Palliative Pelvic Exenteration: Patient Selection and Results

Drs. Finlayson and Eisenberg provide a timely, in-depth reviewof total pelvic exenteration in the palliation of incurable pelviccancer. The authors conclude that total pelvic exenteration hasa role as a palliative treatment for patients with recurrent pelviccancer-a conclusion that I believe remains unproven.

The fact that total pelvic exenteration has cured many women withgynecologic cancer is not in dispute. The operation continuesto have an important place in the arsenal of therapeutic optionsavailable to patients with pelvic cancer. The authors correctlypoint out that the efficacy of total pelvic exenteration was establishednot by a prospective clinical trial, but rather, by trial anderror. The pioneers identified by the authors reached the conclusionthat total pelvic exenteration has curative potential only whenthe tumor can be completely removed because patients with incompleteresection invariably die. Surgeons subsequently became much moreselective regarding indications for this procedure, which, inturn, led to an increase in the proportion of survivors. At present,most gynecologic oncologists undertake total pelvic exenterationonly if it is clear that the disease is completely resectable.

Associated Morbidity Still Significant

Total pelvic exenteration is an extremely traumatic procedure,and despite all of the advances in the care of surgical patientsthat have taken place during the last 50 years, this operationis still associated with significant morbidity. At The Universityof Texas M. D. Anderson Cancer Center, which has a long institutionalexperience with total pelvic exenteration [1-7], operating timeranges from 6 to 10 hours, minimum blood loss is 1,000 mL, significantmorbidity develops in about half of patients, and a small numberof deaths continue to occur. Minimum length of hospitalizationis 10 days, and hospital stays of 2 to 4 weeks are common.

Despite the associated morbidity and mortality, we aggressivelypursue total pelvic exenteration for patients who are in reasonablemedical condition and have a realistic chance for cure, even ifit is small. In patients with surgical findings revealing thatthe tumor is not completely resectable, we abandon the procedure.

Three Definitions of Palliative Exenteration

The authors offer three definitions of "palliative totalpelvic exenteration." They differentiate between patientsoperated on specifically for symptom control, those operated onas part of salvage therapy, and those operated on with curativeintent in whom surgical findings indicate incurable disease. Thedefinition of "to palliate" is to "reduce the violenceof," "abate," or "moderate the intensity of[8]."I believe that the medical literature on this subjectwould be clarified if the term "palliative total pelvic exenteration"were reserved for surgery performed in symptomatic patients withthe intention of relieving these symptoms. Patients treated withtotal pelvic exenteration with the intention of extending survivalshould be in a different category. Standard clinical trial designcould be used to test the efficacy of pelvic exenteration forthis purpose.

The standard forms of palliation for patients with recurrent pelviccancer are pain control with narcotic analgesics, antiemetics,surgical diversion of urine and/or stool, and perineal hygiene.Chemotherapy is another form of palliation, although, as the authorspoint out, response rates are low and toxicity is not always minor.The authors provide some evidence that total pelvic exenterationcan relieve the symptoms of recurrent unresectable pelvic cancerin many patients during the immediate postoperative period. However,this fact alone is not sufficient to reach a conclusion that theoperation is a desirable form of palliation for recurrent pelviccancer.

A more important question is, how does total pelvic exenterationcompare with the other standard forms of palliation? Such factorsas cost, toxicity, duration of symptom relief, and risk of symptomrecurrence need to be considered. Since the cost and risks oftotal pelvic exenteration are high, compared with standard techniques,the benefits of this procedure must be clear and measurable tojustify its use. Advocates of palliative exenteration must providesome form of comparative analysis to strengthen the argument thatits indications should be extended to include palliation.

Our philosophy is that a multidisciplinary team of physicians,nurses, and enterostomal therapists can provide an array of palliativetreatments for patients with recurrent pelvic cancer, includingchemotherapy, diversionary surgery, pain management, and woundand ostomy care. When surgical and chemotherapeutic options areexhausted, we refer patients for hospice care. Clear and candidexplanations of the patient's prognosis, median survival, andthe risks and benefits of various therapeutic options are vitalif the patient is to reach a truly informed decision.

Conclusion

There is no doubt that recurrent pelvic cancer results in a greatdeal of pain and suffering, and that standard forms of palliationdo not render patients free of symptoms in many cases. It is alsotrue that many pelvic surgeons have the skill necessary to performtotal pelvic exenteration with a respectable margin of safety.However, these facts do not justify replacing standard symptommanagement and palliative therapies with total pelvic exenterationin patients with incurable pelvic cancer. Until such time as datashow that total pelvic exenteration compares favorably with standardtreatment, it should be considered an unproven therapy for palliationof incurable pelvic cancer.

References:

1. Miller B, Morris M, Rutledge F, et al: Aborted exenterativeprocedures in recurrent cervical cancer. Gynecol Oncol 50:94-99,1993.

2. Matthews CM, Morris M, Burke TW, et al: Pelvic exenterationin the elderly patient. Obstet Gynecol 79:773-777, 1992.

3. Rutledge FN, McGuffie VB: Pelvic exenteration: Prognostic significanceof regional lymph node metastasis. Gynecol Oncol 26:374-380, 1987.

4. Rutledge FN, Smith JP, Wharton JT, et al: Pelvic exenteration:analysis of 296 patients. Am J Obstet Gynecol 129:881-892, 1977.

5. Miller B, Morris M, Gershenson DM, et al: Intestinal fistulaafter pelvic exenteration: A review of The University of TexasM.D. Anderson Cancer Center experience, 1957-1990. Gynecol Oncol56:207-210, 1995.

6. Cozier M, Morris M, Levenback C, et al: Pelvic exenterationfor adenocarcinoma of the uterine cervix. Gynecol Oncol 58:74-78,1995.

7. Miller B, Morris M, Levenback C, et al: Pelvic exenterationfor primary and recurrent vulvar cancer. Gynecol Oncol 58:202-205,1995.

8. Merriam-Webster's Collegiate Dictionary, 10th Ed. Springfield,Massachusetts, Merriam-Webster, Inc, 1993.