In the past, the mere mention that a patient with persistent or recurrent pelvic cancer might benefit from a palliative pelvic exenteration was met with vigorous opposition. This was due, in part, to the fact that the term "palliative pelvic exenteration" was new and not clearly defined. There was also concern that the mortality, morbidity, and overall cost previously associated with pelvic exenterative procedures were out of keeping with the concept of palliation for cancer. However, much experience with pelvic exenterative surgery has been gained during the past 40 years, and the mortality, morbidity, length of stay, and overall cost of the procedure have decreased significantly. This has made the concept of pelvic exenteration for palliation reconcilable in carefully selected patients in the 1990s.
In a series of 323 pelvic exenterations performed at the Mayo Clinic, 59 (18%) of patients underwent palliative exenteration. Their survival rate was 47% at 2 years and 17% at 5 years. Of the 59 palliative exenterations, 44 were done for cancer that recurred after irradiation or surgery. Postoperative hospital stay was 22 days on average and was less than 20 days in 49% of patients and less than 30 days in 78%. It was a surprise to many that these unfortunate patients were able to enjoy additional survival as a result of this operation . It is of interest to this commentator that survival after palliative pelvic extenteration is remarkably similar to that after extensive cytoreductive surgery for ovarian cancer followed by chemotherapy.
Finlayson and Eisenberg provide an eloquent historical review of pelvic exenterative surgery. That history directs surgeons today to have a primary concern for the proper selection of patients for pelvic exenterative operations, whether or not the intent is curative or palliative. Patient selection is the factor that significantly reduces the mortality and complications from these ultraradical surgical procedures. This is not to downplay the numerous surgical advances-most notably, Bricker's method of urinary diversion and the use of the omentum in the management of the pelvic floor-that have brought us to the present standard.
The "Intent" of Surgery
The authors make a significant contribution to our understanding of palliative pelvic exenteration and its definition by focusing on the "intent" of surgery. They delineate three groupings based on intent: (1) palliative exenteration where it is foreknown that all tumor cannot be removed; (2) palliative exenteration where, after extensive operative dissection, unresectable gross or microscopic disease is left behind; and (3) palliative exenteration as salvage therapy in patients with locally recurrent or persistent disease after failure of primary surgery, irradiation, or chemotherapy.
With gynecologic malignancies, and I assume other recurrent pelvic cancers as well, patients in the second grouping, particularly those who have only microscopic residual disease, are most likely to enjoy increased survival. The authors describe the ideal patient for palliative exenteration as being medically fit, having severe discomfort or disability, and undergoing complete resection of local tumor, except for probable microscopic disease.
Palliative Exenteration Combined With Intraoperative Radiation
In our experience at the Mayo Clinic, patients with postoperative residual cancer involving the pelvic sidewalls or para-aortic or pelvic lymph nodes may benefit from the use of electron-beam intraoperative radiation therapy (IORT) in conjunction with palliative pelvic exenterative surgery. Although the complications of this combined-modality therapy are not insignificant, it offers the potential for cure in a select group of patients with locally recurrent disease who are otherwise poor candidates for salvage .
Finally, palliative pelvic exenteration has a particular role in cancer management when our immediate goals are to improve an individual's quality of life, relieve pain, and prolong survival. Palliative exenteration will likely play a more critical role in cancer management in the future, especially if combined with IORT.