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An adjunct to cytology to differentiate between malignancy-related ascites and benign causes of ascites formation
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.
Alpha-fetoprotein (AFP) measurement in serum is used in the management of patients with hepatocellular carcinoma (HCC). Measurement of AFP in ascites fluid might be useful, when used in conjunction with cytology, in patients with a history of HCC and in whom a cause of peritoneal fluid accumulation is uncertain.
An interpretive report will be provided.
A peritoneal fluid alpha-fetoprotein (AFP) concentration >6.0 ng/mL is suspicious but not diagnostic of ascites related to hepatocellular carcinoma (HCC). This clinical decision limit cutoff yielded a sensitivity of 58%, specificity of 96% in a study of 137 patients presenting with ascites. AFP concentrations were significantly higher in ascites caused by HCC. Ascites caused by malignancies other than HCC routinely had AFP concentrations <6.0 ng/mL. Therefore, negative results should be interpreted with caution.
Do not use peritoneal fluid alpha-fetoprotein (AFP) concentration as absolute evidence of the presence or the absence of malignant disease. The AFP 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.
AFP values are method-dependent; therefore, the same method should be used to serially monitor patients.
An in-house study was performed to select a clinical decision limit to differentiate between malignancy-related and benign causes of ascites with high specificity. The study included 83 cases of benign ascites and 54 cases of malignancy-related ascites. Within the malignancy-related ascites, there were 12 cases of hepatocellular carcinoma (HCC). Using a clinical decision limit cutoff of >6 ng/mL, the specificity was 96% for the benign ascites group. The sensitivity for the HCC was 58%.
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 Nov-Dec;48(42):1616-1621