Maligner Aszites

Zusammenfassung

Maligner Aszites ist definiert als abnorme Ansammlung größerer Flüssigkeitsmengen in der Bauchhöhle als Folge einer Tumorerkrankung. Große Mengen von Aszites führen nicht nur zu einem beeinträchtigten Körperbild und reduzierter Mobilität, sondern durch den erhöhten abdominellen Druck auch zu belastenden Symptomen wie Schmerzen, Atemnot, Appetitverlust und Übelkeit. Ziel der palliativmedizinischen Betreuung ist hier, eine gute Symptomlinderung mit relativ unbelastenden und die verbleibende Lebensqualität möglichst nicht weiter einschränkenden Behandlungsmaßnahmen zu erreichen. Im Folgenden soll daher ein kurzer Überblick zur Pathophysiologie, Diagnose und Therapie des malignen Aszites gegeben werden.

Abstract

Malignant ascites occurs in association with a variety of neoplasms and is defined as abnormal accumulation of fluid in the peritoneal cavity as a consequence of cancer. Although paracentesis, diuretics and shunting are commonly used procedures, the evidence is weak. This article provides an overview of pathogenesis, diagnosis and therapy of malignant ascites. Based on a review of the literature a guideline on the management of symptomatic malignant ascites by abdominal paracentesis, diuretics and shunting will be presented.

Literatur

• 1 Atkinson M. Ascites in liver disease.  Postgrad Med J. 1956;  32 482-485
• 2 D'Amico G, Morabito A, Pagliaro L. et al . Survival and prognostic indicators in compensated and decompensated cirrhosis.  Dig Dis Sci. 1986;  31 468-475
• 3 Regnard C F, Mannix K. Management of ascites in advanced cancer – a flow diagram.  Palliative Medicine. 1989;  4 45-47
• 4 Radbruch L, Ostgathe C, Elsner F. et al . Prozesse und Interventionen auf den deutschen Palliativstationen. Ergebnisse der Kerndokumentation 2001.  Schmerz. 2004;  18 179-188
• 5 Ringenberg Q S, Doll D C, Loy T S. et al . Malignant ascites of unknown origin.  Cancer. 1989;  64 753-755
• 6 Wiest R, Schölmerich J. Aktuelle Diagnostik und Therapie des Ascites.  Gastroenterologe. 2008;  1 57-67
• 7 Smith E M, Jayson G C. The current and future management of malignant ascites.  Clin Oncol (R Coll Radiol). 2003;  15 59-72
• 8 Adam R A, Adam Y G. Malignant ascites: past, present, and future.  J Am Coll Surg. 2004;  198 999-1011
• 9 Runyon B A. Care of patients with ascites.  N Engl J Med. 1994;  330 337-342
• 10 Wiest R, Schölmerich J. Diagnostik und Therapie des Aszites.  Dtsch Ärztebl. 2006;  103 A1972-A1981
• 11 Bergmann J F, Bidart J M, George M. et al . Elevation of CA 125 in patients with benign and malignant ascites.  Cancer. 1987;  59 213-217
• 12 Rimola A, Garcia-Tsao G, Navasa M. et al . Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. International Ascites Club.  J Hepatol. 2000;  32 142-153
• 13 Wong F, Bernardi M, Balk R. et al . Sepsis in cirrhosis: report on the 7th meeting of the International Ascites Club.  Gut. 2005;  54 718-725
• 14 Appenrodt B, Sauerbruch T. Antibiotische Therapie und Prophylaxe bei Leberzirrhose und Infektion.  Dtsch Med Wochenschr. 2007;  132 623-626
• 15 Becker G, Galandi D, Blum H E. Malignant ascites: systematic review and guideline for treatment.  Eur J Cancer. 2006;  42 589-597
• 16 McNamara P. Paracentesis – an effective method of symptom control in the palliative care setting?.  Palliat Med. 2000;  14 62-64
• 17 Gotlieb W H, Feldman B, Feldman-Moran O. et al . Intraperitoneal pressures and clinical parameters of total paracentesis for palliation of symptomatic ascites in ovarian cancer.  Gynecol Oncol. 1998;  71 381-385
• 18 Appelqvist P, Silvo J, Salmela L. et al . On the treatment and prognosis of malignant ascites: is the survival time determined when the abdominal paracentesis is needed?.  J Surg Oncol. 1982;  20 238-242
• 19 Fischer D S. Abdominal paracentesis for malignant ascites.  Arch Intern Med. 1979;  139 235
• 20 Er F, Erdmann E, Pfister R. Die Aszitespunktion.  Dtsch Med Wochenschr. 2007;  132 1177-1179
• 21 Moore K P, Aithal G P. Guidelines on the management of ascites in cirrhosis.  Gut. 2006;  55 (Suppl. 6) VI1-12
• 22 Lee C W, Bociek G, Faught W. A survey of practice in management of malignant ascites.  J Pain Symptom Manage. 1998;  16 96-101
• 23 Boyer T D. Transjugular intrahepatic portosystemic shunt: current status.  Gastroenterology. 2003;  124 1700-1710
• 24 Leveen H H, Christoudias G, Ip M. et al . Peritoneo-venous shunting for ascites.  Ann Surg. 1974;  180 580-591
• 25 Lund R, Newkirk J. Peritoneovenous shunting system for surgical management of ascites.  Contemp Surg. 1979;  14 31-45
• 26 Parsons S L, Watson S A, Steele R J. Malignant ascites.  Br J Surg. 1996;  83 6-14
• 27 Barnett T D, Rubins J. Placement of a permanent tunneled peritoneal drainage catheter for palliation of malignant ascites: a simplified percutaneous approach.  J Vasc Interv Radiol. 2002;  13 379-383
• 28 Iyengar T D, Herzog T J. Management of symptomatic ascites in recurrent ovarian cancer patients using an intra-abdominal semi-permanent catheter.  Am J Hosp Palliat Care. 2002;  19 35-38
• 29 Fleming N D, Alvarez-Secord A, Gruenigen V von. et al . Indwelling Catheters for the Management of Refractory Malignant Ascites: A Systematic Literature Overview and Retrospective Chart Review.  J Pain Symptom Manage. 2009, im Druck; 
• 30 Rosenberg S, Courtney A, Nemcek A AJ. et al . Comparison of percutaneous management techniques for recurrent malignant ascites.  J Vasc Interv Radiol. 2004;  15 1129-1131
• 31 Hogberg T, Glimelius B, Nygren P. A systematic overview of chemotherapy effects in ovarian cancer.  Acta Oncol. 2001;  40 340-360
• 32 Alberts D S, Liu P Y, Hannigan E V. et al . Intraperitoneal cisplatin plus intravenous cyclophosphamide versus intravenous cisplatin plus intravenous cyclophosphamide for stage III ovarian cancer.  N Engl J Med. 1996;  335 1950-1955
• 33 Markman M, Bundy B N, Alberts D S. et al . Phase III trial of standard-dose intravenous cisplatin plus paclitaxel versus moderately high-dose carboplatin followed by intravenous paclitaxel and intraperitoneal cisplatin in small-volume stage III ovarian carcinoma: an intergroup study of the Gyneco.  J Clin Oncol. 2001;  19 1001-1007
• 34 Baker A R, Weber J S. Treatment of malignant ascites. In: DeVita VT, Hellmann S, Rosenberg SA, eds Cancer, Principles and Practise of Oncology. Philadelphia; Lippincott 1993: 2255-2261
• 35 Stuart G C, Nation J G, Snider D D. et al . Intraperitoneal interferon in the management of malignant ascites.  Cancer. 1993;  71 2027-2030
• 36 Rath U, Kaufmann M, Schmid H. et al . Effect of intraperitoneal recombinant human tumour necrosis factor alpha on malignant ascites.  Eur J Cancer. 1991;  27 121-125
• 37 Sherer D M, Eliakim R, Abulafia O. The role of angiogenesis in the accumulation of peritoneal fluid in benign conditions and the development of malignant ascites in the female.  Gynecol Obstet Invest. 2000;  50 217-224
• 38 Xu L, Yoneda J, Herrera C. et al . Inhibition of malignant ascites and growth of human ovarian carcinoma by oral administration of a potent inhibitor of the vascular endothelial growth factor receptor tyrosine kinases.  Int J Oncol. 2000;  16 445-454
• 39 Zucker S, Lysik R M, Zarrabi M H. et al . M(r) 92,000 type IV collagenase is increased in plasma of patients with colon cancer and breast cancer.  Cancer Res. 1993;  53 140-146
• 40 Beattie G J, Smyth J F. Phase I study of intraperitoneal metalloproteinase inhibitor BB94 in patients with malignant ascites.  Clin Cancer Res. 1998;  4 1899-1902
• 41 Cairns W, Malone R. Octreotide as an agent for the relief of malignant ascites in palliative care patients.  Palliat Med. 1999;  13 429-430
• 42 Bodisch A, Muschitz C, Karthaus M. Maligner Ascites – Möglichkeiten der Symptomkontrolle.  Wien Med Wochenschr. 2008;  158 687-694
• 43 Mahler F, Rapin C H, Macgee W. Corynebacterium parvum as palliative treatment in malignant ascites.  J Palliat Care. 1988;  4 58-62
• 44 Katano M, Torisu M. New approach to management of malignant ascites with a streptococcal preparation, OK-432. II. Intraperitoneal inflammatory cell-mediated tumor cell destruction.  Surgery. 1983;  93 365-373
• 45 Torisu M, Katano M, Kimura Y. et al . New approach to management of malignant ascites with a streptococcal preparation, OK-432. I. Improvement of host immunity and prolongation of survival.  Surgery. 1983;  93 357-364
• 46 SIGN, Scottish Intercollegiate Guidelines Network .http://www.sign.ac.uk/methodology/index.html; Stand:. 09.07.2009
• 47 Hentrich M, Hartenstein R. Behandlung maligner Körperhöhlenergüsse.  Der Onkologe. 1997;  3 163-173