Ascites, Malignant

Key Features

• Two-thirds of cases are due to peritoneal carcinomatosis from adenocarcinomas of the

  • Ovary

  • Uterus

  • Pancreas

  • Stomach

  • Colon

  • Lung

  • Breast

• One-third of cases are due to lymphatic obstruction or portal hypertension from

  • Hepatocellular carcinoma

  • Diffuse hepatic metastases

Clinical Findings

• Nonspecific abdominal discomfort and weight loss

• Increased abdominal girth

• Nausea or vomiting caused by partial or complete intestinal obstruction

Diagnosis

• Abdominal CT

  • Useful to demonstrate primary malignancy or hepatic metastases

  • Seldom confirms diagnosis of peritoneal carcinomatosis

• Paracentesis demonstrates

  • Low serum ascites–albumin gradient (< 1.1 mg/dL)

  • Increased total protein (> 2.5 g/dL)

  • Elevated WBC (often both neutrophils and mononuclear cells but with a lymphocyte predominance)

• Ascitic fluid cytology is positive in 95%

• Laparoscopy is diagnostic in patients with negative cytology

Treatment

• Diuretics not useful in controlling ascites

• Periodic large-volume paracentesis for symptomatic relief; for patients approaching end of life, indwelling (PleurX^TM) peritoneal catheters can be left in place for vacuum-assisted drainage of treatment-resistant, recurrent malignant ascites

• Intraperitoneal chemotherapy sometimes used

• Prognosis is extremely poor: only 10% survival at 6 months

• Ovarian cancer is an exception; with surgical debulking and intraperitoneal chemotherapy, long-term survival is possible