The development of clinical guidelines on paracentesis for ascites related to malignancy

Chronological Course and Clinical Features after Denver Peritoneovenous Shunt Placement in Decompensated Liver Cirrhosis

BACKGROUND

Refractory ascites affects the prognosis and quality of life in patients with liver cirrhosis. Peritoneovenous shunt (PVS) is a treatment procedure of palliative interventional radiology for refractory ascites. Although it is reportedly associated with serious complications (e.g., heart failure, thrombotic disease), the clinical course of PVS has not been thoroughly evaluated.

OBJECTIVES

To evaluate the relationship between chronological course and complications after PVS for refractory ascites in liver cirrhosis patients.

MATERIALS AND METHODS

This was a retrospective study of 14 patients with refractory ascites associated with decompensated cirrhosis who underwent PVS placement between June 2011 and June 2023. The clinical characteristics, changes in cardiothoracic ratio (CTR), and laboratory data (i.e., brain natriuretic peptide (BNP), D-dimer, platelet) were evaluated. Follow-up CT images in eight patients were also evaluated for ascites and complications.

RESULTS

No serious complication associated with the procedure occurred in any case. Transient increases in BNP and D-dimer levels, decreased platelet counts, and the worsening of CTR were observed in the 2 days after PVS; however, they were improved in 7 days in all cases except one. In the follow-up CT, the amount of ascites decreased in all patients, but one patient with a continuous increase in D-dimer 2 and 7 days after PVS had thrombotic disease (renal and splenic infarction). The mean PVS patency was 345.4 days, and the median survival after PVS placement was 474.4 days.

CONCLUSIONS

PVS placement for refractory ascites is a technically feasible palliative therapy. The combined evaluation of chronological changes in BNP, D-dimer, platelet count and CTR, and follow-up CT images may be useful for the early prediction of the efficacy and complications of PVS.

Hemodynamic Variability During Drainage of Large Volumes of Malignant Ascites in Patients With Cancer

This study compared the variability in mean arterial pressure (MAP) during drainage of ascites in patients with cancer who underwent drainage of a large (5-10 L) or small (<5 L) volume of ascites. We prospectively enrolled 50 patients scheduled for cell-free and concentrated ascites reinfusion therapy. Equivalence was considered to be established if the 95% confidence interval (95% CI) for the highest variability rate of MAP was within ±20%. The median volume of ascites removed was 3.30 L (95% CI [2.84, 4.40]) in the small-drainage-volume group (n = 15) and 6.75 L (95% CI [6.40, 7.30]) in the large-drainage-volume group (n = 34). The 95% CIs for the highest variability rates in MAP ranged from -19.60 to -6.23 and from -19.16 to -12.95 (p = .594), respectively, indicating equivalence. These findings indicate that variability in MAP during drainage of ascites is not dependent on drainage volume.

The Impact of ASCITIC Paracentesis on Symptomatic Outcomes in Palliative Patients: 3-Year Experience of a Melbourne Inpatient Palliative Care Unit Using Palliative Care Outcomes Collaboration Assessments

Background. Ascites formation is a common occurrence in patients receiving palliative care. This is associated with symptoms that may respond to drainage. Aim. To review and quantify ascites-related symptoms pre- and post-paracentesis to evaluate its benefit in an inpatient palliative care setting. Methods. A retrospective audit of patients admitted to an inpatient palliative care unit who underwent paracentesis between November 2016 to June 2020 was performed. The primary outcome was a symptomatic benefit of paracentesis. Secondary outcomes assessed the associated complications as well as the alterations to functional status. Data were analysed using a paired T-test. Results. 43 instances of ascitic paracentesis were performed on a total of 26 patients. Three patients were excluded from the study due to the technical failure of their paracentesis procedure. There was a mean 0.16-point reduction in pain (95% confidence interval (CI) −0.33 to 0.65), a mean 0.03-point increase in dyspnoea (95% CI −0.51 to 0.46), and a mean 0.32-point reduction in nausea (95% CI −0.09 to 0.74). Conclusions. Ascitic paracentesis in the palliative setting may demonstrate some benefit in managing symptoms associated with ascites. Although the findings of this study did not achieve statistical significance, these results may be substantiated by future studies with larger sample size.

Long-Term Peritoneal Indwelling Catheters for Malignant Ascites: A Retrospective Case Series of PleurX and Peritoneal Port

Objectives: To compare outcomes of PleurX and peritoneal port for malignant ascites. Design: Retrospective review of medical records was conducted. Setting/Subjects: Subjects were consecutive patients receiving PleurX or peritoneal port for malignant ascites in a center in Sydney, Australia. Measurements: Demographic data, complication rates, hospitalization rates, and survival were measured. Results: Sixteen cases were analyzed: 6 had peritoneal port (170 catheter days) and 10 had PleurX (477 catheter days). Complication rates were low with both drainage systems. Cellulitis rate was 33% (1.2 events/100 catheter days) for peritoneal port and 10% (0.2 events/100 catheter days) for PleurX. Hospital admission days were 27 days/100 catheter days for peritoneal port and 5.2 days/100 catheter days for PleurX. Conclusions: Both PleurX and peritoneal port seem feasible options in draining malignant ascites. Further research is needed to ascertain whether there are true differences in cellulitis/admission rates. Patient quality of life, experience, and preference should be included in future studies.

Optimal Paracentesis Volume for Terminally Ill Cancer Patients With Ascites

CONTEXT

Patients with malignant ascites often suffer from distressing symptoms, especially in their end-of-life stage. Although paracentesis is the most common treatment modality to alleviate such symptoms, the optimal volume of paracentesis is not known.

OBJECTIVES

To explore the efficacy and safety of paracentesis by the drainage volume for terminally ill cancer patients with malignant ascites.

METHODS

This was part of a multicenter prospective observational study (EASED study). Consecutive adult patients with advanced cancer admitted to 23 participating palliative care units were eligible. We analyzed patients with malignant ascites who received paracentesis. We compared paracentesis-free survival (PFS) using Cox regression among three groups with different paracentesis volumes: minimum: ≤ 1500 mL, small: 1500-2500 mL, and moderate: > 2500 mL. Trends of the difference in the numerical rating scale of abdominal distension (0-10) and adverse events were compared among the 3 groups.

RESULTS

Of the 1926 patients enrolled, 673 developed ascites (symptomatic, n = 374 and asymptomatic, n = 299). Finally, we analyzed 87 patients with paracentesis. Median PFS was 7 days. Compared with a moderate volume, small-volume paracentesis was not a significant risk for shorter PFS (HR: 1.14, 95% CI: 0.69-1.93), while a minimum volume was a significant risk (HR: 2.34). The abdominal distension intensity significantly decreased after paracentesis (median: 7.5 to 4.0), while the difference did not significantly increase as the volume of paracentesis rose (P = 0.61). No severe adverse event was observed.

CONCLUSION

Even small-volume paracentesis could alleviate abdominal distension of terminally ill cancer patients with malignant ascites without shortening the paracentesis interval compared with moderate-volume paracentesis. Small-volume paracentesis was a well-balanced treatment for these patients.

Quality of life assessment of cell-free and concentrated ascites reinfusion therapy during initial treatment for advanced ovarian cancer: A prospective cohort study

AIM

Cell-free and concentrated ascites reinfusion therapy (CART) is applied to relieve symptoms in patients with malignant ascites. We performed a prospective cohort study to evaluate the efficacy and safety of CART performed on patients with advanced ovarian and peritoneal cancers with massive ascites during the initial treatment.

METHODS

From April 2018 to July 2020, CART was performed during the initial treatment of 31 patients with advanced ovarian and peritoneal cancers with cancerous ascites. Patient characteristics and clinical information before and after CART were collected. We performed quality of life assessment using the Japanese version of the M.D. Anderson Symptom Inventory (MDASI-J) 24 h before and after CART.

RESULTS

CART was performed 38 times in 24 patients before or during neoadjuvant chemotherapy and 11 times in 11 patients prior to surgery. Four patients underwent CART before primary surgery and before and/or during chemotherapy. Grade 1-2 fever was observed in 18 of 31 cases (58%), and all were controllable by nonsteroidal anti-inflammatory drugs. CART did not adversely affect the main treatment, chemotherapy, or surgery. CART significantly improved the MDASI-J symptom and interference scores within 24 h after the procedure. The symptom and interference scores decreased from 2.4 to 1.8 and from 4.8 to 3.0, respectively.

CONCLUSIONS

CART can be safely performed and is useful for symptom relief and improvement of general condition prior to initial surgery and during initial chemotherapy in ovarian and peritoneal cancers. Performing CART at the time of initial treatment may facilitate initiation of the main treatment.

Symptom Management in Pancreatic Cancer

OPINION STATEMENT

Despite extensive research that has identified new risk factors, genetic mutations, and therapeutic options, pancreatic ductal adenocarcinoma continues to be a leading cause of cancer related death. Patients with pancreatic cancer, along with their clinicians, must balance realistic hope alongside a life-threatening diagnosis. As the search for treatments to reduce the morbidity and mortality continues, symptom management and quality of life remain the focus of our efforts. In addition to side effects of cancer-directed therapy, patients are at risk for malnutrition, pain, and fatigue. These factors are often overlooked in practice, so a multidisciplinary team is critical in optimizing the care of patients.

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.

Abdominal paracentesis: use of a standardised procedure checklist and equipment kit improves procedural quality and reduces complications

BACKGROUND

Paracentesis is a common invasive procedure performed by junior doctors. Audit of procedure conduct at two New Zealand hospitals in 2012 revealed poor performance across a range of quality measures, including documentation of informed consent, excessive catheter dwell times and inappropriate albumin prescription. Complication rates were 12.7%, compared with published rates of around 9%. A local procedure protocol did not exist.

AIM

To evaluate the effect of a standardised procedure checklist (PC) and equipment kit (EK) on procedural quality and complication rates for abdominal paracentesis.

METHODS

After presenting the 2012 audit results to resident doctors, we reviewed the paracentesis literature and developed a local procedure protocol (PC and EK). These tools were made readily available after an education campaign. Paracenteses performed after the intervention were studied to determine the impact on procedural quality and safety.

RESULTS

Seventy-four paracenteses (14 diagnostic; 60 therapeutic) were performed in 10 months after the introduction of PC and EK. Significant improvements were observed with the use of PC including documentation of informed consent (97% vs 74%, P = <0.01) and aseptic technique (100% vs 62%, P = <0.01). Catheter dwell times <6 h improved (72% vs 48%, P = 0.02). Inappropriate albumin prescriptions were less frequent (21% vs 66%, P = <0.01). Complication rates decreased from 12.7% to 2.8% (P = <0.01).

CONCLUSIONS

The PC and EK improved rates of informed consent, appropriate documentation and protocol adherence. Significantly fewer procedure-related complications occurred after introduction of these tools.

CART: Cell-free and Concentrated Ascites Reinfusion Therapy against malignancy-related ascites

A standard strategy against ascites, a common symptom observed in cirrhotic and cancer patients, includes restriction of sodium intake and use of a diuretic. Paracentesis is a widely applied method against refractory ascites that do not react to such treatment. However, emerging fatigue and hemodynamic instability are possibly attributable to a loss of protein included in ascites. Cell-free and Concentrated Ascites Reinfusion Therapy (CART) is also applied against refractory ascites. CART comprises three processes. After ascites is first filtered to remove cell components, it is concentrated to reduce its volume. Fluid obtained through these processes, including useful proteins such as albumin and globulin, is finally reinfused intravenously. CART was reported first in the 1970s. Since then, it has been applied mainly against cirrhotic ascites with a thinner cell component. Now, its indication is expanding to include malignancy-related ascites. Additionally, CART can be applied safely against malignancy-related ascites. Its favorable effects on control of patients' symptoms are anticipated, especially on fatigue. Although related evidence has not been established, CART can be anticipated for use as a strategy against refractory ascites.

Characteristics of Patients and Their Ascites Who Underwent Repeated Cell-Free and Concentrated Ascites Reinfusion Therapy

Novel cell-free and concentrated ascites reinfusion therapy (KM-CART) is easy to use, safe and applicable for refractory ascites. We can get the full amount of ascites, filtrate, and concentrate in a short time. KM-CART can be applied as palliative care for dying patients including patients with massive malignant ascites. Some patients who underwent repeated KM-CART survived longer than those who did not repeat the therapy. The aim of this study was to identify the type of patients with ascites for whom KM-CART would be effective and candidates for repeated KM-CART. In this retrospective cohort observational study, we examined 123 CART processes performed on 58 patients with refractory ascites. Data were collected before and after processing of the ascites. We compared two groups; patients who underwent KM-CART ≥ 5 times and those who underwent this process ≤ 4 times. Age, disease, benign or malignant status of the disease, the amount of ascites, concentrations of total protein (TP) and albumin (Alb) and their amounts in the original ascites and the filtered and concentrated ascitic fluid and the recovery ratio of TP and Alb were determined. No significant difference was observed between the two groups in age, disease, amount of ascites, and the recovery ratio of TP and Alb. Significant differences were observed in the amounts of TP and Alb in the original ascites and the filtered and concentrated ascitic fluid. Patients who underwent KM-CART ≥ 5 times had higher Alb levels in the original ascites than those who underwent this therapy ≤ 4 times. Patients with higher Alb concentrations in the original ascites could be candidates for repeated KM-CART.

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

Backgrounds

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

Methods

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

Results

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

Conclusions

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

Patient experience of non-malignant ascites and its treatment: a qualitative study

BACKGROUND

Ascites is an accumulation of serous fluid in the abdominal cavity. It can be caused by both malignant and non-malignant conditions and produces distressing symptoms. There have been no qualitative studies looking at the experiences of patients with non-malignant ascites.

AIMS

To explore the experiences of patients living with non-malignant ascites and its management. Also, to explore the views of these patients about services available to them.

METHOD

Phenomenological qualitative research study using digitally recorded semi-structured interviews.

SETTING AND PARTICIPANTS

Six adult patients with non-malignant ascites who were receiving paracentesis to manage their symptoms in an acute hospital day unit.

RESULTS

Participants experienced a wide variety of physical symptoms. They discussed how the ascites impacted on their social lives. They had views on diuretics, low sodium diet and paracentesis as methods of symptom management. Participants' confidence in staff performing paracentesis was a common finding, particularly as ultrasound was rarely used. While only some were suitable for liver transplant, all discussed their future care needs.

CONCLUSION

Participants' experiences of non-malignant ascites are that it has a considerable effect on their quality of life. Patients like the system of day case admission for drainage, but question whether this is sustainable. Advanced practitioners can successfully provide a paracentesis service for these patients in hospitals and potentially this is transferable to hospices. Patients seemed happy to consider the option of semi-permanent drains and pumps as methods of managing ascites.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS FOR PRACTICE

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

The experiences of patients with ascites secondary to cancer: a qualitative study

BACKGROUND

Ascites secondary to cancer has a dramatic effect on all aspects of patients' lives. Healthcare professional surveys have shown that there is considerable variation in the management of ascites.

AIM

To explore patients' experiences of living with ascites and its management.

DESIGN

Qualitative research study using digitally recorded semi-structured interviews.

SETTING/PARTICIPANTS

Twelve adult patients with ascites who, between them, had undergone 47 paracentesis procedures in hospitals and/or specialist palliative care units in Southern England.

RESULTS

Symptoms were pain, discomfort and effects on appetite, digestion, breathing and mobility. All participants had experienced paracentesis in hospital or a specialist palliative care unit, and these experiences differed. They had views on what constituted a good procedure: setting, competence and pain control. They reported rapid improvement of symptoms after paracentesis. While some did not like the idea of a semi-permanent drain, those with them appreciated the convenience and not having to wait for repeated admissions or the recurrence of symptoms. The interval between ascitic taps was seen as a useful guide as to when a semi-permanent drain should be offered. Participants had mixed views on participation in a hypothetical randomised controlled trial of repeated ascitic taps versus semi-permanent drains.

CONCLUSION

Patients' experiences of ascites management are variable and could be improved. These experiences can inform healthcare professionals. They have views on when semi-permanent drains should be offered and future research.

Single center experience of cell-free and concentrated ascites reinfusion therapy in malignancy related ascites

Cell-Free and Concentrated Ascites Reinfusion Therapy (CART) is expected to improve patients' symptoms related to ascites. Use of a patient's own proteins in ascites might reduce the risk of infection. However, several reports have described that reinfusion of concentrated ascites might elevate body temperature. The aim of this study is to examine the safety and efficacy of the CART system performed exclusively on patients with malignancies. In this retrospective cohort observational study, we examined 81 CART processes performed on 24 patients with malignancies. Data were collected from medical records and records during processing of ascites. We investigated the effectiveness and adverse events during the procedures. The amount of ascites processed was 2.6 ± 1.4 L on average. The concentration ratio was 9.31 ± 5.45 on average. We found an increase in the urine volume after the procedure, which was significantly related to the amount of reinfused protein. The body temperature increased by 0.44°C. Systolic blood pressure decreased by 4 mm Hg after paracentesis, but no significant difference was found between the pressure before paracentesis and after reinfusion. In platelet counts, no significant change was observed. After all, no clinically significant adverse event was confirmed during CART procedures. Results show that CART can be performed safely even on patients with malignancy-related ascites and that the procedure might improve diuresis.

Safety, cost-effectiveness and feasibility of daycase paracentesis in the management of malignant ascites with a focus on ovarian cancer

BACKGROUND

Paracentesis for malignant ascites is usually performed as an in-patient procedure, with a median length of stay (LoS) of 3-5 days, with intermittent clamping of the drain due to a perceived risk of hypotension. In this study, we assessed the safety of free drainage and the feasibility and cost-effectiveness of daycase paracentesis.

METHOD

Ovarian cancer admissions at Hammersmith Hospital between July and October 2009 were audited (Stage 1). A total of 21 patients (Stage 2) subsequently underwent paracentesis with free drainage of ascites without intermittent clamping (October 2010-January 2011). Finally, 13 patients (19 paracenteses, Stage 3), were drained as a daycase (May-December 2011).

RESULTS

Of 67 patients (Stage 1), 22% of admissions and 18% of bed-days were for paracentesis, with a median LoS of 4 days. In all, 81% of patients (Stage 2) drained completely without hypotension. Of four patients with hypotension, none was tachycardic or symptomatic. Daycase paracentesis achieved complete ascites drainage without complications, or the need for in-patient admission in 94.7% of cases (Stage 3), and cost £954 compared with £1473 for in-patient drainage.

CONCLUSIONS

Free drainage of malignant ascites is safe. Daycase paracentesis is feasible, cost-effective and reduces hospital admissions, and potentially represents the standard of care for patients with malignant ascites.

Management of Symptomatic Ascites in Hospice Patients With Paracentesis

Refractory ascites causes significant distress to patients and can be managed in various ways. In hospice patients where the goal of care is to preserve comfort and foster better quality of life, diuretics should be tried first; however, in resistant cases, home-based paracentesis should be entertained. Home-based paracentesis is a safe and simple procedure that can be done blindly, if done under standard precautions there is minimal associated risk of bleeding, infection or perforation and no need for pre or post-laboratory testing or the correction of high international normalization ratio or thrombocytopenia. Home-based paracentesis is cost effective, provides immediate symptomatic relief, good patient and caregiver satisfaction and obviates the associated distress to the patient and family of transporting the patient for either outpatient or inpatient paracentesis.

Symptom management in metastatic breast cancer

Approximately 40,000 women die as a result of breast cancer each year and many more live with advanced disease. When breast cancer recurs, the goals of treatment often shift from one of cure to controlling the disease for as long as possible while palliating symptoms interfering with the patient's functional status and quality of life. This requires ongoing discussions with the patient and family about the goals of care. Many symptoms depend on the site of metastasis, with bone being the most frequent, and commonly occur with fatigue, depression, insomnia, and pain. The purpose of this paper is to identify and provide an overview of the management of the most common symptoms in patients with breast cancer metastases.

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.

Paracentesis in ovarian cancer: a study of the physiology during free drainage of ascites

Ascites is frequently seen in patients suffering with ovarian cancer. Paracentesis is a well-established method to provide symptomatic relief. Systemic adverse effects have occurred in paracentesis for ascites arising from other conditions. However, malignancy-related ascites has a different pathophysiology than nonmalignant ascites and as such the concerns related to the latter condition may not apply in patients with ovarian cancer. This study has shown that paracentesis is both effective and safe as an outpatient procedure for managing malignancy-related ascites.

Ascites regression and survival increase in mice bearing advanced-stage human ovarian carcinomas and repeatedly treated intraperitoneally with CpG-ODN

Tumor cell growth, even in advanced stages of ovarian cancer, is nearly always restricted to the peritoneal cavity; therefore, repeated intraperitoneal injections of oligodeoxynucleotides containing dinucleotides with unmethylated CpG motifs (CpG-ODN) recruiting and activating innate effector cells throughout the abdominal cavity to the tumor site might control tumor cell growth and ascites formation. After a single CpG-ODN treatment, in IGROV-1 ovarian tumor ascites-bearing athymic mice, the number of tumor cells declined rapidly and markedly, and ascites volumes declined shortly after treatment (5 h), increasing thereafter at a slower rate than in controls. When administered every 7 days for 4 weeks, CpG-ODN had only a marginal effect on survival time, whereas administration 5 days/wk for 3 or 4 weeks led to a significantly increased survival time as compared with controls (P<0.005) and completely controlled ascites growth without apparent toxicity, although a disorganization of lymphoid organs was observed. Bio-plex assay of cytokine levels in peritoneal fluid of ascites-bearing mice after CpG-ODN treatment revealed an increase in interleukin (IL)-6, IL-10, IL-12, and interferon-gamma at 24 hours, which returned to control mice levels at 48 to 96 hours, whereas the high levels of angiogenic factors remained unchanged. Depletion of natural killer or monocytes/macrophages only slightly influenced the CpG-ODN-induced reduction of ascites tumor cells, indicating that the antitumor activity might not be related to a specific cell/cytokine but rather to the repertoire of cells and cytokines accumulated in the peritoneal cavity. Thus, our data suggest a relevant role for repeated activation of cells and cytokines of innate immunity in the therapy of ovarian cancer patients with malignant ascites.

Palliative ultrasound for home care hospice patients

The evolving relationship between emergency and palliative medicine is expected to benefit patients of each. Two collaborative care encounters involving home hospice patients are discussed. Portable bedside ultrasound was performed in the home to diagnose ascites and to guide palliative paracentesis. Specific interventions and outcomes are reported. The interface of emergency and palliative care and the use of paracentesis in cancer palliation are briefly reviewed. It is concluded that home-performed ultrasound and ultrasound-guided procedures are promising palliative modalities for care at the end of life.

Management of drainage for malignant ascites in gynaecological cancer

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Management of ascites due to gastrointestinal malignancy

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

Peritoneal catheter for continuous drainage of ascites in advanced cancer patients

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.

Effective relief of malignant ascites in patients with advanced ovarian cancer by a trifunctional anti-EpCAM x anti-CD3 antibody: a phase I/II study

PURPOSE

Malignant ascites in ovarian carcinoma patients is associated with poor prognosis and reduced quality of life. The trifunctional antibody catumaxomab (anti-EpCAM x anti-CD3) enhances the antitumor activity by redirecting T cells and Fcgamma receptor I/III--positive accessory cells to the tumor. This multicenter phase I/II dose-escalating study investigated tolerability and efficacy of i.p. catumaxomab application in ovarian cancer patients with malignant ascites containing epithelial cell adhesion molecule (EpCAM)--positive tumor cells.

EXPERIMENTAL DESIGN

Twenty-three women with recurrent ascites due to pretreated refractory ovarian cancer were treated with four to five i.p. infusions of catumaxomab in doses of 5 to 200 microg within 9 to 13 days.

RESULTS

The maximum tolerated dose was defined at 10, 20, 50, 200, and 200 microg for the first through fifth doses. Side effects included transient fever (83%), nausea (61%), and vomiting (57%), mostly CTCAE (Common Terminology Criteria for Adverse Events) grade 1 or 2. A total of 39 grade 3 and 2 grade 4 treatment-related adverse events (AE), 9 of them after the highest dose level (200 microg), were observed in 16 patients. Most AEs were reversible without sequelae. Treatment with catumaxomab resulted in significant and sustained reduction of ascites flow rate. A total of 22/23 patients did not require paracentesis between the last infusion and the end of study at day 37. Tumor cell monitoring revealed a reduction of EpCAM-positive malignant cells in ascites by up to 5 log.

CONCLUSION

I.p. immunotherapy with catumaxomab prevented the accumulation of ascites and efficiently eliminated tumor cells with an acceptable safety profile. This suggests that catumaxomab is a promising treatment option in ovarian cancer patients with malignant ascites.

Ovarian cancer and ascites: A questionnaire on current management in the United kingdom

A questionnaire on ovarian cancer ascites management was sent to members of the British Gynaecological Cancer Society (BGCS), the National Gynaecological Oncology Nurses, and the Assoication of Palliative Medicine. Questions were asked on diuretics, hematologic investigations, paracentesis, and duration of stay. Nine hundred ninety-five questionnaires were distributed, of which 492 replies were received (49% response rate). Fifty-five percent of responders used paracentesis as first-line management of ovarian cancer ascites (15% diuretics). Seventy-five percent performed some blood tests in relation to paracentesis. Ultrasound was used by 43.6% during paracentesis (15.7% for direct visualization, 27.9% to mark an entry site). Seventy-seven percent used a Bonanno catheter. Eighty-three percent used no intravenous fluids during paracentesis, and there was a wide variation in the amount and rate of drainage of ascites (1 L maximum up to free drainage of all ascites, median 5 L; 0.5 L per hour to free drainage). Gynecologists tended to use more interventions (paracentesis, ultrasound, and intravenous fluids) than palliative care physicians or medical oncologists, while palliative care physicians used fewer interventions but admitted patients for longer periods of time. This identified several areas for future study: the value of hematologic investigations, the use of outpatient management for paracentesis, and the use of ultrasound and the rate of drainage of ascites.

Malignant ascites: systematic review and guideline for treatment

A guideline on the management of symptomatic malignant ascites by abdominal paracentesis, diuretics and peritoneovenous shunting, based on a systematic review of the literature is presented. Thirty-two relevant studies were identified. None were randomized control trials, one was a non-randomized open controlled trial, five were cohort studies or prospective uncontrolled trials, 26 studies were non-analytic studies like case series. Although paracentesis, diuretics and shunting are commonly used procedures, the evidence is weak. Available data show good, although temporary effect of paracentesis on symptom relief. Fluid withdrawal speed and concurrent intravenous hydration is not sufficiently studied. Peritoneovenous shunts can control ascites in patients with malignant ascites, but have to be balanced by the potential risks of this procedure. The available data about diuretics in treatment of malignant ascites are controversial. The use of diuretics therefore should be considered in all patients, but has to be evaluated individually.