A New Problem

I am very sorry you are going through this with your girlfriend. My condolences for the passing of your fathers wife. I can't imagine how emotionally distraught you must be. I really don't have any advice , I am not that familiar with those drugs. I am sure others will be along soon that can help you out. Sending you a hug.

I am terribly sorry to hear about the passing of your father's wife, and of your girlfriend's diagnosis. It is very loving of you to reach out on your girlfriend's behalf, and you are indeed a wonderful advocate for her.

If the type of cancer your girlfriend has is Lobular, it's not unusual for it to migrate to the abdominal area, where it sometimes precipitates ascites (fluid buildup). Since the fluid was tested for cancer, your girlfriend should request a copy of the pathology report, and specifically look for Estrogen Receptivity (ER), Progesterone Receptivity (PR) and HER2 receptivity. It is possible that the cancer cells may have changed their pathology, so this is crucial info because it may influence her future treatment. (In addition, your girlfriend should retain personal copies of all medical records and test results for ease of reference, and in case she seeks a second opinion).

Ascites can also prevent the patient from ingesting enough food, and as such it should be taken very seriously. Draining the area (as she has in the past) should be discussed with her doctor.

It is possible that your girlfriend's current treatment may help over time. Please discuss your girlfriend's supplemental therapies (such as Avemar) and her current therapy with her oncologist and naturopath to ensure they are compatible. I hope your girlfriend begins to feel better soon!

Below from my MBC Guide is information about ascites.You (and others) are welcome to request a complimentary copy of the 119 page booklet by visiting the top of this page:https://community.breastcancer.org/forum/8/topics/831507?page=2#idx_39

Patients with metastatic lobular breast cancer are more likely than are other types of metastatic breast cancer patients to have their cancer spread to the abdominal (gastric) area, the ovary, and/or the peritoneum (which is the membrane that lines the abdominal cavity and covers most of the abdominal organ).

Breast cancer metastasis to the stomach represents evidence of systemic disease and therefore systemic therapy, such as chemotherapy and/or hormonal therapy (rather than surgical resection) is indicated.In most cases, surgical resection is not possible due to local invasion.Some experts feel that surgical treatment should be reserved only for patients who develop complications such as obstruction or bleeding.However, one study showed that patients with metastasis only to the gastrointestinal tract who underwent palliative surgical resection tended to have a more prolonged median survival (44 vs. 9 months).The decision-making process for surgical intervention should be based on the clinical presentation and symptoms, the availability of chemotherapeutic options, and a quality of life discussion.From: http://ar.iiarjournals.org/content/29/11/4759.full

• Peritoneal metastasis (metastasis to the thin tissue lining the abdomen) is a bit difficult to treat, but recently a new procedure called Hyperthermic IntraPeritoneal Chemotherapy (HIPEC) has been developed and appears promising.This is a highly concentrated, heated chemotherapy treatment that is delivered directly to the abdomen during surgery.Of five patients treated in one study, one patient died of disease at 56 months, and 4 are alive and disease-free at 13, 45, 74 and 128 months.These encouraging outcomes suggest that cytoreduction (surgical removal of visible tumors) and HIPEC may be a viable approach to offer to highly selected patients with peritoneal carcinomatosis from breast cancer.From: http://www.ncbi.nlm.nih.gov/pubmed/23523180

It is possible that the doctor will recommend systemic therapy based upon the patient's hormonal and HER2 profile after cancer metastasizes to the above site(s).

Ascites (excess fluid):"Ascites" is a gastroenterological term that refers to an accumulation of fluid in the abdominal (peritoneal) cavity. The ascites can arise from tumors' expression of epithelial cell-adhesion molecule (EpCAM). Additionally, vascular endothelial growth factor (VEGF) has been cited as an important factor affecting vascular permeability, a key factor in ascites production.From: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC288034...

Ascites are generally evidenced by a distended stomach, shortness of breath, bloating, and/or other discomfort.Patients who believe they may have ascites should notify their doctors immediately.

In patients with cancer-related ascites, diet restrictions and/or diuretics will generally not be effective, although there have been some exceptions. Paracentesis (a procedure whereby fluid is taken out using a long, thin needle put through the belly) may be the first-line ascites treatment. If needed, a catheter (either indwelling or a peritoneovenous shunt) may be left in place to drain so that fluid can be removed in such a manner that the patient does not need to undergo repeated procedures. Some patients have reported that draining the ascites daily instead of every few days provides them with superior relief. From: http://www.emedicinehealth.com/ascites/page7_em.ht...

Catheters for Draining: Treatment options for draining abdominal ascites often entails the use of an indwelling catheter, paracentesis, or peritoneovenous shunting.

• Indwelling (Pleurx or Aspira) Catheter: This is the surgical insertion, under general anesthesia, of a small tube placed temporarily into the abdominal space that allows the patient or his/her family member to drain the fluid into a bottle as needed.Patients with an indwelling catheter are fully mobile and are not "attached" to the draining bottle except when draining the fluid.If there is no more drainage at all, the catheter is removed either in the doctor's office or an outpatient procedure.The Pleurx catheter works via suction, and the newer gentler model is the Aspira catheter, which may be a bit less uncomfortable because uses gravity instead of suction for draining.

• Paracentesis: Under sterile conditions, a needle is placed into the peritoneal space and fluid is withdrawn. Paracentesis may be a viable first step if the ascites accumulate quickly and the abdominal distension causes pain or shortness of breath. Because the peritoneal fluid contains albumin, if large amounts of fluid (more than 5 liters) are withdrawn, an albumin transfusion may be needed.If warranted, the catheter maybe left in place to drain, so that fluid can be periodically removed and the patient does not need to undergo repeated procedures.Paracentesis may be done more than once, but if it becomes a frequent necessity for symptom control, other options may be considered.

• Peritoneovenous shunting: This is a surgical operation that may on occasion be used in patients who are not candidates for, or who have failed treatment with, paracentesis or indwelling catheters. Peritoneovenous shunting entails the use of a tube for draining fluid back into the veins, instead of draining fluid externally as is done with indwelling catheters.

Drugs that may help alleviate ascites and/or related discomfort:

• Avastin (Bevacizumab)
• Catumaxomab (Removab)
• Iscador (Mistletoe extract)
• Octreotide (Sandostatin LAR®)

• Avastin (Bevacizumab): In one study, nine patients with refractory malignant ascites were given Avastin.Three patients had breast cancer, three had colon cancer, 2 had uterine cancer and one had ovarian cancer.Prior therapy included systemic chemotherapy and large volume paracentesis. All patients had rapid re-accumulation within 2 weeks of paracentesis before treatment. Patients were given intraperitoneal bevacizumab at 5 mg/kg monthly. Malignant ascites resolved without reaccumulation or repeat paracentesis in all nine patients after a single intraperitoneal dose of bevacizumab over a median observation period of over two months.From: http://meeting.ascopubs.org/cgi/content/short/25/1...

• Catumaxomab (Removab): Although the author was not able to locate studies with breast cancer patients, a study on ovarian cancer patients was reported.Catumaximab was evaluated as part of a Phase I/II dose-escalating study for intraperitoneal (IP) application in 23 patients with ovarian cancer who had ascites with EpCAM-positive tumor cells.The patients were treated with 4–5 intraperitoneal infusions of catumaxomab in doses of 10 to 200 micrograms within 9–13 days with loading doses of 5–10 μg. The maximum tolerated dose was defined at 10, 20, 50, 200, and 200 μg for the first through fifth doses. Treatment with catumaxomab resulted in significant and sustained reduction of ascites flow rate. A total of 22 of 23 patients did not require paracentesis between the last infusion and the end of study one month later, and tumor cell monitoring revealed a reduction of EpCAM-positive malignant cells in the ascites.From: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2880345/

A separate study of 26 cancer patients who received at least three of four IP instillations of catumaxomab led to a median interval of 15 days before a patient required an intraperitoneal puncture.Median overall survival was 92.5 days, but five patients remained alive and free of puncture for as long as 876 days. It was concluded that IP catumaxomab can be administered in relatively frail outpatients, achieving good ascites control. A survival benefit was seen in fit patients who received complete IP catumaxomab treatment and were able to undergo subsequent systemic therapy.From: http://www.medpagetoday.com/MeetingCoverage/SGO/44...

• Iscador (Mistletoe extract):Iscador is a nontoxic therapy widely used in Europe that is made from the extract of fresh sap of the plant known as mistletoe.It must be prescribed by a doctor. A Phase 2 study was undertaken of 23 patients with various types of cancer who had ascites which required repeated peritoneal punctures for draining. The time-interval between the first two punctures was measured and defined as the baseline. Following each subsequent puncture, Iscador M® 10 mg was injected intraperitoneally. The intervals between later punctures were compared to previous intervals.Following the first injection, the median time-interval between draining increased from 7 to 12 days, reaching 13 days after the second injection, nearly double the initial draining interval. One patient with ovarian cancer had a clinical objective response represented by a reduction in CA-125 levels from 800 U/ml to 102 U/ml, and improvement in ascites accumulation and in performance status; this regression lasted for 12 months. No toxicity was observed in any of the patients.From: http://ar.iiarjournals.org/content/26/1B/709.full....

Note: Once prescribed, Iscador may be difficult to procure.One reputable source is H & F Apothecary, Ltd., Chestnut Ridge, NY.Telephone: 1.845.352.6165 The contact there is Carol atfarrajs@hotmail.com

• Octreotide (Sandostatin LAR®): Thirty-three patients were enrolled in a two-arm study, with 16 patients assigned to the octreotide arm and 17 to the control arm. The median time to next paracentesis was 28 and 14 days in the octreotide and placebo arm, respectively. After adjustment for extracted ascites volume and abdominal girth change, no statistically significant difference between the groups was observed, although octreotide-treated patients described less of abdominal bloating,abdominal discomfort, and shortness of breath at one month.As prescribed in this trial, octreotide did not seem effective in prolonging the time to next paracentesis, although symptoms had improved.From: http://www.ncbi.nlm.nih.gov/pubmed/22572824

Thoughts & prayers for your girlfriend's healing. You are surely a great advocate for her and that is a gift beyond measure...as is your love. Best Bird's info is so valuable, as is the experience of others here on the boards, so I hope you stay connected. Condolences on you father's wife's passing. Sending hope for answers & peace

Very sorry to hear of your Father's wife dying. You seem to be a wonderful advocate for your girlfriend. I know they drain fluid but don't know what it means if there's cancer in there. Wishing the best treatment for your girlfriend.

Terri