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Malignancy accounts for approximately 7% of cases of ascites formation. Malignant disease can cause ascites by various mechanisms including: peritoneal carcinomatosis (53%), massive liver metastasis causing portal hypertension (13%), peritoneal carcinomatosis plus massive liver metastasis (13%), hepatocellular carcinoma plus cirrhosis (7%), and chylous ascites due to lymphoma (7%). The evaluation and diagnosis of malignancy-related ascites is based on the patient clinical history, ascites fluid analysis, and imaging tests.
The overall sensitivity of cytology for the detection of malignancy-related ascites ranges from 58% to 75%. Cytology examination is most successful in patients with ascites related to peritoneal carcinomatosis as viable malignant cells are exfoliated into the ascitic fluid. However, only approximately 53% of patients with malignancy-related ascites have peritoneal carcinomatosis. Patients with other causes of malignancy-related ascites almost always have a negative cytology.
Carcinoembryonic antigen (CEA) is a glycoprotein that is shed from the surface of malignant cells. Measurement of CEA in ascitic fluid has been proposed as a helpful test in detecting malignancy-related ascites given the limited sensitivity of cytology.
An adjunct to cytology to differentiate between malignancy-related and benign causes of ascites formation
A peritoneal fluid carcinoembryonic antigen (CEA) concentration >6.0 ng/mL is suspicious but not diagnostic of malignancy-related ascites. This clinical decision limit cutoff yielded 48% sensitivity and 99% specificity in a study of 137 patients presenting with ascites. CEA concentrations were significantly higher in ascites caused by malignancies known to be associated with elevated serum CEA levels including lung, breast, ovarian, gastrointestinal, and colorectal cancers. However, ascites caused by other malignancies such as lymphoma, mesothelioma, leukemia, and melanoma and hepatocellular carcinoma, routinely had CEA concentrations <6.0 ng/mL. Therefore, negative results should be interpreted with caution, especially in patients who have or are suspected of having a malignancy not associated with elevated CEA levels in serum.
Do not use peritoneal fluid carcinoembryonic antigen (CEA) concentration as absolute evidence of the presence or the absence of malignant disease. The CEA result should be interpreted in conjunction with information from the clinical evaluation of the patient and other diagnostic procedures.
Immunometric assays can, in rare occasions, be subject to interferences such as "hooking" at very high analyte concentrations (false-low results) and heterophilic antibody interference (false-high results). If the clinical picture does not fit the laboratory result, these possibilities should be considered.
CEA values are method-dependent; therefore, the same method should be used if patients are serially monitored.
An interpretive report will be provided.
1. Torresini RJ, Prolla JC, Diehl AR, et al: Combined carcinoembryonic antigen and cytopathologic examination in ascites. Acta Cytol 2000;44(5):778-782
2. Tuzun Y, Yilmaz S, Dursun M, et al: How to increase the diagnostic value of malignancy-related ascites: discriminative ability of the ascitic tumour markers. J Int Med Res 2009;37(1):87-95