Chylous Ascites in Recurrent Gynaecological Malignancies

Dear Editor,Chylous ascites is an unusual phenomenon where there is accumulation of chyle in the peritoneal cavity.It is especially rare following treatment of gynaecological cancers.The mechanism is thought to be due to the destruction or obstruction of the lymphatics.Short chain lipids are absorbed into the circulation directly from the small intestines whereas long chain lipids (>12 carbon molecules) are absorbed into the lacteals after emulsification by bile acids.These lacteals converge into the cisterna chyli, drain into the thoracic duct and finally into the circulation via the superior vena cava. 1 The lipids in the lacteals leak into the peritoneal cavity and result in chylous ascites when the lymphatics are disrupted or obstructed for whatever reason.We report 2 cases seen in our unit and discuss about the aetiology and management of this rare condition. Case ReportPatient 1 is a 66-year-old lady with Stage 3C grade 3 serous adenocarcinoma of the ovary diagnosed in November 2003.She underwent a total hysterectomy bilateral salpingooophorectomy, anterior resection and infragastric omentectomy followed by 6 cycles of adjuvant chemotherapy.The disease recurred 8 months later in the paraaortic and left obturator lymph nodes.Despite palliative chemotherapy, the disease persisted but she remained asymptomatic.In April 2006, there was general progression of the left para-aortic, aortocaval and mesenteric lymphadenopathy and she developed straw-coloured ascites.The ascites resolved after 6 cycles of palliative chemotherapy with reduction in the lymphadenopathy.In March 2007, the disease progressed and she developed matted para-aortic as well as mesenteric lymphadenopathy and gross ascites.Abdominal tap revealed milky white fluid that was positive for adenocarcinoma as well as high levels of lipids (Fig. 1).She was put on high protein, low fat diet.She required serial parencentesis every 3 weeks to relieve the pressure symptoms from the ascites.She finally succumbed to the recurrent cancer and passed away in June 2007.Patient 2 is a 54-year-old lady with Stage 4B grade 2 adenocarcinoma of the cervix diagnosed in January 2004.She had lung metastases at presentation.She received chemotherapy followed by extended field radiotherapy.In July 2006, she developed enlarged aorto-caval and paraaortic nodes.She declined further treatment then.The disease progressed and in January 2007, she developed