Palliative Surgery for Sarcoma

by J. Harrison Howard, MD and Raphael Pollock, MD, PhD
in ESUN's Opinions and Hypotheses

As surgeons we pride ourselves on being able to offer sarcoma patients the opportunity for cure. Radiation and chemotherapy may make our scalpels more effective, but surgery remains the cornerstone of sarcoma therapy. Experience with the disease quickly humbles our pride as we have patients that recur despite multidisciplinary care and our personal best efforts. After recurrence, perhaps we have a second opportunity to operate for cure. We might even have a third or fourth chance, but for many sarcoma patients there will come a time when the scalpel can no longer offer the opportunity for cure; however, can it still help? With experience, communication, and proper judgment, palliative surgery may significantly improve the quality of life for sarcoma patients despite their having incurable disease.

One of the intriguing yet challenging aspects of sarcoma surgery is that the disease can present anywhere in the body. It is common to need multi-specialty surgical teams to successfully resect a sarcoma and then reconstruct the defect. Although these operations are personally gratifying to perform, the complexity of the disease can lead to recurrences and complications, iatrogenic and otherwise, that are very difficult to manage. Based on the heterogeneity of sarcoma, disease-related problems in need of palliative surgery may present as obstruction of a hollow viscus, chronic necrotic or ulcerated wounds, bleeding, or other debility. As surgeons we simply cannot abandon patients by declaring that there is nothing else that can be done other than palliative chemotherapy, radiation, or terminal care as treatment options. This clinical scenario provides a unique opportunity to have focused and frank discussions with patients about end of life issues, their personal goals regarding on-going care, the quality of their remaining life, and how palliative surgical intervention may help. Surgeons engaging patients during this time of great need are able to help create an ambience replete with gratifyingly high satisfaction rates reported by these patients.¹ Most patients with incurable disease will not need surgical intervention; however, as part of a multidisciplinary sarcoma team, surgeons must be vigilantly aware of the proper patient and proper time to intervene with palliative surgical intent.

Palliative surgery has been defined as the deliberate use of an operative procedure on behalf of a patient with incurable disease with the intention of relieving symptoms while minimizing psychic distress, thereby improving the quality of life.² Data concerning the use of palliative surgery for end stage cancer patients is limited; however, symptom resolution in the aftermath of palliative surgical intervention has been reported as high as 80-90%.^1,3 In the study by Miner, et al median symptom free survival after palliative surgery was 135 days.³ This is an important observation in that the same study determined that the median survival for these patients was 194 days, suggesting that palliative surgical approaches can offer a bona fide improvement in the quality of life for patients in the final stages of their existence.

Communication between the surgeon, patient, and family is of the utmost of importance when discussing palliative surgical options. Clearly defined goals of the surgery and associated risks should be clearly articulated. Patients often have trouble grasping the idea of a palliative operation; time should be taken to explain what might reasonably be accomplished via an operation which is not of curative intent. It is equally important for the physician to understand the goals of the patient and not project his own expectations or value judgments into this admittedly difficult circumstance. The patient may be willing to accept an outcome that might be unacceptable to the surgeon; it should be remembered that there is neither a right nor a wrong choice for the patient, and that the goal is to arrive at a shared and mutually acceptable decision between patient, physician, and family.

Careful patient selection is a critical factor when offering palliative surgery to the sarcoma patient. End-stage cancer patients have many surgical risk factors such as malnutrition, anemia, and other systemic side effects from chemotherapy that result in postoperative morbidity rates between 20-40%.^1,3,4 One of the few prospective studies examining palliative surgery demonstrated that patients were most likely to opt for palliative surgery as a means to resolve symptoms leading to improvement in quality of life; very few patients expressed concerns about perioperative morbidity.⁵ In fairness and in the spirit of frank and open discussion, the patient should be fully informed that complications could lead to worsening, unresolved, or new symptoms and perhaps even hasten their demise. While all possible complications cannot be accurately predicted, open and advance communication about these possibilities usually facilitates a deep sense of personal trust between surgeons, their patients and patient family members. In this trusting context, it has been observed that patients are often very satisfied after palliative operations for end stage cancer even when symptoms are not resolved or when serious complications are encountered.¹

The decision to pursue palliative surgery in the sarcoma patient is complex. It may require major and potentially disfiguring surgery to attain a patient's treatment goal. These deliberations should ideally involve a sarcoma tumor board to ensure that multidisciplinary disease-specific expertise has been brought to bear in that such decisions often involve surgical experience and judgment in lieu of evidence based perspectives which may simply not be available. As a sarcoma community there is an opportunity for leadership and education in the field of palliative surgery. It is critical to expose trainees to the difficult decisions regarding palliative surgery; of necessity, these conversations must involve trainees if future generations of surgeons are to be comfortable in leading such discussions. As treatment options advance, it is likely that end stage sarcoma patients will live longer and consequently present more frequently with situations that mandate active consideration of palliative surgical approaches. High volume sarcoma center personnel should implement prospective trials to enhance identification and selection of patients who stand the best chance of improved quality of life via specific palliative surgical interventions. In tandem, these efforts may also provide the opportunity to improve education and communication with patients so that they have a realistic grasp of the goals of palliative surgery.

By using palliative surgery in sarcoma patients to allow them to eat, to relieve their pain, or to help resolve a necrotic, foul smelling wound we may offer an opportunity for these individuals to leave the hospital, return home, and maintain their dignity and sense of self at the end of life. While there is great personal and professional fulfillment in rendering a patient free of disease using the scalpel, equally gratifying is the opportunity to use the surgical armamentarium on behalf of the grateful patient whose dignity is restored due to timely interventions to relieve pain and suffering when cure is no longer possible.