Supplemental Online Case Discussion: Management of Malignant Ascites in the Acute Oncology Setting

Case History A 57-year-old female presented to her local hospital with a 2-month history of retrosternal discomfort that was initially diagnosed as esophageal spasm. She had progressive symptoms, had regurgitation of food, and underwent upper gastrointestinal endoscopy. The stomach appeared grossly abnormal and had the morphological appearances of linitis plastica. Staging computed tomography (CT) showed a thickwalled stomach, omental nodularity, and large volume ascites. Biopsy found HER2-negative signet ring adenocarcinoma of gastric origin. Cytological analysis of her ascitic fluid was consistent with metastatic adenocarcinoma. She was staged as T3NXM1. She was seen in the oncology clinic and assessed as suitable for systemic treatment (performance status 1). Palliative epirubicin, cisplatin, and 5-fluorouracil (ECF) chemotherapy was commenced. She developed nausea, abdominal discomfort, and constipation and was admitted for therapeutic paracentesis. A total of 8 liters was removed; midprocedure, the drain was temporarily clamped at 5 liters to allow for hemodynamic adjustment. During the course of chemotherapy, the fluid re-accumulated rapidly, requiring repeat drainage. Consequently, to avoid repeated admissions for drainage, she underwent insertion of a PleurX peritoneal catheter (Becton Dickinson Global, CareFusion, San Diego, CA, http://www.carefusion.com/our-products/interventional-specialties/drainage/about-the-pleurx-drainagesystem/pleurx-drainage-system). This allowed weekly drainage by the district nursing team at home. Despite four cycles of ECF, she had disease progression, as evidenced by repeat accumulation of ascites. She generally deteriorated and was admitted to her local hospice, where she passed away 7 months from diagnosis.