From the Guidelines
Malignant ascites due to adenocarcinoma should be managed with systemic chemotherapy appropriate for the specific cancer type, and symptomatic relief may include therapeutic paracentesis, diuretics, and in some cases, peritoneovenous shunts or intraperitoneal chemotherapy. The treatment of malignant ascites due to adenocarcinoma depends on the primary source of the cancer. For gastric cancer, the Chinese Society of Clinical Oncology recommends first-line chemotherapy regimens based on fluoropyrimidine combined with platinum and/or taxanes 1. For patients with symptomatic ascites, drainage and hyperthermic intraperitoneal perfusion chemotherapy (HIPEC) can be considered, although HIPEC is not recommended for routine use in clinical practice 1.
Diagnosis and Treatment
- Diagnosis typically requires paracentesis with cytological examination of the fluid, which shows elevated protein content, high serum-ascites albumin gradient (SAAG), and presence of malignant cells.
- Additional diagnostic approaches include CT scans, MRI, and sometimes laparoscopy with peritoneal biopsies to identify the primary tumor source.
- Treatment focuses on managing the underlying cancer with systemic chemotherapy, while symptomatic relief may include therapeutic paracentesis, diuretics, and in some cases, peritoneovenous shunts or intraperitoneal chemotherapy.
- For patients with bowel obstruction or massive ascites due to severe peritoneal metastases, chemotherapy regimens with mild toxicity profiles such as infusional 5-fluorouracil and paclitaxel could be considered 1.
Chemotherapy Regimens
- Fluoropyrimidine, platinum, and taxanes are the main therapeutic drugs for late-stage gastric cancer 1.
- The selection of first-line chemotherapy regimens should be based on the patients’ physical condition, age, and any underlying disease 1.
- For patients with HER2-positive metastatic gastric cancer, trastuzumab in combination with first-line chemotherapy can improve efficacy and survival 1.
Symptomatic Relief
- Therapeutic paracentesis can provide symptom relief for patients with malignant ascites 1.
- Diuretics such as spironolactone can decrease the reabsorption of water and sodium in the kidneys and provide some relief from ascites 1.
- Peritoneovenous shunts or intraperitoneal chemotherapy can be considered in some cases, although the evidence for these treatments is limited 1.
From the Research
Malignant Ascites Due to Adenocarcinoma
Malignant ascites is a condition where fluid accumulates in the abdominal cavity due to cancer, including adenocarcinoma. The management of malignant ascites is crucial to improve the quality of life of patients.
Treatment Options
- Paracentesis: a procedure where fluid is drained from the abdominal cavity, providing temporary symptom relief 2, 3, 4, 5, 6
- Diuretics: may be used to manage malignant ascites, but their effectiveness is controversial and often declines with tumor progression 2, 5, 6
- Indwelling catheters, peritoneal ports, peritoneovenous shunts, intraperitoneal catumaxomab, and hyperthermic intraperitoneal chemotherapy: options for durable symptom management, but may not improve overall survival 5
- Laparoscopy and hyperthermic intraperitoneal chemotherapy (HIPEC): proposed as palliative therapy, with limited evidence 2
Considerations for Treatment
- The optimal volume of paracentesis is not well established, but small-volume paracentesis may be a well-balanced treatment option for terminally ill cancer patients with malignant ascites 3
- Early insertion of an indwelling tunneled catheter may be considered to avoid repeated paracenteses 4
- The use of diuretics should be evaluated individually, as their effectiveness is controversial 6
- The management of malignant ascites should prioritize symptom relief and improvement of quality of life, as overall survival may not be improved by treatment 2, 5