Malignant Effusions
Summary of Key Points
Malignant Ascites
• Malignant ascites is a common complication of cancer.
• Malignant ascites accounts for 10% of all cases of ascites.
• Malignant ascites most commonly occurs in patients with ovarian cancer, gastrointestinal malignancies, and carcinoma of unknown primary location.
• Malignant ascites is rarely life threatening, but occurrence signals advanced cancer.
Treatment
• Monitor the situation if the ascites volume is small and/or asymptomatic.
• Consider the patient’s performance status and likelihood of response to systemic therapy in choosing a treatment approach.
• Treatment approaches include use of diuretics, drainage or diversion of fluid, or use of intracavitary therapies.
Evaluation
• Diagnosis more commonly follows a cancer diagnosis.
• The differential diagnosis of pericardial effusion in patients with cancer also includes treatment-related adverse effects such as radiation.
• Fluid sampling for cytology is needed for definitive diagnosis but has low sensitivity; a pericardial biopsy may increase sensitivity.
• Two-dimensional echocardiography provides valuable information about the location, size, and effect on heart function.
• Patients should be evaluated for clinical signs of cardiac tamponade (e.g., hypotension, signs of low cardiac output, and abnormal pulsus paradoxus).
Treatment
• Patients with small and/or asymptomatic effusions may be monitored.
• Patients with cardiac tamponade require urgent pericardiocentesis to drain fluid.
• Treatment depends on symptoms of effusion and performance status of the patient.
• Treatment options include subxiphoid pericardiostomy, instillation of sclerosants in the pericardial space, and pericardial window.
Treatment
• Asymptomatic effusions can be monitored.
• Systemic chemotherapy can be effective in stable patients.
• For symptomatic patients, effective options include systemic therapy for patients with very responsive disease (e.g., hematologic malignancies, germ cell tumors, breast cancer, and small cell lung cancer) or repeated thoracentesis.
• For patients with rapidly recurring effusions, options include pleurodesis with talc, long-term intrapleural drainage catheters, or video-assisted thoracoscopic surgery with mechanical abrasion.
1. The most common cause of ascites is which of the following?
2. Tamponade physiology is when:
A Intracardiac pressures exceed pericardial pressures, resulting in incomplete filling of the ventricles, causing decreased cardiac output.
B Pericardial pressures exceed intracardiac pressure, resulting in compression of the cardiac chambers, compromising cardiac filling and output.
3. Which accounts for 50% to 60% of cases of malignant pleural effusion?
4. Malignant pleural effusions are usually exudates by Light criteria. Which characteristic is most likely associated with a malignant pleural effusion?
1. Answer: B. Gastrointestinal malignancies such as gastric cancer, as well as ovarian cancer, are malignancies that commonly cause malignant ascites.
2. Answer: B. When tamponade occurs, pericardial pressures exceed the intracardiac pressure, resulting in decreased cardiac filling and decreased cardiac output.
3. Answer: A. All of these malignancies can cause a malignant pleural effusion, but lung and breast cancer combined are the most common causes of a malignant pleural effusion.
4. Answer: C. A malignant effusion usually has a low glucose level, low pH, high LDH level, and a lymphocyte-predominant cell count.
