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Palliative Pelvic Exenteration: Patient Selection and Results

Palliative Pelvic Exenteration: Patient Selection and Results

ABSTRACT: Total pelvic exenteration is a radical abdominoperineal operation designed to treat locally extensive pelvic malignancy. In the past, the morbidity and mortality has been such that this procedure was considered justified only in the curative setting. As experience has increased and operative survival has improved, the indications for radical pelvic surgery have expanded to include palliation of the symptoms of pelvic tumors, including pain, obstruction, fistulas, and bleeding. The careful selection of suitable candidates for palliative pelvic exenteration requires an extensive preoperative evaluation of the patient's underlying physical and emotional health, as well as an assessment of the local and distant extent of the tumor. In appropriately selected patients, significant palliation of the symptoms associated with an uncontrolled pelvic malignancy can be accomplished with substantial improvement in quality of life.

Introduction

Total pelvic exenteration is a radical extirpative procedure designed
to treat pelvic malignancy that has invaded more than one of the
hollow organs of the genitourinary or gastrointestinal tracts.
The early experience with exenterative surgery focused on cervical
and rectal cancer [1-5]. The biologic characteristics of these
tumors (ie, central pelvic growth in a locally advanced pattern
without distant disease) permit the consideration of radical,
extensive pelvic surgery. Other extensive or recurrent tumors
that may be amenable to exenterative surgery are vaginal squamous-
and clear-cell carcinoma; squamous-cell carcinoma of the vulva;
endometrial carcinoma; leiomyosarcomas of the vagina, cervix,
and uterus; melanoma of the vagina or vulva; and Bartholin gland
tumors [6]. Less favorable cancers are ovarian, prostate, and
bladder carcinomas, because of their tendency toward widespread
hematogenous metastases in the presence of limited primary tumor
growth.

Bulky pelvic malignancy is notorious for the production of disabling
symptoms. Pain, infection, bleeding, obstruction, and fistula
formation are the most serious consequences of uncontrolled local
tumor growth. The goal of treatment in the initial widespread
application of pelvic exenterative surgery was palliation of these
symptoms in patients who had either failed to respond to or were
not candidates for conventional therapy [1]. Institutional operative
mortality as high as 33% was reported in these early series. Morbidity
was also significant, and postoperative recovery was often long
and arduous.

Nevertheless, the operation was considered beneficial with regard
to relieving symptoms in patients with limited options. As reported
by Brunschwig: "Because of the advanced stage of their disease,
it is not to be anticipated that many, if any, of these patients
will survive for very prolonged periods....On the other hand,
of those surviving at this writing, not one has expressed the
feeling that they would have preferred to have remained as they
were and not to have had the operation [1]."

As more of these procedures were performed and longer follow-up
was reported, it became apparent that some carefully selected
patients were long-term survivors after pelvic exenteration. Five-year
survival rates after radical pelvic surgery for gynecologic malignancy
approached 60%7-10 and were as high as 50% [11-14] for some patients
with locally advanced primary colorectal cancer.

Despite favorable results in some patients, the recognized morbidity
and mortality associated with exenterative surgery added to the
controversy surrounding its use as a palliative procedure, and
strict guidelines were established to select those patients who
were most likely to benefit from this procedure. These criteria
include an exhaustive preoperative and operative evaluation to
ensure the absence of extrapelvic spread of disease, as well as
to assess pelvic bones, muscles, major nerves, and blood vessels
for extent of cancer involvement. An assessment of the patient's
underlying physical and psychiatric condition, with consideration
of malnutrition, sepsis, obesity, advanced age, or inadequate
cardiopulmonary reserve, also should be carried out before the
final decision about whether to perform a palliative pelvic exenteration
is made [15]. As with many technically demanding procedures, a
learning curve has been identified for radical pelvic surgery.
The literature following the institutional experience with pelvic
exenteration over the past 47 years has demonstrated a dramatic
decrease in mortality associated with this surgery. Since the
early 1970s, reports of operative mortality of less than 5% have
been published, and these types of statistics are becoming more
common in the current literature [15-18].

Thus, although the value of radical pelvic surgery for the palliation
of symptoms caused by pelvic malignancy continues to be a controversial
issue [19], several institutions are reporting good results, with
improvements in quality of life and reasonable associated operative
morbidity and mortality. In this article, we will explore the
definition of palliation in the context of radical pelvic surgery
and the process of selecting appropriate patients for this type
of surgery, as well as the expected results.

Three Definitions of Pelvic Exenteration

Radical pelvic surgery for palliation of local symptoms have been
defined in three ways in the literature. The most obvious definition
is based on intent. If an operation is embarked upon with the
foreknowledge that all of the tumor cannot be removed, the objective
of the operation is not cure, but rather palliation of the symptoms
of local tumor growth. This definition may include patients with
minimal distant metastases associated with uncontrolled local
symptoms.

A second use of the term "palliative pelvic exenteration"
relates to patients who undergo an operation with curative intent
but intraoperatively have either known gross or microscopic disease
left behind. This group includes patients who, after extensive
operative dissection, are discovered to have invasion of the bony
sacrum or pelvic sidewall.

A third definition found in the literature describes patients
who have locally recurrent or persistent disease after having
failed primary surgical, radiation, or chemotherapy for their
pelvic malignancy. This includes patients who have a local recurrence
after curative resection of a rectal cancer or recurrent cervical
cancer after standard radiation or surgical treatment. These patients
then undergo radical pelvic surgery as a form of salvage therapy
and are often said to have undergone palliative pelvic exenteration
following discovery and evaluation of locoregional pelvic recurrent
disease.

All three of these definitions will be incorporated in the following
discussion on patient selection and results.

Patient Selection

Virtually all patients who present for consideration of palliative
pelvic exenteration have local symptoms. In general, asymptomatic
tumors identified on screening evaluation are recognized earlier,
are smaller, and are more amenable to standard local therapy,
and rarely require radical pelvic surgery for initial local control.
Most patients with bulky disease present with symptoms of pain
often associated with gastrointestinal or urinary obstruction,
fistulas, infection, or bleeding. These symptoms can often lead
to severe disability and diminished quality of life.

All treatment options, including surgery, radiation therapy, and
chemotherapy, must be considered in a multimod- ality approach.
In general, chemotherapy has minimal impact on bulky pelvic disease
[20]. It remains a last resort for patients who are not surgical
candidates, and can be used alone or in combination with radiotherapy.
Patients with severely disabling symptoms, however, rarely benefit
from chemotherapy. Chemotherapy also is a difficult option for
treating patients with localized pelvic sepsis secondary to complications
of pelvic tumor.

In the palliative setting, radiotherapy can be used only in patients
who have not been previously treated with pelvic radiation. Most
patients with recurrent disease or bulky initial disease will
have undergone pelvic radiation in the initial course of treatment.
However, in individuals who are eligible for palliative radiation,
symptoms of pain, tenesmus, bleeding, and discharge may have an
initial favorable response to this treatment. Arnott reported
a 75% response rate for the treatment of pain and a 60% response
rate for the treatment of pelvic drainage in a select group of
patients [21].

The duration of response to palliative radiation is usually quite
limited, ranging from 3 to 6 months [22]. An enterocutaneous fistula,
on the other hand, is rarely improved by radiotherapy and, indeed,
may develop as a side effect of this treatment. In the palliative
setting, radiation therapy is most appropriate for patients who
have failed other attempts at local control and whose underlying
medical condition or disease extent limits their anticipated life
expectancy to a few months.

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