Treatment of malignant ascites

Cost Comparison of Treatment Alternatives for Pleural Effusion and Ascites from a Payer Perspective: Are There Cost Savings from Indwelling Catheters?

Background: The presence of pleural effusions and ascites in patients is often considered a marker of illness severity and a poor prognostic indicator. This study aims to compare inpatient and outpatient costs of alternative invasive treatments for ascites and pleural effusions. Methods: The retrospective single-institution study included inpatient cases treated for pleural effusion (J90 and J91) or ascites (R18) at the University Hospital Cologne (UHC) in Germany between January 01, 2020, and December 31, 2021. Costs for punctures and indwelling catheter systems (ICSs) as well as pleurodesis were analyzed in different comparator treatment pathways. Real-world data from the UHC tertiary care center were based on diagnosis-related group fees from 2020 to 2021. A simulation of outpatient expenses was carried out to compare inpatient and outpatient costs for each pathway from a payer perspective. Results: A total of 4323 cases (3396 pleural effusions and 1302 ascites) were analyzed. For ascites, inpatient implantation with home care drainage was found to be the most expensive option, with total costs of €1,918.58 per procedure, whereas outpatient puncture was the least expensive option at €60.02. For pleural effusions, the most expensive treatment pathway was pleurodesis at €8,867.84 compared with the least costly option of outpatient puncture resulting in total costs per procedure of €70.03. A break-even analysis showed that outpatient puncture remains the most inexpensive treatment option, and the ICS comprises a cost-saving potential. Longevity of several months with the use of ICSs results in both enhanced quality of life for patients and increased cost savings.

Is Low Volume Drainage of Ascites Associated With Improved Survival in Digestive System Cancer Patients With Malignant Ascites?-A Retrospective Cohort Study

Objectives: To determine whether the volume of paracentesis for malignant ascites in acute care hospital wards is associated with survival and symptom relief. Methods: Patients with malignant ascites caused by digestive system cancer who underwent paracentesis between January 2010 and April 2022 were retrospectively analyzed from medical records. Collected data included the drainage volume per paracentesis procedure, survival time from the first paracentesis procedure, symptoms, and adverse events. According to the volume per paracentesis procedure, we divided the patients into the "small-drainage" (≤1500 mL) and "standard-drainage" (>1500 mL) groups. Results: The median age of the 144 patients was 69 years, 33% were female, and 64% had gastrointestinal cancer. The median survival from the first paracentesis procedure was 36 days. Eighty-nine (61.8%) and 55 (38.2%) patients were allocated to the small-drainage and standard-drainage groups, respectively. The median number of paracentesis procedures in the small-drainage and standard-drainage groups was 12 and 7, respectively (P=.001). The median survival in the small-drainage and standard-drainage groups was 50 and 44 days, respectively (P=.76). The multivariate analysis showed that the amount of drainage per session was not significantly associated with survival. Symptoms improved similarly in the 2 groups. No serious adverse events were observed. Conclusions: Paracentesis was demonstrated to be effective and safe, irrespective of the amount of fluid drained, for patients with malignant ascites in an acute care hospital. Thus, a strategy of limiting the amount of drainage is not associated with longer survival.

Mechanism of ozone alleviation of malignant ascites in hepatocellular carcinoma through the inhibition of neutrophil extracellular traps

Malignant ascites in hepatocellular carcinoma is usually a sign of advanced disease and poor prognosis and is also thought to be associated with chronic inflammation mediated by neutrophil extracellular trap (NET) networks. Although ozone, a strong oxidant, has significant antibacterial and anti-inflammatory effects, its effectiveness in treating malignant liver ascites is unclear. We first measured the levels of NETs in the peripheral blood of patients with liver cancer and healthy individuals. Next, we constructed the H22 tumor-bearing mouse model and observed the abdominal girth, body weight, survival rate, and survival time in each group; we marked the proteins associated with NETs in mouse intestinal tissues by immunofluorescence; cf-DNA and cytokines in ascites such as: tumor necrosis factor alpha (TNF-α), vascular endothelial growth factor (VEGF), interleukin 6 (IL-6), matrix metalloprotein 9 (MMP-9), and interferon gamma (IFN-γ) levels in ascites were measured by enzyme-linked immunosorbent assay. The expression levels of phosphorylated adenylate-activated protein kinase (P-AMPK) and scavenger receptor-A (SR-A) were detected by immunocytochemistry in the intestinal tissues of each group of mice. We further examined the expression of P-AMPK and SR-A proteins in ascites deposits by Western blotting. The results show, the plasma levels of NETs were higher in patients with hepatocellular carcinoma than in normal subjects (P < 0.01). Abdominal girth and body weight were significantly reduced in the ozone-treated group compared with the model group, while survival and survival time were dose dependently increased (both P < 0.05). NET-associated guanine histone H3 and myeloperoxidase were abundantly expressed at neutrophil aggregates in the intestinal tissues of the model mice, whereas their expression was significantly reduced in the ozone-treated group. The levels of cf-DNA, IL-6, IFN-γ, MMP-9, VEGF, and TNF-α were dose dependently increased in the ascites of H22 tumor-bearing mice in the ozone-treated group compared with the model group (all P < 0.01), while the expression of P-AMPK and SR-A proteins was increased in the ozone-treated group compared with the model group. Ozone showed significant antiperitoneal fluid production properties in H22 tumor-bearing mice, and ozone reduced peritoneal fluid production by activating AMPK and up-regulating SR-A phagocytosis damage-associated molecular patterns to reduce the production of NETs. This suggests that ozone could be used as a new drug for the treatment of malignant ascites in hepatocellular carcinoma.

A Nomogram for Predicting Prognosis of Advanced Schistosomiasis japonica in Dongzhi County-A Case Study

BACKGROUNDS

Advanced schistosomiasis is the late stage of schistosomiasis, seriously jeopardizing the quality of life or lifetime of infected people. This study aimed to develop a nomogram for predicting mortality of patients with advanced schistosomiasis japonica, taking Dongzhi County of China as a case study.

METHOD

Data of patients with advanced schistosomiasis japonica were collected from Dongzhi Schistosomiasis Hospital from January 2019 to July 2022. Data of patients were randomly divided into a training set and validation set with a ratio of 7:3. Candidate variables, including survival outcomes, demographics, clinical features, laboratory examinations, and ultrasound examinations, were analyzed and selected by LASSO logistic regression for the nomogram. The performance of the nomogram was assessed by concordance index (C-index), sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). The calibration of the nomogram was evaluated by the calibration plots, while clinical benefit was evaluated by decision curve and clinical impact curve analysis.

RESULTS

A total of 628 patients were included in the final analysis. Atrophy of the right liver, creatinine, ascites level III, N-terminal procollagen III peptide, and high-density lipoprotein were selected as parameters for the nomogram model. The C-index, sensitivity, specificity, PPV, and NPV of the nomogram were 0.97 (95% [CI]: [0.95-0.99]), 0.78 (95% [CI]: [0.64-0.87]), 0.97 (95% [CI]: [0.94-0.98]), 0.78 (95% [CI]: [0.64-0.87]), 0.97 (95% [CI]: [0.94-0.98]) in the training set; and 0.98 (95% [CI]: [0.94-0.99]), 0.86 (95% [CI]: [0.64-0.96]), 0.97 (95% [CI]: [0.93-0.99]), 0.79 (95% [CI]: [0.57-0.92]), 0.98 (95% [CI]: [0.94-0.99]) in the validation set, respectively. The calibration curves showed that the model fitted well between the prediction and actual observation in both the training set and validation set. The decision and the clinical impact curves showed that the nomogram had good clinical use for discriminating patients with high risk of death.

CONCLUSIONS

A nomogram was developed to predict prognosis of advanced schistosomiasis. It could guide clinical staff or policy makers to formulate intervention strategies or efficiently allocate resources against advanced schistosomiasis.

A novel oncolytic virus induces a regional cytokine storm and safely eliminates malignant ascites of colon cancer

BACKGROUND

Given malignant ascites with a terrible prognosis and a unique immune microenvironment, our purpose is to evaluate whether oncolytic herpes simplex virus type 2(OH2) is able to safely eliminate ascites of colon cancer and through which specific mechanism it exerts antitumor immunity.

METHODS

We established an ascites mice model through intraperitoneal injection of CT26 cells and obtained an appropriate dose range for in vivo tests. Efficacy and safety of OH2 were detected by weight of ascites, blood routine analysis, histopathological examination, and the survival time of mice. The specific mechanism underlying antitumor immunity was analyzed by cytometric bead array, flow cytometry, and single-cell RNA sequencing. Furthermore, anti-interleukin (IL)-6R antibody tocilizumab was synchronously or sequentially delivered with OH2 to explore the role of the regional cytokine storm, mainly IL-6 hypersecretion.

RESULTS

OH2 was able to eliminate ascites and significantly prolong the survival of mice-bearing CT26 tumor cells by intraperitoneal injection, without obvious systemic damage to the main organs even though a regional cytokine storm. Hypersecretion of pro-inflammatory cytokines, mainly IL-6, and increased infiltration of CD4+ and CD8+ T cells were observed in ascites mice treated by OH2, compared with those treated by 5-fluorouracil or nonresponders. Furthermore, the initial-stage blocking of the IL-6 pathway was able to considerably suppress antitumor immune responses driven by OH2. Surprisingly, we discovered upregulations of the immune checkpoint genes such as Cd274 and Pdcd1 by single-cell RNA sequencing.

CONCLUSIONS

OH2 could safely eliminate malignant ascites of colon cancer and convert the cold immune microenvironment by inducing a remarkably regional cytokine storm in ascites, mainly IL-6, in the early stage of antitumor immune responses beyond directed oncolytic virotherapy.

Effect of paracentesis on the survival of patients with terminal cancer and ascites: a propensity score-weighted analysis of the East Asian Collaborative Cross-cultural Study to Elucidate the Dying Process

PURPOSE

Paracentesis is among the most widely utilized treatments for malignant ascites (MA). However, paracentesis in patients with MA has the potential to be associated with life-shortening effects. Thus, this study aimed to investigate whether paracentesis affected the duration of survival in such patients.

METHODS

We performed a post hoc analysis of a prospective multicenter observational study investigating the dying process and end-of-life care in patients with terminal cancer, admitted to 23 palliative care units in Japan. Survival duration was compared between patients who did (paracentesis group) and did not undergo paracentesis (non-paracentesis group). We used inverse probability of treatment weighting (IPTW) to control for baseline covariates between groups.

RESULTS

Among the 1896 initially enrolled patients, 568 with ascites were included in the study cohort. Eighty-five (15.0%) patients underwent paracentesis. The primary tumor site was the pancreas (51.9%, n = 295), followed by the gastrointestinal tract (22.7%, n = 129). Non-adjusted median durations of survival were 22 days (95% confidence interval [CI]: 16-25) and 12 days (95% CI: 11-13) in the paracentesis and non-paracentesis groups, respectively (hazard ratio [HR]: 0.69, 95% CI: 0.54-0.88; p = 0.003). The IPTW-adjusted median survival durations were 22 (95% CI: 16-25) and 16 days (95% CI: 12-22) in the paracentesis and non-paracentesis groups, respectively (HR: 0.89, 95% CI: 0.64-1.24; p = 0.492). No serious adverse events occurred in the paracentesis group.

CONCLUSIONS

Paracentesis does not negatively affect the survival of patients with cancer and MA and can be a standard treatment in palliative care settings.

Management of drainage for malignant ascites in gynaecological cancer

BACKGROUND

Ascites is the accumulation of fluid within the abdominal cavity. Most women with advanced ovarian cancer and some women with advanced endometrial cancer need repeated drainage for ascites. Guidelines to advise those involved in the drainage of ascites are usually produced locally and are generally not evidence-based. Managing drains that improve the efficacy and quality of the procedure is key in making recommendations that could improve the quality of life (QoL) for women at this critical period of their lives.

OBJECTIVES

To evaluate the effectiveness and adverse events of different interventions for the management of malignant ascites drainage in the palliative care of women with gynaecological cancer.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase to 4 November 2019. We checked clinical trial registries, grey literature, reports of conferences, citation lists of included studies, and key textbooks for potentially relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of women with malignant ascites with gynaecological cancer. If studies also included women with non-gynaecological cancer, we planned to extract data specifically for women with gynaecological cancers or request the data from trial authors. If this was not possible, we planned to include the study only if at least 50% of participants were diagnosed with gynaecological cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data, evaluated the quality of the included studies, compared results, and assessed the certainty of the evidence using Cochrane methodology.

MAIN RESULTS

In the original 2010 review, we identified no relevant studies. This updated review included one RCT involving 245 participants that compared abdominal paracentesis and intraperitoneal infusion of catumaxomab versus abdominal paracentesis alone. The study was at high risk of bias in almost all domains. The data were not suitable for analysis. The median time to the first deterioration of QoL ranged from 19 to 26 days in participants receiving paracentesis alone compared to 47 to 49 days among participants receiving paracentesis with catumaxomab infusion (very low-certainty evidence). Adverse events were only reported among participants receiving catumaxomab infusion. The most common severe adverse events were abdominal pain and lymphopenia (157 participants; very low-certainty evidence). There were no data on the improvement of symptoms, satisfaction of participants and caregivers, and cost-effectiveness.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence to recommend the most appropriate management of drainage for malignant ascites among women with gynaecological cancer, as there was only very low-certainty evidence from one small RCT at overall high risk of bias.

Palliation of malignant ascites

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.

Patients' perspectives towards malignant ascites: results of a prospective observational trial regarding expectations, characteristics and quality of life-a study of the North-Eastern-German Society of Gynecological Oncology

PURPOSE

Malignant ascites (MA) is a frequent and common symptom in (gyneco-) oncological patients. The present trial evaluated and assessed patients' characteristics, clinical features and the possible influence of MA on QoL measurements.

METHODS

A prospective observational trial was conducted from Oct 2013 until Nov 2016. Therefore an interdisciplinary questionnaire was developed. Overall 250 patients with histological confirmed MA were included with different cancer entities (gynecological, gastrointestinal). The correlation of MA caused symptoms and QoL measurements was assessed using Kendall's tau b. Multivariable logistic regression models were applied to analyze the risks of symptoms or severe limitation in daily activities.

RESULTS

125 questionnaires could be analyzed. The majority of patients with MA had diagnosis of ovarian cancer (68.8%) and were under current cancer treatment (57.6%), mostly chemotherapy. Over 50% reported abdominal tension as major symptom, around 56% of the patients had MA when cancer was firstly diagnosed. Regression analysis showed that patients with MA above 2l were significantly more likely to be harmed in everyday activities. However, the age, gender, type of malignancy and the current treatment (chemotherapy vs. no chemotherapy) had no significant influence.

CONCLUSION

MA has a significantly impact on QoL measurements in cancer patients and might influence everyday activities including basic needs like eating, walking and body care. There is a high need for more information and education of patients with MA.

Usefulness of cell-free and concentrated ascites reinfusion therapy in the therapeutic management of advanced ovarian cancer patients with massive ascites

BACKGROUND

The management of refractory ascites in advanced ovarian cancer (AOC) is vital for patients with abdominal distention, respiratory distress, and anorexia due to massive ascites with cancer peritonitis. We analyzed the benefits of concentrated ascites reinfusion therapy (CART) in the management of AOC.

METHODS

We reviewed records of AOC patients who underwent CART between January 2011 and March 2017. We retrospectively analyzed patients' backgrounds and physiological changes, including body weight, abdominal girth, urine volume, blood component values, blood pressure, heart rate, and body temperature before and after CART. We investigated the clinicopathological significance of CART by measuring the mean number of ascites tumor cell (ATC) clusters before CART.

RESULTS

A retrospective analysis was performed on 29 cases of AOC with massive ascites involving 47 CART sessions. The patients' mean age was 56.6 ± 12.8 years, and the mean number of sessions was 1.7 ± 1.2. The mean volume of the processed ascites was 2,937 ± 820 mL, which was concentrated to 272 ± 84 mL containing 85.0 ± 33.2 g protein on average. Significant reductions in abdominal girth (- 5.30 ± 0.65 cm; p < 0.0001) and body weight (- 2.97 ± 0.26 kg; p = 0.0011), increased urine volume (+ 824.29 ± 145.21 mL; p < 0.0001), and improved serum albumin levels (+ 0.18 ± 0.34; p < 0.0001) were observed after CART. Analysis of variance revealed significant elevations in body temperature after CART in 11 patients with a small number of ATC clusters.

CONCLUSIONS

CART is useful for the therapeutic management of AOC patients with refractory massive ascites. Elevations of body temperature after CART may be avoided by the investigation of patients' peritoneal cytology before CART.

Modeling the effect of ascites-induced compression on ovarian cancer multicellular aggregates

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.

Combined antitumor effects of P-5m octapeptide and 5-fluorouracil on a murine model of H22 hepatoma ascites

The present study has demonstrated that P-5m octapeptide (P-5m) has therapeutic potential in metastatic human hepatocarcinoma, possibly through the modulation of matrix metalloproteinase-2 expression. The purpose of the present study was to evaluate the antitumor effect of P-5m combined with 5-fluorouracil (5-Fu) on the treatment of hepatoma 22 (H22) hepatocarcinoma malignant ascites in a mouse model. The inhibitory effect on the growth of mouse ascites tumors was monitored by measuring body weight gain, survival time, ascites volume, numbers of tumor cells, DNA synthesis and peritoneal capillary permeability analysis. The present data revealed a significant reduction in ascites volume and cell count in mice that were treated with P-5m plus 5-Fu. Furthermore, the median survival time in mice in the combination group was prolonged compared with the disease control group. Moreover, a significant reduction in the total H22 ascites cell count in mice from the combination group was observed when compared with the disease control group. P-5m plus 5-Fu was able to induce the cell cycle arrest and inhibit the peritoneal capillary permeability of the mice. To conclude, the present study indicated that P-5m may have therapeutic potential in ascites caused by hepatocellular carcinoma.

Polysaccharides Extracted from Rhizoma Pleionis Have Antitumor Properties In Vitro and in an H22 Mouse Hepatoma Ascites Model In Vivo

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.

Symptomatic Fluid Drainage: Tunneled Peritoneal and Pleural Catheters

Malignant ascites and pleural effusion are significant contributors to patient symptoms such as shortness of breath, abdominal distension, and nausea in the setting of cancer. There are numerous methods employed to control such symptoms such as serial drainages, pleurodesis, and tunneled drainage catheters. Tunneled drainage catheters are a safe, effective, and a minimally invasive procedure to palliate the symptoms of malignant ascites and pleural effusion.

Palliative care in ovarian carcinoma patients-a personalized approach of a team work: a review

Most ovarian cancer patients are diagnosed in an advanced stage; and after the initial treatment experience disease recurrence, which eventually becomes palliative. Many questions arise in this setting including how to address patients in the palliative setting, how to discuss end-of-life issues, and how to manage symptoms. In this review, we discuss the timing and setting of end-of-life discussion in the context of end-stage ovarian cancer. We review the approach to relieving disease burden by improving and decreasing symptoms. These symptoms include recurrent ascites, bowel obstruction, pain, pulmonary effusion, and deep vein thrombosis.

Effects of Combined Simultaneous and Sequential Endostar and Cisplatin Treatment in a Mice Model of Gastric Cancer Peritoneal Metastases

Objective. Aimed to study the effects of endostar and cisplatin using an in vivo imaging system (IVIS) in a model of peritoneal metastasis of gastric cancer. Methods. NUGC-4 gastric cancer cells transfected with luciferase gene (NUGC-4-Luc) were injected i.p. into nude mice. One week later, mice were randomly injected i.p.: group 1, cisplatin (d1-3) + endostar (d4-7); group 2, endostar (d1-4) + cisplatin (d5-7); group 3, endostar + cisplatin d1, 4, and 7; group 4, saline for two weeks. One week after the final administration, mice were sacrificed. Bioluminescent data, microvessel density (MVD), and lymphatic vessel density (LVD) were analyzed. Results. Among the four groups, there were no significant differences in the weights and in the number of cancer cell photons on days 1 and 8 (P > 0.05). On day 15, the numbers in groups 3 and 1 were less than that in group 2 (P < 0.05). On day 21, group 3 was significantly less than group 2 (P < 0.05). MVD of group 4 was less than that of groups 1 and 2 (P < 0.01). There was no significant difference between groups 2 and 3 (P > 0.05) or in LVD number among the four groups (P > 0.05). Conclusions. IVIS® was more useful than weight, volume of ascites, and number of peritoneal nodules. The simultaneous group was superior to sequential groups in killing cancer cells and inhibiting vascular endothelium. Cisplatin-endostar was superior to endostar-cisplatin in killing cancer cells, while the latter in inhibiting peritoneal vascular endothelium.

Pancreas Adenocarcinoma: Ascites, Clinical Manifestations, and Management Implications

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.

The management of malignant ascites and impact on quality of life outcomes in women with ovarian cancer

Malignant ascites is one of the most common sequela of epithelial ovarian cancer. It causes significant symptoms and can have a detrimental impact on patient quality of life, especially in women with recurrent ovarian cancer. The management of symptomatic ascites consists of both mechanical treatments that aim to drain the peritoneal cavity, and medical therapies that prevent and diminish the development of ascites. Mechanical options include serial paracentesis, peritoneal catheters, and peritoneovenous shunts. Pharmaceutical treatments include diuretics, angiogenesis inhibitors, and other targeted agents. There is a perception, without formal analysis, that intractable ascites is less common in the taxane era of therapy. In this review paper, we highlight current and emerging therapeutic strategies, complications and contraindications, and their effects on patient quality of life.

Effect of Glycyrrhiza on the Diuretic Function of Euphorbia kansui: An Ascites Mouse Model

We investigated the therapeutic role of the herbal combination Euphorbia kansui (GS) and Glycyrrhiza (GC) in ascites during hepatocellular carcinoma (HCC). The AVPR2 and AQP2 expression in kidney tissues of ascites mice in different groups was determined by immunohistochemistry, Western blot, and real-time PCR analyses. When the dose of GS was less than 0.70 g/kg at a ratio of GC : GS not exceeding 0.4 : 1, the combination of GS and GC exhibited synergistic effects on HCC ascites and significantly elevated the expression levels of AVPR2 and AQP2 (all P < 0.05). On the contrary, when GS ≥ 0.93 g/kg and GC ≥ 1.03 g/kg with the GC-to-GS ratio exceeding 1.11 : 1, the combination of GS and GC displayed antagonistic effects on HCC ascites and dramatically reduced the expression levels of AVPR2 and AQP2 (all P < 0.05). Furthermore, the administration of herbal pair GS and GC at different ratios did not exacerbate the pathological changes in liver and kidney tissues of HCC ascites mice. The different combinations of GS and GC exerted synergistic or antagonistic effects on HCC ascites, partially by regulating the expression of AVPR2 and AQP2.

Revealing the Effects of the Herbal Pair of Euphorbia kansui and Glycyrrhiza on Hepatocellular Carcinoma Ascites with Integrating Network Target Analysis and Experimental Validation

Although the herbal pair of Euphorbia kansui (GS) and Glycyrrhiza (GC) is one of the so-called "eighteen antagonistic medicaments" in Chinese medicinal literature, it is prescribed in a classic Traditional Chinese Medicine (TCM) formula Gansui-Banxia-Tang for cancerous ascites, suggesting that GS and GC may exhibit synergistic or antagonistic effects in different combination designs. Here, we modeled the effects of GS/GC combination with a target interaction network and clarified the associations between the network topologies involving the drug targets and the drug combination effects. Moreover, the "edge-betweenness" values, which is defined as the frequency with which edges are placed on the shortest paths between all pairs of modules in network, were calculated, and the ADRB1-PIK3CG interaction exhibited the greatest edge-betweenness value, suggesting its crucial role in connecting the other edges in the network. Because ADRB1 and PIK3CG were putative targets of GS and GC, respectively, and both had functional interactions with AVPR2 approved as known therapeutic target for ascites, we proposed that the ADRB1-PIK3CG-AVPR2 signal axis might be involved in the effects of the GS-GC combination on ascites. This proposal was further experimentally validated in a H22 hepatocellular carcinoma (HCC) ascites model. Collectively, this systems-level investigation integrated drug target prediction and network analysis to reveal the combination principles of the herbal pair of GS and GC. Experimental validation in an in vivo system provided convincing evidence that different combination designs of GS and GC might result in synergistic or antagonistic effects on HCC ascites that might be partially related to their regulation of the ADRB1-PIK3CG-AVPR2 signal axis.

Repeat Large-Volume Paracentesis Versus Tunneled Peritoneal Catheter Placement for Malignant Ascites: A Cost-Minimization Study

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.

Peritoneal Dissemination Requires an Sp1-Dependent CXCR4/CXCL12 Signaling Axis and Extracellular Matrix-Directed Spheroid Formation

Peritonitis carcinomatosa is an advanced and intractable state of gastrointestinal and ovarian cancer, where mechanistic elucidation might enable the development of more effective therapies. Peritoneal dissemination of this type of malignancy has been generally thought to initiate from "milky spots" of primitive lymphoid tissues in the peritoneal cavity. In this study, we offer evidence challenging this idea, based on the finding that tumor implantation and directional dissemination was not required for the presence of milky spots, but rather SCF/CXCL12-expressing niche-like cells located at the border regions of perivascular adipose tissue. Interestingly, we found that peritoneal cavity lavage fluid, which specifically contains peritoneal collagen type IV and plasma fibronectin, dramatically facilitated spheroid formation of murine and human colon cancer cells. Spheroid formation strongly induced the expression of CXCR4 in an Sp1-dependent manner to promote niche-directed metastasis. Notably, disrupting sphere formation or inhibiting Sp1 activity was sufficient to suppress tumor dissemination and potentiated chemosensitivity to 5-fluorouracil. Our findings illuminate mechanisms of peritoneal cancer dissemination and highlight the Sp1/CXCR4/CXCL12 signaling axis as a rational target for the development of therapeutics to manage this intractable form of malignancy.

Effective recovery of highly purified CD326(+) tumor cells from lavage fluid of patients treated with a novel cell-free and concentrated ascites reinfusion therapy (KM-CART)

For the production of tumor-specific vaccines, including dendritic cell (DC) vaccines, the tumor cells themselves are an ideal source. Floating tumor cells in the ascites fluid from patients with malignant ascites are a good candidate source, but it is not easy to obtain pure tumor cells from ascites because of various types of cell contamination as well as protein aggregates. We here report an effective method to recover pure tumor cells from malignant ascites. We used lavage fluid from 13 patients with malignant ascites who were treated with modified cell-free and concentrated ascites reinfusion therapy (KM-CART). Cellular components were separated from the lavage fluid by centrifugation, enzymatic digestion and hemolysis. Tumor cells were purified by depleting CD45⁺ leukocytes with antibody-conjugated magnetic beads. The tumor cell lysate was extracted by freeze-and-thaw cycles. The mean obtained total cell number was 7.50 × 10⁷ cells (range 4.40 × 10⁶–2.48 × 10⁸ cells). From this fraction, 6.39 × 10⁶ (range 3.23 × 10⁵–2.53 × 10⁷) CD45⁻ cells were collected, and the tumor cell purity was over 80 % defined as CD45⁻CD326⁺. A sufficient amount of tumor lysate, average  = 2416 μg (range 25–8743 μg), was extracted from CD45⁻CD326⁺ tumor cells. We here established an effective method to produce highly purified tumor cells from KM-CART lavage fluid. The clinical feasibility of this simple preparation method for generating tumor lysate should be examined in clinical studies of DC vaccines.

[Supportive care for malignant ascites in palliative phase: Place of paracentesis and diuretics]

Malignant ascites, occurring in advanced stages of cancer, is linked with poor prognosis and can cause invalidating symptoms. Physiopathological mechanisms of ascites formation are complex and have yet to be fully elucidated. In most cases, ascites is due to peritoneal carcinomatosis in which vascular permeability is enhanced by VEGF production while lymphatic drainage decreases. Ascites can also be secondary to portal hypertension, for example in case of multiple liver metastases, or due to lymphatic obstruction. While paracentesis and diuretics are commonly used, their efficiency has never been compared in a randomized controlled study. Paracentesis brings immediate but temporary relief in over 90% of cases, and implies multiple hospitalizations. Literature reports ascites control by aldosterone alone or in association with furosemide. But, available data is controversial, and there is no predictive factor to identify patients that respond to diuretic treatment. The indication of diuretic treatment is left to the appreciation of physicians. Existing recommendations are old, and practices influenced by results obtained in non-neoplastic ascites. Additional evidences are required before guidelines can be established for the palliative management of malignant ascites.

Macrophage Blockade Using CSF1R Inhibitors Reverses the Vascular Leakage Underlying Malignant Ascites in Late-Stage Epithelial Ovarian Cancer

Malignant ascites is a common complication in the late stages of epithelial ovarian cancer (EOC) that greatly diminishes the quality of life of patients. Malignant ascites is a known consequence of vascular dysfunction, but current approved treatments are not effective in preventing fluid accumulation. In this study, we investigated an alternative strategy of targeting macrophage functions to reverse the vascular pathology of malignant ascites using fluid from human patients and an immunocompetent murine model (ID8) of EOC that mirrors human disease by developing progressive vascular disorganization and leakiness culminating in massive ascites. We demonstrate that the macrophage content in ascites fluid from human patients and the ID8 model directly correlates with vascular permeability. To further substantiate macrophages' role in the pathogenesis of malignant ascites, we blocked macrophage function in ID8 mice using a colony-stimulating factor 1 receptor kinase inhibitor (GW2580). Administration of GW2580 in the late stages of disease resulted in reduced infiltration of protumorigenic (M2) macrophages and dramatically decreased ascites volume. Moreover, the disorganized peritoneal vasculature became normalized and sera from GW2580-treated ascites protected against endothelial permeability. Therefore, our findings suggest that macrophage-targeted treatment may be a promising strategy toward a safe and effective means to control malignant ascites of EOC.

The anthelmintic drug mebendazole inhibits growth, migration and invasion in gastric cancer cell model

The present study aimed to investigate the effects of MBZ on a human malignant ascites cell line derived from a primary gastric cancer tumor. Our data reveal that MBZ showed high cytotoxicity in vitro, displaying an IC50 of 0.39 μM and 1.25 μM in ACP-02 and ACP-03, respectively. The association between MBZ and 5-FU increased slightly the cytotoxicity when compared to MBZ and 5-FU alone. Furthermore, MBZ disrupted the microtubule structure of AGP-01 cells and inhibited significantly the invasion and migration of these cells. Activity of active MMP-2 significantly decreased at all tested concentration of MBZ compared to negative control. These results support the indication of MBZ in combination with chemotherapeutic agents as a possible adjuvant therapy for the management/treatment of patients with advanced gastric cancer since MBZ is a drug of low cost with acceptable safety profile and reduced toxicity to normal cells. However, clinical trials must be performed in o to evaluate its efficacy in gastric cancer patients.

Differential expression of vascular endothelial growth factor-A, -C and -D for the diagnosis and prognosis of cancer patients with malignant effusions

Elevated levels of vascular endothelial growth factor (VEGF) contribute to angiogenesis and serous cavity effusions. The present study evaluated the diagnostic and prognostic values of VEGF-A, -C and -D proteins in the serum, supernatant fluid and exfoliated cells of cancer patients with malignant effusions compared with patients with benign effusions. An enzyme-linked immunosorbent assay was used to detect levels of VEGF-A, -C and -D proteins in the sera of 79 cases (30 lung cancer, 21 gastric cancer and 28 benign effusions) and the supernatant fluid of 96 cases (38 lung cancer, 30 gastric cancer, and 28 benign effusion). Immunocytochemistry detected the expression of VEGF-A, -C and -D proteins in effusion cells from 71 cases (34 lung cancer, 17 gastric cancer and 20 benign effusions). The data were further investigated to determine whether there was an association between VEGF subtype expression and clinicopathological characteristics and prognosis. The expression levels of VEGF-A in the supernatant fluid were increased in the lung and gastric cancer patient samples compared with the benign effusions (P<0.05). The VEGF-A level in the supernatant fluid was significantly increased compared with the corresponding sera of patients with malignant effusion (P<0.05). VEGF-A, -C and -D proteins in the exfoliated cells from primary lung or gastric cancer effusions were expressed at 52.94, 70.58 and 82.35%, respectively, whereas their expression was not detected in the exfoliated cells from benign effusion, with the exception of mesothelial cells. The levels of VEGF-A and VEGF-C in the supernatant fluid levels and the cell levels of VEGF-A were inversely associated with age; in addition, VEGF-A levels in the supernatant fluid were associated with malignant and bloody effusion, and only cavity metastasis (P<0.05). Survival analysis demonstrated a relatively reduced survival time for patients with VEGF-A levels of >406.19 pg/ml in the supernatant fluid compared with patients with VEGF-A levels of ≤406.19 pg/ml (P=0.066). Serum VEGF-A, -C and -D levels exhibited no evident clinical significance in the diagnosis and prognosis of serous cavity effusions. VEGF-A in the supernatant fluid merits further study as a tumor marker in the clinical setting to discriminate benign from malignant effusions, while cellular VEGF-C and -D may contribute to the formation of malignant effusions.

Endostar inhibits ascites formation and prolongs survival in mouse models of malignant ascites

Endostar, a modified recombinant human endostatin, inhibits the growth of a variety of tumors by suppressing neovascularization. Vascular endothelial growth factor (VEGF) has an important role in malignant ascites formation. In order to determine whether Endostar can suppress the formation of ascites and prolong survival times, mouse models of malignant ascites were established using S180 and H22 tumor cells. The experimental mice were randomly divided into four groups: The three treatment groups received different doses of Endostar (4, 8 and 16 mg/kg), and the control group received 0.9% w/v NaCl. The volume of ascites, and the tumor cell, red blood cell (RBC), VEGF protein and mRNA content of the ascites was measured alongside the peritoneal permeability and the mouse survival time. In vitro analysis of cultured Endostar-treated S180 and H22 cells was also performed in order to examine cellular proliferation and the level of VEGF secreted protein and mRNA. The results revealed that Endostar suppressed the ascites volume, decreased the level of tumor cells, RBCs and VEGF in the ascites fluid, and lowered the permeability of the peritoneum. The tumor cells collected from the ascites in the Endostar-treated mice demonstrated a decrease in the expression of VEGF mRNA. The survival rates of the 8 and 16 mg/kg Endostar-treated mice were longer than those of the controls. The in vitro experiments revealed a significant inhibition of VEGF protein secretion and VEGF mRNA by Endostar, but no effect on cellular proliferation. In conclusion, Endostar lowers ascites production by downregulating VEGF expression, and may therefore be effective for the treatment of malignant ascites.

Management of malignancy-related ascites

A 65-year-old Polish immigrant named T. J. was diagnosed with metastatic colon cancer in January 2012 when he presented with obstructing sigmoid colon cancer and liver metastases. A diverting colostomy as well as biopsy of his liver metastases was performed and chemotherapy with FOLFOX (5-fluorouracil [5-FU], leucovorin, oxaliplatin) and bevacizumab was initiated. After three months, he transitioned to maintenance therapy with infusional 5-FU and bevacizumab until he progressed in August 2012. Oxaliplatin was reintroduced and he responded until he developed progressive neuropathy in November and his therapy was changed to FOLFIRI (5-FU, leucovorin, irinotecan) and bevacizumab. T. J. developed liver progression after three months and, because he was Kras wild type, irinotecan and panitumumab were initiated. Liver-directed therapy also was pursued and he underwent radioembolization with yittrium-90 followed by chemoembolization with irinotecan-eluded beads. At the time of these procedures, T. J.'s portal and hepatic venous systems were patent (i.e., no thrombosis or obstruction causing portal hypertension).

A survey of treatment approaches of malignant ascites in Germany and Austria

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.

Re-challenge with catumaxomab in patients with malignant ascites: results from the SECIMAS study

Malignant ascites is a common phenomenon in cancer patients. It poses a great challenge to the clinician, because of limited treatment options and strong impairment of the quality of life of the often palliative patients. The SECIMAS study investigated the feasibility of a re-challenge with four catumaxomab intraperitoneal infusions in patients who had already received a first cycle of four infusions in the phase III CASIMAS study, which compared catumaxomab with and without prednisolone premedication. The primary endpoint was the proportion of patients who received at least three catumaxomab infusions. Secondary endpoints included a composite safety score (CSS) summarising the worst grades for the main catumaxomab-related adverse events (pyrexia, nausea, vomiting and abdominal pain), safety, efficacy and the occurrence of anti-drug antibodies (ADAs). Eight of nine screened patients received a second catumaxomab cycle. Compliance with a catumaxomab re-challenge was high: all eight patients (100%) received all four infusions. The median CSS was 3.0 versus 3.4 in CASIMAS. The tolerability profile of the second catumaxomab cycle was comparable to that of the first cycle. Median puncture-free survival (48 days) and overall survival (407 days) were longer than in CASIMAS (35 and 103 days, respectively), although median time to next puncture was shorter (60 vs. 97 days). Of six patients sampled, all were ADA positive at screening and remained ADA positive until the end of the study. The presence of ADAs did not affect catumaxomab's safety or efficacy. The CSS and tolerability profile for catumaxomab in SECIMAS were comparable to those in CASIMAS. The majority of patients benefitted from a second cycle of catumaxomab. A re-challenge seems to be feasible and safe for selected patients with recurrent malignant ascites due to carcinoma after a first cycle of catumaxomab.

Safety of repeated cell-free and concentrated ascites reinfusion therapy for malignant ascites from gastrointestinal cancer

Malignant ascites due to peritoneal metastasis is one of the major problems caused by advanced gastrointestinal cancer. Although drainage of a large amount of ascitic fluid improves symptoms such as abdominal fullness, it may lead to protein loss and renal dysfunction. Cell-free and concentrated ascites reinfusion therapy (CART) may help avoid such complications due to paracentesis. The purpose of this study was to evaluate the safety of CART. We performed a total of 51 sessions of CART in 5 patients, 4 of whom had gastric cancer and 1 appendiceal cancer. We retrospectively evaluated laboratory data immediately prior to CART, on the following day, 1 week later and 2 weeks later. We also measured the amount of total protein and albumin in collected and concentrated ascites. The mean amount of collected ascites was 4,007 ml. All the patients exhibited improvement of symptoms such as abdominal fullness. Four patients developed fever (>38°C) immediately after reinfusion of the concentrated ascites and 3 of these patients required corticosteroid administration. The mean total protein and albumin in the collected ascites were 122 and 64 g, respectively, and those in the concentrated ascites 75 and 39 g, respectively. The serum levels of total protein, albumin and creatinine after CART were almost identical to those prior to CART. Blood hemoglobin concentration was significantly decreased 1 day after CART and returned to baseline levels in 1-2 weeks. CART does not cause renal dysfunction and does not decrease serum albumin; therefore, repeated CART is safe and may be used to improve the symptoms of malignant ascites from gastrointestinal cancer.

Colorectal cancer emergencies

INTRODUCTION

Colorectal cancer (CRC) is a common type of malignancy encountered in the United States. A significant proportion of patients with CRC will seek emergency medical care during the course of their illness and treatment.

BACKGROUND

Emergent presentations can be the result of either local tumor invasion, regional progression, or therapeutic techniques. Specific complications of CRC which present emergently include rectal bleeding, abdominal pain, and bowel obstruction. Less common issues encountered include malignant ascites, neutropenic enterocolitis, and radiation enteropathy.

CONCLUSION

The care of CRC patients in the setting of an acute severe illness typically requires the joint efforts of the emergency medical team in consultation with surgical, medical, and radiation oncology. A high degree of suspicion for the typical and atypical complications of CRC is important for all clinicians who are responsible for the care of these patients.

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.

Catumaxomab: in malignant ascites

Catumaxomab is a rat/murine hybrid, trifunctional, bispecific (anti-human epithelial cell adhesion molecule [EpCAM] × anti-CD3) monoclonal antibody. Compared with paracentesis alone, paracentesis followed by catumaxomab therapy was associated with significant prolongation of paracentesis-free survival and time to repeat paracentesis in a randomized, open-label, multicentre, pivotal phase II/III trial in patients with recurrent symptomatic malignant ascites due to EpCAM-positive tumours who were resistant to conventional chemotherapy. The benefits of catumaxomab were seen across a broad range of epithelial ovarian and nonovarian cancers, and irrespective of whether or not catumaxomab recipients developed human anti-mouse antibodies. Combining catumaxomab with paracentesis also resulted in more pronounced and prolonged reductions in ascites signs and symptoms and a delayed deterioration in health-related quality of life compared with paracentesis alone. Despite the study not being designed or powered to evaluate overall survival, significant differences favouring the addition of catumaxomab to paracentesis were seen in analyses of the safety population and the subpopulation of patients with gastric cancer. Catumaxomab was generally well tolerated in the pivotal phase II/III trial. The most frequent adverse events attributed to catumaxomab treatment included cytokine-release-related symptoms, which were mostly of mild to moderate severity and manageable with standard symptomatic treatment.

Oxidative dna damage of lymphocytes in peripheral blood and ascites in cancer patients

BACKGROUND

Patients with malignant ascites (ma) usually experience poor quality of life, and treatment of this symptom remains a challenge. Oxidative stress, which can cause oxidative damage to dna, plays a pivotal role in carcinogenesis; however, the relationship between oxidative stress and dna damage to tumour-associated lymphocytes (tals) in ma is unclear.

METHODS

We measured the total antioxidant capacity (tac) of plasma and ma supernatant in 31 cancer patients with ma, and we used a comet assay to assess dna damage to both peripheral blood mononuclear cells (pbmcs) and tals. Measurements in age- and sex-matched healthy volunteers were used as controls.

RESULTS

The tac of plasma was remarkably lower in cancer patients (9.73 ± 1.96 U/mL) than in healthy control subjects (11.31 ± 1.50 U/mL, p < 0.001). The tac of ma supernatant (6.34 ± 1.57 U/mL) was significantly lower than that of plasma in cancer patients (7.42 ± 1.36 U/mL, p < 0.001). The comet percentage of pbmcs was higher in cancer patients (17.26% ± 6.04%) than in healthy control subjects (9.44% ± 4.47%, p < 0.01). In cancer patients, the comet percentage of tals (36.14% ± 17.85%) was significantly higher than that of pbmcs (17.26% ± 6.04%, p < 0.001). In cancer patients with ma, negative correlations were observed between plasma tac and dna damage to pbmcs (r = -0.505, p = 0.004) and between the tac of ma supernatant and the comet percentage of tals (r = -0.588, p = 0.001).

CONCLUSIONS

Results indicate the presence of significant oxidative damage to the dna of lymphocytes in peripheral blood and ascites from patients with ma, being especially higher in the cells from ascites. The lower tac of ma supernatant may be related to a higher degree of dna damage to tals. The present study suggests that an oxidant-antioxidant imbalance may be one of the mechanisms leading to the dna damage detected in peripheral blood and local tals in patients with ma, which may provide a novel approach to the treatment of ma.

The role of laparoscopy in peritoneal surface malignancies selected for hyperthermic intraperitoneal chemotherapy (HIPEC)

BACKGROUND

Cytoreductive surgery (CS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) was developed as locoregional treatment for primary or secondary peritoneal tumors. The role of laparoscopy over several stages of diagnosis and the treatment of the patients affected by peritoneal carcinomatosis and selected for CS + HIPEC shows some peculiarities, and their potential application in this field is not fully known. Our aim was to review and summarize the applications, the results, and the future directions of laparoscopy in the management of the patients affected by carcinomatosis and scheduled for CS + HIPEC.

METHODS

Appropriate keywords were adopted to identify the relevant studies on this topic in PubMed/Medline electronic databases.

RESULTS

The role of laparoscopy in diagnosis and staging of patients selected for CS + HIPEC seems to have a great but probably underestimated potential. Laparoscopic CS + HIPEC is technically feasible with an acceptable morbidity profile, especially in patients with low tumor load. In selected patients with malignant ascites, laparoscopic HIPEC achieves a good palliative effect, with a low morbidity profile.

CONCLUSIONS

Laparoscopy plays a partially explored role in diagnosis and staging of patients selected for CS + HIPEC. The use of laparoscopic HIPEC with an adjuvant, curative, or palliative intent seems feasible, but further studies are required in order to explore and validate all potential indications. For all these reasons, it would be advisable to provide every HIPEC center with specific laparoscopic skills.

A myriad of symptoms: new approaches to optimizing palliative care of patients with advanced pancreatic cancer

Patients with advanced pancreatic cancer (APC) require early and frequent palliative interventions to achieve optimal quality of life for the duration of illness. Evidence-based supportive treatments exist to maximize quality of life for any patient, whether receiving chemotherapy or not. This article provides a comprehensive review of symptoms with current treatment recommendations and directions for future development. Celiac plexus neurolysis improves pain in the majority of patients with APC and should be moved earlier in the analgesic paradigm. Malignant bowel obstruction can be palliated quickly with optimal management via gastric decompression, octreotide, parenteral opioids, and standing antiemetics. Recommendations are provided for best treatment of malignant gastroparesis, gastric outlet obstruction, and chemotherapy-induced nausea and vomiting in this population. Malignant ascites can be treated initially with diuretics and sodium-restriction in patients with an exudative process; however, an indwelling catheter is recommended for patients with recurrent ascites, particularly because of carcinomatosis or a refractory process. With exocrine insufficiency contributing to weight loss, pancreatic enzyme replacement is essential to improve nourishment in the majority of patients. Presently, megestrol acetate is the only U.S. Food and Drug Administration (FDA)-approved therapy for the anorexia-cachexia syndrome, although future developments are promising. Finally, patients with advanced pancreatic cancer should be screened and treated early for depression as a common comorbid diagnosis. Early palliative care consultation also helps address the existential and psychosocial concerns of patients facing death from pancreatic cancer in a holistic manner.

[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.

Antagonism of VEGF by genetically engineered dendritic cells is essential to induce antitumor immunity against malignant ascites

Malignant ascitis (MA) is a highly intractable and immunotherapy-resistant state of advanced gastrointestinal and ovarian cancers. Using a murine model of MA with CT26 colon cancer cells, we here determined that the imbalance between the VEGF-A/vascular permeability factor and its decoy receptor, soluble fms-like tryrosine kinase receptor-1 (sFLT-1), was a major cause of MA resistance to dendritic cell (DC)-based immunotherapy. We found that the ratio of VEGF-A/sFLT-1 was increased not only in murine but also in human MA, and F-gene-deleted recombinant Sendai virus (rSeV/dF)-mediated secretion of human sFLT-1 by DCs augmented not only the activity of DCs themselves, but also dramatically improved the survival of tumor-bearing animals associated with enhanced CTL activity and its infiltration to peritoneal tumors. These findings were not seen in immunodeficient mice, indicating that a VEGF-A/sFLT-1 imbalance is critical for determining the antitumor immune response by DC-vaccination therapy against MA.

[Permanent tunneled drainage for malignant ascites: initial experience with the PleurX® catheter]

OBJECTIVE

The most common treatment in recurrent malignant ascites is generally temporary peritoneal drainage. We present our experience in placing permanent tunneled catheters in a series of patients and analyze the safety and efficacy of the treatment.

MATERIAL AND METHODS

We used total aseptic measures in the interventional ultrasonography suite to place permanent tunneled catheters in 10 patients under ultrasonographic guidance and local anesthesia.

RESULTS

The catheters remained patent for a median of 52 days in the nine patients who died. In one of these, the catheter was withdrawn while still patent due to generalized sepsis. At the end of the study, one patient still had a permeable catheter 124 days after placement.

CONCLUSION

Although the low number of patients in our series precludes generalizations, tunneled peritoneal catheters seem to be a safe and effective minimally invasive treatment for malignant ascites in terminal oncologic patients. This approach facilitates the draining of the ascites at home, obviating the need for repeated hospital visits and punctures and the risks involved therein. Nevertheless, further experience and prospective randomized trials are necessary.

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.