Dense ascites: CT manifestations and clinical implications.

Ascites is a not infrequent finding on CT. Causes of ascites include congestive heart failure, hypoalbuminemia, cirrhosis, inflammation, and neoplasm. In most cases the attenuation of ascites is that of clear fluid, measuring around 0 HU. Rarely, however, a considerably higher density of ascites is seen. This finding may be a challenge for the radiologist, particularly since some of the conditions associated with it are of major clinical importance requiring prompt intervention.

Primary effusion lymphoma. A case report.

BACKGROUND: Primary effusion lymphoma (PEL) is a rare type of lymphoma that presents as an effusion, seldom with evidence of a solid neoplasm elsewhere; thus, cytology is the basic diagnostic method. It usually occurs in HIV-positive males with a history of Kaposi's sarcoma (KS), and DNA sequences of human herpesvirus 8 (HHV-8) are detected by molecular analysis. The distinct morphologic, immunophenotypic, molecular and clinical characteristics render this neoplasm a new pathologic entity. CASE: A 57-year-old, HIV-positive man presented to the hospital with ascites and absence of neoplasm on radiologic investigation. Cytologic evaluation of the ascitic fluid revealed the presence of highly atypical, pleomorphic lymphoid cells. Immunocytochemistry of the lymphoma cells was positive for CD45 (leukocyte common antigen), CD30 and epithelial membrane antigen antigens and negative for panB, panT and cytokeratin antigens. DNA sequences of HHV-8 were identified by polymerase chain reaction (PCR), and DNA ploidy analysis showed aneuploidy. The patient died 5 months after the diagnosis. CONCLUSION: Conventional and ThinPrep (Cytyc Corp., Boxborough, Massachusetts, U.S.A.) cytology, in combination with immunocytochemistry and PCR for HHV-8 DNA sequences, can lead to an accurate diagnosis of PEL. DNA ploidy analysis confirms the aggressive nature of this neoplasm.

[Report of two cases with pleural effusion and ascites that responded dramatically to the combination of thalidomide, celecoxib, irinotecan, and CDDP infused in thoracic and abdominal cavities].

Malignant pleural effusion (PE) and ascites are associated with highly symptomatic, advanced-stage cancers. These fluid accumulations cause severe symptoms such as abdominal distention, shortness of breath, cachexia, anorexia, and fatigue. Malignant PE and ascites have consistently been shown to indicate a poor prognosis in advanced-stage cancer patients, being associated with high morbidity and mortality. The efficacy of this treatment is variable and does not prolong the survival of cancer patients. Clearly, a more effective therapy for malignant PE and ascites is needed. Vascular permeability factor (VPF) from malignant ascites and PE have been hypothesized to be responsible for the fluid accumulations. In addition, malignant PE and ascites contain high levels of biologically active VEGF. VEGF was discovered as a potent angiogenesis stimulator and recognized to be VPF. Increased amounts of COX-2 have been detected in epithelial and stromal cells and COX-2 in mammary tissue is sufficient to induce cancer. It is suggested that COX-2 stimulates angiogenesis. A combination of molecular target inhibitors (thalidomide and celecoxib) and standard cytotoxic drugs appear to increase efficacy of each drug, decrease the side effects of cytotoxic drugs and prolong life.

Ascitis en los pacientes oncológicos. Fisiopatogenia y opciones de tratamiento / Ascites in cancer patients. Physiopathology and therapeutic options

La ascitis definida como la presencia de fluido en la cavidad peritoneal, es un hallazgo observado en diversas entidades patológicas, principalmente en enfermedades hepáticas y oncológicas. Los pacientes con cáncer desarrollan asicitis en un 15 a 50 por ciento. Los carcinomas de ovario, mama, endometrio, colon, estómago, páncreas y bronquios tienen una alta incidencia de ascitis. Su patogénesis involucra varios factores como son: elevación de la presión hidrostática, disminución de la presión coloido-osmótica, aumento en la permeabilidad capilar y escape de líquido a la cavidad peritoneal. El líquido de ascitis es analizado con fines diagnósticos (gradiente de albúmina sérica-ascítica, concentración de amilasa y triglicéridos; cuenta celular, cultivo y tinción de gram; pH, citología, determinación de glucosa y fibronectina) y terapéuticos; siendo de vital importancia la valoración clínica para el diagnóstico, apoyándonos en signos clásicos como son el abombamiento de los flancos, el signo de la ola, signo de efusión pleural, edema de miembros pélvicos, genitales, etc. Y en determinados casos será necesario el apoyo a través de estudios de gabinete para corroborar la presencia de líquido en cavidad abdominal. El tratamiento de esta entidad dependerá de su etiología. En pacientes no oncológicos la restricción de sal en la dieta y los esquemas de diuréticos dan buenos resultados. En pacientes oncológicos puede implementarse la quimioterapia intraperitoneal. Los casos refractarios o con escasa respuesta son candidatos a drenaje del líquido ascítico a través de múltiples técnicas como son la paracentesis clásica, paracentesis total, colocación de drenaje semi-permanente o permanente con o sin la ayuda de imagenología, cortocircuitos, etc., valorando previo procedimiento las condiciones globales del paciente para obtener un máximo beneficio con un mínimo riesgo. Se concluye que la ascitis de cualquier etiología comprende diversas alteraciones fisiopatológicas que han provocado la implementación de diversas modalidades de manejo tanto farmacológico como invasivas para el tratamiento eficaz de la misma (AU)

[A patient with stage IIIc ovarian cancer with massive ascites who was chemotherapy resistant showed complete response with intraperitoneal hyperthermic chemoperfusion].

Intraperitoneal hyperthermic chemoperfusion (IHCP) was performed on a stage IIIc ovarian cancer patient with massive ascites who had been chemotherapy resistant. Complete response was observed after the treatment. A 59-year-old woman with advanced ovarian cancer complained of massive refractory ascites after 2 years' history of chemotherapy. The patient received IHCP combined with surgery to remove the primary tumors and omentum. Soon after the treatment, the massive ascites disappeared and CA125 level decreased to normal. The patient remained free of ascites for 14 months after the treatment.

[Bilateral pneumothorax and tamponade after acupuncture]. / Pneumothorax bilatéral et tamponnade après acupuncture.

INTRODUCTION: The "target" of acupuncture is usually the muscle, but it occasionally approaches other anatomical structures such as the pleura, which may subsequently suffer damage. OBSERVATION: During a session of acupuncture, a 25-year-old woman had a malaise with shock and neurological disorders. The initial examinations revealed a bilateral pneumothorax associated with pericardial and peritoneal effusions. Symptomatic reanimation combining dopamine, left pleural draining and pericardial puncture led to rapid haemodynamic improvement. The etiological exploration, having eliminated an underlying pathology, concluded in the diagnosis of tamponade and bilateral pneumothorax following a session of acupuncture. COMMENTS: Our patient presented the association of two traumatic complications of acupuncture: cardiac tamponade due to haemopericardium and bilateral pneumothorax. Although these complications are rare, they must be known.

Evaluation of intraperitoneal vincristine in malignant peritoneal effusion.

The efficacy and safety of intraperitoneal administration of vincristine sulphate was determined in mice bearing Ehrlich ascitic carcinoma. The tumor bearing animals were administered with 0.5 mg/kg body weight (b.wt) of freshly prepared vincristine sulphate intraperitoneally on day 6 after tumor transplantation followed by drug administration once daily 5 days a week consecutively. The observations regarding the survival, alteration in the volume of peritoneal fluid, increase in life span and pathological changes in the liver, kidney, gastrointestinal tract and bone tissues were made. The vincristine sulphate treatment reduced the malignant cell population significantly and there were no significant changes in the histological picture of liver, kidney, bone, except the intestine, where atropy of villi demonstrating nests and cords of uniform small round cells were observed. Our experimental data suggests that intraperitoneal administration of vincristine is beneficial in malignant peritoneal effusion.

[A case of pancreatic tail cancer with peritoneal carcinosis treated with gemcitabine hydrochloride].

This paper reports a case of pancreatic tail cancer with peritoneal carcinosis that showed a good response to gemcitabine hydrochloride. A 52-year-old man, who had undergone a gastrojejunostomy for pancreatic tail cancer with peritoneal carcinosis, was referred to our hospital for anticancer therapy. Laboratory data on admission disclosed hypoalbuminemia and a high level of serum CA19-9 (156 IU/ml). These findings indicated that the patient was in a cancer cachexic condition. Gemcitabine hydrochloride treatment (1,000 mg/m2/week x 3/4 weeks) was started. Ascites disappeared after 2 courses of treatment, and the tumor was reduced (62% of the reduction rate) after 5 courses of treatment. Furthermore, the serum CA19-9 level and serum albumin value returned to normal, and performance status was improved to grade 1. The patient has been well for 15 months after the diagnosis of pancreatic tail cancer with peritoneal carcinosis. Gemcitabine hydrochloride may have not only reduced the tumor volume and improved cancer cachexic condition, but also prolonged the survival time in this case.

[Ultrasound investigation and mini-invasive ultrasound-assisted technologies in diagnosis and treatment of extra-organ separate fluid formations in abdominal cavity]. / Ul'trazvukovoe issledovanie i maloinvazivnye tekhnologii pod kontrolem UZI v diagnostike i lechenii vneorgannykh otgranichennykh skoplenii zhidkosti v briushnoi polosti.

The authors discuss the use of ultrasound-assisted percutaneous puncture and drainage for diagnosis and treatment of extraorganic separate fluid formations in abdominal cavity (abscess, limited non-infected fluid formation, hematoma with clotted blood), determination of their sizes and obtaining material for laboratory study. 307 patients with various extraorganic separate fluid in formations in abdominal cavity were examined. Ultrasonic symptoms of abscess were described in 54 patients, of limited non-infected fluid formation--in 234, of hematoma with clotted blood in 19 patients. 146 patients were cured conservatively, 75 patients underwent US-assisted puncture, 76--US-assisted drainage. Mean time of drainage was 14 days (ranged from 10 to 20). There were neither complications nor lethal outcomes. Ultrasound examination and US-assisted mini-invasive surgery permit to detect precisely the nature of fluid formation, to perform timely and low-traumatic treatment.

The lactate dehydrogenases in malignant and non-malignant diseases.

The objective of this paper was to determine different patterns of Lactate Dehydrogenase(LD) isoenzymes in serum, pleural effusions and ascitic fluid collections and their usefulness in the differential diagnosis of malignant and non-malignant diseases. It was a case control study carried out at the Lagos University Teaching Hospital. Forty- six patients with pleural or ascitic fluid collection (male and female, age range between 18 and 65 years) made up of Twenty-two patients with malignant diseases and twenty-four with non- malignant diseases were recruited. Control group comprised 50 apparently healthy subjects of both sexes with age ranging between 18 and 65 years. Serum, pleural and ascitic fluid collections were assayed for total lactate dehydrogenase(LD) and it s isoenzymes. Total LD was estimated using the pyruvate to lactate reaction. LD isoenzyme analysis was estimated by cellulose acetate electrophoresis and stained with formazan. The mean total serum LD activity in the disease groups (malignant and non-malignant) was significantly higher than the mean total serum LD activity in the control group. The pleural fluid LD was highest in patients with empyema thoracis. Five isoenzymes of LD (LD1 - LD5) were present in both control and patient sera. The serum LD1 and LD2 isoenzymes were predominant in the controls. The serum LD4 and LD5 isoenzymes were predominant in the disease groups (malignant and non-malignant). LD4 and LD5 were the predominant isoenzymes in both pleural and ascitic fluids obtained in malignant and non-malignant diseases. Serum LD4 was significantly higher than serum LD5 in non-malignant disease while serum LD5 was significantly higher than serum LD4 in malignant disease. The types of malignancies could not be differentiated by serum and effusion fluid LD isoenzyme pattern. Pleural fluid total LD estimation is useful in monitoring patients on chest tubes and may be used to determine when to insert them. Serum LD4 and LD5 differentiates malignant from non-malignant disease but the effusion LD isoenzyme pattern does not.

[Usefulness of CEA, CA 15-3 and CA 125 tumor markers in the differential diagnostics of peritoneal effusion]. / Przydatnosc markerów nowotworowych CEA, CA 15-3 i CA 125 w diagnostyce plynów wysiekowych w jamie brzusznej.

To differentiate malignancy-related from non-malignant exudate is important for cancer diagnosis, determining clinical stage of the disease, establishing treatment strategy, and also for prognosis. Carcinoembryonic antigen (CEA), CA 15-3 and CA 125 levels were analysed in plasma and in peritoneal fluid of 37 cancer patients (13 with breast cancer, 18 with ovarian cancer and 6 with colorectal cancer) and 15 patients with peritoneal fluid not related to malignancy. CEA, CA 15-3 and CA 125 were measured by electrochemiluminescence assay (ECL). The results were correlated with cytological and histological findings as well as clinical data. Initial observations indicate that the analysis of tumour markers CEA, CA 15-3 and CA 125 may be useful in the differential diagnosis of peritoneal effusion.

[A case of advanced gastric cancer that was resectable after asctic fluid had disappeared following administration of TS-1].

A 60-year-old man who had suffered from epigastic pain and general malaise from November 1999 was admitted to our hospital due to Borrmann type 3 gastric cancer with ascites on December 7, 1999. We considered a radical B operation impossible, and placed the patient on neoadjuvant TS-1 chemotherapy consisting of 1 M tegafur, 0.4 M gimestat, and 1 M otastat potassium. There were no side effects other than Grade 1 nausea and mild loss of appetite throughout the chemotherapy. After 8 weeks of administration, the primary lesion was reduced in size, and ascitic fluid had disappeared on abdominal computed tomography images. Therefore, a total gastrectomy with splenectomy and D2 lymph node dissection was performed on March 31, 2000. This was a radical B operation that was not possible earlier. The pathological diagnosis was tub2, SE, N1, CY0, H0, P0, M0, INF gamma, ly1, v1, PM (-), DM (-) and the antitumor efficacy of TS-1 was Grade 2 histologically. The patient remains alive and in good condition with no relapse of the gastric cancer 8 months after surgery.

[Eosinophilic ascites as a presenting symptom of the hypereosinophilic syndrome].

We report a case of a 22 year old man with a history of bronchial asthma, suffering from diarrhea, eosinophilic ascites and prominent blood and bone marrow eosinophilia. The patient responded to corticosteroid treatment. Later, hydroxyurea was added to this treatment because of recurrence of eosinophilia, ascites and hepatosplenomegaly. Eosinophilic ascites is rarely the outstanding symptom of the hypereosinophilic syndrome. Following the exclusion of other reasons for eosinophilia, concomitant unexplained hepatosplenomegaly suggested the diagnosis of a hyperereosinophilic syndrome.