The treatment of malignant ascites

By | April 23, 2012

The treatment of malignant ascites, malignant ascites is caused by a variety of malignant ascites, and more can be found in the shedding of malignant ascites cells, accounting for 10% of all ascites. The primary cause of malignant ascites in ovarian cancer disease, the most common, accounting for 30% -54%, the other by the gastrointestinal tract tumor, pancreatic cancer, liver cancer, uterine cancer and other causes, gastrointestinal tract, 10% -15% of the tumor malignant ascites, abdominal malignancies, such as outside the breast, lung and lymphoma can also cause malignant ascites. In addition, about 20% of the primary lesions of patients is unknown. Poor prognosis of malignant ascites, with an average survival of about 20 weeks, but the primary lesion is different from the prognosis of difference to the gastrointestinal tract, the worst sources of malignant ascites, the survival of 12-20 weeks. Malignant ascites formation mechanism is not very clear, breast cancer cells under mechanical lymphatic obstruction caused by reflux may be the main obstacle. Recent studies indicate that some cytokines such as vascular endothelial growth factor, matrix metalloproteinases, etc. can promote tumor invasion and metastasis, and promote angiogenesis and increase vascular permeability, leading to increased fluid filtration, and think that since the formation of malignant ascites important role. On the treatment of malignant ascites, more clinical approach, but the overall effect is limited. As the pathophysiology of malignant ascites in-depth understanding in recent years, some new treatment strategies. In this paper, the status and progress of treatment of a brief introduction.
(A) of the diuretic
Diuretic therapy is the most common means of ascites due to cirrhosis, but the general effect of malignant ascites is poor, the effective rate reported in the literature about 44% (49/112). Its effectiveness may be associated with plasma renin / wake up solid from the same level, and plasma renin / awake patients with high solid pay diuretic therapy may be effective, on the contrary, the possibility of a large void. It was also reported that serum ascites albumin gradient> llg / L in patients on diuretics and more effective treatment that can be used as predictors of efficacy. Security for the diuretic spironolactone is usually preferred, or combined with furosemide, the dose compared with conventional dosage, it is recommended for safety and comfort through the 160mg / d start, gradually increase the volume, the therapeutic efficacy after 2 / 3 the amount of maintenance, attention to regular monitoring of electrolytes and urea.
(B) abdominal paracentesis
Intra-abdominal pressure is increased in patients with malignant ascites symptoms occur such as nausea, vomiting, abdominal distension, abdominal pain, dyspnea, or orthopnea subretinal fluid paracentesis when possible, about 90% of patients receive temporary relief of symptoms, the average maintenance of 10.4 days. Because of its simple, quick relief of symptoms, is still basic clinical treatment, but many need to be repeated. The amount of ascites more non-encapsulated ascites, extensive adhesions, and no tumor mass in patients with large blind commonly used to wear, or in the ultrasound-guided puncture is safer. Subretinal fluid paracentesis repeatedly with a large number of effective circulating blood volume caused by reduced low sodium acidosis, renal dysfunction, and low risk of complications such as hypoalbuminemia, high-risk patients can be put on the same time using dextrose solution intoxicated (dextran) expansion or albumin infusion. Fischer subretinal fluid in the abdomen while wearing a 5% dextrose intravenous drip off, put up liquid ravioli, no serious hypotension. Subretinal fluid paracentesis even can cause pulmonary embolism, intestinal perforation and peritonitis, but the incidence is very low. Appelqvist other 100 patients reported abdominal treatment through subretinal fluid 127, including 2 cases of pulmonary embolism, 1 case of intestinal perforation, 1 case of peritonitis.
(C) of the peritoneal shunt
Peritoneal shunt (peritoneovenous shunts, PVS) for the first time in 1974 for the treatment of refractory ascites, and then gradually applied to the treatment of malignant ascites. Liquid ratio and placed paracentesis, PVS including the LeVeen or Denver shunt could not only alleviate symptoms, while avoiding a large number of repeated paracentesis induced protein loss, hypoproteinemia and increase with the plasma protein levels. Subretinal fluid with repeated paracentesis can not control the symptoms, consider the line PVS, but not associated with clotting mechanism for liver failure, infection recently or are, wrapped ascites, pseudomyxoma peritonei, and bloody ascites, ascites protein concentration> 45g / L in patients on peritoneal cytology positive or accompanied by a relative contraindication in patients with heart failure, the source of the gastrointestinal tract of patients, because the prognosis is poor, but also do not advocate application.
16 Smith and other recent comprehensive study, the results of the efficiency of PVS treatment of malignant ascites was 75% (283/377). Shunt obstruction is the main reason for treatment failure, the recent blocking rate was 26% (91/345), to keep them open, the average time of about 3 months. Dust can be made of disseminated intravascular coagulation (DIC), pulmonary edema, pulmonary embolism, infection and other complications, including the occurrence of subclinical DIC highest rate is 76% (192/251), clinical incidence of DIC 2 % (9 / 449), pulmonary edema, pulmonary embolism, infection rates were 12% (47/395), 7% (14/209) and 5% (20/366) 0 PVS has caused cancer spread potential hazards, the occurrence rate of about 5% – 7%, but their clinical significance is not yet clear. Tann et al reported treatment of 15 cases of PVS patients, 7 patients with pulmonary or vascular metastasis, but patients are not the cause of death. Souter and other treatment of 33 patients with PVS, the autopsy in 12 cases, the autopsy cases, 5 patients had evidence of metastasis, but it has nothing to do with the patients died.
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