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Seminar in Palliative Care
September 26 – October 02, 2010
Salzburg, Austria
in Collaboration with
The
EPEC-O
TM
Education in Palliative and End-of-life Care - Oncology
Project
The EPEC-O Curriculum is produced by the EPECTM Project with major funding
provided by NCI, with supplemental funding provided by the Lance Armstrong
Foundation.
Fluid Metabolism,
Edema, Effusions
Jamie H. Von Roenn, MD
Northwestern University,
Feinberg School of Medicine,
Chicago, Illinois, USA
Ascites
Malignant ascites . . .
• Definition: accumulation of fluid in the
abdomen
. . . Malignant ascites
Epidemiology
• 10 % caused by malignancy
• 80 % of malignant ascites is epithelial:
Ovaries
Endometrium
Breast
Colon
GI tract
Pancreas
Runyon, et al. Hepatology, 1998.
. . . Malignant ascites
• Impact: dyspnea, early satiety, fatigue,
abdominal pain
• Prognosis: poor
Mean survival with malignant ascites
< 4 months
If chemo-responsive cancer,
eg, newly Dx ovarian ca,
mean survival = 6 months – 1 year
Key points
1. Pathophysiology
2. Assessment
3. Management
Pathophysiology . . .
• Normal physiology:
Intravascular pressure = extravascular
pressure
No extravascular fluid accumulation
• Ascites:
Fluid influx increases
Fluid outflow decreases
Fluid accumulates
. . . Pathophysiology
• Elevated hydrostatic pressure
e.g., congestive heart failure, cirrhosis
• Decreased osmotic pressure
e.g., nephrotic syndrome, malnutrition
• Fluid production > fluid resorption
( infections, malignancy )
Assessment . . .
History & symptoms
•
•
•
•
•
•
•
Ankle swelling
Weight gain
Girth
Fullness
Bloating
Discomfort
Heaviness
•
•
•
•
•
•
Indigestion
Nausea
Vomiting
Reflux
Umbilical changes
Hemorrhoids
. . . Assessment
Physical examination
•
•
•
•
Bulging flanks
Flank dullness
Shifting dullness
Fluid wave
Extra-abdominal
signs of ascites
•
•
•
•
•
•
Enlarged liver
Hernias
Scrotal edema
Lower extremity edema
Abdominal venous engorgement
Flattened, protuberant umbilicus
Diagnostic imaging
• If physical exam is equivocal
• Detects small amounts of fluid,
loculation
• ‘Ground Glass’ X-ray
• CT scan
Diagnostic paracentesis
•
•
•
•
•
Color
Cytology
Cell count
Total protein concentration
Serum-ascites albumin gradient
Hoefs J. Lab Clin Med, 1983.
Diagnosing ascites - Summary
• Malignant etiology likely when ascitic
fluid has:
Blood
Positive cytology
Absolute neutrophil count < 250 cells / ml
Total protein concentration > 25 gm / L
Serum-ascites albumin gradient < 11 gm / L
Management
• Goal: to relieve the symptoms
• With little or no discomfort –
don’t treat
• Before intervening, discuss
prognosis, benefits, risks
When to treat ?
• With these symptoms:
Dyspnea
Abdominal pain
Fatigue
Anorexia
Early satiety
Reduced exercise tolerance
Therapeutic options
•
•
•
•
•
Dietary restriction
Chemotherapy
Diuretics
Therapeutic paracentesis
Surgery
Dietary management
• Sodium and severe fluid restriction
Difficult for patients
Discuss benefits, burdens &
other treatment options first
Diuretics
• Effective
• Well-tolerated
• Treatment goals:
Remove only enough fluid to
manage the symptoms
Slow & gradual diuresis
Pockros J, et al. Gastroenterology, 1992.
Selecting a diuretic
• Spironolactone 25 mg – 50 mg / day
• Amiloride 5 mg / day
• Furosemide 20 mg / day
Precautions with diuretics
• Avoid salt substitutes
• Evaluate benefits & burdens
• Not appropriate in patients with:
Limited mobility
UT flow problems
Poor appetite, poor oral intake
Polypharmacy problems
Diuretic adverse effects
• Problems with
Sleep deprivation
Self-esteem
Skin
Safety
Fatigue
Hypotension
Therapeutic paracentesis
• Indications:
Respiratory distress
Diuretic failure
Rapid symptomatic relief
• Safe
• In clinic or home
Therapeutic paracentesis
technique
• Patient supine or •
semirecumbent
•
• Select site
• Cleanse,
•
disinfect skin
Insert
Attach 3-way
connector
Evacuate
• Reposition
Surgery
• Peritoneovenous shunts
Drains ascitic fluid into internal
jugular vein
Rarely done
• Tenckhoff, other catheters
Local anesthesia
Large volume ascites
Outpatient use
Barnett TD, Rubins J. J Vasc Intery Radio, 2002.
Burger JA, et al. Ann Oncol, 1997.
Summary . . .
• Ascites causes distress in patients
with advanced cancer
• Rule out nonmalignant causes
• Treatment is palliative
• Dietary, pharmacological, and
interventional options are available
Malignant Pleural
Effusions
Malignant pleural effusions . . .
• Definition: fluid accumulation in the
potential space between the visceral
(inner) layer covering the lungs and the
parietal (outer) layer covering the chest
wall
. . . Malignant pleural effusions
Impact:
•
•
•
•
Dyspnea
Cough
Chest pain
Decreased mobility and fear
Overview
•
•
•
•
•
•
•
Scope of the problem
Causes
Pathophysiology
Diagnosis
Prognosis
Management options
Treatment strategies
Impact
• > 25 % of newly diagnosed pleural
effusions are due to malignancy
• 50 % of cancer patients will develop a
pleural effusion
• In US, approx. 100,000 malignant
effusions / year
• Life expectancy 4 – 12 months
Causes
• Breast and lung cancer
• Lymphoma, GU, GI
• Unknown primary
50 – 65 %
25 %
7 – 15 %
Prognosis
• Mortality 54 % at 1 month,
84 % at 6 months
• Survival ~ 10 months where pleural
effusion is first evidence of cancer
• Known CA, exudate, negative cytology
poor prognosis compared to positive
cytology
• Role of pH, Karnofsky Performance
Scale ?
Key points
1. Pathophysiology
2. Assessment
3. Management
Pathophysiology
• Fluid production = fluid resorption
• Causes
Tumor cells blocking lymphatic drainage
Changes in colloid osmotic pressure due
to hypoalbuminemia
Assessment
• History of dyspnea, chest pain, cough
• Physical examination of decreased
breath sounds, dullness to percussion
. . . Assessment
• Symptoms: dyspnea, dry cough,
pleuritic pain, chest discomfort,
limited exercise tolerance
• Exam: decreased breath sounds,
dullness to auscultation and
percussion
• CXR PA, lateral and decubitus films
• Chest CT or U / S if loculated
Differential diagnosis
•
•
•
•
Parapneumonic effusion
Empyema
Chylothorax
Transudate
Benign vs.
malignant effusions . . .
• Light’s criteria
Pleural fluid LDH > 0.6
Serum LDH
Pleural fluid protein > 0.5
Serum protein
Pleural fluid LDH > 2 / 3 ULN
serum LDH
. . . Benign vs.
malignant effusions . . .
• Heffner meta-analysis:
Pleural LDH > 0.45 ULN
Pleural cholesterol > 45 mg / dl
Pleural protein > 2.9 gm / dl
Heffner 1997.
. . . Benign vs.
malignant effusions
• Cytology
Positive in approximately 55 – 65 %
initially
Yield up to 77 % on
3 pleural fluid samples
Management
Intrapleural
catheter
Doxycycline
pleurodesis
Initial drainage
97 %
68 %
Pleurodesis
46 %
54 %
Late
recurrence
13 %
21 %
13 % outpt
14 % inpt
Complications
Putnam 1999.
Management options
•
•
•
•
•
•
•
•
Thoracentesis
Tube thoracostomy
Small-bore chest tubes
Pleurodesis
Thoracoscopy
Intrapleural catheters
Pleuroperitoneal shunting
Subcutaneous access ports
Thoracentesis
•
•
•
•
Diagnostic, therapeutic
Temporary relief
Many contraindications
Risks:
Pneumothorax
Reexpansion pulmonary edema
( especially if > 1,500 ml removed )
Treatment
recommendations…
• Thoracentesis: diagnosis, palliation
until more definitive procedure,
medically ill, short-life expectancy
• Tube thoracostomy:
free-flowing effusions,
unable to tolerate general anesthesia
…Treatment
recommendations
• Thoracoscopy:
life expectancy > 3 months,
loculated effusions, biopsies
• Intrapleural catheters:
outpatient pleurodesis
Thoracoscopy benefits…
• Direct visualization of lung re-expansion
• Identify loculated areas and drain
• Administration of dry talc, chest tube
placement
• Confirm equal distribution of talc
…Thoracoscopy benefits
• Shorter hospital stay than tube
thoracostomy
• Diagnostic yield 90 %,
pleurodesis success rate 90%
Tube thoracostomy
and pleurodesis . . .
• More definitive than repeated
thoracentesis for recurrent effusions
• Chest tube 12 – 24 hr or until
drainage < 250 ml / 24 hr
. . . Tube thoracostomy
and pleurodesis
• Sclerosing agent when dry
Talc, bleomycin, doxycycline
Tube clamping controversial
Rotation vs. nonrotation
• Failure rate 10 – 40 %
• Most widely used and cost effective
method
Summary
Use comprehensive assessment and
pathophysiology-based therapy
to treat the cause and improve the
cancer experience