The authors provide an excellent overview of the role of pelvic exenteration performed as a curative cancer operation or for palliation. They extend the customary definition of palliation, however, to include exenteration intended for cure when tumor is knowingly left behind or is discovered by pathologic review of the operative specimen. The added definitions are apparently based on observations indicating that these procedures can relieve or reduce symptoms related to the disease or its treatment in some patients, resulting in an improved "quality of life," and that some patients also enjoy an extended survival after exenteration.
Most of the reports suggesting a role for palliative exenteration other than for relief of symptoms are based on retrospective reviews of patients who underwent pelvic exenteration for cure but had cancer left behind. Survival rates at 5 years, depending on the sites and amount of residual disease in this situation, range from 0% to as high as 20%. Significant morbidity can be expected in up to 50% of patients.
I strongly disagree with the authors' assertion that an operation embarked upon with curative intent where tumor extension to the sacrum or pelvic sidewall is discovered can proceed but the objective is palliation. Stanhope and Symmonds have reported on a series of patients who were considered retrospectively to have undergone a palliative exenteration. Despite a mortality rate of 11% at 3 months, the overall survival at 5 years was commendable (17%). However, in no patient surviving more than 8 months was gross disease left behind at the time of exenteration. In a study reported by McCullough and Nahhas, 7 of 8 patients whose exenterations were considered to have been palliative based on the presence of residual tumor died of their disease after 2 weeks to 23 months, and only one patient was alive with advanced terminal disease 12 months after surgery.
The combination of residual pelvic cancer and lymph node metastases is well known to portend a poor prognosis.[3,4] Should not the considerable risk of this operation also be balanced against the same criteria defined for exenteration undertaken with the intent of palliation? Are not quality-of-life issues important in this setting? The operative mortality of 3% and overall morbidity of 47% in the authors' series is balanced by a median overall survival of 20 months and a median overall disease-free survival of 3.5 months. By the authors' criteria, 11 of 33 patients enjoyed only a slight improvement in quality of life, while in 4 patients there was either no improvement or deterioration. In almost half of the patients, therefore, the cost-benefit ratio becomes an important consideration.
Quality of life in patients with advanced cancer is a complicated issue. Sophisticated instruments for patient assessment, however, are available, such as the McGill Quality of Life Questionnaire, among others. Results of such studies should be applied prospectively as outcome measures to truly define the benefit of noncurative pelvic exenterations. This approach can also decrease the possible physician bias that may occur when retrospective reviews of these patients are reported.
Consider Less Radical Approaches First
As the authors point out, exenteration performed with palliative intent, where the goal is relief of symptoms related to uncontrolled cancer, prior treatment, or both, was one of the goals of the operation initially designed by Brunschwig. Few authorities would disagree with this indication in appropriately selected patients. However, since exenteration done for this purpose is also associated with significant morbidity and, in some cases, death, it seems prudent to first consider less radical management approaches. Before recommending exenteration, palliation by less invasive techniques should have been demonstrated to be unsuccessful. As an example, specialists who treat pain have reached a high degree of expertise in the management of cancer pain. In many cases, these sophisticated pain management techniques may be more effective in relieving symptoms in patients with advanced pelvic malignancy than is exenteration. Such an approach to management of pain may therefore be the preferred alternative to exenteration contemplated for this purpose.
Palliation of symptoms related to intestinal fistulae can be accomplished by bypass operations or colostomy and should be considered before exenteration when possible. Similarly, efforts to palliate symptoms caused by urinary fistulae should consider the safety of the Bricker ileal conduit diversion or even cutaneous ureterostomy in selected patients as an alternative to exenteration. None of these palliative measures requires removal of the pelvic viscera, a factor recognized by most experienced surgeons as a significant cause of morbidity and death.
Barber's Criteria for Exenteration Still Valid
Several decades ago, Barber outlined the criteria for exenteration and listed what he considered to be absolute and relative contraindications to cure. He also called attention to the significant mortality at that time in patients who underwent palliative surgical procedures. Current improvements in techniques for urinary diversion, colostomy construction or avoidance, and management of the denuded pelvic floor have decreased morbidity and mortality and have made the procedure safer and more acceptable to patients. Advances in preoperative preparation of patients, in addition to intraoperative monitoring of fluid and electrolyte balance, better control of infectious complications, and the availability of skilled surgical intensive-care units, have all significantly decreased mortality and improved survival rates. As a result of these advances, the indications for pelvic exenteration have broadened.
There is general agreement that palliative operations, defined as procedures to relieve symptoms of advanced, uncontrolled pelvic cancer, can benefit some patients. Performing pelvic exenteration in patients with recurrent disease complicated by known lymph node metastases or pelvic sidewall extension is controversial. In recommending exenteration in these situations, it should be anticipated that equivalent or better survival and quality of life could not have been achieved by alternative approaches that do not have the cost and morbidity associated with excision of the pelvic viscera. With these factors in mind, it is worth reflecting again on Barber's criteria for operability. His study remains a valuable reference for many surgeons who would perform these operations.