2 results
Quality of life improves after palliative placement of percutaneous tunneled drainage catheter for refractory ascites in prospective study of patients with end-stage cancer
- Piera Cote Robson, Mithat Gonen, Ai Ni, Lynn Brody, Karen T. Brown, George Getrajdman, Bridgette Thom, Nancy Kline, Anne Covey
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- Journal:
- Palliative & Supportive Care / Volume 17 / Issue 6 / December 2019
- Published online by Cambridge University Press:
- 18 March 2019, pp. 677-685
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- Article
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Objective
Percutaneous tunneled drainage catheter (PTDC) placement is a palliative alternative to serial paracenteses in patients with end-stage cancer and refractory ascites. The impact of PTDC on quality of life (QoL) and long-term outcomes has not been prospectively described. The objective was to evaluate changes in QoL after PTDC.
MethodEligible adult patients with end-stage cancer undergoing PTDC placement for refractory ascites completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire and McGill Quality of Life instruments before PTDC placement and at 2 to 7 days and 2 to 4 weeks after PTDC. Catheter function, complications, and laboratory values were assessed. Analysis of QoL data was evaluated with a stratified Wilcoxon signed-rank test.
ResultFifty patients enrolled. Survey completion ranged from 65% to 100% (median 88%) across timepoints. All patients had a Tenckhoff catheter, with 98% technical success. Median survival after PTDC was 38 days (95% confidence interval = 32, 57 days). European Organization for Research and Treatment of Cancer scores showed improvement in global QoL (p = 0.03) at 1 week postprocedure (PP). Significant symptom improvement was reported for fatigue, nausea/vomiting, pain, dyspnea, insomnia, and appetite at 1 week PP and was sustained at 3 weeks PP for dyspnea (p < 0.01), insomnia (p < 0.01), and appetite loss (p = 0.03). McGill Quality of Life demonstrated overall QoL improvement at 1 (p = 0.03) and 3 weeks (p = 0.04) PP. Decline in sodium and albumin values pre- and post-PTDC slowed significantly (albumin slope –0.43 to –0.26, p = 0.055; sodium slope –2.50 to 1.31, p = 0.04). Creatinine values increased at an accelerated pace post-PTDC (0.040 to 0.21, p < 0.01). Thirty-eight catheter-related complications occurred in 24 of 45 patients (53%).
Significance of resultsQoL and symptoms improved after PTDC placement for refractory ascites in patients with end-stage malignancy. Decline in sodium and albumin values slowed postplacement. This study supports the use of a PTDC for palliation of refractory ascites in cancer patients.
31 - Palliative procedures for ascites and effusion
- from Section X - Specialized interventional techniques in cancer care
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- By Hooman Yarmohammadi, Department of Radiology, George I. Getrajdman, Department of Radiology
- Edited by Jean-Francois H. Geschwind, Michael C. Soulen
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- Book:
- Interventional Oncology
- Published online:
- 05 September 2016
- Print publication:
- 22 September 2016, pp 323-332
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Summary
Introduction
The definition of ascites is the pathological accumulation of fluid in the peritoneal cavity. Malignant ascites is accumulation of fluid in the peritoneal cavity as a consequence of cancer. Refractory ascites is when ascites fail to respond to: (1) bed rest; (2) fluid restriction to 1500 mL/day and salt restriction to 80 mmol/day; (3) 400 mg/day spironolactone or 300 mg/day triamterene plus 120 mg/day furosemide for 4 weeks; or (4) when patients are intolerant to medical therapy because of azotemia.
The most common cause of benign and malignant ascites, accounting for nearly 80% of cases, is liver cirrhosis. Malignant ascites is present in approximately 10% of all patients with ascites. The cancers most commonly associated with ascites can be divided into two groups of intra-abdominal (i.e., ovary, stomach, pancreas, and colon) and extra-abdominal (i.e., breast, lung, and lymphoma) malignancies. In approximately 20% of all patients with malignant ascites the primary origin of the tumor is unknown.
The pathophysiology of malignant ascites is multifactorial and not completely clear. The cause of ascites in cancer patients differs from that in patients with cirrhosis. The most common recognized pathophysiology is alteration in vascular permeability of the parietal peritoneum and metastatic spread to the peritoneum or peritoneal carcinomatosis (50%). Vascular endothelial growth factor (VEGF) increases vascular permeability. Multiple reviews have demonstrated high levels of VEGF in patients with malignant ascites, particularly in patients with ovarian, gastric, and colorectal cancers. Other mentioned causes are obstruction of draining lymphatics due to lymphatic invasion (20%; most commonly seen in lymphoma and breast cancer), liver metastasis, resulting in portal vein hypertension (15%), and hormonal mechanisms. Depleted or reduced circulatory blood volume activates the renin–angiotensin–aldosterone system, leading to sodium retention in patients with ascites, including patients with malignant ascites.
Diagnostic tests
A basic metabolic panel, including serum electrolytes, blood urea nitrogen and creatinine, hepatic function panel, including serum albumin, and urinary sodium levels, provides measures of liver function, volume, and nutritional depletion, and helps to guide initial therapy. A diagnostic paracentesis should be performed for cell count with differential, Gram stain with culture, albumin level, and cytology. Cytology is 97% sensitive for carcinomatosis. A serum-ascites albumin gradient > 1.1 gram/dL is 97% accurate for the diagnosis of portal hypertension.