Drs. Finlayson and Eisenberg provide a timely, in-depth review
of total pelvic exenteration in the palliation of incurable pelvic
cancer. The authors conclude that total pelvic exenteration has
a role as a palliative treatment for patients with recurrent pelvic
cancer-a conclusion that I believe remains unproven.
The fact that total pelvic exenteration has cured many women with
gynecologic cancer is not in dispute. The operation continues
to have an important place in the arsenal of therapeutic options
available to patients with pelvic cancer. The authors correctly
point out that the efficacy of total pelvic exenteration was established
not by a prospective clinical trial, but rather, by trial and
error. The pioneers identified by the authors reached the conclusion
that total pelvic exenteration has curative potential only when
the tumor can be completely removed because patients with incomplete
resection invariably die. Surgeons subsequently became much more
selective regarding indications for this procedure, which, in
turn, led to an increase in the proportion of survivors. At present,
most gynecologic oncologists undertake total pelvic exenteration
only 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 patients
that have taken place during the last 50 years, this operation
is still associated with significant morbidity. At The University
of Texas M. D. Anderson Cancer Center, which has a long institutional
experience with total pelvic exenteration [1-7], operating time
ranges from 6 to 10 hours, minimum blood loss is 1,000 mL, significant
morbidity develops in about half of patients, and a small number
of deaths continue to occur. Minimum length of hospitalization
is 10 days, and hospital stays of 2 to 4 weeks are common.
Despite the associated morbidity and mortality, we aggressively
pursue total pelvic exenteration for patients who are in reasonable
medical condition and have a realistic chance for cure, even if
it is small. In patients with surgical findings revealing that
the tumor is not completely resectable, we abandon the procedure.
Three Definitions of Palliative Exenteration
The authors offer three definitions of "palliative total
pelvic exenteration." They differentiate between patients
operated on specifically for symptom control, those operated on
as part of salvage therapy, and those operated on with curative
intent in whom surgical findings indicate incurable disease. The
definition of "to palliate" is to "reduce the violence
of," "abate," or "moderate the intensity of
."I believe that the medical literature on this subject
would be clarified if the term "palliative total pelvic exenteration"
were reserved for surgery performed in symptomatic patients with
the intention of relieving these symptoms. Patients treated with
total pelvic exenteration with the intention of extending survival
should be in a different category. Standard clinical trial design
could be used to test the efficacy of pelvic exenteration for
The standard forms of palliation for patients with recurrent pelvic
cancer 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 authors
point out, response rates are low and toxicity is not always minor.
The authors provide some evidence that total pelvic exenteration
can relieve the symptoms of recurrent unresectable pelvic cancer
in many patients during the immediate postoperative period. However,
this fact alone is not sufficient to reach a conclusion that the
operation is a desirable form of palliation for recurrent pelvic
A more important question is, how does total pelvic exenteration
compare with the other standard forms of palliation? Such factors
as cost, toxicity, duration of symptom relief, and risk of symptom
recurrence need to be considered. Since the cost and risks of
total pelvic exenteration are high, compared with standard techniques,
the benefits of this procedure must be clear and measurable to
justify its use. Advocates of palliative exenteration must provide
some form of comparative analysis to strengthen the argument that
its 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 palliative
treatments for patients with recurrent pelvic cancer, including
chemotherapy, diversionary surgery, pain management, and wound
and ostomy care. When surgical and chemotherapeutic options are
exhausted, we refer patients for hospice care. Clear and candid
explanations of the patient's prognosis, median survival, and
the risks and benefits of various therapeutic options are vital
if the patient is to reach a truly informed decision.
There is no doubt that recurrent pelvic cancer results in a great
deal of pain and suffering, and that standard forms of palliation
do not render patients free of symptoms in many cases. It is also
true that many pelvic surgeons have the skill necessary to perform
total pelvic exenteration with a respectable margin of safety.
However, these facts do not justify replacing standard symptom
management and palliative therapies with total pelvic exenteration
in patients with incurable pelvic cancer. Until such time as data
show that total pelvic exenteration compares favorably with standard
treatment, it should be considered an unproven therapy for palliation
of incurable pelvic cancer.
1. Miller B, Morris M, Rutledge F, et al: Aborted exenterative
procedures in recurrent cervical cancer. Gynecol Oncol 50:94-99,
2. Matthews CM, Morris M, Burke TW, et al: Pelvic exenteration
in the elderly patient. Obstet Gynecol 79:773-777, 1992.
3. Rutledge FN, McGuffie VB: Pelvic exenteration: Prognostic significance
of 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 fistula
after pelvic exenteration: A review of The University of Texas
M.D. Anderson Cancer Center experience, 1957-1990. Gynecol Oncol
6. Cozier M, Morris M, Levenback C, et al: Pelvic exenteration
for adenocarcinoma of the uterine cervix. Gynecol Oncol 58:74-78,
7. Miller B, Morris M, Levenback C, et al: Pelvic exenteration
for primary and recurrent vulvar cancer. Gynecol Oncol 58:202-205,
8. Merriam-Webster's Collegiate Dictionary, 10th Ed. Springfield,
Massachusetts, Merriam-Webster, Inc, 1993.