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Muacevic A, Adler JR, Kopparthi RM, Kuber R, Kishore JVS. Ultrasound-Guided Pigtail Catheter Drainage: An Effective Alternative to Exploratory Laparotomy. Cureus 2023; 15:e33479. [PMID: 36756029 PMCID: PMC9902053 DOI: 10.7759/cureus.33479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2023] [Indexed: 01/09/2023] Open
Abstract
Introduction It has been long established that open surgeries were the only options available for the management of intra-abdominal abscesses or collections. These were associated with increased morbidity and mortality. Traditionally, the idea of percutaneous needling could not gain popularity due to poor localization of collections. However, with the advent of ultrasound, percutaneous pigtail-catheter drainage has proven to be minimally invasive and allows precise localization of the drainage site. Objectives To study the effectiveness of ultrasound-guided pigtail catheter drainage as an alternative to exploratory laparotomy for the management of intra-abdominal abscesses or collections. Materials and methods A total of 48 patient cases, which included liver abscesses, perinephric collections, malignant ascites, splenic collections, pseudocysts, and psoas abscesses, were studied prospectively in a medical college in India from October 2020 to October 2021. The efficacy of the drainage was assessed by serial ultrasound. Results Out of 48 patients, 34 were male and 14 were female, ranging in age from 19 to 64 years, who were diagnosed with intra-abdominal abscesses or collections and underwent ultrasound-guided pigtail catheter drainage. The average hospital stay for patients was 2.5 days. They were followed up periodically for three months post-procedure, and none had significant complications or recurrence. Conclusion The pigtail catheter is the treatment of choice for liquefied intra-abdominal collections or abscesses, which helps to reduce post-procedure hospital stays and complications. Contribution This article reiterates the use of minimally invasive techniques in place of open surgeries with less morbidity.
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Seah DS, Wilcock A, Chang S, Sousa MS, Sinnarajah A, Teoh CO, Allan S, Chye R, Doogue M, Hunt J, Agar M, Currow DC. Paracentesis for cancer-related ascites in palliative care: An international, prospective cohort study. Palliat Med 2022; 36:1408-1417. [PMID: 36113139 DOI: 10.1177/02692163221122326] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Paracentesis is commonly undertaken in patients with cancer-related ascites. AIM To systematically investigate the symptomatic benefits and harms experienced by patients with cancer undergoing paracentesis using real-world data in the palliative care setting. DESIGN Prospective, multisite, observational, consecutive cohort study. Benefits and harms of paracentesis were assessed between 01/07/2018 and 31/02/2021 as part of routine clinical assessments by treating clinicians at four timepoints: (T0) before paracentesis; (T1) once drainage ceased; (T2) 24 h after T1 and (T3) 28 days after T1 or next paracentesis, if sooner. SETTING/PARTICIPANTS Data were collected from 11 participating sites across five countries (Australia, England, Hong Kong, Malaysia and New Zealand) on 111 patients undergoing paracentesis via a temporary (73%) or indwelling (21%) catheter: 51% male, median age 69 years, Australia-modified Karnofsky Performance Score 50. RESULTS At T1 (n = 100), symptoms had improved for most patients (81%), specifically abdominal distension (61%), abdominal pain (49%) and nausea (27%), with two-thirds experiencing improvement in ⩾2 symptoms. In the remaining patients, symptoms were unchanged (7%) or worse (12%). At least one harm occurred in 32% of patients, the most common being an ascitic leak (n = 14). By T3, 89% of patients had experienced some benefit and 36% some harm, including four patients who experienced serious harm, one of which was a fatal bowel perforation. CONCLUSION Most patients obtained rapid benefits from paracentesis. Harms were less frequent and generally mild, but occasionally serious and fatal. Our findings help inform clinician-patient discussions about the potential outcomes of paracentesis in this frail population.
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Affiliation(s)
- Davinia Se Seah
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,Sacred Heart Health Service, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Andrew Wilcock
- Hayward House Specialist Palliative Care Unit, School of Clinical Oncology, University of Nottingham, Nottingham, England
| | - Sungwon Chang
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Mariana S Sousa
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Aynharan Sinnarajah
- Division of Palliative Medicine, Department of Medicine, School of Medicine, Queen's University, Kingston, ON, Canada
| | | | | | - Richard Chye
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,Sacred Heart Health Service, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Matthew Doogue
- University of Otago - Christchurch & Canterbury District Health Board, Christchurch, New Zealand
| | - Jane Hunt
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Meera Agar
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
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Ito T, Hanafusa N, Soneda N, Isoai A, Kobayashi R, Torii N, Kato M. Safety and efficacy of cell-free and concentrated ascites reinfusion therapy against cirrhotic ascites in comparison with malignancy-related ascites. J Gastroenterol Hepatol 2021; 36:3224-3232. [PMID: 34250635 DOI: 10.1111/jgh.15620] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/28/2021] [Accepted: 07/02/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Cell-free and concentrated ascites reinfusion therapy (CART) has been performed against cirrhotic ascites, one of the most common complications seen in patients with decompensated cirrhosis. The aim of this study is to investigate its safety and efficacy, and differences in clinical profiles from CART against malignancy-related ascites with different pathological background. METHODS The present investigation involved a sub-analysis of data obtained from a prospective observational study of CART performed at 22 centers. The condition of each procedure, therapeutic options, laboratory data, performance status, dietary intake, and abdominal circumference of participants were analyzed. Clinical parameters were compared between before and after CART, with or without albumin infusion, and also primary diseases including cirrhosis and malignant disease. RESULTS Between January 2014 and January 2015, a total of 48 and 275 CART procedures were performed in patients with cirrhosis and malignancies. In cirrhotic patients, serum albumin concentration increased significantly in groups both with and without concomitant albumin infusion (P = 0.002 and P = 0.023), and no significant difference in CART interval was seen between these groups (P = 0.393). CART interval was not significantly different between cirrhosis and malignancy groups (P = 0.334). Dietary intake significantly improved after CART in both groups (P = 0.043 and P < 0.001). Adverse events were with no clinical significance as observed in patients with malignancies. CONCLUSIONS Cell-free and concentrated ascites reinfusion therapy was performed safely and effectively in patients with ascites related to decompensated cirrhosis and offers the potential efficacy to maintain plasma colloid osmotic pressure after paracentesis as well as in patients with malignancy.
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Affiliation(s)
- Tetsuya Ito
- Department of Palliative Care, Japanese Red Cross Medical Center, Tokyo, Japan.,Department of Palliative Medicine and Advanced Clinical Oncology, IMSUT Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Norio Hanafusa
- Department of Blood Purification, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Noriko Soneda
- Blood Purification Division, Asahi Kasei Medical Co., Ltd., Tokyo, Japan
| | - Ayako Isoai
- Blood Purification Division, Asahi Kasei Medical Co., Ltd., Tokyo, Japan
| | - Ryosuke Kobayashi
- Blood Purification Division, Asahi Kasei Medical Co., Ltd., Tokyo, Japan
| | - Naoko Torii
- Blood Purification Division, Asahi Kasei Medical Co., Ltd., Tokyo, Japan
| | - Michio Kato
- Kato Michio Clinic of Liver Diseases, Hyogo, Japan
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Fotopoulou C, Berg T, Hausen A, Hennig R, Jalan R, Malagó M, Capel J, De Gottardi A, Stirnimann G. Continuous low flow ascites drainage through the urinary bladder via the Alfapump system in palliative patients with malignant ascites. BMC Palliat Care 2019; 18:109. [PMID: 31805921 PMCID: PMC6896754 DOI: 10.1186/s12904-019-0497-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 12/02/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malignant Ascites (MA) is a therapeutic dilemma significantly impairing patients' quality of life (QoL). The Sequana Medical alfapump System (AP), a subcutaneous, externally rechargeable, implantable device, continually draining ascites via the urinary bladder, has been well established in liver cirrhosis, but not yet in MA. The AP-system was evaluated in cancer patients in reducing the need for large volume paracentesis (LVP). METHODS A retrospective multicentre evaluation of all eligible patients who received an AP for MA-palliation was performed. AP was evaluated for its ability to reduce LVP and cross-correlated with adverse events (AE), survival and retrospective physician-reported QoL. RESULTS Seventeen patients with median age of 63 years (range: 18-81), 70.6% female, across 7 primary tumour types were analysed. Median duration of AP-implantation was 60 min (range: 30-270) and median post-implantation hospital stay: 4 days (range: 2-24). Twelve protocol-defined AE occurred in 5 patients (29.4%): 4 kidney failures, 4 pump/catheter-related blockages, 3 infections/peritonitis and 1 wound dehiscence. Median ascitic volume (AV) pumped daily was 303.6 ml/day (range:5.6-989.3) and median total AV drained was 28 L (range: 1-638.6). Median patient post-AP-survival was 111 days (range:10-715) and median pump survival was 89 days (range: 0-715). Median number of paracenteses was 4 (range: 1-15) per patient pre-implant versus 1 (range: 0-1) post-implant (p = 0.005). 71% of patients were reported to have an improvement of at least one physician reported QoL-parameters. CONCLUSIONS AP appears to be effective in palliating patients with MA by an acceptable morbidity profile. Its broader implementation in oncology services should be further explored. TRIAL REGISTRATION NCT03200106; June 27, 2017.
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Affiliation(s)
- Christina Fotopoulou
- Imperial College London, Department of Surgery and Cancer, Gynecologic Oncology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK. .,Present address: Krankenhaus Freudenstadt, Karl-von-Hahn-Straße 120, 72250, Freudenstadt, Germany.
| | - Thomas Berg
- Sektion Hepatologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Annekristin Hausen
- Medizinische Klinik und Poliklinik I - Innere Medizin und Gastroenterologie, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany
| | - René Hennig
- Allgemein- und Viszeralchirurgie, Klinikum Stuttgart - Bad Cannstatt, Prießnitzweg 24, 70374, Stuttgart, Germany
| | - Rajiv Jalan
- Royal Free Hospital, Institute for Liver and Digestive Health, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Massimo Malagó
- Royal Free Hospital, Institute for Liver and Digestive Health, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Jeroen Capel
- Sequana Medical, Technoparkstrasse 1, 8005, Zürich, Switzerland
| | - Andrea De Gottardi
- University Clinic for Visceral Surgery and Medicine, University Hospital Inselspital and University of Bern, Bauchzentrum Bern, 3010, Bern, Switzerland
| | - Guido Stirnimann
- University Clinic for Visceral Surgery and Medicine, University Hospital Inselspital and University of Bern, Bauchzentrum Bern, 3010, Bern, Switzerland
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Bekes I, Löb S, Holzheu I, Janni W, Baumann L, Wöckel A, Wulff C. Nectin-2 in ovarian cancer: How is it expressed and what might be its functional role? Cancer Sci 2019; 110:1872-1882. [PMID: 30843637 PMCID: PMC6549928 DOI: 10.1111/cas.13992] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 02/20/2019] [Accepted: 02/28/2019] [Indexed: 12/14/2022] Open
Abstract
Nectin‐2 is an adhesion molecule that has been reported to play a role in tumor growth, metastasis and tumor angiogenesis. Herein, we investigated Nectin‐2 in ovarian cancer patients and in cell culture. Tumor as well as peritoneal biopsies of 60 ovarian cancer patients and 22 controls were dual stained for Nectin‐2 and CD31 using immunohistochemistry. Gene expression of Nectin‐2 was quantified by real‐time PCR and differences analyzed in relation to various tumor characteristics. In the serum of patients, vascular endothelial growth factor (VEGF) was quantified by ELISA. Effect of VEGF on Nectin‐2 expression as well as permeability was investigated in HUVEC. In tumor biopsies, Nectin‐2 protein was mainly localized in tumor cells, whereas in peritoneal biopsies, clear colocalization was found in the vasculature. T3 patients had a significantly higher percentage of positive lymph nodes and this correlated with survival. Nectin‐2 was significantly upregulated in tumor biopsies in patients with lymph node metastasis and with residual tumor >1 cm after surgery. Nectin‐2 expression was significantly suppressed in the peritoneal endothelium of patients associated with significantly increased VEGF serum levels. In cell culture, VEGF stimulation led to a significant downregulation of Nectin‐2 which was reversed by VEGF‐inhibition. In addition, Nectin‐2 knockdown in endothelial cells was associated with significantly increased endothelial permeability. Nectin‐2 expression in ovarian cancer may support tumor cell adhesion, leading to growth and lymph node metastasis. In addition, VEGF‐induced Nectin‐2 suppression in peritoneal endothelium may support an increase in vascular permeability leading to ascites production.
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Affiliation(s)
- Inga Bekes
- Department of Obstetrics and Gynecology, University of Ulm, Ulm, Germany
| | - Sanja Löb
- Department of Obstetrics and Gynecology, University of Würzburg, Würzburg, Germany
| | - Iris Holzheu
- Department of Obstetrics and Gynecology, University of Ulm, Ulm, Germany
| | - Wolfgang Janni
- Department of Obstetrics and Gynecology, University of Ulm, Ulm, Germany
| | - Lisa Baumann
- Department of Pathology, University of Ulm, Ulm, Germany
| | - Achim Wöckel
- Department of Obstetrics and Gynecology, University of Würzburg, Würzburg, Germany
| | - Christine Wulff
- Department of Obstetrics and Gynecology, University of Würzburg, Würzburg, Germany
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Hodge C, Badgwell BD. Palliation of malignant ascites. J Surg Oncol 2019; 120:67-73. [PMID: 30903617 DOI: 10.1002/jso.25453] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 03/03/2019] [Indexed: 12/17/2022]
Abstract
Malignant ascites (MA) carries a poor prognosis. It can have a significant impact on quality of life (QOL), with increasing abdominal distention, pain, and dyspnea. Diuretics typically do not work well for MA. Paracentesis is effective in providing temporary symptom relief but requires frequent repeat procedures. Options for durable symptom management include indwelling catheters, peritoneal ports, peritoneovenous shunts, intraperitoneal (i.p.) catumaxomab, and hyperthermic i.p. chemotherapy. These interventions do not necessarily improve overall survival but may improve QOL.
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Affiliation(s)
- Caitlin Hodge
- Department of General Surgery, Abington Memorial Hospital, Abington, Pennsylvania
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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7
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Ratre BK, Suvvari P, Hoda W, Roychoudhury P, Bharti SJ, Bhatnagar S. Central Venous Catheter as Peritoneal Indwelling Catheter for the Management of Recurrent Malignant Ascites: A Case Series. Indian J Palliat Care 2019; 25:57-60. [PMID: 30820103 PMCID: PMC6388607 DOI: 10.4103/ijpc.ijpc_145_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Background Malignant ascites is an accumulation of fluid in the peritoneal cavity due to the manifestation of terminal metastatic malignancies. Accumulation of ascitic fluid could cause abdominal distention, early satiety, and shortness of breath. The onset and progression of these symptoms are not only distressing but also cause deterioration of the quality of life. Malignant ascites is associated with poor prognosis with anticipated life expectancy ranging from 1 to 4 months. Therapeutic paracentesis is the mainstay of palliation for malignant ascites. It only provides a temporary relief of symptoms, ascites re-accumulates, and paracentesis has to be repeated. Objectives The aim of this case series was to evaluate our experiences when treating malignant ascites with placement of central venous catheter in the peritoneal cavity, with special emphasis on patient satisfaction, comfort of caregiver, technical success, and adverse events. Methods Five patients with advanced disease and recurrent malignant ascites who required multiple paracentesis were selected for placement of 7-FG triple-port Central venous catheter in the peritoneal cavity. Maximum fluids that can be tapped were removed in ward. Patients and their relatives were assessed for satisfaction with the procedure. Results Out of 5 patients, 3 were female and 2 male (age between 46 and 62 years). Two patients had carcinoma gallbladder and one each of carcinoma ovary, breast, and prostate. All patients were followed up till 1 month from catheter placement. Patients and their relatives were well satisfied in terms of frequent hospital visit for paracentesis. Conclusion In summary, we suggest that central venous catheter may be used as indwelling peritoneal catheter for the symptom management of recurrent malignant ascites. It provides a relatively safe and cost-effective alternative to serial large-volume paracentesis that requires multiple hospital admissions.
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Affiliation(s)
- Brajesh Kumar Ratre
- Department of Oncoanaesthesia and Palliative Medicine, Dr. B.R. Ambedkar IRCH, AIIMS, New Delhi, India
| | - Praneeth Suvvari
- Department of Oncoanaesthesia and Palliative Medicine, Dr. B.R. Ambedkar IRCH, AIIMS, New Delhi, India
| | - Wasimul Hoda
- Department of Oncoanaesthesia and Palliative Medicine, Dr. B.R. Ambedkar IRCH, AIIMS, New Delhi, India
| | - Priodarshi Roychoudhury
- Department of Oncoanaesthesia and Palliative Medicine, Dr. B.R. Ambedkar IRCH, AIIMS, New Delhi, India
| | - Sachidanand Jee Bharti
- Department of Oncoanaesthesia and Palliative Medicine, Dr. B.R. Ambedkar IRCH, AIIMS, New Delhi, India
| | - Sushma Bhatnagar
- Department of Oncoanaesthesia and Palliative Medicine, Dr. B.R. Ambedkar IRCH, AIIMS, New Delhi, India
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8
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Ong E, Diven C, Abrams A, Lee E, Mahadevan D. Laparoscopic Hyperthermic Intraperitoneal Chemotherapy (Hipec) for Palliative treatment of Malignant Ascites from Gastrointestinal Stromal Tumours. J Palliat Care 2018. [DOI: 10.1177/082585971202800409] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Evan Ong
- E Ong (corresponding author): Department of Surgery, University of Arizona College of Medicine, 1501 N. Campbell Avenue, PO Box 245131, Tucson, Arizona, USA, 85724–5058
| | - Conrad Diven
- C Diven, A Abrams: Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA; E Lee, D Mahadevan: Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Andrew Abrams
- C Diven, A Abrams: Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA; E Lee, D Mahadevan: Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Ellyn Lee
- C Diven, A Abrams: Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA; E Lee, D Mahadevan: Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Daruka Mahadevan
- C Diven, A Abrams: Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA; E Lee, D Mahadevan: Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
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Klymenko Y, Wates RB, Weiss-Bilka H, Lombard R, Liu Y, Campbell L, Kim O, Wagner D, Ravosa MJ, Stack MS. Modeling the effect of ascites-induced compression on ovarian cancer multicellular aggregates. Dis Model Mech 2018; 11:dmm034199. [PMID: 30254133 PMCID: PMC6176988 DOI: 10.1242/dmm.034199] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 07/29/2018] [Indexed: 12/12/2022] Open
Abstract
Epithelial ovarian cancer (EOC) is the most lethal gynecological malignancy. EOC dissemination is predominantly via direct extension of cells and multicellular aggregates (MCAs) into the peritoneal cavity, which adhere to and induce retraction of peritoneal mesothelium and proliferate in the submesothelial matrix to generate metastatic lesions. Metastasis is facilitated by the accumulation of malignant ascites (500 ml to >2 l), resulting in physical discomfort and abdominal distension, and leading to poor prognosis. Although intraperitoneal fluid pressure is normally subatmospheric, an average intraperitoneal pressure of 30 cmH2O (22.1 mmHg) has been reported in women with EOC. In this study, to enable experimental evaluation of the impact of high intraperitoneal pressure on EOC progression, two new in vitro model systems were developed. Initial experiments evaluated EOC MCAs in pressure vessels connected to an Instron to apply short-term compressive force. A Flexcell Compression Plus system was then used to enable longer-term compression of MCAs in custom-designed hydrogel carriers. Results show changes in the expression of genes related to epithelial-mesenchymal transition as well as altered dispersal of compressed MCAs on collagen gels. These new model systems have utility for future analyses of compression-induced mechanotransduction and the resulting impact on cellular responses related to intraperitoneal metastatic dissemination.This article has an associated First Person interview with the first authors of the paper.
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Affiliation(s)
- Yuliya Klymenko
- Department of Biological Sciences, University of Notre Dame, Notre Dame, IN 46556, USA
- Harper Cancer Research Institute, University of Notre Dame, Notre Dame, IN 46617, USA
| | - Rebecca B Wates
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Holly Weiss-Bilka
- Department of Biological Sciences, University of Notre Dame, Notre Dame, IN 46556, USA
| | - Rachel Lombard
- Harper Cancer Research Institute, University of Notre Dame, Notre Dame, IN 46617, USA
| | - Yueying Liu
- Harper Cancer Research Institute, University of Notre Dame, Notre Dame, IN 46617, USA
| | - Leigh Campbell
- Harper Cancer Research Institute, University of Notre Dame, Notre Dame, IN 46617, USA
| | - Oleg Kim
- Harper Cancer Research Institute, University of Notre Dame, Notre Dame, IN 46617, USA
- Department of Applied and Computational Mathematics and Statistics, University of Notre Dame, Notre Dame, IN 46556, USA
- Department of Mathematics, University of California, Riverside, CA 92521, USA
| | - Diane Wagner
- Department of Mechanical and Energy Engineering, Indiana University-Purdue University Indianapolis, Indianapolis, IN 46202, USA
| | - Matthew J Ravosa
- Department of Biological Sciences, University of Notre Dame, Notre Dame, IN 46556, USA
- Harper Cancer Research Institute, University of Notre Dame, Notre Dame, IN 46617, USA
| | - M Sharon Stack
- Harper Cancer Research Institute, University of Notre Dame, Notre Dame, IN 46617, USA
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN 46556, USA
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Fang Y, Ning A, Li S, Zhou S, Liu L, Joseph TP, Zhong M, Jiao J, Zhang W, Shi Y, Zhang M, Huang M. Polysaccharides Extracted from Rhizoma Pleionis Have Antitumor Properties In Vitro and in an H22 Mouse Hepatoma Ascites Model In Vivo. Int J Mol Sci 2018; 19:E1386. [PMID: 29735884 PMCID: PMC5983843 DOI: 10.3390/ijms19051386] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 04/23/2018] [Accepted: 04/24/2018] [Indexed: 02/06/2023] Open
Abstract
Malignant ascites is a highly severe and intractable complication of advanced or recurrent malignant tumors that is often immunotherapy-resistant. Rhizoma Pleionis is widely used in traditional medicine as an antimicrobial and anticancer agent, but its effectiveness in treating malignant ascites is unclear. In the current study, we investigated the effect of polysaccharides isolated from Rhizoma Pleionis (PRP) on murine hepatocarcinoma H22 cells in an ascites model. We have found that the main components of PRP, that presented a relative molecular weight of 383.57 kDa, were mannose and glucose. We also found that PRP reduced the occurrence of abdominal ascites and increased survival in our mouse model. An immune response in the ascites tumor model was observed by performing a lymphocytes proliferation experiment and an E-rosette test. The ratios of CD8+ cytotoxic T cells and NK cells in the spleen were examined by flow cytometry, and the mRNA expression of Foxp3+in CD4⁺CD25⁺ (T regulatory Tregs) was measured by RT-PCR (reverse transcription-polymerase chain reaction). The levels of the cytokines TNF-α (tumor necrosis factor), VEGF (vascular endothelial growth factor), IL-2 (interleukin), and IFN-γ (interferon) in the serum and ascites supernatants were measured by ELISA. The expression of Foxp3 and Stat3 in peritoneal cells in the mouse model was measured by immunocytochemistry. The results indicated that PRP increased H22 tumor cell apoptosis in vivo by activating and enhancing the immune response. Furthermore, the effects of PRP on the proliferation of H22 cells were assessed by the CCK8 assay, Hoechest 33258, and TUNEL staining in vitro. We found that PRP suppressed the proliferation of H22 tumor cells but had no effect on BRL (Big rat liver) -3A rat hepatoma normal cells in vitro. Next, we investigated the underlying immunological mechanism by which PRP inhibits malignant ascites. PRP induced tumor cell apoptosis by inhibiting the Jak1⁻Stat3 pathway and by activating Caspase-3 and Caspase-8 to increase the Bax/Bcl-2 ratio. Collectively, our results indicate that PRP exhibits significant antitumor properties in H22 cells in vivo and in vitro, indicating that PRP may be used as a new therapeutic drug for cancer treatment.
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Affiliation(s)
- Yukun Fang
- Department of Microbiology, Dalian Medical University, Dalian 116044, China.
| | - Anhong Ning
- Department of Microbiology, Dalian Medical University, Dalian 116044, China.
| | - Sha Li
- Department of Microbiology, Dalian Medical University, Dalian 116044, China.
| | - Shaozheng Zhou
- Department of Microbiology, Dalian Medical University, Dalian 116044, China.
| | - Lei Liu
- Department of Microbiology, Dalian Medical University, Dalian 116044, China.
| | | | - Mintao Zhong
- Department of Microbiology, Dalian Medical University, Dalian 116044, China.
| | - Jilong Jiao
- Department of Microbiology, Dalian Medical University, Dalian 116044, China.
| | - Wei Zhang
- Department of Microbiology, Dalian Medical University, Dalian 116044, China.
| | - Yonghui Shi
- Department of Microbiology, Dalian Medical University, Dalian 116044, China.
| | - Meishan Zhang
- Department of Microbiology, Dalian Medical University, Dalian 116044, China.
| | - Min Huang
- Department of Microbiology, Dalian Medical University, Dalian 116044, China.
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Differentiating Transudative From Exudative Ascites Using Quantitative B-Mode Gray-Scale Ultrasound Histogram. AJR Am J Roentgenol 2017; 209:313-319. [DOI: 10.2214/ajr.16.16509] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Lu CS, Lin JK, Chen WS, Lin TC, Jiang JK, Yang SH, Wang HS, Chang SC, Lan YT, Lin CC, Lin HH, Teng HW. Intraperitoneal ziv-aflibercept effectively manages refractory ascites in colorectal cancer patients. Oncotarget 2017; 8:36707-36715. [PMID: 27888621 PMCID: PMC5482690 DOI: 10.18632/oncotarget.13543] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 11/12/2016] [Indexed: 01/07/2023] Open
Abstract
Ascites related to metastatic colorectal cancer (mCRC) reduces patient survival and quality of life, and systemic chemotherapy is largely ineffective for managing ascites. Here, we examined the clinical efficacy of intraperitoneal (IP) ziv-aflibercept for managing refractory ascites in 15 mCRC patients who did not respond to standard chemotherapy. Fifty or 100 mg of ziv-aflibercept in 100 mL of saline solution were infused through a pigtail catheter and retained for 24 h. When the ascites drainage volumes were subsequently monitored, 73.3% of patients showed an objective response (OR) to IP ziv-aflibercept treatment. Patients with low Eastern Cooperative Oncology Group (ECOG) performance status or with serum ascites albumin gradients (SAAG) less than 1.1 g/dL had better responses to treatment, and 4 patients with SAAG less than 1.1 g/dL showed rapid objective responses (rOR). These findings indicate that intraperitoneal ziv-aflibercept therapy may be a highly effective means of treating refractory ascites in mCRC patients, and that SAAG may be predictive of a rapid response to this treatment.
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Affiliation(s)
- Chieh-Sheng Lu
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
- Division of Hematology and Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Division of Medical Oncology, Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jen-Kou Lin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Colon and Rectum Surgery, Department of Surgery, Taipei Veterans General Hospital & National Yang-Ming University, Taipei, Taiwan
| | - Wei-Shone Chen
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Colon and Rectum Surgery, Department of Surgery, Taipei Veterans General Hospital & National Yang-Ming University, Taipei, Taiwan
| | - Tzu-Chen Lin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Colon and Rectum Surgery, Department of Surgery, Taipei Veterans General Hospital & National Yang-Ming University, Taipei, Taiwan
| | - Jeng-Kai Jiang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Colon and Rectum Surgery, Department of Surgery, Taipei Veterans General Hospital & National Yang-Ming University, Taipei, Taiwan
| | - Shung-Haur Yang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Colon and Rectum Surgery, Department of Surgery, Taipei Veterans General Hospital & National Yang-Ming University, Taipei, Taiwan
| | - Huann-Sheng Wang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Colon and Rectum Surgery, Department of Surgery, Taipei Veterans General Hospital & National Yang-Ming University, Taipei, Taiwan
| | - Shih-Ching Chang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Colon and Rectum Surgery, Department of Surgery, Taipei Veterans General Hospital & National Yang-Ming University, Taipei, Taiwan
| | - Yuan-Tzu Lan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Colon and Rectum Surgery, Department of Surgery, Taipei Veterans General Hospital & National Yang-Ming University, Taipei, Taiwan
| | - Chun-Chi Lin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Colon and Rectum Surgery, Department of Surgery, Taipei Veterans General Hospital & National Yang-Ming University, Taipei, Taiwan
| | - Hung-Hsin Lin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Colon and Rectum Surgery, Department of Surgery, Taipei Veterans General Hospital & National Yang-Ming University, Taipei, Taiwan
| | - Hao-Wei Teng
- Division of Medical Oncology, Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Hicks AM, Chou J, Capanu M, Lowery MA, Yu KH, O'Reilly EM. Pancreas Adenocarcinoma: Ascites, Clinical Manifestations, and Management Implications. Clin Colorectal Cancer 2016; 15:360-368. [PMID: 27262896 PMCID: PMC5099112 DOI: 10.1016/j.clcc.2016.04.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Revised: 03/28/2016] [Accepted: 04/27/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Ascites develops in a subset of patients with pancreatic adenocarcinoma (PAC) at presentation or as the disease advances. Limited data exist on the prognostic importance of malignant ascites in PAC. Our hypothesis is that this information will provide an understanding of the natural history and facilitate management decisions. METHODS We conducted a retrospective analysis of 180 patients treated at Memorial Sloan Kettering Cancer Center diagnosed between January 1, 2009 and December 31, 2014, with PAC and with ascites either at presentation or that developed during the disease course. RESULTS For the 180 patients, the overall survival was 15 months. The time from diagnosis to ascites presentation was 11 months, and the survival time after ascites development was 1.8 months (range, 1.6-2.3 months; 95% confidence interval). Of 62 patients (34%) who had ascitic fluid analyzed, 36 (58%) had positive cytology. Fifty-one (82%) patients had a serum ascites albumin gradient ≥ 1, and 11 (18%) had serum ascites albumin gradient < 1. Sixty-four (36%) patients had their ascites managed solely by serial paracenteses. A total of 116 patients required a catheter; of these, 108 (93%) had a Tenckhoff catheter, 4 (3%) a Pleurx catheter, 4 (3%) a pigtail catheter, and 1 (1%) a Denver catheter. Eight (7%) patients required 2 catheters to be placed, and in 6 (5%), Tenckhoff catheters had to be removed. The main observed complications were spontaneous bacterial peritonitis in 7 (11%) managed with paracenteses versus 26 (23%) who had a catheter placed, catheter malfunction in 8 (7%), and acute renal failure in 6 (3%). After ascites development, 79 (44%) patients received active anti-cancer therapy, and 101 (56%) patients were managed with supportive care alone. CONCLUSIONS In patients with PAC who presented with or developed ascites, serial paracenteses and indwelling catheters are common methods used for providing symptomatic relief. The complication rate was higher with indwelling catheters, primarily related to infection (eg, bacterial peritonitis). Overall, ascites has a significantly negative prognostic import with a short median survival.
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Affiliation(s)
- Angel Mier Hicks
- Department of Medicine, Icahn School of Medicine at Mount Sinai/St. Luke's Roosevelt Hospital Center Program, New York, NY
| | - Joanne Chou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marinela Capanu
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Maeve A Lowery
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kenneth H Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Eileen M O'Reilly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
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The role of ascitic fluid viscosity in differentiating the nature of ascites and in the prediction of renal impairment and duration of ICU stay. Eur J Gastroenterol Hepatol 2016; 28:1021-7. [PMID: 27218209 DOI: 10.1097/meg.0000000000000669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Serum-ascites albumin gradient (SAAG) has been used in the classification of ascites for the last 20 years but it has some drawbacks. This study searches for possible correlations between ascitic fluid viscosity and the etiology of ascites, renal impairment, and length of ICU stay. MATERIALS AND METHODS The study was conducted in Zagazig University Hospital, Egypt. It included 240 patients with ascites due to various causes. The patients were divided into two groups: the cirrhotic ascites group, which included 120 patients, and the noncirrhotic ascites group, which included 120 patients. Ascitic patients on medical management with diuretics, antibiotics, paracentesis, and infusion of plasma or albumin were excluded.The laboratory analysis included routine investigations to detect the cause of ascites as well as specific investigations such as ascitic fluid viscosity using a falling ball viscosimeter (microviscosimeter) at 37°C. RESULTS The mean ascitic viscosity of patients with SAAG at least 1.1 was 1.16±0.56, which was associated with serum creatinine 1.35±0.52 mg/dl and ICU stay of 3.3±1.2 days. In patients with SAAG less than 1.1 g/dl, the mean ascitic viscosity was 2.98±0.87, with serum creatinine 2.1±0.56 mg/dl and ICU stay of 7.1±1.3 days. Ascitic viscosity can discriminate ascites due to portal hypertension from those associated with nonportal hypertension at a cut-off value of 1.65; it can predict renal impairment in hepatic patients at a cut-off of 1.35 and long ICU stay at a cut-off of 1.995 using receiver operating characteristic analysis. CONCLUSION Ascitic viscosity measurement is rapid, inexpensive, and requires small sample volumes. Ascitic viscosity can discriminate ascites due to portal hypertension from those associated with nonportal hypertension at a cut-off value of 1.65. It can predict renal impairment in hepatic patients at a cut-off of 1.35 and long ICU stay at a cut-off of 1.995.
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Jordan K, Luetkens T, Gog C, Killing B, Arnold D, Hinke A, Stahl M, Freier W, Rüssel J, Atanackovic D, Hegewisch-Becker S. Intraperitoneal bevacizumab for control of malignant ascites due to advanced-stage gastrointestinal cancers: A multicentre double-blind, placebo-controlled phase II study – AIO SUP-0108. Eur J Cancer 2016; 63:127-34. [DOI: 10.1016/j.ejca.2016.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 04/22/2016] [Accepted: 05/04/2016] [Indexed: 10/21/2022]
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Bekes I, Friedl TWP, Köhler T, Möbus V, Janni W, Wöckel A, Wulff C. Does VEGF facilitate local tumor growth and spread into the abdominal cavity by suppressing endothelial cell adhesion, thus increasing vascular peritoneal permeability followed by ascites production in ovarian cancer? Mol Cancer 2016; 15:13. [PMID: 26868378 PMCID: PMC4751711 DOI: 10.1186/s12943-016-0497-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Accepted: 02/04/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Ovarian cancer is mostly associated with pathologically regulated permeability of peritoneal vessels, leading to ascites. Here, we investigated the molecular regulation of endothelial permeability by the vascular endothelial growth factor (VEGF) and both tight and adherens junction proteins (VE-cadherin and claudin 5) with regards to the tumor biology of different ovarian cancer types. METHODS Serum and ascites samples before and after surgery, as well as peritoneal biopsies of 68 ovarian cancer patients and 20 healthy controls were collected. In serum and ascites VEGF protein was measured by ELISA. In peritoneal biopsies co-localization of VE-cadherin and claudin 5 was investigated using immunohistochemical dual staining. In addition, the gene expression of VE-cadherin and claudin 5 was quantified by Real-time PCR. Differences in VEGF levels, VE-cadherin and claudin 5 gene expression were analyzed in relation to various tumor characteristics (tumor stage, grading, histological subtypes, resection status after surgery) and then compared to controls. Furthermore, human primary ovarian cancer cells were co-cultured with human umbilical vein endothelial cells (HUVEC) and changes in VE-cadherin and claudin 5 were investigated after VEGF inhibition. RESULTS VEGF was significantly increased in tumor patients in comparison to controls and accumulates in ascites. The highest VEGF levels were found in patients diagnosed with advanced tumor stages, with tumors of poor differentiation, or in the group of solid / cystic-solid tumors. Patients with residual tumor after operation showed significantly higher levels of VEGF both before and after surgery as compared to tumor-free resected patients. Results of an immunohistochemical double-staining experiment indicated co-localization of VE-cadherin and claudin 5 in the peritoneal vasculature. Compared to controls, expression of VE-cadherin and claudin 5 was significantly suppressed in peritoneal vessels of tumor patients, but there were no significant differences regarding VE-cadherin and claudin 5 expression in relation to different tumor characteristics. A significant positive correlation was found between VE-cadherin and claudin 5 expression. VEGF inhibition in vitro was associated with significant increase in VE-cadherin and claudin 5. CONCLUSIONS Our results indicate that increased peritoneal permeability in ovarian cancer is due to down-regulation of adhesion proteins via tumor derived VEGF. Advanced ovarian cancer with aggressive tumor biology may be associated with early dysregulation of vascular permeability leading to ascites. These patients may benefit from therapeutic VEGF inhibition.
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Affiliation(s)
- Inga Bekes
- Department of Obstetrics and Gynecology, University of Ulm, Prittwitzstrasse 42, 89075, Ulm, Germany.
| | - Thomas W P Friedl
- Department of Obstetrics and Gynecology, University of Ulm, Prittwitzstrasse 42, 89075, Ulm, Germany.
| | - Tanja Köhler
- Department of Obstetrics and Gynecology, University of Ulm, Prittwitzstrasse 42, 89075, Ulm, Germany.
| | - Volker Möbus
- Department of Obstetrics and Gynecology, Klinikum Frankfurt Hoechst, Gotenstraße 6-8, 65929, Frankfurt am Main, Germany.
| | - Wolfgang Janni
- Department of Obstetrics and Gynecology, University of Ulm, Prittwitzstrasse 42, 89075, Ulm, Germany.
| | - Achim Wöckel
- Department of Obstetrics and Gynecology, University of Würzburg, Josef-Schneider-Strasse 4, 97080, Würzburg, Germany.
| | - Christine Wulff
- Department of Obstetrics and Gynecology, University of Würzburg, Josef-Schneider-Strasse 4, 97080, Würzburg, Germany.
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Repeat Large-Volume Paracentesis Versus Tunneled Peritoneal Catheter Placement for Malignant Ascites: A Cost-Minimization Study. AJR Am J Roentgenol 2016; 205:1126-34. [PMID: 26496562 DOI: 10.2214/ajr.15.14484] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of this study was to determine the point in time at which tunneled peritoneal catheter placement becomes less costly than repeat large-volume paracentesis (LVP) for patients with malignant ascites. MATERIALS AND METHODS Procedure costs were based on 2013 Medicare reimbursement rates. Rates for specific complications were obtained from the literature and were assigned costs. A decision tree-based Markov chain Monte Carlo model was designed with 11 cycles of 10 days, to simulate 4000 subjects per trial. Patients were grouped according to initial treatment decision (LVP vs catheter placement), and the total cost at the end of each 10-day cycle was calculated. The point at which catheter placement became less costly than LVP was determined. Additional simulations were used for bivariate analyses of all cost and probability variables and for trivariate analysis of cycle length and volume of fluid drained per cycle. RESULTS Individual input probabilities were not significantly different from corresponding simulation outcomes (p value range, 0.068-0.95). When complications were included in the model, the cost curves crossed at a mean (± SD) of 82.8 ± 3.6 days (range, 75.8-89.6 days), corresponding to a time between the performance of the ninth and 10th LVP procedures. Intersection occurred earlier in simulations with a shorter cycle length and less fluid per cycle, but it was minimally affected by changing individual complication probabilities and costs. CONCLUSION For patients with malignant ascites, LVP becomes more costly once the procedure is performed nine or 10 times or at approximately 83 days, if paracentesis is repeated every 10 days, with 5 L of fluid removed each time. Use of a tunneled peritoneal catheter improves the cost advantage for patients who receive LVP more frequently or patients who have less than 5 L of fluid drained per procedure.
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Meier M, Mortensen FV, Madsen HHT. Malignant ascites in patients with terminal cancer is effectively treated with permanent peritoneal catheter. Acta Radiol Open 2015; 4:2058460115579934. [PMID: 26346641 PMCID: PMC4548747 DOI: 10.1177/2058460115579934] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 03/10/2015] [Indexed: 02/01/2023] Open
Abstract
Background Malignant ascites is a pathological condition caused by intra- or extra-abdominal disseminated cancer. The object of treatment is palliation. In search of an effective and minimally invasive palliative treatment of malignant ascites placement of a permanent intra peritoneal catheter has been suggested. Purpose To evaluate our experiences with treatment of malignant ascites by implantation of a permanent PleurX catheter. Material and Methods A retrospective study was conducted, comprising 20 consecutive patients with terminal cancer, who had a permanent PleurX catheter implanted because of malignant ascites in the period from February to November 2014. Using the patients’ medical records, we retrieved data on patients and procedures. Results The technical success rate was 100%. Catheter patency was 95.2%, one catheter was removed due to dislocation. Ten patients (50.0%) experienced minor adverse events. No procedural difficulties were reported and there was no need for additional treatment of malignant ascites after catheter implantation. Median residual survival after catheter implantation was 27 days. Conclusion Implantation of a permanent PleurX catheter is a minimally invasive and effective procedure with only minor adverse events and a high rate of catheter patency in patients with malignant ascites caused by terminal cancer disease.
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Affiliation(s)
- Michelle Meier
- Department of Surgery, Section for Upper Gastrointestinal and Hepato-pancreatico-biliary Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Frank V Mortensen
- Department of Surgery, Section for Upper Gastrointestinal and Hepato-pancreatico-biliary Surgery, Aarhus University Hospital, Aarhus, Denmark
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Intraperitoneal administration of cisplatin plus bevacizumab for the management of malignant ascites in ovarian epithelial cancer: results of a phase III clinical trial. Med Oncol 2015; 32:292. [PMID: 25609006 DOI: 10.1007/s12032-014-0292-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 10/13/2014] [Indexed: 10/24/2022]
Abstract
Bevacizumab is a humanized antihuman VEGF-A monoclonal antibody. This study aims to evaluate the efficacy and safety of intraperitoneal administration of cisplatin plus bevacizumab (Avastin) in the management of malignant ascites in ovarian epithelial cancer. Fifty-eight ovarian epithelial cancer patients with malignant ascites were randomly assigned to receive either intraperitoneal administration of cisplatin only (control group, n = 27, cisplatin: 40 mg/m(2) every 2 weeks, for 6 weeks) or cisplatin plus bevacizumab (study group, n = 31, cisplatin: 40 mg/m(2), bevacizumab: 300 mg, every 2 weeks for 6 weeks). All patients regularly received TC regimen (paclitaxel 135 mg/m(2) d1 + carboplatin AUC 5 d1) every 3 weeks. The outcome, quality of life (QoL) and adverse effect of the treatment were analyzed, and VEGF and CA-125 level in ascites were detected by ELISA. After treatment with cisplatin plus bevacizumab, VEGF level in ascites was significantly decreased compared to baseline (P < 0.05). Meanwhile, ascites VEGF level of study group was significantly lower than that of control group (P < 0.05). The overall response rate (ORR) of study group was significantly higher than that of control group (ORR 90.32 vs. 59.26 %, P < 0.05). QoL improvement rate of study group was also significantly higher than that of control group (93.55 vs. 48.15 %, P < 0.05). All patients were well tolerated, and no serious adverse effect occurred. Intraperitoneal administration of cisplatin plus bevacizumab is effective and safe for the management of malignant ascites in ovarian epithelial cancer.
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A survey of treatment approaches of malignant ascites in Germany and Austria. Support Care Cancer 2014; 23:2073-8. [PMID: 25528551 DOI: 10.1007/s00520-014-2557-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 12/07/2014] [Indexed: 01/26/2023]
Abstract
BACKGROUND Malignant ascites (MA) is a common manifestation of advanced cancer. Currently, there are no evidence-based guidelines for the management of MA. We conducted a survey with physicians throughout Germany and Austria, to get an overview of current approaches and opinions in the treatment of MA. METHODS One hundred and twenty-eight medical oncologists (MO), gastroenterologists (GE), and gynecologists (GYN) completed an electronic questionnaire consisting of 33 questions. RESULTS Ninety percent of the physicians were from Germany and 10% from Austria; 48% of those were MO, 30% were GYN, and 14% were GE. Most physicians treated an average of 34 patients (pts)/year with MA. Twenty-six percent of these pts suffered from ovarian, 20% from pancreatic, 17% from gastric, and 14% from colorectal cancer. The majority of the physicians associated MA with poor prognosis (92%) and significant reduction in quality of life (87%). One third felt that MA was a contraindication for full dosing of systemic chemotherapy. Paracentesis (PC) was performed in 70% of pts with symptom relieve and quality of life being the main reasons. Almost half of the pts required 3-5 PC, 50% even more than 5 PC during the course of their disease. Only 15% of pts needed multiple PC per week; the majority (79%) needed the procedure either once a week or every 14 days. In 61% of pts, 3-5 L of ascites fluid was drained. Only in 8%, 5 L and more were removed. Volume substitution with IV albumin was performed in 40% of pts. Most pts (55%) had to stay 1-3 h in a healthcare facility for the procedure. However, 21% had to stay ≥1 day. While almost all physicians (89%) performed a PC at some point in the treatment of MA, 75% felt that a systemic chemotherapy and 55% thought a concomitant diuretic therapy were a necessary adjunct. Seven percent of the pts received a targeted treatment with catumaxomab. CONCLUSIONS Repeated PC is the main pillar of treatment of MA; its effect is only temporary and requires significant hospital resources. Further treatment strategies of MA have to be evaluated in prospective studies. Targeted therapies like catumaxomab and VEGF inhibitors should be integrated into these.
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Agah S, Tavakoli S, Nikbakht H, Najafi M, Al-Agha A. Central venous pressure catheter for large-volume paracentesis in refractory ascites. Indian J Gastroenterol 2014; 33:310-5. [PMID: 24756422 DOI: 10.1007/s12664-014-0448-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 02/13/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS About 10 % of cirrhotic patients are unresponsive to sodium restriction and diuretics and develop refractory ascites. Such patients usually require recurrent large-volume paracentesis and lots of hospital admissions. Hereby, we introduce a method applying a central vein (CV) catheter for large-volume paracentesis in patients with refractory ascites in up to 4 days associated with sodium restriction and high dose of diuretics. METHODS Non-tunneled triple lumen CV catheter was used to drain the ascites fluid of 30 cirrhotic patients. After precise percussion, the point of highest fluid accumulation was marked for puncture. Then, the skin and subcutaneous tissue were anesthetized. CV catheter set guide wire was entered into the peritoneal cavity and the dilator of the CV catheter set was passed through the guide wire and extracted after some rotations around its insertion site on the skin. The catheter was passed over the guide wire and the guide wire was extracted gradually from one of the lumens and fixed to the skin. RESULTS Nineteen males and 11 females with mean (±SD) age of 59.4 ± 11.7 years old underwent the procedure. A minimum of 9 and maximum of 29 L (12 ± 6.6 L) ascites fluid drained during a minimum of 2 and maximum of 5 days of hospital stay. All catheters were patent during the drainage. None of the patients developed hemodynamic instability. Number of re-hospitalizations for paracentesis was 1.9 times during the following year. No complication occurred. CONCLUSIONS This technique is a simple noninvasive method that can be performed in the endoscopy unit or even at the patient's bedside and may reduce the need for repeated admissions.
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Affiliation(s)
- Shahram Agah
- Colorectal Research Center, Rasool-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran,
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Molecular profiling and clinical outcome of high-grade serous ovarian cancer presenting with low- versus high-volume ascites. BIOMED RESEARCH INTERNATIONAL 2014; 2014:367103. [PMID: 24982872 PMCID: PMC4055662 DOI: 10.1155/2014/367103] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 05/05/2014] [Indexed: 11/25/2022]
Abstract
Epithelial ovarian cancer consists of multiple histotypes differing in etiology and clinical course. The most prevalent histotype is high-grade serous ovarian cancer (HGSOC), which often presents at an advanced stage frequently accompanied with high-volume ascites. While some studies suggest that ascites is associated with poor clinical outcome, most reports have not differentiated between histological subtypes or tumor grade. We compared genome-wide gene expression profiles from a discovery cohort of ten patients diagnosed with stages III-IV HGSOC with high-volume ascites and nine patients with low-volume ascites. An upregulation of immune response genes was detected in tumors from patients presenting with low-volume ascites relative to those with high-volume ascites. Immunohistochemical studies performed on tissue microarrays confirmed higher expression of proteins encoded by immune response genes and increased tumorinfiltrating cells in tumors associated with low-volume ascites. Comparison of 149 advanced-stage HGSOC cases with differential ascites volume at time of primary surgery indicated low-volume ascites correlated with better surgical outcome and longer overall survival. These findings suggest that advanced stage HGSOC presenting with low-volume ascites reflects a unique subgroup of HGSOC, which is associated with upregulation of immune related genes, more abundant tumor infiltrating cells and better clinical outcomes.
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Malayev Y, Levene R, Gonzalez F. Palliative Chemotherapy for Malignant Ascites Secondary to Ovarian Cancer. Am J Hosp Palliat Care 2012; 29:515-21. [DOI: 10.1177/1049909111434044] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Although research has shown that palliative chemotherapy is beneficial compared to lack of treatment (Schorge JO, Schaffer JI, Halvorson LM, et al. ed. Williams Gynecology. New York, NY: McGraw Hill Medical; 2008.), other studies show aggressive end-of-life treatment adversely affects quality of life and shortens life span (Arriba L, Fader A, Frasure H, von Gruenigen V. A review of issues surrounding quality of life among women with ovarian cancer. Gynecol Oncol. 2010;119(2):390-396.). Without a consensus on palliative chemotherapy, underutilization during end of life prevails, and likely will continue without additional research (Barbera L, Elit L, Krzyzanowska M, et al. End of life care for women with gynecologic cancers. Gynecol Oncol. 2010;118(2):196-201.). This article aims to evaluate and examine existing chemotherapy for palliation of malignant ascites secondary to ovarian cancer and compare commonly used regimens. Agents will be evaluated by their modes of administration. Oral agents include cyclophosphamide and thalidomide, and intraperitoneal vehicles include taxane-based agents, platinum-based agents, antibiotics, and biologic agents. In addition, cost, ethics, and quality of life discussions factor into this review. Palliative care’s goal is to find a balance between life expectancy and symptom relief with minimal adverse effects.
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Affiliation(s)
- Yuliya Malayev
- College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Richard Levene
- Hospice of Palm Beach County, University of Miami Miller School of Medicine, West Palm Beach, FL, USA
| | - Faustino Gonzalez
- Hospice of Palm Beach County, 5300 East Avenue, West Palm Beach, FL. 33407
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Radiologically placed tunneled peritoneal catheter in palliation of malignant ascites. Eur J Radiol 2011; 80:265-8. [DOI: 10.1016/j.ejrad.2010.06.047] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2010] [Accepted: 06/25/2010] [Indexed: 11/20/2022]
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Abstract
The development of a pleural effusion or ascites in patients with underlying malignancy typically heralds end-stage disease and often results in a significant reduction in the patient&'s quality of life. The goal of treatment is the safe and effective palliation of symptoms with minimal inconvenience to the patient. Malignant fluid collections in the chest and abdomen are amenable to percutaneous management with either intermittent thoracentesis or paracentesis or by placement of temporary or permanent drainage catheters.
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Affiliation(s)
- Leann S Stokes
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
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The role of ascitic fluid viscosity in the differential diagnosis of ascites. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2010; 24:255-9. [PMID: 20431815 DOI: 10.1155/2010/896786] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Ascites is defined as the pathological accumulation of fluid in the peritoneal cavity. It is the most common complication of cirrhosis, which is also the most common cause of ascites. Viscosity is a measure of the resistance of a fluid to deform under shear stress. Plasma viscosity is influenced by the concentration of plasma proteins and lipoproteins, with the major contribution from fibrinogen. To our knowledge, the viscosity of ascitic fluid has not yet been studied. OBJECTIVE To evaluate the role of ascitic fluid viscosity in discriminating between ascites due to portal hypertension-related and nonportal hypertension-related causes, and to compare results with the serum-ascites albumin gradient (SAAG). METHODS The present study involved 142 patients with ascites presenting with diverse medical problems. Serum total protein, albumin, glucose, lactate dehydrogenase (LDH) levels and complete blood count were obtained for all subjects. Paracentesis was performed routinely on admission and all ascitic fluid samples were evaluated by manual cell count with differential, ascitic fluid culture and biochemistry (total protein, albumin, glucose and LDH). Cultures of ascitic fluid were performed at bedside in all patients using blood culture bottles. Ascitic fluid viscosity was measured in a commercially available cone and plate viscometer. RESULTS Of the 142 patients studied, 34 (24%) had an SAAG of 11 gL or less, whereas 108 (76%) had an SAAG of greater than 11 gL. Sex and mean age did not differ significantly between the two groups (P>0.05). Serum total protein, albumin, glucose, LDH levels, leukocyte count, ascitic fluid glucose levels and ascitic fluid leukocyte counts were similar in both groups, with no statistically significant relationship detected (P>0.05). However, the mean (+/-SD) ascitic fluid total protein (0.0172+/-0.1104 gL versus 0.043+/-0.011 gL), albumin (0.0104+/-0.0064 gL versus 0.0276+/-0.0069 gL) and LDH (102.76+/-80.95 UL versus 885.71+/-199.93 UL) were found to be higher in patients with an SAAG of 11 gL or less than in those with an SAAG of greater than 11 gL (P<0.001). The mean ascitic fluid viscosities were 0.86+/-0.12 centipoise (cP) and 1.22+/-0.25 cP in patients with an SAAG greater than 11 gL and an SAAG of 11 gL or less, respectively (P<0.001). Although ascitic fluid infection was detected in 35 patients (24.6%) (19 patients with spontaneous bacterial peritonitis, seven patients with culture-negative neutrocytic ascites, three patients with monobacterial non-neutrocytic bacterascites and six patients with secondary bacterial peritonitis), no significant effect on ascitic fluid viscosity was detected. Multiple linear regression analysis revealed that ascitic fluid total protein, albumin and LDH levels were independent predictors of ascitic fluid viscosity (P<0.001). The sensitivity, specificity, and positive and negative predictive values of ascitic fluid viscosity for the discrimination between ascites due to portal hypertension-related and nonportal hypertension-related causes according to the SAAG were determined by receiver operating characteristic analysis. Regarding the cut-off value of 1.03 cP, ascitic fluid viscosity measurement had a high sensitivity, specificity (98% and 80%, respectively), and positive and negative predictive value (79% and 94%, respectively) for the etiological discrimination of ascites. CONCLUSION The measurement of ascitic fluid viscosity correlates significantly with SAAG values. In view of its simplicity, low cost, small sample volume requirement and allowance for measurement in previously frozen samples, measurement of ascites viscosity could be useful for the accurate and rapid classification of ascites.
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Ammouri L, Prommer EE. Palliative treatment of malignant ascites: profile of catumaxomab. Biologics 2010; 4:103-10. [PMID: 20531969 PMCID: PMC2880345 DOI: 10.2147/btt.s6697] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- Lila Ammouri
- Mayo Clinic Hospice and Palliative Medicine Program, Mayo Clinic College of Medicine, Mayo Clinic Hospital, Scottsdale, AZ, USA
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Kobold S, Hegewisch-Becker S, Oechsle K, Jordan K, Bokemeyer C, Atanackovic D. Intraperitoneal VEGF inhibition using bevacizumab: a potential approach for the symptomatic treatment of malignant ascites? Oncologist 2009; 14:1242-51. [PMID: 20008305 DOI: 10.1634/theoncologist.2009-0109] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Despite overall improvements in oncological care in the palliative setting, symptomatic malignant ascites remains a severe clinical problem. This form of effusion is known to be widely resistant to established modes of systemic therapy. Accordingly, frequent paracentesis often represents the only effective way for symptom relief in patients with advanced cancer. This invasive mode of therapy, however, is often very burdensome for the patient who is already severely distressed by the underlying malignancy. Recently, the trifunctional monoclonal antibody catumaxomab given i.p. has shown symptom relief in patients with ovarian cancer and malignant ascites. On another front, the release of vascular endothelial growth factor (VEGF) by tumor cells has been identified as a main factor promoting the i.p. secretion of fluid. Accordingly, recent evidence suggests that targeting VEGF may have the potential to suspend the ascites production resulting from peritoneal metastasis. Here, we review preclinical and clinical data supporting this hypothesis. We show current evidence suggesting that the i.p. application of the anti-VEGF antibody bevacizumab, which is already in use as an i.v. therapeutic drug for a variety of tumors, might represent an effective way to prevent local fluid accumulation. Because such an effect would result in significant relief for patients, future clinical studies should stringently assess the effectiveness of this targeted therapy for the treatment of malignant i.p. effusions.
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Affiliation(s)
- Sebastian Kobold
- Department of Oncology/Hematology/Bone Marrow Transplantation with the Section Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Complete remission of ovarian cancer induced intractable malignant ascites with intraperitoneal bevacizumab. Immunological observations and a literature review. Invest New Drugs 2009; 28:887-94. [PMID: 19936983 DOI: 10.1007/s10637-009-9351-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Accepted: 10/28/2009] [Indexed: 12/11/2022]
Abstract
Malignant ascites resistant to conventional drugs frequently affects ovarian cancer patients at the end of life. Here we report the case of a patient who benefited from complete resolution of ascites after low dose intraperitoneal administration of bevacizumab. Immunological analyses showed an initial increase in proportion and function of CD8(+) effector T cells and a reduction of circulating T(reg) cells. A review of the current literature regarding bevacizumab in ovarian cancer is reported. Bevacizumab has shown a high efficacy in the treatment of ovarian cancer. Intraperitoneal administration induces an immune activation and appears promising in the treatment of malignant ascites.
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Holtmann M, Siepmann U, Mahlkow S, Domagk D, Pott G. Gastroenterologische Symptomenkontrolle in der Palliativmedizin (Teil 2). GASTROENTEROLOGE 2009. [DOI: 10.1007/s11377-008-0254-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Chenganakkattil S, Sallnow L. Managing malignant ascites at home. PROGRESS IN PALLIATIVE CARE 2009. [DOI: 10.1179/096992609x392213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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[Methods of symptom control in malignant ascites]. Wien Med Wochenschr 2009; 158:687-94. [PMID: 19165448 DOI: 10.1007/s10354-008-0621-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2008] [Accepted: 10/28/2008] [Indexed: 10/21/2022]
Abstract
Ascites remains a challenge in many patients with advanced cancers in palliative care. Although paracentesis, diuretics and shunting are the commonly used procedures, the evidence is weak. A fast but temporary effect is achieved on symptom relief by paracentesis. Some inherent risks have to be taken into account. On the basis of a case report, different attempts to control malignant ascites are discussed. The report of a young woman with relapsing ovarian cancer and recurrent ascites is presented including the management of symptomatic malignant ascites.
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Management of Ascites. J Hosp Palliat Nurs 2008. [DOI: 10.1097/01.njh.0000319157.05102.c2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Intraperitoneal bevacizumab for the palliation of malignant ascites in refractory ovarian cancer. Gynecol Oncol 2008; 111:530-2. [PMID: 18561992 DOI: 10.1016/j.ygyno.2008.04.028] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Revised: 04/19/2008] [Accepted: 04/22/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND Malignant ascites often has a profound impact on the quality of life of patients with refractory ovarian cancer. Current treatments, including dietary, medical, and procedural are often temporary and unsatisfactory options in patients approaching the end of life. CASE We present a case of an 88 year-old receiving home hospice care with refractory ovarian cancer and severe symptomatic ascites. We performed a paracentesis and treated her with intraperitoneal bevacizumab with dramatic improvement in her ascites and the quality of her final weeks of life. CONCLUSION Intraperitoneal bevacizumab may be a useful tool in the palliation of malignant ascites and is worthy of further study.
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Mercadante S, Intravaia G, Ferrera P, Villari P, David F. Peritoneal catheter for continuous drainage of ascites in advanced cancer patients. Support Care Cancer 2008; 16:975-8. [PMID: 18449571 DOI: 10.1007/s00520-008-0453-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Accepted: 04/03/2008] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Advanced cancer patients with refractory ascites do not often respond to dietary sodium restriction and diuretics. While paracentesis is effective, the condition invariably recurs, necessitating repeated procedures. A continuous peritoneal drainage by an indwelling catheter has been reported to be hugely beneficial symptomatically, avoiding the hazards and disadvantages of multiple repeated procedures and direct and indirect costs. MATERIALS AND METHODS Forty patients with advanced cancer patients admitted to an acute pain relief and palliative care unit, who presented symptomatic ascites, were recruited for continuous drainage of peritoneal fluid. A central venous catheter set for Seldinger technique was used. Technical failure was defined as an unsuccessful drainage of fluid through the catheter. Immediate and late complications, including hypotension, haemorrhage, tube blockage, dislodgment and sepsis were recorded. Record of daily drainage during admission were noted. At time of discharge, patients were asked to rate their global symptom burden as improved, unchanged or worsened. The follow-up was performed with frequent phone contacts or day-hospital admission in case of problems. RESULTS The mean patients' age was 68 years, and 21 were men. Patients were receiving unsuccessfully a mean dose of furosemide of 32 mg/day. The technique was not painful and was easily accepted by patients. Insertion was technically successful in almost all patients. Mean admission time was 5.5 days (range 2-14), and the mean drained volume during admission was 8,499 ml (range 800-20,700), 2,850 ml (300-4,200) being drained on the first 24 h. No immediate complications were recorded. Six patients died during admission. The mean survival was 38.9 days (range 1-120). Of the 34 patients who were discharged home, 22 patients stated that symptom burden had improved, while in 10 patients symptom burden did not change or worsened, probably due to the advanced status of diseases and multiple contributing factors. Five, two, and one patients required skin sutures at 1, 2 and 3 months, respectively. About one third of patients had mechanical problems, some of them requiring a catheter replacement. No infection was recorded. CONCLUSION In conclusion, a permanent peritoneal catheter was a valuable method to remove abdominal fluids and reduce symptom burden attributable to ascites and was also easy to use at home. Complication rate was acceptable and balanced by the benefits of the technique which avoided frequent paracentesis and associated complications.
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Affiliation(s)
- Sebastiano Mercadante
- Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy.
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