Gynecological cancers occurs most frequently in 34% of our patients with malignant effusions including lavage probes for ovarian tumors. These findings becomes importance, because they results from a single center, which exclude an unproportional influence of any clinical section on the tumor distribution in comparison to various other studies [2, 3, 4, 7, 8, 11, 15, 19–23]. Further leads the predominance of gynecological tumors to an overbalance of female patients in malignant effusions and required both from clinical as well as from immunohistochemical viewpoint a sex specific data analysis [1].
Most (65.3%) of all gynecologic malignancies we diagnosed in the peritoneal cavity and in 71.1% of female patients with malignant abdominal cytology we observed gynecological neoplasms. It is widely accepted in the literature that ovarian carcinoma is the prototype of dissiminated peritoneal spread in malignant ascites [5, 6, 12, 24–27]. In our previous studies on ovarian cancer we described the highest malignancy rate, at 85.7%, the earliest occurrence, and a predominance of the high-grade papillary subtype in patients with malignant abdominal cytology [10]. The correlation between malignant abdominal cytology and high-grade serous papillary subtype we could extent in the present study on endometrium carcinomas. These findings underline the discrimination between non aggressive type 1 endometrium cancer with lacking occurrence of malignant ascites in our study from aggressive type 2 endometrium cancer with appearance of malignant ascites in high-grade serous papillary subtype and also MMMT [28, 29]. Moreover, we obtained in tumors from the lower genital tract the highest rate of 31.4% for secondary pleural involvement compared to 6.1% for female patients with GI tumors. Therefore is the knowledge of previous findings for all patients necessary, which exclude in our study an alone pleural involvement for ovarian carcinomas. These finding is remarkable because ovarian carcinoma achieves in various other studies the third or fourths most common epithelial tumor of malignant pleura effusions [12, 24, 25]. Further it may affect the dayly diagnostic practice, because in both involvement of peritoneal and pleural involvement a gynecological malignancy is more probably, whereas GI tumors showed a predominant peritoneal or an infrequently pleural involvement. The exclusive involvement of peritoneal and pleural cavity by high-grade serous papillary subtype highlights the aggressive potential of this subtype and should be noted at initial diagnosis for continous follow-up controls.
Malignant ascites from gynecological tumors include in 10.5% patients with breast cancer, which showed a lobular subtype in 80% with a characteristic diffuse pattern in effusion fluids and is in agreemet with literature data [30, 31]. In contrast to other gynecolocigal and gi malignancies appears malignant ascites in breast cancer patients only in 20% within 12 months, compared to 60% in endometrium cancer, 98.7% in ovarian carcinoma and 97% in female patients with gastrointestinal tumors. These late metastatic potential in patients with breast cancer should be correlated with a positive receptor state for this patients, which we also obtained in 90% of our patients [13, 32–35].
Second most frequent gynecological neoplasms were found in 33.3 % of malignant pleura effusions after patients with lung cancer [12, 14]. As mentioned above reduced our cytological clinical correlation the occurrence of malignant pleura effusions in patients with gynecological neoplasms to breast cancer and if we compared only female patients we received a slight overbalance of 49 patients with breast cancer to 48 patients with lung cancer. In contrast to malignant ascites the most often occurring subtype of NST carcinomas predominates in malignant pleura effusion. Similar to malignant ascites they obtained only in 22.4% of the patients within 12 months after primary diagnosis compared to 81.2% for female lung cancer patients and 88.2% in female patients with GI tumors [33, 35]. These time associated occurrence of breast cancer in malignant pleural effusion may help at first in dayly diagnostic practice to discriminate lung from breast carcinoma and could further prove by immunostains.
Only 1.4% of the malignant effusions we could detect in the pericardium with female predominance and similar tumor distribution as in the pleural cavity, which is in agreement with literature data [12, 36, 37, 38]. Also similar clinical symptoms, such as dyspnea, cough and chest pain characterize patients both with pleural and pericardial effusions [19, 37]. Patients with malignant pericardial effusion were 7.3 years younger than patients with malignant pleura effusions and the effusion fluid is extremely bloody because of cavitary and intralymphatic tumor spread [4]. We diagnosed only 1 patient with breast cancer and 1 patient with cervix carcinoma and both patients showed an involvement of the pericardium within 12 months. These major findings correlated with literature data, however, the number of patients is low [12, 37, 38].
Hematological neoplasms were the most common nonepithelial tumor in malignant effusions in our study, occuring in 3.4% of the patients with female predominance in 66.6%. In agreement with the findings in the literature 80% of them were located in the pleura and 20% in the peritoneum [39–41]. Immunohistochemically, B-cell lymphomas were represented in 86.7% and high grade subtype in 66.6% of the patients. The cytological impact of these findings is the diffuse tumor cell pattern for malignant lymphomas in differential diagnosis to lobular breast carcinoma and all other diffuse enddifferentiated carcinomas, which require applications of further immonstains.
Strengths of the present study are the large number of patients included. Limitation of the study is its retrospective single center design and the fact that the effusion fluids from the peritoneal cavity includes intraoperative lavage probes.