Peritoneovenous shunting for cirrhotic versus malignant ascites

The use of the peritoneovenous shunt in patients with cirrhosis is associated with a significantly higher complication rate than in patients with malignant ascites. Since many patients subsequently died due to the complications of shunt placement and the efficacy has never been clearly established by a randomized trial, it is difficult to recommend a procedure which may shorten the already brief life expectancy of the patient. We conclude that for the patients with ascites due to cirrhosis, the peritoneovenous shunt should be reserved for a carefully selected group, such as those patients with pending rupture of a hernia. However, for the patient with malignant ascites, the relatively low complication rate of peritoneovenous shunt placement and the lack of an adverse effect on survival time indicates that use of this successful palliative technique seems warranted in selected patients.     

Simple revision of the Denver peritoneovenous shunt with nonfunction from inflow occlusion

Occlusion of the Denver peritoneovenous shunt can occur when fibrinous debris block the inflow tubing or valve chamber. In this situation, revision is simplified by replacing only the valve chamber and inflow tubing, without requiring exposure of the central vein or the peritoneum. The outflow tubings are then joined over a Teflon adapter.     

Peritoneo-cystic shunt for malignant ascites

Peritoneo-venous shunting has been used extensively in the treatment of benign ascites and, to a limited extent, in the palliative management of malignant ascites. Acceptance of this therapy for malignant ascites has been slow because of concern over intravascular dissemination of disease. Recently a patient with advanced drug-resistant ovarian carcinoma was treated with peritoneo-cystic shunt. This patient's tumor had progressed on multiple chemotherapeutic agents. She continued to work 40 hr per week but her activity was limited by massive ascites. The Denver Shunt (Storz) was selected in preference to the strut-type shunt. The Denver Shunt has a miter valve which is less likely to become occluded by fibrinous and cellular debris, and manual compression of the pumping chamber allows flushing and control of flow. This patient's shunt remained patent for 5 months, until her death, documented by urine cytology and cystoscopy. Initial control of ascites was only fair, probably due to the virtual absence of a pressure gradient between the peritoneal cavity and the bladder. Without a pressure gradient, spontaneous flow would be expected to be nil. Though feasible and well tolerated, this technique is probably not useful in the management of malignant ascites. If modifications of the device could be made to increase the manual flow rate, then this technique might be acceptable.     

Prenatal shunting of fetal ascites in nonimmune hydrops fetalis

A case of severe nonimmune hydrops fetalis presenting at 24 weeks gestation is presented. Ultrasound, echocardiographic, and fetal ascitic fluid studies were nondiagnostic. Because of massive fetal ascites an indwelling peritoneal amniotic cavity shunt was placed. Despite functioning of the shunt, a fetal death in utero occurred.     

Management of malignant ascites

The management of malignant ascites is a significant clinical problem. Although most of the patients who have this complication develop have rather significantly limited life expectancy rates, they may be successfully palliated if appropriate steps are taken to provide them with the proper therapy. All of the aforementioned treatment modalities, specifically intracavitary radiotherapy, radioactive colloids, intracavitary chemotherapy, peritoneovenous shunting and immunotherapy have distinct advantages and limitations. With the proper selection of the modality to fit the individual patient, a relatively good result can be obtained, providing, of course, that proper care is taken to anticipate the potential complications, which occur frequently in the treatment of malignant effusion.     

Long-term semi-permanent catheter use for the palliation of malignant ascites

BACKGROUND: Malignant ascites is a common complication of advanced or recurrent ovarian cancer and multiple other neoplasms, causing significant patient morbidity as well as a large treatment obstacle for the physician. While multiple methods of peritoneal drainage have been reported, including large volume therapeutic paracentesis, peritoneogastric, peritoneourinary, and peritoneovenous shunting procedures, peritoneal port-a-catheter placement and hemodialysis catheter drainage, all have their associated limitations and adverse effects. CASE: We report off label semi-permanent catheter placement in a patient for treatment of malignant ascites that functioned effectively with drainage of 2 l daily for approximately 18 months, the longest reported use in the literature. CONCLUSION: Long-term semi-permanent catheter use is a potentially valuable modality for the palliation of malignant ascites.     

The FACIT-AI,a new tool for assessing symptoms associated with malignant ascites

ObjectiveThe objectives of this study are to assess the clinical relevance and validity of the Functional Assessment of Chronic Illness Therapy-Ascites Index (FACIT-AI) in women with ovarian cancer and malignant ascites, and to modify the instrument guided by qualitative feedback from patients with recurrent malignant ascites.MethodsFourteen adult female patients with recurrent symptomatic malignant ascites were enrolled from three centers. All completed an open-ended symptom list to identify their primary concerns regarding their condition. They then completed a draft 10-item FACIT-AI questionnaire created from expert input. Eleven patients provided comments regarding the FACIT-AI questionnaire using a written feedback format. Three patients participated in a “think-aloud” cognitive debriefing interview to ensure patient comprehension of questionnaire items.ResultsOf the first 11 patients surveyed, 7 believed that the draft FACIT-AI contained all important symptoms associated with malignant ascites. Responses from the remaining 4 patients revealed three symptoms that 2 or more patients nominated for inclusion: urinary frequency, constipation and emotional distress. These items were added to the original FACIT-AI to produce a 13-item index of symptoms associated with malignant ascites.ConclusionsThe 13-item FACIT-AI has content validity among women with malignant ascites associated with ovarian cancer. It is available for use in clinical research or practice, with the expectation that more will be learned about its performance and interpretation over time.     

Intraoperative placement of a self-retaining Foley catheter for continuous drainage of malignant ascites

Malignant ascites in advanced cancer is usually treated by repeated paracentesis, causing both discomfort and inconvenience to patients in the terminal stages of disease. We present a case of advanced ovarian carcinoma in which intraoperative placement of a Foley's self-retaining catheter into the peritoneal cavity was used to facilitate long-term continuous drainage of malignant ascites. This is a simple, convenient and cost-effective method which decreases the need for repeated hospital admissions. The aim complication might be peritonitis, but with proper care of the device and the use of antibiotics, this was not seen in our patient.     

Treatment of malignant ascites with allogeneic and autologous lymphokine-activated killer cells

Two cases of peritonitis carcinomatosa with gynecological cancer, which did not respond to conventional treatment, were treated by intraperitoneal adoptive immunotherapy with allogeneic or autologous lymphokine-activated killer (LAK) cells plus interleukin-2. In case 1, reduction of acute ascites and disappearance of malignant cells from the peritoneal fluid and decreased levels of tumor markers (CA12-5 and CA19-9) were demonstrated during the treatment. In case 2, which also received additional treatment for pleuritis carcinomatosa, reduction of ascites and pleural effusion and disappearance of malignant cells from the pleural fluid were noted. In these cases allogeneic LAK therapy was well tolerated. This therapy did not prolong the patients' lives, but the findings indicate that it had appreciable local antitumor effects on peritonitis and pleuritis carcinomatosa in these patients with gynecological cancer.     

Procollagen-derived biomarkers in malignant ascites of ovarian cancer. Independent prognosticators for progression-free interval and survival

OBJECTIVE: Matrix formation is a hallmark of solid tumor biology. Circulating antigens of structural matrix proteins should reflect this fact, yet are subject to systemic variables. We propose that if measured regionally, in a cancer-induced extravascular fluid pool such as malignant ascites of ovarian cancer, the same antigens retain their conceptual advantage as surrogate markers for tumor biology. METHODS: In malignant ascites obtained at staging laparatomy of 35 women with ovarian cancer, the protein-normalized levels of the C-terminal propeptide of procollagen type I (pnPICP) and the N-terminal propeptide of procollagen type III (pnPIIINP) were determined. Using univariate and multivariate analysis, we examined these parameters, their (pnPIIINP/pnPICP) quotient, and clinical criteria (FIGO stage, age, residual tumor, histology, and tumor grade) for impact on progression-free interval and survival. RESULTS: The absolute level of pnPIIINP was the single most powerful independent factor impacting on survival, its P value being distinctly below (P = 0.0005 vs 0.003) and its risk ratio distinctly above (15 vs 2.5) residual tumor after debulking surgery. The relative level of pnPIIINP, i.e. (pnPIIINP / pnPICP), impacted on the likelihood of recurrence even more than residual tumor. By Kaplan-Meier analysis, cutoff values for the absolute or relative pnPIIINP level significantly discriminated patients with shortened survival or progression-free interval, respectively. CONCLUSIONS: Since malignant ovarian epithelium itself forms collagen type III, and since collagen type III is a solid-phase regulator of angiogenesis, we propose that ascitic pnPIIINP is a fluid-phase indicator for angiogenic activity in ovarian cancer and thus represents a tumor virulence index.     

Studies on fibrinolysis and ascites accumulation associated with peritonitis carcinomatosa--inducer of plasminogen activator (IPA) in malignant ascites tumor

This study was undertaken to investigate the mechanism for hyperfibrinolysis in the ascites associated with peritonitis carcinomatosa. Various combinations of mouse MM2 ascites tumor (MAT) and mouse peritoneum (Mpr) and plasminogen (Plg) were incubated in medium 199 and the fibrinolytic activity of each preparation was assayed. 1) Among the preparations, the preparation of MAT plus Mpr plus Plg showed particularly high fibrinolytic activity. This suggests that plasminogen activator (PA) production is initiated by MAT together with Mpr. 2) Equal volumes of the ultrafiltrate and the concentrate of supernatant from MAT were each separately treated with a Mpr plus Plg preparation and incubated. The fibrinolytic activity of the ultrafiltrate was 10 times as great as that of the concentrate. 3) The ultrafiltrate of MAT was extracted in turn with petroleum ether, ether and hexane. The fibrinolytic activity of the petroleum ether and hexane extracts was higher than that of the ether extracts. These results suggest that MAT has a low polarity, low molecular weight, and lipid like substance (inducer of PA,IPA), which stimulates the Mpr to release PA.     

Resolution of malignant ascites after intraperitoneal chemotherapy in women with carcinoma of the ovary

The treatment of malignant ascites is a difficult task that faces the physician who is treating patients with advanced carcinoma. We describe the clinical course of three patients with malignant ascites caused by advanced carcinoma of the ovary who were treated with cisplatin-based intraperitoneal chemotherapy. In all three patients, there was resolution of the ascites with relief of symptoms caused by abdominal distention. Although one patient had a fall in the serum level of CA 125 (the antigen marker of carcinoma of the ovary) with repeated courses of intraperitoneal therapy, there was little reduction in the bulky abdominal tumors. Even though intraperitoneal chemotherapy, as currently administered, does not appear to effect a significant reduction in tumor in women with bulky carcinoma of the ovary, it may be of benefit in improving the quality of life. Larger numbers of patients should be studied to better assess the role of this method of treatment in the palliative cure of patients with symptomatic malignant ascites.     

Pleuroamniotic shunting for decompression of fetal pleural effusions

Pleuroamniotic shunting was performed at 22-35 weeks' gestation in 11 fetuses with pleural effusions. Eight of the infants, born two to 16 weeks after shunting, had no evidence of pulmonary hypoplasia. Three died in the neonatal period; one because of pseudomonas septicemia, one because of pulmonary hypoplasia caused by an associated diaphragmatic hernia, and the third because of a major cardiac defect. Pleural effusions and their prenatal decompression offer an experimental human model for the study of the effect of intrathoracic compression on pulmonary development.     

Acute chlamydial salpingitis with ascites and adnexal mass simulating a malignant neoplasm.

Chlamydia trachomatis is a well-known cause of acute and chronic salpingitis, accounting for approximately half of all cases of pelvic inflammatory disease. Typically, patients with acute chlamydial salpingitis present with acute lower abdominal pain, tenderness on bimanual pelvic examination, or vaginal discharge. We describe a case of acute chlamydial salpingitis with marked ascites and an adnexal mass that simulated a malignant neoplasm. Microscopically, a severe lymphofollicular salpingitis and a marked lymphofollicular hyperplasia of the omentum and retroperitoneal lymph nodes were found. Chlamydial inclusions in the fallopian tube epithelium were demonstrated by immunohistochemistry using a mouse monoclonal antibody to a genus-specific outer membrane lipoprotein. Chlamydial infection may cause marked ascites and a palpable adenexal mass and should be considered whenever marked chronic inflammation with a lymphofollicular hyperplasia involves the fallopian tube or other female genital tract sites.