Ascites is a pathological accumulation of fluid in the abdominal cavity. Among patients with ascites, most suffer from cirrhosis and portal hypertension. Ascites associated with malignant neoplasms is much less common: in about 7% of patients. Some patients have two causes of ascites at once, for example, cirrhosis and peritoneal carcinomatosis (multiple peritoneal metastases).
Why does ascites develop?
Ascites associated with malignant neoplasms can be observed in many tumors, including malignant tumors of the ovary, breast, colon, lung, pancreas and liver. Lymphoma can also be complicated by ascites.
Ascites usually develop in conditions of recurrent or progressive cancer. Before ascites develops, patients may have metastatic lesions of the peritoneum or liver, enlarged intra-abdominal lymph nodes, or a large tumor volume
The origin of the primary tumor influences the development of ascites.
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Malignant tumors of the ovary and bladder, as well as peritoneal mesothelioma, usually cause peritoneal carcinomatosis. In such cases, the accumulation of fluid is the result of blocking draining lymphatic channels and increased vascular permeability.
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Colon, stomach, breast, pancreatic, and lung cancers can cause peritoneal carcinomatosis and/or massive liver metastases, leading to ascites either due to tumor cells producing fluid in the abdominal cavity, obstruction/compression of portal veins, leading to portal hypertension, or liver failure.
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Lymphomas can cause obstruction of the lymph nodes with accumulation of ascites, or symptomatic serous effusions.
Ascites in liver tumors
Ascites in patients with liver disease is usually caused by hepatocellular carcinoma rather than liver metastases. The development of ascites may be the first sign of primary hepatocellular liver carcinoma.
The four most common variants of ascites associated with hepatocellular liver carcinoma:
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in patients with chronic hepatitis B acquired in infancy or childhood
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in patients with non-alcoholic fatty liver disease,
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in patients with chronic hepatitis C,
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in patients with alcoholic cirrhosis.
In these conditions, ascites often develops when the tumor volume increases to such an extent that it replaces a critical part of the functional mass of the liver or leads to portal vein thrombosis.
Symptoms of ascites
Patients often seek medical help due to abdominal pain, shortness of breath, or rapid satiation, and leg swelling often develops. Abdominal pain can be caused by a combination of factors, including nerve invasion by a tumor, stretching of the liver capsule, or in patients with severe ascites— stretching of the abdominal wall. Since ascites usually develops in conditions of a large tumor mass, patients usually lose weight before ascites develops (despite the added weight from the ascitic fluid itself).
Diagnosis of ascites
The diagnosis of ascites associated with malignant neoplasms is based on clinical manifestations, imaging methods, puncture and analysis of ascitic fluid.
Patients with an established cancer diagnosis who develop ascites often do not require extensive examination. Since the development of ascites associated with malignant neoplasms is a poor prognostic sign, the diagnostic approach should focus on rapid assessment and evacuation of ascites, while treatment is aimed at improving the patient's quality of life. On the other hand, the presence of ascites in a woman with epithelial ovarian cancer is not necessarily associated with a very poor prognosis.
A physical examination allows you to approximately determine the level of ascites accumulation.Patients with suspected ascites associated with malignant neoplasms should undergo an examination to confirm the presence of ascites. The examination begins with ultrasound of the abdominal organs, and if necessary, CT or MRI examination of the abdominal organs is performed.
Laparocentesis (puncture of the peritoneal wall) with appropriate analysis of ascitic fluid is the most effective way to confirm the presence of ascites, diagnose its cause and determine whether the fluid is infected and whether there are malignant cells in it.
Ascites treatment
The main method of treating peritoneal carcinomatosis is therapeutic laparocentesis (evacuation of fluid from the abdominal cavity). The exception is ascites in ovarian cancer. Peritoneal ports and catheters may be recommended for patients who cannot tolerate repeated laparocentesis. Patients with portal hypertension (with massive liver metastases, cirrhosis with hepatocellular carcinoma or malignant Budd-Chiari syndrome) may be prescribed diuretics (medications that increase urination).
In patients with ascites in ovarian cancer, treatment options include cytoreductive surgery (removal of as much of the tumor and metastases as possible) and chemotherapy.
The EMC Institute of Oncology at Shchepkina St., Moscow, provides comprehensive care for patients with ascites according to modern international standards. Ascites can be evacuated both in an inpatient and outpatient setting. Sometimes, in difficult cases, if the manipulation is poorly tolerated or if desired, the patient may be hospitalized.
Hospitalization at the EMC can also be an emergency – 24 hours a day, surgeons on duty are ready to assist in the evacuation of ascites.
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