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Case History

Image not available. An 84-year-old woman with stable angina, a history of a previous transient ischaemic attack (TIA) and chronic obstructive pulmonary disease presents with abdominal distension, lower limb oedema and anorexia. Her Eastern Cooperative Oncology Group (ECOG) performance status is 2. Computed tomography (CT) of the abdomen shows the presence of marked ascites, diffuse omental thickening and a possible mass on the right ovary.

What differential diagnoses would you consider?

How would you approach further diagnosis and management?

Background

What differential diagnoses would you consider?

Image not available. Non-malignant causes account for about 80% of all cases of ascites. These include raised right atrial pressure secondary to cardiac disease or constrictive pericarditis, chronic pulmonary disease, and liver cirrhosis. The CT findings in the present case point to a malignant cause. The most likely diagnosis is epithelial carcinoma of the ovary or primary peritoneal carcinoma. This is compatible with the CT findings and a fairly common malignancy in this age group. It is also possible that the woman has an upper gastrointestinal malignancy such as gastric or pancreatic carcinoma, causing ascites and a secondary ovarian metastasis (Krukenberg's tumour). This is less likely, although not impossible, as the CT scan suggests no abnormality in the pancreas or stomach. Occasionally lobular breast cancer may present as pelvic disease with ascites and therefore a full clinical examination of the breast should be undertaken. However, it is more common in younger women than in this patient's age group. Finally, non-Hodgkin's lymphoma may occasionally present as ascites and peritoneal disease.

Discussion

How would you approach further diagnosis and management?

Image not available. The diagnosis and management should be approached with the twin goal of symptom control and pursuing a diagnosis insofar as further treatment would be feasible. The logical first step is therapeutic ascitic drainage, which may also yield a diagnosis on cytological examination. Guidelines have been developed on paracentesis for ascites related to malignancy. These emphasize carrying out ultrasound investigations only in cases of uncertainty, allowing up to 5 l of fluid to drain without clamping, leaving the drain in for no more that 6 hours and giving intravenous fluid only when specifically indicated.1

In the present case, particular attention should be paid to the patient's cardiovascular status during drainage because of her age and comorbidity. If adenocarcinoma cells are seen in the ascitic fluid, the morphology and/or immunohistochemical staining may support a diagnosis of ovarian or peritoneal carcinoma. This would also be supported by extremely elevated serum concentrations of CA125. However, serum CA125 is not specific for ovarian malignancy and may be moderately elevated in almost any cancer presenting with ascites and peritoneal disease. Gastrointestinal or lobular breast cancer may also be distinguishable on cytological examination, lobular breast cancer being characterized by hormone receptor positivity. A finding of peritoneal lymphocytosis may prove less definitive as reactive lymphocytosis ...

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