Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Malignancy-related ascites

Bruce A Runyon, MD
Section Editors
Lawrence S Friedman, MD
Eduardo Bruera, MD
Don S Dizon, MD, FACP
Deputy Editors
Anne C Travis, MD, MSc, FACG, AGAF
Diane MF Savarese, MD


Among patients with ascites in the United States, most (85 percent) have cirrhosis and portal hypertension [1]. Malignancy-related ascites is much less common, accounting for or contributing to ascites formation in approximately 7 percent of patients [1]. Some patients have two causes for ascites formation (eg, cirrhosis plus peritoneal carcinomatosis).

This topic will review malignancy-related ascites. A general approach to the evaluation of patients with ascites, the management of patients with ascites in the setting of cirrhosis, and less common causes of ascites are presented separately. (See "Evaluation of adults with ascites" and "Ascites in adults with cirrhosis: Initial therapy" and "Ascites in adults with cirrhosis: Diuretic-resistant ascites" and "Chylous, bloody, and pancreatic ascites".)


Malignancy-related ascites may be seen with several tumors, including malignancies of the ovary, breast, colon, lung, pancreas, and liver. In addition, lymphoma can be complicated by chylous ascites. There is a common misconception that malignancy-related ascites is synonymous with peritoneal carcinomatosis [2]. Malignant disease can cause ascites by at least six mechanisms (table 1) [3]. Thus, the phrase "malignancy-related ascites" is a more appropriate descriptor than "malignant ascites" since it includes all of these causes.

Influence of tumor type — Ascites typically develops in the setting of recurrent and/or advanced cancer. Patients may have a history of metastases to the peritoneum or liver, enlarged abdominal lymph nodes, or a large tumor burden prior to the development of ascites. The origin of the primary tumor has an impact on the sites of abdominal metastases and the etiology of the ascites [3]:

Malignancies of ovarian and urinary bladder origin as well as peritoneal mesothelioma tend to cause peritoneal carcinomatosis. In such cases, the accumulation of fluid is the result of blockage of the draining lymphatic channels (which normally keep the amount of intraperitoneal fluid low) and increased vascular permeability.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Jun 16, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Runyon BA, Montano AA, Akriviadis EA, et al. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med 1992; 117:215.
  2. Smith EM, Jayson GC. The current and future management of malignant ascites. Clin Oncol (R Coll Radiol) 2003; 15:59.
  3. Runyon BA, Hoefs JC, Morgan TR. Ascitic fluid analysis in malignancy-related ascites. Hepatology 1988; 8:1104.
  4. Press OW, Press NO, Kaufman SD. Evaluation and management of chylous ascites. Ann Intern Med 1982; 96:358.
  5. Giannini EG, Marabotto E, Savarino V, et al. Hepatocellular carcinoma in patients with cryptogenic cirrhosis. Clin Gastroenterol Hepatol 2009; 7:580.
  6. Runyon BA. Management of adult patients with ascites caused by cirrhosis. Hepatology 1998; 27:264.
  7. Runyon BA. Ascites and spontaneous bacterial peritonitis. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease. Pathophysiology/Diagnosis/ Management, 8th ed, Feldman M, Friedman LS, Brandt LJ (Eds), WB Saunders, Philadelphia 2006. p.1935.
  8. Runyon BA. Malignancy-related ascites and ascitic fluid "humoral tests of malignancy". J Clin Gastroenterol 1994; 18:94.
  9. Rector WG Jr. Spontaneous chylous ascites of cirrhosis. J Clin Gastroenterol 1984; 6:369.
  10. Cardozo PL. A critical evaluation of 3000 cytologic analyses of pleural fluid, ascitic fluid, and pericardial fluid. Acta Cyto 1966; 10:455.
  11. Decker D, Stratmann H, Springer W, et al. Benign and malignant cells in effusions: diagnostic value of image DNA cytometry in comparison to cytological analysis. Pathol Res Pract 1998; 194:791.
  12. Kielhorn E, Schofield K, Rimm DL. Use of magnetic enrichment for detection of carcinoma cells in fluid specimens. Cancer 2002; 94:205.
  13. Chetty R, Learmonth GM, Taylor DA. Giant cell hepatocellular carcinoma. Cytopathology 1990; 1:233.
  14. Falconieri G, Zanconati F, Colautti I, et al. Effusion cytology of hepatocellular carcinoma. Acta Cytol 1995; 39:893.
  15. Cruikshank DP, Buchsbaum HJ. Effects of rapid paracentesis. Cardiovascular dynamics and body fluid composition. JAMA 1973; 225:1361.
  16. Loewenstein MS, Rittgers RA, Feinerman AE, et al. Carcinoembryonic antigen assay of ascites and detection of malignancy. Ann Intern Med 1978; 88:635.
  17. Patel NP, Taylor CA, Levine EA, et al. Cytomorphologic features of primary peritoneal mesothelioma in effusion, washing, and fine-needle aspiration biopsy specimens: examination of 49 cases at one institution, including post-intraperitoneal hyperthermic chemotherapy findings. Am J Clin Pathol 2007; 128:414.
  18. Hassan R, Alexander R, Antman K, et al. Current treatment options and biology of peritoneal mesothelioma: meeting summary of the first NIH peritoneal mesothelioma conference. Ann Oncol 2006; 17:1615.
  19. Zuckerman E, Lanir A, Sabo E, et al. Cancer antigen 125: a sensitive marker of ascites in patients with liver cirrhosis. Am J Gastroenterol 1999; 94:1613.
  20. Barker SD, Casado E, Gomez-Navarro J, et al. An immunomagnetic-based method for the purification of ovarian cancer cells from patient-derived ascites. Gynecol Oncol 2001; 82:57.
  21. Pinto MM. DNA analysis of malignant effusions. Comparison with cytologic diagnosis and carcinoembryonic antigen content. Anal Quant Cytol Histol 1992; 14:222.
  22. Gulyás M, Kaposi AD, Elek G, et al. Value of carcinoembryonic antigen (CEA) and cholesterol assays of ascitic fluid in cases of inconclusive cytology. J Clin Pathol 2001; 54:831.
  23. Sari R, Yildirim B, Sevinc A, et al. The importance of serum and ascites fluid alpha-fetoprotein, carcinoembryonic antigen, CA 19-9, and CA 15-3 levels in differential diagnosis of ascites etiology. Hepatogastroenterology 2001; 48:1616.
  24. Chen SJ, Wang SS, Lu CW, et al. Clinical value of tumour markers and serum-ascites albumin gradient in the diagnosis of malignancy-related ascites. J Gastroenterol Hepatol 1994; 9:396.
  25. Torresini RJ, Prolla JC, Diehl AR, et al. Combined carcinoembryonic antigen and cytopathologic examination in ascites. Acta Cytol 2000; 44:778.
  26. Pinto MM. CA-15.3 assay in effusions: comparison with carcinoembryonic antigen and CA-125 assay and cytologic diagnosis. Acta Cytol 1996; 40:437.
  27. Numnum TM, Rocconi RP, Whitworth J, Barnes MN. The use of bevacizumab to palliate symptomatic ascites in patients with refractory ovarian carcinoma. Gynecol Oncol 2006; 102:425.
  28. Lee CM, Changchien CS, Shyu WC, Liaw YF. Serum-ascites albumin concentration gradient and ascites fibronectin in the diagnosis of malignant ascites. Cancer 1992; 70:2057.
  29. Que Y, Wang X, Liu Y, et al. Ultrasound-guided biopsy of greater omentum: an effective method to trace the origin of unclear ascites. Eur J Radiol 2009; 70:331.
  30. Pombo F, Rodriguez E, Martin R, Lago M. CT-guided core-needle biopsy in omental pathology. Acta Radiol 1997; 38:978.
  31. Becker G, Galandi D, Blum HE. Malignant ascites: systematic review and guideline for treatment. Eur J Cancer 2006; 42:589.
  32. Saif MW, Siddiqui IA, Sohail MA. Management of ascites due to gastrointestinal malignancy. Ann Saudi Med 2009; 29:369.
  33. Stephenson J, Gilbert J. The development of clinical guidelines on paracentesis for ascites related to malignancy. Palliat Med 2002; 16:213.
  34. Zama IN, Edgar M. Management of symptomatic ascites in hospice patients with paracentesis: a case series report. Am J Hosp Palliat Care 2012; 29:405.
  35. O'Neill MJ, Weissleder R, Gervais DA, et al. Tunneled peritoneal catheter placement under sonographic and fluoroscopic guidance in the palliative treatment of malignant ascites. AJR Am J Roentgenol 2001; 177:615.
  36. Barnett TD, 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.
  37. Rosenberg S, Courtney A, Nemcek AA Jr, Omary RA. Comparison of percutaneous management techniques for recurrent malignant ascites. J Vasc Interv Radiol 2004; 15:1129.
  38. Savin MA, Kirsch MJ, Romano WJ, et al. Peritoneal ports for treatment of intractable ascites. J Vasc Interv Radiol 2005; 16:363.
  39. Brooks RA, Herzog TJ. Long-term semi-permanent catheter use for the palliation of malignant ascites. Gynecol Oncol 2006; 101:360.
  40. Coupe NA, Cox K, Clark K, et al. Outcomes of permanent peritoneal ports for the management of recurrent malignant ascites. J Palliat Med 2013; 16:938.
  41. Lungren MP, Kim CY, Stewart JK, et al. Tunneled peritoneal drainage catheter placement for refractory ascites: single-center experience in 188 patients. J Vasc Interv Radiol 2013; 24:1303.
  42. Tapping CR, Ling L, Razack A. PleurX drain use in the management of malignant ascites: safety, complications, long-term patency and factors predictive of success. Br J Radiol 2012; 85:623.
  43. Narayanan G, Pezeshkmehr A, Venkat S, et al. Safety and efficacy of the PleurX catheter for the treatment of malignant ascites. J Palliat Med 2014; 17:906.
  44. Burleigh J, Mehta Z, Ellison N. Tunneled Indwelling Catheters for Malignant Ascites #308. J Palliat Med 2016; 19:671.
  45. Kirk IR, Carrasco CH, Lawrence DD, et al. Intraperitoneal catheters: percutaneous placement with fluoroscopic guidance. J Vasc Interv Radiol 1993; 4:299.
  46. Halpin TF, McCann TO. Dynamics of body fluids following the rapid removal of large volumes of ascites. Am J Obstet Gynecol 1971; 110:103.
  47. Pockros PJ, Esrason KT, Nguyen C, et al. Mobilization of malignant ascites with diuretics is dependent on ascitic fluid characteristics. Gastroenterology 1992; 103:1302.
  48. Tomiyama K, Takahashi M, Fujii T, et al. Improved quality of life for malignant ascites patients by Denver peritoneovenous shunts. Anticancer Res 2006; 26:2393.
  49. Hussain FF, Meer ZF, Lopez AJ. Peritoneovenous shunt insertion for intractable ascites: a district general hospital experience. Cardiovasc Intervent Radiol 2004; 27:325.
  50. Schumacher DL, Saclarides TJ, Staren ED. Peritoneovenous shunts for palliation of the patient with malignant ascites. Ann Surg Oncol 1994; 1:378.
  51. Cannistra SA. Cancer of the ovary. N Engl J Med 2004; 351:2519.
  52. Aleem A, Siddiqui N. Chronic myeloid leukemia presenting with extramedullary disease as massive ascites responding to imatinib mesylate. Leuk Lymphoma 2005; 46:1097.
  53. Ng T, Pagliuca A, Mufti GJ. Intraperitoneal rituximab: an effective measure to control recurrent abdominal ascites due to non-Hodgkin's lymphoma. Ann Hematol 2002; 81:405.
  54. Kitayama J, Ishigami H, Kaisaki S, et al. Weekly intravenous and intraperitoneal paclitaxel combined with S-1 for malignant ascites due to advanced gastric cancer. Oncology 2010; 78:40.
  55. Randle RW, Swett KR, Swords DS, et al. Efficacy of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy in the management of malignant ascites. Ann Surg Oncol 2014; 21:1474.
  56. Went PT, Lugli A, Meier S, et al. Frequent EpCam protein expression in human carcinomas. Hum Pathol 2004; 35:122.
  57. Goéré D, Flament C, Rusakiewicz S, et al. Potent immunomodulatory effects of the trifunctional antibody catumaxomab. Cancer Res 2013; 73:4663.
  58. Heiss MM, Murawa P, Koralewski P, et al. The trifunctional antibody catumaxomab for the treatment of malignant ascites due to epithelial cancer: Results of a prospective randomized phase II/III trial. Int J Cancer 2010; 127:2209.
  59. Ayantunde AA, Parsons SL. Pattern and prognostic factors in patients with malignant ascites: a retrospective study. Ann Oncol 2007; 18:945.