malignant ascites

Ascites can be caused by many kinds of diseases. Patients with undetermined ascites represent a diagnostic challenge. The aims of this study were to determine the diagnostic value of vascular endothelial growth factor (VEGF) in differentiation of malignant ascites from benign ascites and to investigate the clinical value of ascitic VEGF as an independent prognostic parameter. The study included 462 consecutive patients with malignant ascites and 550 patients with benign ascites, VEGF level in ascites were determined by a sandwich enzyme-linked immunosorbent assay. The survival rate was calculated by the Kaplan-Meier method and the log-rank test. Multivariate survival analysis was performed using the Cox hazards model. In our study, we found VEGF levels in malignant ascites (676.59 ± 303.86 pg/ml) were significantly higher than those in benign ascites (218.37 ± 98.15 pg/ml) (P < 0.001). Meanwhile, we also found that VEGF levels in malignant ascites from patients with ovarian cancer were higher than those with other cancers. Areas under the receiver operating characteristic (ROC) curves of ascitic VEGF was 0.940. At a cutoff value of 319.5 pg/ml, VEGF yielded a sensitivity of 89.2 % and a specificity of 88.4 %. Patients associated with the high-level VEGF value (≥613.38 pg/ml) in malignant ascites exhibited poor mean survival rates (8.3 ± 0.52 vs 15.11 ± 0.66 months, P < 0.001). In a multivariate Cox regression model, higher ascitic VEGF was an independent prognostic factor for overall survival. Planned subgroup analysis was performed for patients with tumor node metastasis (TNM) stage I. In the univariate analysis, only ascitic VEGF was associated with overall survival. VEGF was found to have a highly accurate sensitivity and specificity, suggesting that it could be considered as a new biomarker to differentiate malignant ascites from the benign one. The high level of VEGF value in malignant ascites may be used as an independent prognostic factor in patients with all stages of cancer.

Outpatient Intraperitoneal Catumaxomab Therapy for Malignant Ascites Related to Advanced Gynecologic Neoplasms

BACKGROUND

Catumaxomab (CATU) is a trifunctional antibody approved for intraperitoneal (i.p.) treatment of malignant ascites (MA) related to carcinomas expressing the epithelial cell-adhesion molecule (EpCAM). CATU is mostly given to hospitalized patients, although outpatient treatment seems appropriate in selected individuals. This observational trial sought to obtain more detailed information regarding the feasibility of CATU in outpatients with MA related to various gynecologic tumors, including epithelial ovarian (EOC) and metastatic breast cancer (MBC).

MATERIALS AND METHODS

A total of 30 patients were included, 17 with EOC, 7 with MBC, and 6 with other malignancies. The patients had failed a median of 5 (range 1-12) previous systemic treatments. CATU was administered via an indwelling i.p. catheter at four increasing doses (i.e., 10, 20, 50, and 150 µg) given at 4-day intervals over 2 weeks. Toxicities were scored according to the Common Terminology Criteria for Adverse Events, version 4.03. Puncture-free survival (PuFS) was calculated from the start of CATU until the next puncture for MA, death, or loss to follow-up. Overall survival (OS) was calculated from the start of CATU to death from any reason or loss to follow-up. We also investigated various clinical parameters to predict PuFS and OS. These included age, tumor type, performance status, intensity of pretreatment, presence of extraperitoneal metastases, relative lymphocyte count at baseline, patient adherence to therapy, and the patients' ability to undergo systemic treatment after CATU.

RESULTS

CATU was exclusively given on an outpatient basis, and 19 patients (63.3%) received all four planned i.p. instillations. Toxicity was the reason for discontinuation in only 2 patients. Toxicity was generally manageable, with abdominal pain, nausea/vomiting, fatigue, and fever the predominant adverse effects. Secondary hospitalization was necessary for 7 patients (23.3%), with a general deteriorated condition in 5 and fever/infection or abdominal pain in 1 patient each. Subsequent systemic treatment was possible in 11 patients (36.7%). Only 5 patients (16.7%) required a second puncture after i.p. CATU. The median PuFS was 56 days, and the median OS was 79.5 days. Positive predictors of both PuFS and OS were performance status, absence of extraperitoneal tumor, the capability to receive all four CATU infusions, and the ability to undergo subsequent systemic treatment.

CONCLUSION

Outpatient i.p. CATU therapy for MA related to various gynecologic carcinomas is safe and effective in producing good ascites control in most individuals, allowing for subsequent systemic therapy in a substantial proportion of patients.

IMPLICATIONS FOR PRACTICE

Intraperitoneal treatment with the trifunctional antibody catumaxomab (CATU) was possible in a selected population of 30 outpatients with malignant ascites due to epithelial female genital tract or breast carcinoma. Toxicity was largely manageable. Patients in good condition at baseline, without extraperitoneal tumor and/or liver metastases, and with the ability to complete all four planned CATU instillations and the capability of undergoing subsequent systemic therapy benefited the most in terms of both puncture-free and overall survival. Outpatient i.p. CATU is safe and effective in a selected group of patients with malignant ascites due to various gynecologic malignancies and could be cost-saving compared with an inpatient approach.

Efficacy and safety of cell-free and concentrated ascites reinfusion therapy (CART) in gynecologic cancer patients with a large volume of ascites

AIM

The aim of this study was to evaluate the efficacy and safety of cell-free concentrated ascites reinfusion therapy (CART) on a large amount of ascites.

MATERIAL AND METHODS

Fifty-eight CART procedures were performed in nine patients with ovarian, endometrial, or cervical cancer from February 2013 to September 2014. The medical records were retrospectively reviewed for the amount of collected ascites, vital signs, and laboratory results before and after CART.

RESULTS

No obvious change in the plasma protein and plasma albumin concentration was found after CART for < 5 L of ascites; however, obvious increases in both were observed in CART for ≥ 5 L of ascites (P < 0.001). The optimum cut-off value for obtaining a positive variant of plasma protein and plasma albumin after CART was 7.9 L. CART for ≥ 5 L of ascites did not increase the risk of transient water retention in the body (odds ratio = 2.2; 95% confidence interval: 0.35-13.83; P = 0.38); however, CART for ≥ 7.9 L of ascites increased the risk of water retention (odds ratio = 8.4; 95% confidence interval: 1.91-44.09; P = 0.004). The optimal cut-off value of ascites for predicting water retention due to CART was 9.2 L.

CONCLUSION

Massive ascites collection in CART < 9.2 L appears to be a safe and effective treatment for improving general condition, plasma protein, and electrolytes in gynecologic cancer patients.

Ascites in Ovarian Carcinoma - Reliability and Limitations of Cytological Analysis

OBJECTIVE

The objective of this study was to examine the validity of ascitic fluid cytology in the detection of pathological findings, to examine the percentage of false positive and false negative results in the cytology of ascitic fluid and to determine the validity of peritoneal cytology in relation to the histopathological type of the ovarian tumour.

METHODS

This retrospective study included 170 peritoneal cytology findings. The study was conducted from January 2010 to December 2012. The experimental group included 76 cytology findings obtained from patients diagnosed with ovarian carcinoma, whereas the control group was composed of 94 cytology findings of benign ovarian tumours and liver cirrhosis ascites. The patients with ovarian carcinoma had grades III, as well as grades I and IIc but only in cases where operative and pathological finding indicated a ruptured or perforated tumour capsule.

RESULTS

The sensitivity of peritoneal cytology is 68.92%, specificity is 93.61%, positive predictive value is 89.65% and negative predictive value is 78.57%. In 30.02% of patients, the peritoneal cytology showed false negative results, while in 6.38%, the results were false positive. The highest percentage of false negative findings was 77%, found in endometrioid carcinoma.

CONCLUSION

Peritoneal cytology of ascitic fluid is highly specific but has relatively low sensitivity, particularly in the case of endometrioid ovarian carcinoma. In order to increase sensitivity, peritoneal cytology should be combined with monoclonal antibodies and other biochemical and immunohistochemical markers.

Peritoneal lymphomatosis: a rare presentation of follicular lymphoma mimicking peritoneal carcinomatosis

Patients presenting with ascites associated with peritoneal disease have a wide differential diagnosis including both malignant and non-malignant related causes. We present the unusual case of a patient, clinically deteriorating, whose malignant peritoneal disease was due to an underlying follicular lymphoma. An urgent staging CT scan followed by a peritoneal biopsy allowed the patient to start chemotherapy within days of acute presentation to the hospital. This case emphasises the importance of obtaining tissue diagnosis urgently in these patients to ensure that the correct treatment can be started in a timely manner.

Effects of cell-free and concentrated ascites reinfusion therapy (CART) on symptom relief of malignancy-related ascites

BACKGROUND

It is expected that cell-free and concentrated ascites reinfusion therapy (CART) will relieve the symptoms caused by ascites. To date, however, no report of objective changes in patients' symptoms has been published. We have therefore evaluated symptom management by CART.

METHODS

From April 2011 to July 2012, 37 patients at our hospital, most of whom had malignancies, received CART. Symptom severity was evaluated in each patient 24 h before and after the first CART procedure using a numerical rating scale for abdominal tension and the Japanese version of the M. D. Anderson Symptom Inventory (MDASI-J) for various symptoms.

RESULTS

CART significantly improved the scores for abdominal tension and the symptom and interference scores of the MDASI-J within 24 h of the procedure. The abdominal tension scores decreased from 7.19 to 3.81 (p < 0.001), the symptom scores of the MDASI-J decreased from 4.73 to 2.75 and the interference scores of the MDASI-J decreased from 7.05 to 5.12. Detailed investigation revealed many symptoms, including fatigue and gastric symptoms, which are the usual targets of paracentesis, as well as general symptoms. No significant correlation between improved scores and the amount of reinfused protein or ascites removed was observed. Patients experienced no severe adverse event.

CONCLUSIONS

Among the 37 patients receiving CART, various symptoms related to malignant ascites, especially fatigue, improved within the 24-h period following CART. Factors that ameliorate these symptoms remain to be elucidated.

Safety and efficacy of the PleurX catheter for the treatment of malignant ascites

BACKGROUND

Malignant ascites is a common complication seen in association with various types of neoplastic processes. Due to high recurrence rates, patients may require multiple paracenteses, which have associated complications such as increased risk of bleeding, infection, pain, and volume and electrolyte depletion.

OBJECTIVE

This study evaluated the management of malignant ascites by placement of the PleurX® tunneled catheter system at a single center.

METHODS

This was a retrospective study of 38 patients who underwent PleurX catheter placement for refractory malignant ascites between February 2006 and March 2012 at our institution. Pretreatment characteristics and outcome measures were reported using descriptive statistics.

RESULTS

The population included 21 males and 17 females with a mean age of 60.6 years (range, 36-79 years) diagnosed with metastatic disease from a variety of primary malignancies, the most common of which was pancreatic cancer (10 patients). In 84% of patients (32/38) who were not lost to follow-up, mean survival time was 40.7 days (range 4-434 days). Technical success rate of catheter placement was 100%.

CONCLUSIONS

The PleurX catheter can be used to manage malignant ascites in severely ill patients with metastatic cancer, with a high rate of procedural success and a low incidence of potentially serious adverse events, infections, or catheter-related complications.

Efficacy of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy in the management of malignant ascites

BACKGROUND

In peritoneal surface disease, accumulation of malignant ascites represents a difficult problem to treat, with adverse impact on quality of life. The role of cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in controlling malignant ascites is not well defined.

METHODS

A retrospective analysis of a prospectively maintained database of 1,000 procedures was performed. Type of malignancy, resolution of ascites, duration and agent of chemoperfusion, performance status, resection status, morbidity, mortality, and survival were reviewed.

RESULTS

Ascites was found in 299 patients (310 procedures) either before or during exploration. A total of 142 (46 %) procedures were performed for appendiceal primary disease, 53 (17 %) colorectal, 20 (6 %) gastric, 45 (15 %) mesothelioma, and 26 (8 %) ovarian. A total of 288 (93 %) patients had resolution of ascites by 3 months' follow-up. In patients with ascites, complete cytoreduction was obtained in 15 versus 59 % when ascites was not present (p < 0.001). In the group of patients who had their ascites controlled, 243 of 288 (84 %) had resection with residual macroscopic disease (R2 status). Twenty-two patients (7 %) had persistent ascites at 3 months' follow-up, 19 (86 %) of whom had an R2 resection. Univariate analysis revealed that type of primary disease, resection status, duration or agent of chemoperfusion, and performance status did not predict failure.

CONCLUSIONS

CRS-HIPEC is effective in controlling ascites in 93 % of patients with malignant ascites, even when a complete cytoreduction is not feasible. Ascites is predictive of incomplete cytoreduction and worse overall survival. Although complete cytoreduction remains the goal of this procedure, HIPEC can provide palliative value in selected patients with malignant ascites.

Meeting the challenge of ascites in ovarian cancer: new avenues for therapy and research

Malignant ascites presents a considerable clinical challenge to the management of ovarian cancer, but also provides a wealth of opportunities for translational research. The accessibility of ascitic fluid and its cellular components make it an excellent source of tumour tissue for the investigation of prognostic and predictive biomarkers, pharmacodynamic markers and for molecular profiling analysis. In this Opinion article, we discuss recent advances in our understanding of its pathophysiology, the development of new methods to characterize its molecular features and how these findings can be used to improve the treatment of malignant ascites, particularly in the context of ovarian cancer.

Ascites metabolism measurement enhanced the diagnostic value and accuracy of prognostic evaluation in 18F-FDG PET/CT studies in malignant ascites patients

OBJECTIVE

This study aimed to evaluate the role of ascites metabolism measurement in (18)F-fluorodeoxyglucose ((18)F-FDG) PET/computed tomography (CT) for auxiliary diagnosis and prognostic evaluation of malignant ascites.

MATERIALS AND METHODS

This was a retrospective study on 55 patients, including 36 with malignant ascites and 19 with benign ascites of undetermined origin, before they underwent their first (18)F-FDG PET/CT scan. The χ(2) -test was used to compare the diagnostic efficiencies among (18)F-FDG PET/CT ascites metabolism measurement, tumor localization, and ascites cytology examination. The standard uptake values of ascites and of the normal liver were measured, respectively, and their ratio, denoted as T/NT, was calculated for each patient. The receiver-operating characteristic curve was used to analyze the diagnostic efficiency of the ascites T/NT, ascites carcinoembryonic antigen, ascites CA1(25), and ascites CA(199), and the linear regression was used to analyze the relationship between the ascites T/NT and the survival time of patients.

RESULTS

The metabolic level of malignant ascites was high. The sensitivity and accuracy of ascites metabolism measurement were higher than those of ascites cytology examination (χ(2) =6.98, 4.58; all P's<0.05). The specificity of ascites metabolism measurement was higher than that of (18)F-FDG PET/CT tumor localization (χ(2) =5.70, P<0.05). The T/NT value of malignant ascites (0.68 ± 0.17) was higher than that of benign ascites (0.38 ± 0.10) (t=7.21, P<0.05). The area under the receiver-operating characteristic curve of ascites T/NT was larger than those of ascites carcinoembryonic antigen, CA(125), and CA(199). There was a negative correlation between the ascites T/NT and the survival of patients with malignant ascites (r=-0.647, P<0.01).

CONCLUSION

Ascites metabolism measurement has an important auxiliary diagnostic value in (18)F-FDG PET/CT for ascites patients. The ascites T/NT may be a good index for prognostic evaluation of malignant ascites.

Matrix protein of vesicular stomatitis virus: a potent inhibitor of vascular endothelial growth factor and malignant ascites formation

Malignant ascites is common in various types of cancers and is difficult to manage. Vascular endothelial growth factor (VEGF) has a pivotal role in malignant ascites. The matrix protein of vesicular stomatitis virus (VSVMP) has been shown to inhibit host gene expression and induce the apoptosis of cancer cells. The present study was designed to determine whether VSVMP suppresses the formation of ascites in ascites-producing peritoneal carcinomatosis. BALB/c female mice, 6-8 weeks old, bearing peritoneal tumors of H22 or MethA cells received an intraperitoneal administration of 50 μg VSVMP/250 μg liposome complexes, 50 μg empty plasmid/250 μg liposome complexes or 0.9% NaCl solution, respectively, every 2 days for 3 weeks. Administration of VSVMP resulted in a significant inhibition in ascites formation, improvement in health condition and prolonged survival of the treated mice. Decreased peritoneum osmolarity and reduced tumor vascularity coincided with dramatic reductions in the VEGF level in ascites fluid and plasma. Examination of floating tumor cells collected from the peritoneal wash revealed an apparently increased number of apoptotic cells and profound downregulation of VEGF mRNA in the VSVMP-treated mice. Our data indicate for the first time that in BALB/c mice bearing H22 or MethA cell peritoneal tumors, VSVMP may inhibit VEGF production and suppress angiogenesis, consequently abolishing ascites formation.

Palliative venting gastrostomy in patients with malignant bowel obstruction and ascites

BACKGROUND

Fluoroscopic-guided placement of a percutaneous decompression gastrostomy tube (PDGT) is used to palliate patients with malignant bowel obstruction (MBO). We report our clinical experience in cases of MBO and ascites that were known to be technically difficult and at increased risk for complications after PDGT placement.

METHODS

Between October 2005 and April 2010, a total of 89 consecutive oncology patients with MBO and ascites underwent at least one attempt at PDGT placement. We retrospectively reviewed the electronic medical record to collect demographic details, procedure information, and morbidity and mortality data. Kaplan-Meier curves were used to calculate median survival after PDGT.

RESULTS

Ninety-three new gastrostomy encounters occurred in 89 patients. The primary and secondary technical success rates were 72 % (67 of 93) and 77.4 % (72 of 93), respectively. Inadequate gastric distention was the reason for failure in 84.6 % (22 of 26) of the cases in which the initial PDGT attempt was unsuccessful. For ascites management, 13 patients underwent paracentesis and 78 patients underwent placement of an intraperitoneal catheter. The overall complication rate in successful placements was 13.9 %, with a major complication rate of 9.7 %. After PDGT, the median overall survival rate was 28.5 days (95 % confidence interval 20-42).

CONCLUSIONS

PDGT is feasible in the majority of patients with MBO and ascites, although there is an inherent risk of major complications. An intraperitoneal catheter can be used to manage ascites to facilitate PDGT.

Deterioration in quality of life (QoL) in patients with malignant ascites: results from a phase II/III study comparing paracentesis plus catumaxomab with paracentesis alone

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. Following the demonstration of the superiority of catumaxomab and paracentesis over paracentesis on puncture-free survival, this analysis aimed at comparing deterioration in QoL between both the treatment options.

PATIENTS AND METHODS

In a randomised, multicentre, phase II/III study of patients with MA due to epithelial cell adhesion molecule (EpCAM) positive cancer, the QoL was evaluated using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 items (EORTC QLQ-C30) questionnaire at screening, 1, 3 and 7 months after treatment and in the case of re-puncture on the day of paracentesis. Time to first deterioration in QoL was defined as a decrease in the QoL score of at least five points and compared between the catumaxomab (n=160) and control (n=85) groups using the log-rank test and Cox proportional hazards models adjusted for baseline score, country and primary tumour type.

RESULTS

Deterioration in QoL scores appeared more rapidly in the control than in the catumaxomab group (median 19-26 days versus 47-49 days). The difference in time to deterioration in QoL between the groups was statistically significant for all scores (P<0.01). The hazard ratios ranged from 0.08 to 0.24 (P<0.01).

CONCLUSIONS

Treatment with catumaxomab delayed deterioration in QoL in patients with MA. Compared with paracentesis alone, catumaxomab enabled patients to benefit from better QoL for a prolonged survival period.

Synergistic effects of Endostar combined with β-elemene on malignant ascites in a mouse model

To explore an effective combination therapy for malignant ascites, the therapeutic value of the combination of Endostar, a modified recombinant human endostatin, and β-elemene, an active component of a traditional Chinese herb, in an H22 mouse malignant ascites model was investigated. The optimal dose combination of Endostar and β-elemene was determined by evaluating the inhibition of ascites volume and increase in the survival rate of the mice. Other therapeutic effects and the underlying mechanisms were investigated under the optimal dose combination (8 mg/kg Endostar plus 100 mg/kg β-elemene). The mice were randomly divided into four treatment groups and received intraperitoneal injection once a day for eight days: control (0.9% normal saline), Endostar (8 mg/kg), β-elemene (100 mg/kg) or optimal dose combination (8 mg/kg Endostar plus 100 mg/kg β-elemene), respectively. The results of this study revealed that the combination therapy had significant synergistic effects on the inhibition of ascites formation and a deceased number of tumor cells and protein levels in ascites compared with the results of treatment with a single agent. A decreased peritoneal microvascular permeability and reduction in VEGF, MMP-2 and hypoxia inducible factor 1α (HIF1α) was noted in the combination group, when compared with single agent treatment. These studies found that in the ascitic tumor cells, the protein levels of VEGF and MMP-2, as well as levels of VEGF mRNA, were significantly inhibited by the combination therapy. The potentiating effects of the combination of Endostar with β-elemene suggest that this novel therapy may yield an effective therapy for the treatment of malignant ascites.

Development and validation of the self-completed ascites impact measure to understand patient motivation for requesting a paracentesis

Background:

The Ascites Impact Measure (AIM) was developed to record patients’ daily experiences of symptoms that trigger a request for a paracentesis.

Methods:

Development of the AIM followed a rigorous step-wise approach, including a review of the literature, expert opinions, and qualitative research involving patients who experience symptomatic malignant ascites. The AIM’s measurement properties were assessed using data from two international trials, including 59 ovarian cancer patients with symptomatic malignant ascites.

Results:

Following the literature review and expert discussions to develop the conceptual model, ten patients with symptomatic malignant ascites were interviewed in the item elicitation phase, resulting in a draft questionnaire with four questions. Validation analyses consisted of 59 patients pooled from two international trials. Inter-items correlations for the AIM were good (r > 0.60), except for the Pain item. Internal consistency reliability (α = 0.89) improved after removing the Pain item from the Total Symptom score (TSS). Test-retest reliability was sufficient. Scores significantly improved after paracentesis except for the Pain item. Preliminary estimates indicate that a two-point improvement on the three-item TSS (without the Abdominal Pain item) could be interpreted as clinically meaningful.

Conclusion:

The Abdominal Pain item appears to behave differently than the other three items, and could be more related to cancer. While the validity of the AIM TSS (four-item) is acceptable, removing the Pain item from the TSS scoring algorithm demonstrated better construct validity. In addition, test-retest reliability and responsiveness were found to be similar to the results for the four-item AIM TSS. The Pain item should be used as a supplemental item to the three-item AIM TSS, as it provides additional information about the underlying cancer state.

Malignant ascites: A review of prognostic factors, pathophysiology and therapeutic measures

Malignant ascites indicates the presence of malignant cells in the peritoneal cavity and is a grave prognostic sign. While survival in this patient population is poor, averaging about 20 wk from time of diagnosis, quality of life can be improved through palliative procedures. Selecting the appropriate treatment modality remains a careful process, which should take into account potential risks and benefits and the life expectancy of the patient. Traditional therapies, including paracentesis, peritoneovenous shunt placement and diuretics, are successful and effective in varying degrees. After careful review of the patient’s primary tumor origin, tumor biology, tumor stage, patient performance status and comorbidities, surgical debulking and intraperitoneal chemotherapy should be considered if the benefit of therapy outweighs the risk of operation because survival curves can be extended and palliation of symptomatic malignant ascites can be achieved in select patients. In patients with peritoneal carcinomatosis who do not qualify for surgical cytoreduction but suffer from the effects of malignant ascites, intraperitoneal chemotherapy can be safely and effectively administered via laparoscopic techniques. Short operative times, short hospital stays, low complication rates and ultimately symptomatic relief are the advantages of laparoscopically administering heated intraperitoneal chemotherapy, making it not only a valuable treatment modality but also the most successful treatment modality for achieving palliative cure of malignant ascites.

Laparoscopic hyperthermic intraperitoneal chemotherapy: indications, aims, and results: a systematic review of the literature

PURPOSE

To evaluate laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) with neoadjuvant, adjuvant, or palliative purpose in order to discuss potential clinical implications.

METHODS

A systematic search of PubMed's Medline through August 2011 using the keywords laparoscopic, hyperthermic, and chemotherapy.

RESULTS

Eight studies encompassing a total of 183 patients were considered. The indications for laparoscopic HIPEC was neoadjuvant in 5 patients, adjuvant in 102 patients, and palliative in 76 patients. There were 13 minor complications not requiring repeat operation, and no deaths related to procedure were recorded. When performed to treat refractory malignant ascites, the procedure was effective in 95 % of cases.

CONCLUSIONS

Laparoscopic HIPEC appears to be a safe and effective procedure when performed to treat malignant ascites refractory to less aggressive treatments. The effectiveness of laparoscopy to perform HIPEC with neoadjuvant or adjuvant purpose needs to be confirmed by further studies.

Rad51 promoter-targeted gene therapy is effective for in vivo visualization and treatment of cancer

Rad51 protein is overexpressed in a wide range of human cancers. Our previous in vitro studies demonstrated that a construct comprised Rad51 promoter driving expression of the diphtheria toxin A gene (pRad51-diphtheria toxin A (DTA)) destroys a variety of human cancer cell lines, with minimal to no toxicity to normal human cells. Here we delivered Rad51 promoter-based constructs in vivo using linear polyethylenimine nanoparticles, in vivo jetPEI, to visualize and treat tumors in mice with HeLa xenografts. For tumor detection, we used pRad51-Luc, a construct containing the firefly luciferase under the Rad51 promoter, administered by intraperitoneal (IP) injection. Tumors were detected with an in vivo bioluminescent camera. All mice with cancer displayed strong bioluminescence, while mice without cancer displayed no detectable bioluminescence. Treatment with pRad51-DTA/jetPEI decreased tumor mass of subcutaneous (SC) and IP tumors by sixfold and fourfold, respectively, along with the strong reduction of malignant ascites. Fifty percent of the mice with SC tumors were cancer-free after six pRad51-DTA/jetPEI injections, and for the mice with IP tumors, mean survival time increased by 90% compared to control mice. This study demonstrates the clinical potential of pRad51-based constructs delivered by nanoparticles for the diagnostics and treatment of a wide range of cancers.

[Pathogenesis and management of refractory malignant ascites]

Malignant ascites are the cancer-associated accumulation of fluids in the peritoneal cavity. The neoplasms most frequently associated with ascites are ovarian, breast, colon, stomach and pancreas adenocarcinomas. Symptoms are abdominal distention, nausea, vomiting, anorexia, dyspnea and limbs oedemas. Several pathophysiological mechanisms might be implicated such as peritoneal carcinomatosis, lymphatic vessels' obstruction, portal hypertension or heart failure. Its diagnosis is most often performed in a context of already known neoplasia. Malignant ascites are associated with a pejorative evolution. Ascites which cannot be mobilized or show early recurrence and cannot be prevented by medical treatment are defined as refractory ascites. Therefore, management of refractory malignant ascites takes place in the context of palliative care and aims at improving the quality of life of these patients. This review lists the current data reported on the pathophysiology of malignant ascites and describes the present and future options for refractory malignant ascites management.

Biomarkers of malignant ascites-a myth or reality

BACKGROUND

Ascitic fluid aspirate cytology, although reasonably specific is not a good screening tool for malignant ascites due to poor sensitivity. Simple test(s) on ascitic fluid or serum which can help differentiate between benign and malignant causes of ascites will be a boon. Ascitic fluid lactate dehydrogenase, cholesterol, and ferritin are the candidate markers evaluated in this study.

METHODS

Ascitic fluid cytology was done on 30 patients of malignant ascites. The modalities used for diagnosing malignant ascites were positive peritoneal biopsy or CT scan evidence of hepatic metastases. Ascitic fluid biochemistry was done in all these 30 patients as well as 30 cases of non-malignant ascites. The parameters analysed were cholesterol, lactate dehydrogenase, and ferritin. The biochemical parameters were estimated in serum as well.

RESULTS

Cytology had a sensitivity of 40% for the diagnosis of malignant ascites. Ascitic fluid cholesterol, lactate dehydrogenase, and ferritin had sensitivities of 70%, 74%, and 100%, respectively. Serum cholesterol, lactate dehydrogenase, and ferritin had sensitivities of 57%, and 91%, respectively.

CONCLUSION

Hence, these biochemical markers in ascitic fluid as well as serum can be good screening tools for the diagnosis of malignant ascites.

Clinical significance of vascular endothelial growth factor and endostatin levels in the differential diagnosis of malignant and benign ascites

The aim of this study is to evaluate the performance of VEGF and endostatin levels in the differential diagnosis of malignant and benign ascites. The study included 101 consecutive patients with malignant ascites (55.2 ± 15.8 years, 63 men and 38 women) and 81 patients with benign ascites (53.0 ± 17.2 years, 51 men and 30 women). VEGF and endostatin levels in serum and ascites were determined by a sandwich enzyme immunoassay technique using a commercially available assay kit. The serum VEGF, ascites VEGF, and ascites endostatin levels of patients with malignant ascites were significantly higher than those in patients with benign ascites (P < 0.001), but there was no difference in serum endostatin levels between the two groups (P = 0.267). Ascites endostatin levels correlated positively with ascites VEGF (r = 0.5193, P < 0.01), and serum endostatin showed a low correlation with serum VEGF (r = 0.3291, P < 0.01) in patients with malignant ascites. Areas under the ROC curves of ascites VEGF, ascites endostatin, serum VEGF, and serum endostatin were 0.890, 0.815, 0.694, and 0.552, respectively. The combination of ascites VEGF and endostatin improved the sensitivity up to 90.1%, the specificity up to 87.7%, and the accuracy up to 89.0% in the differential diagnosis of malignant and benign ascites. VEGF and endostatin levels in ascites appear to be suitable for differentiating between malignant and benign ascites, which can be applied to clinical examination.

Peritoneal and pleural ports for management of refractory ascites and pleural effusions: assessment of impact on patient quality of life and hospice/home nursing care

PURPOSE

Patients with end-stage malignancies often have refractory ascites or pleural effusions requiring repeated paracenteses or thoracenteses. Subcutaneous peritoneal and pleural port catheters are an alternative therapeutic option. We evaluate the clinical utility of this approach and the impact on quality of life (QOL) and home/hospice care.

MATERIALS AND METHODS

Thirty ports were placed, 16 peritoneal and 14 pleural, in patients with a mean age of 62 years. Retrospective chart review and interviews were held with patients and nursing care providers. Mean follow-up was 59 days.

RESULTS

On a 10-point scale, QOL improvement, compared to that prior to port placement, was rated a mean of 9.5 by patients and 9.0 by the nursing staff. Both patients and nurses reported a high degree of convenience (rated at 9.7 and 9.6, respectively) and improvement of symptoms and comfort (9.6 and 9.3, respectively). Nursing staff reported a high degree of comfort (9.9) using the aspiration ports. Six of 14 pleural ports were removed following pleurodesis. One pleural port was removed due to patient discomfort and another due to pneumothorax. Two patients with pleural ports developed tumor seeding in the subcutaneous tissues. Of 14 peritoneal ports, 3 required removal for leaking and probable chemical cellulitis. Four became temporarily occluded with patency restored using tissue plasminogen activator (TPA) infusion.

CONCLUSIONS

Peritoneal and pleural ports offer a convenient and relatively safe alternative to frequent paracenteses/thoracenteses in the management of refractory ascites and pleural effusions. This approach can improve the QOL for patients with end-stage disease.

The trifunctional antibody catumaxomab for the treatment of malignant ascites due to epithelial cancer: Results of a prospective randomized phase II/III trial

Malignant ascites is a common manifestation of advanced cancers, and treatment options are limited. The trifunctional antibody catumaxomab (anti-epithelial cell-adhesion molecule x anti-CD3) represents a targeted immunotherapy for the intraperitoneal (i.p.) treatment of malignant ascites secondary to epithelial cancers. In this phase II/III trial (EudraCT 2004-000723-15; NCT00836654), cancer patients (n = 258) with recurrent symptomatic malignant ascites resistant to conventional chemotherapy were randomized to paracentesis plus catumaxomab (catumaxomab) or paracentesis alone (control) and stratified by cancer type (129 ovarian and 129 nonovarian). Catumaxomab was administered as an i.p. infusion on Days 0, 3, 7 and 10 at doses of 10, 20, 50 and 150 μg, respectively. The primary efficacy endpoint was puncture-free survival. Secondary efficacy parameters included time to next paracentesis, ascites signs and symptoms and overall survival (OS). Puncture-free survival was significantly longer in the catumaxomab group (median 46 days) than the control group (median 11 days) (hazard ratio = 0.254: p < 0.0001) as was median time to next paracentesis (77 versus 13 days; p < 0.0001). In addition, catumaxomab patients had fewer signs and symptoms of ascites than control patients. OS showed a positive trend for the catumaxomab group and, in a prospectively planned analysis, was significantly prolonged in patients with gastric cancer (n = 66; 71 versus 44 days; p = 0.0313). Although adverse events associated with catumaxomab were frequent, they were manageable, generally reversible and mainly related to its immunologic mode of action. Catumaxomab showed a clear clinical benefit in patients with malignant ascites secondary to epithelial cancers, especially gastric cancer, with an acceptable safety profile.

Palliative treatment of malignant ascites: profile of catumaxomab

Malignant ascites is the abnormal accumulation of fluid in the peritoneal cavity associated with several intrapelvic and intra-abdominal malignancies. The development of ascites leads to significant symptoms and poor quality of life for the cancer patient. Available therapies for palliation include treatment of the underlying disease, but when there are no treatment options, the use of diuretics, implantation of drainage catheters, and surgical shunting techniques are considered. None of these symptom palliation options affect the course of disease. The development of trifunctional antibodies, which attach to specific overexpressed surface markers on tumor cells, and trigger an immune response leading to cytoreductive effects, represents a new approach to the management of malignant ascites. The purpose of this review is to highlight current therapies for malignant ascites and review data as to the effectiveness of a new trifunctional antibody, catumaxomab.

Management of drainage for malignant ascites in gynaecological cancer

BACKGROUND

Most patients with advanced ovarian cancer and some patients with advanced endometrial cancer need repeated drainage for malignant ascites. Guidelines to advise those involved in the drainage of ascites are usually produced locally and are generally not evidence-based but mainly based on clinicians' anecdotal evidence and experience. To discover whether there are ways of managing drains that have been demonstrated to improve the efficacy and quality of the procedure is key in making recommendations which could improve the quality of life (QOL) for women at this critical period of their lives.

OBJECTIVES

To evaluate the benefit and harms of different practices in the management of drains for malignant ascites in the care of women with advanced or recurrent gynaecological cancer. The review aimed to evaluate the evidence regarding the following questions; How long should the drain stay in place? Should the volume of fluid drained be replaced intravenously? Should the drain be clamped to regulate the drainage of fluid? Should any particular vital observations be regularly recorded?

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 1, 2009, Cochrane Gynaecological Cancer Group Trials Register, MEDLINE1950 to February Week 3 2009, Embase 1980 to 2009 Week 8 2009. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of review articles and contacted experts in the field.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs), quasi-RCTs and non-randomised studies that compared a range of interventions for management of multiple paracentesis in women with malignant ascites who had a confirmed histological diagnosis of gynaecological cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. No trials were found and therefore no data were analysed.

MAIN RESULTS

The search strategy identified 1664 unique references of which 1646 were excluded on the basis of title and abstract. The remaining 18 articles were retrieved in full, but none satisfied the inclusion criteria.

AUTHORS' CONCLUSIONS

Since no relevant studies were identified, we are unable to make recommendations regarding the management of drains for malignant ascites in women with gynaecological cancer. Large, multi-centre RCTs are required to evaluate the efficacy and safety of the management of ascitic drains when in situ and their impact on QOL.

Biodistribution of humanized anti-VEGF monoclonal antibody/bevacizumab on peritoneal metastatic models with subcutaneous xenograft of gastric cancer in mice

PURPOSE

Vascular endothelial growth factor (VEGF) is correlated with peritoneal metastasis of gastric cancer, increasing vascular permeability accompanied by accumulation of ascites. The aim of the current study is to investigate the biodistribution of bevacizumab in a peritoneal metastatic model of gastric cancer and to clarify which is more suited to treatment of peritoneal metastasis, systemic or regional therapy.

METHODS

A highly peritoneal-seeding cell line of gastric cancer, OCUM-2MD3, which exhibited high production and release of VEGF was used in this study. The biodistribution of bevacizumab was investigated using peritoneal metastatic models together with subcutaneous xenografts, and (125)I-radiolabelled bevacizumab was administrated to these models subcutaneously (s.c.) or intraperitoneally (i.p.), respectively. In addition, the anti-tumor response of bevacizumab and paclitaxel was assessed as single agents or in combination using peritoneal metastatic models.

RESULTS

In the analysis of biodistribution, (125)I-bevacizumab administrated i.p. indicated low peritoneal clearance. On the other hand, s.c. administration of (125)I-bevacizumab showed preferential accumulation in subcutaneous tumors and peritoneal nodules, with a high blood concentration. In peritoneal metastatic models, the effects of bevacizumab were found for both the growth inhibition of peritoneal nodules (P < 0.01) and the reduction of ascites (P < 0.05). These effects were more prominent by s.c. administration compared with i.p. administration and were increased in combination with i.p. paclitaxel.

CONCLUSION

Bevacizumab should be administrated systemically compared to regionally, and the combination with i.p. paclitaxel has a potential to be useful for patients with peritoneal metastasis of gastric cancer.

Laparoscopic hyperthermic intraperitoneal peroperative chemotherapy (HIPEC) in the management of refractory malignant ascites: A multi-institutional retrospective analysis in 52 patients

Malignant ascites is a debilitating condition affecting cancer patients in their terminal stage of disease. Recently, laparoscopic hyperthermic intraperitoneal peroperative chemotherapy (HIPEC) was introduced as a new approach. From September 2001 to August 2008, 52 patients were treated with this new modality. No treatment-related mortality was observed. Median survival was 98 days. One patient developed a clinical recurrence. Laparoscopic HIPEC is a safe and effective method for palliating malignant ascites.

Management of ascites due to gastrointestinal malignancy

Ascites is the pathological accumulation of fluid within the abdominal cavity. The most common cancers associated with ascites are adenocarcinomas of the ovary, breast, colon, stomach and pancreas. Symptoms include abdominal distension, nausea, vomiting, early satiety, dyspnea, lower extremity edema, weight gain and reduced mobility. There are many potential causes of ascites in cancer patients, including peritoneal carcinomatosis, malignant obstruction of draining lymphatics, portal vein thrombosis, elevated portal venous pressure from cirrhosis, congestive heart failure, constrictive pericarditis, nephrotic syndrome and peritoneal infections. Depending on the clinical presentation and expected survival, a diagnostic evaluation is usually indicated as it will impact both prognosis and the treatment approach. Key tests include serum albumin and protein and a simultaneous diagnostic paracentesis, checking ascitic fluid, WBCs, albumin, protein and cytology. Median survival after diagnosis of malignant ascites is in the range of 1 to 4 months; survival is apt to be longer for ovarian and breast cancers if systemic anti-cancer treatments are available.

How to Increase the Diagnostic Value of Malignancy-Related Ascites: Discriminative Ability of the Ascitic Tumour Markers

Making a differential diagnosis between malignant and non-malignant ascites is an important clinical issue, but cytological examination has a relatively low diagnostic sensitivity. This study aimed to find a discriminative model that distinguished between malignancy-related and non-malignant ascites. The study included 107 patients: 50 with non-malignant and 57 with malignant ascites. Ascites was analysed using a range of tumour markers and standard cytology. Standardized canonical discriminant function coefficients were used to distinguish between ascites types. The combination of carbohydrate antigen (CA) 15-3, carcinoembryonic antigen (CEA) and cytokeratin 19 fragments (CYFRA-21.1) discriminated between malignancy-related ascites and non-malignant ascites with an accuracy of 98.8% compared with an accuracy of 77.8% for cytological examination. In conclusion, the use of a discriminant function constructed from a combination of CA15-3, CEA and CYFRA-21.1 could distinguish malignant from non-malignant ascites with greater accuracy than cytological examination. Further studies in larger population groups are warranted.

Anti-tumor activity and tumor vessel normalization by the vascular endothelial growth factor receptor tyrosine kinase inhibitor KRN951 in a rat peritoneal disseminated tumor model

We assessed the antitumor efficacy of KRN951, a novel tyrosine kinase inhibitor of vascular endothelial growth factor receptors, using a rat colon cancer RCN-9 syngeneic model in which the tumor cells are transplanted into the peritoneal cavity of F344 rats. KRN951 treatments that commenced 4 days after tumor transplantation (day 4) significantly inhibited tumor-induced angiogenesis, the formation of tumor nodules in the mesenteric windows, and the accumulation of malignant ascites. Moreover, KRN951 treatments initiated on day 14, by which time angiogenesis and malignant ascites have already been well established, resulted in the regression of newly formed tumor vasculatures with aberrant structures and also in the apparent loss of malignant ascites by the end of the study period. Quantitative analysis of the vessel architecture on mesenteric windows revealed that KRN951 not only regressed, but also normalized the tumor-induced neovasculature. Continuous daily treatments with KRN951 significantly prolonged the survival of rats bearing both early stage and more advanced-stage tumors, compared with the vehicle-treated animals. The results of our current study thus show that KRN951 inhibits colon carcinoma progression in the peritoneal cavity by blocking tumor angiogenesis, ascites formation, and tumor spread, thereby prolonging survival. Moreover, these studies clearly demonstrate the therapeutic effects of KRN951 against established tumors in the peritoneal cavity, including the regression and normalization of the tumor neovasculature. Our findings therefore suggest that KRN951 has significant potential as a future therapeutic agent in the treatment of peritoneal cancers with ascites.

Bevacizumab and rapamycin inhibit tumor growth in peritoneal model of human ovarian cancer

Ovarian cancer is the leading cause of death from gynecologic cancer. Often, the disease has spread beyond the ovary to involve the peritoneal cavity and causes ascites. Whereas mammalian target of rapamycin (mTOR) functions to regulate protein translation, cell cycle progression, and metastasis, vascular endothelial growth factor promotes tumor angiogenesis, ascites formation, and metastasis in ovarian cancer. In this study, an i.p. model of human ovarian cancer was used to determine the antitumor activity of rapamycin, bevacizumab, and rapamycin plus bevacizumab (BEV/RAPA). We report that administration of rapamycin, bevacizumab, and BEV/RAPA in mice bearing peritoneal OV-90 ovarian carcinoma resulted in 74.6%, 82.4%, and 93.3% reduction in i.p. tumor burden, respectively. BEV/RAPA-induced reduction in microvessel density and inhibition of cell proliferation were associated with significant reduction in hypoxia-inducible factor-1alpha and cyclin D1 and inactivation of downstream targets of mTOR, p70S6 kinase, S6R, and 4E-binding protein 1. BEV/RAPA treatment was not only able to prolong life of i.p. mice but also more effective than rapamycin and bevacizumab to prevent the development of peritoneal carcinomatosis in adjuvant setting and reverse ascites accumulation in heavy peritoneal disease. Our data indicate that simultaneous inhibition of the vascular endothelial growth factor receptor and mTOR pathways with BEV/RAPA or their analogues may represent a novel approach for prevention of metastasis, recurrence, and treatment of ovarian cancer.

Treatment of malignant ascites in patients with advanced cancer: peritoneovenous shunt versus paracentesis

BACKGROUND

Malignant ascites in patients with advanced cancer is often difficult to treat and effective palliation is not achieved.

METHODS

We performed peritoneovenous shunt (PVS) placement in patients with malignant ascites, who were admitted to our institution between January 2000 and March 2005. The outcome of PVS placement was compared with paracentesis as a treatment option during the same period. Comparisons included changes in abdominal girth, hematocrit (Hct), blood urea nitrogen (BUN) and creatinine (Cr) measurements before and after PVS placement. The number of procedures, changes in the postoperative performance score, the median survival, possibility of discharge, and complications were compared between the two groups.

RESULTS

Twenty patients underwent PVS placement and 49 patients were subjected to paracentesis. After PVS, abdominal girth and Hct decreased significantly. BUN and Cr tended to decrease. The median number of procedures was less in the PVS group than in the paracentesis group (one vs two, respectively; P < 0.0001). The postoperative performance score showed a significant improvement following PVS placement (P = 0.0026). Median survival was significantly longer for patients undergoing PVS placement than for those undergoing paracentesis (42 days vs 18 days, respectively; P = 0.003). The rate of possible discharge was significantly higher for patients undergoing PVS placement (P = 0.0076). Severe complications were observed in one patient in the PVS group and in seven patients in the paracentesis group.

CONCLUSIONS

PVS placement provides an effective treatment option for patients with refractory malignant ascites in advanced cancer, and yields a higher likelihood of discharge compared with conventional paracentesis.

Pattern and prognostic factors in patients with malignant ascites: a retrospective study

BACKGROUND

Malignant ascites is a manifestation of end stage events in a variety of cancers and associated with a poor prognosis. We evaluated the pattern of cancers causing malignant ascites and factors affecting survival.

PATIENTS AND METHODS

Patients coded with the International Classification of Diseases-9 coding system for malignant ascites over a 2-year period were reviewed. The clinicopathological data and patients' survival were compared among cancer groups.

RESULTS

There were 209 patients (140 females and 69 males), median age being 67 (30-98) years. The commonest cancer was ovarian followed by gastrointestinal (GI) cancers. Fifty-eight per cent of the patients had symptoms related to the ascites. Liver metastases were significantly commoner in the GI cancers (P = 0.0001). Fifty-four per cent of our patients presented with ascites at the initial diagnosis of their cancer. Paracentesis was given to 112, diuretics to 70 and chemotherapy to 103 patients. The median survival following diagnosis of ascites was 5.7 months. Ovarian cancer favoured longer survival while low serum albumin, low serum protein and liver metastases adversely affected survival. The independent prognostic factors for survival were cancer type, liver metastases and serum albumin.

CONCLUSION

The identified independent prognostic factors should be used to select patients for multimodality therapy for adequate palliation.

Mechanisms of transcoelomic metastasis in ovarian cancer

Metastasis from epithelial ovarian cancer can occur via the transcoelomic, haematogeneous, or lymphatic route. Of these, transcoelomic metastasis is the most common, and is responsible for the greatest morbidity and mortality in women with this disease. Unfortunately, very little is known about the mechanisms behind this process. This review assesses the current evidence and ideas about the biology of transcoelomic dissemination. The mechanisms of cell detachment, migration, and implantation in transcoelomic metastasis are placed within the context of clinical observations of ovarian cancer to derive a stepwise hypothesis of this process. Evidence for transcoelomic dissemination versus transcoelomic metaplasia in ovarian cancer is presented. Future high throughput microarray studies that compare changes at a genomic and gene expression level between primary ovarian tumours and their peritoneal metastases are hoped to lead to a more conclusive picture of transcoelomic metastasis, and to delineate the key molecular players in this process. These studies might also result in the identification of potential new therapeutic targets in ovarian cancer.

EUS-guided paracentesis for the diagnosis of malignant ascites

BACKGROUND

EUS and EUS-guided fine-needle aspiration (EUS-FNA) have well-defined roles in the diagnosis and staging of GI and pancreaticobiliary malignancy. Malignant ascites usually represents peritoneal carcinomatosis, increases disease stage, and portends a poor prognosis. There are limited data regarding the yield of EUS-guided paracentesis (EUS-P) for the diagnosis of malignant ascites.

OBJECTIVE

To determine the usefulness of EUS-P for the diagnosis of malignant ascites.

DESIGN

Prospective case series.

SETTING

Tertiary referral academic center.

PATIENTS

Those presenting for EUS examination for suspected or proven malignancy over a 16-month period were evaluated prospectively for the presence of ascites.

INTERVENTIONS

EUS-P was performed via a transgastric or transduodenal approach if ascites was detected.

MAIN OUTCOME MEASUREMENTS

Sensitivity, specificity, positive predictive value, and negative predictive value of EUS-P for diagnosing malignant ascites.

RESULTS

Six hundred twenty-nine patients were studied. Twenty-five patients with ascites who met inclusion criteria comprised the study cohort. The mean volume of ascites aspirated was 6.8 mL (range, 1-20 mL). Sixty-four percent (16 of 25) of EUS-P samples revealed malignant cytology. Of the group with negative ascitic cytology, 67% (6 of 9) had a proven malignancy. There was one false-negative cytology result. The sensitivity, specificity, positive predictive value, and negative predictive value of EUS-P for diagnosing malignant ascites was 94%, 100%, 100%, and 89%, respectively. The complication rate was 4%; 1 patient developed bacterial peritonitis after EUS-P.

LIMITATIONS

The study did not address cost savings in patient care based on the diagnosis of malignant ascites.

CONCLUSIONS

EUS-P is highly sensitive and specific for diagnosing malignant ascites. The finding of malignant ascites significantly alters patient management, so an active search for ascites and use of EUS-P should be incorporated into the diagnosis and staging of upper GI and pancreaticobiliary malignancy.

A RETROSPECTIVE STUDY ON THE SONOGRAPHIC FINDINGS OF ABDOMINAL CARCINOMATOSIS IN 14 CATS

A retrospective review was performed on 14 cats with histology- or cytology-proven carcinomatosis. The mean age was 12.7 years with a median of 11 years. The diagnosis of carcinomatosis was made by histology in 11 cats and cytology in three cats. Twelve cats had cytologic examination of the peritoneal free fluid and seven cats (58.3%) had evidence of malignant cells. The primary tumor site was determined in 13 cats. The most common organ locations for the primary tumor were the liver (n = 5), pancreas (n = 3), and small intestine (n = 3). Other sites were stomach and spleen in one cat each. Epithelial cell neoplasia was the primary tumor type in 11 cats. Two cats had abdominal lymphomatosis and one cat had abdominal sarcomatosis secondary to metastatic hemangiosarcoma. Free peritoneal fluid and masses in the connecting peritoneum were found in all cats (100%). Additional findings included primary or metastatic masses in abdominal organs in 10 cats (71.4%), lymph node enlargement in five cats (35.7%), pleural effusion in three cats (21.4%), parietal peritoneal masses in two cats (14.3%), and visceral peritoneal masses in one cat (7.1%). Masses in the connecting peritoneal may be a very specific finding for carcinomatosis in cats, especially with a concurrent abdominal neoplastic mass. Parietal and visceral peritoneal masses, while uncommon in this series of cats, have not been reported for other diseases and seem to strongly support a diagnosis of carcinomatosis.

Le péritoine acteur de la pathologie abdominale

The peritoneum is an important actor in diseases of the abdomen: defects of the peritoneum or mesos may lead to internal hernias; developmental anomalies of the peritoneum may lead to volvulus and bowel obstruction; diffuse or localized primary or secondary tumors of the peritoneum may develop; infectious, inflammatory or ischemic primary diseases of the peritoneum may cause abdominal pain, sepsis or result in the formation of fluid collections. The purpose of this presentation is to illustrate the role of imaging in the diagnosis of these different diseases and to provide some guidelines allowing their detection and characterization.

US of the peritoneum

Familiarity with the pathophysiology of peritoneal disease is the basis of successful ultrasound (US) study of the peritoneum. The pouch of Douglas, diaphragmatic surfaces, the paracolic gutters, and the regions of the mesentery and omentum should receive careful scrutiny in the patient at risk for a peritoneal disease process. An optimal US technique requires assessment of the entire peritoneum with a transducer selected to reflect the depth of the region of interest. US may demonstrate minute quantities of free intraperitoneal fluid and is therefore capable of providing sensitive quantitative information about ascites. Qualitative information may also be inferred, as blood, pus, and neoplastic cells demonstrate correlation with particulate ascites on gray-scale US scans. Peritoneal nodules, plaques, and thickening may be detected on the visceral or parietal peritoneal surfaces, especially when high-frequency probes are used. Transvaginal study in women increases the sensitivity of US for detection of peritoneal disease. In women who have unexplained sepsis or are at risk for carcinomatosis, transvaginal scanning should routinely be added to the regular abdominal and pelvic studies regardless of the findings of those studies. Peritoneal carcinomatosis, primary peritoneal neoplasms, pseudomyxoma peritonei, and peritonitis have characteristic appearances at US.