OncologyTier 1Disease (DEADMAN)

Metastatic disease manifestations - cardiac tamponade or malignant pleural effusion and ascites

Description

Three malignant effusion syndromes sharing one mechanism - tumour infiltration of a serosal surface -> fluid accumulation in a closed space - differing only in which cavity fills
Malignant pericardial effusion/tamponade - fluid in the pericardial sac impairing cardiac filling - oncological emergency
Malignant pleural effusion (MPE) - fluid in the pleural space, causing dyspnoea
Malignant ascites - fluid in the peritoneal cavity from peritoneal carcinomatosis
Any one confirms incurable, disseminated disease in a patient with known malignancy, or is itself the presenting sign of an occult cancer

MPE - commonest causes: lung, breast cancer, lymphoma (~75% of cases combined)
Malignant ascites - commonest causes: ovarian, GI (gastric, colorectal, pancreatic), breast cancer
Malignant pericardial effusion - commonest causes: lung cancer, breast cancer, lymphoma, melanoma
Each signals advanced/metastatic disease and independently predicts poor prognosis

Direct tumour seeding of the serosal surface (pericardium, pleura, peritoneum) -> increased vascular permeability (VEGF-driven) and lymphatic obstruction -> net fluid accumulation exceeding drainage capacity
Tamponade physiology: pericardial fluid accumulates faster than the pericardium can stretch -> rising intrapericardial pressure -> impaired diastolic filling -> reduced cardiac output - rate of accumulation matters more than absolute volume
Malignant ascites - additional contribution from hypoalbuminaemia (reduced oncotic pressure) and portal/lymphatic obstruction from bulky peritoneal disease/liver metastases

Cardiac tamponade

Beck's triad (hypotension, raised JVP, muffled heart sounds) - often incomplete clinically
Pulsus paradoxus (>10mmHg inspiratory fall in systolic BP), tachycardia, dyspnoea
Echocardiography - diagnostic: effusion + diastolic RV collapse, RA systolic collapse, exaggerated respiratory variation in mitral/tricuspid inflow

Malignant pleural effusion

Progressive dyspnoea, dull to percussion, reduced breath sounds; CXR/CT confirms
Pleural fluid cytology - confirms malignant cells in the majority; exudate by Light's criteria
Consider pleural biopsy (image-guided or thoracoscopic) if cytology negative but high suspicion persists

Malignant ascites

Progressive abdominal distension, shifting dullness, fluid wave
Ascitic fluid cytology - confirms malignant cells; SAAG <11g/L typical (high protein, exudative, unlike the transudative SAAG >=11g/L pattern of portal hypertension)

A. Cardiac tamponade - emergency

Urgent pericardiocentesis (echo-guided) - drains fluid and is diagnostic (send for cytology)
Pericardial window (surgical or percutaneous balloon) for recurrent/loculated effusion - definitive, reduces recurrence versus needle drainage alone
Treat the underlying malignancy with systemic therapy once stabilised, where a treatment option exists

B. Malignant pleural effusion

Therapeutic thoracentesis - first step, symptomatic relief and diagnostic
For recurrent/symptomatic MPE, both indwelling pleural catheter (IPC) and pleurodesis (talc) are accepted first-line options - neither is conclusively superior; choice guided by patient preference, performance status, expected survival, and whether the lung re-expands fully (IPC preferred if trapped lung prevents effective pleurodesis)
IPC - avoids hospital admission, allows outpatient intermittent drainage, higher catheter-site infection risk
Talc pleurodesis - durable effusion control if successful, requires the lung to fully re-expand and typically an inpatient admission
Systemic anti-cancer therapy where the tumour is responsive (e.g. hormone-sensitive breast cancer, lymphoma)

C. Malignant ascites

Therapeutic paracentesis - mainstay symptomatic management, repeated as needed
Permanent peritoneal catheter for recurrent ascites requiring frequent drainage - reduces need for repeated hospital procedures
Diuretics - limited efficacy compared with cirrhotic ascites (malignant ascites is exudative, less renin-angiotensin driven) but sometimes trialled
Systemic therapy for chemosensitive tumours; intraperitoneal chemotherapy in select scenarios (e.g. ovarian cancer)

Advanced/metastatic solid organ malignancy (lung, breast, ovarian, GI) and lymphoma
Hypoalbuminaemia, cachexia - compound ascites/effusion formation
Coexistent malignant effusions at multiple sites (pleural + pericardial + peritoneal) common with advanced disseminated disease

All three carry a poor prognostic significance - median survival after diagnosis of malignant effusion is typically months, varying by tumour type and chemosensitivity
Recurrence is common after simple drainage alone without a definitive procedure (pleurodesis/IPC, pericardial window, peritoneal catheter)
Untreated tamponade - rapidly fatal via obstructive shock; the only emergency of the three requiring immediate intervention
Symptom control and quality of life are central management goals once effusions reflect incurable disease - palliative care input is appropriate alongside oncological management

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