Introduction

Palliative surgery is “… used with the primary intention of improving quality of life or relieving symptoms caused by advanced disease. Its effectiveness is judged by the presence and durability of patient-acknowledged symptom resolution.”

Surgical treatment decisions for patients receiving palliative care are challenging. Often they have to be made within a short period of time, and the outcome expectations may vary significantly between the surgeon on one side and the patient/family on the other side. The goals of surgery and those of good palliative care are, however, directly compatible. They often are shared clinical decisions, an evidence base is usually not available, and the consequences of decision-making are profound. Clinical intuition and experience are therefore very important in this situation.

The major prognostic feature is overall well being rather than the organs in which metastases appear. Increasing global frailty is the hallmark of death approaching. If a person is in a catabolic state, anything that accelerates their deterioration is likely to be irreversible. The trauma of surgery compounds the deterioration of the disease itself. Urgent operations are associated with increased risk and 30-day mortality of up to 28% is seen in patients with disseminated malignancy. Despite these risks, patients may experience significant benefits from palliative procedures, with observational studies demonstrating that 80%–90% of patients undergoing palliative surgery experience symptom improvement or resolution. ^, It has also been demonstrated in common solid tumors that the longer a patient survives from the time of diagnosis the more likely they are to survive the next 5 years (conditional survival).

These complexities highlight that when weighing the risks and benefits of surgical intervention in a patient with advanced cancer, the nuances of prognostication are best handled by a multidisciplinary team (MDT). MDTs have been shown to be more accurate at predicting survival than individual clinicians. A multidisciplinary approach is beneficial but due to the wide variation of disease presentation and underlying conditions of patients undergoing palliative surgery only very limited or no studies are available to support treatment decisions. ^,

There is no doubt that decisions in palliative surgery are very difficult but it is important to make every decision in this challenging area of surgery with profound and humble respect for the person who is dying and for their family.

Preoperative Assessment

The overall condition of the patient must be weighed against the proposed intervention in a multifactorial calculus that has little certainty. What is the overall condition of the person? Where might this person be in their disease trajectory either with or without the intervention proposed? What has been the rate of systemic decline in recent weeks and is it reversible? Rapid decline without a reversible cause is likely to delineate a very short prognosis, while a slower decline is likely to indicate a longer prognosis. Ultimately, is this person otherwise going to tolerate this procedure and live long enough to recover from the effects of the procedure to enjoy the benefits offered?

Prognostication is very difficult and clinicians tend to be too optimistic. Gripp et al . showed that patients suffering from metastatic colorectal and breast cancer had a more favorable prognosis, whereas brain metastases, Karnofsky performance status less than 50%, need for strong analgesics, dyspnea, high lactate dehydrogenase (LDH), and leukocytosis were associated with a poor prognosis.

In the preoperative phase it is important to review and clarify the goals of care with the patient and their caregivers, and this should be actively performed by the treating clinicians.

Interventional Radiology

The interventional radiologist can offer less invasive management of complications occurring in patients receiving palliative care.

Complications from vascular thrombosis are the second leading cause of death in patients with malignancy. For larger vessel venous disease, stenting is an option, such as in superior vena cava (SVC) syndrome and less commonly inferior vena cava (IVC). IVC stenting may provide symptomatic relief and can prevent secondary organ failure (renal or hepatic venous involvement).

Hemorrhage can occur in up to 10% of patients with advanced cancer. The role of interventional radiology in management of bleeding lies in embolization of a bleeding vessel, usually after active bleeding has been identified on computed tomography (CT) angiogram. This is performed most commonly via a femoral artery approach.

Embolotherapy can be bland when agents that cause vessel occlusion alone are employed (Gelfoam, polyvinyl alcohol particles, microspheres, coils). ^, Chemoembolization combines chemotherapeutic agents with an embolic agent and is delivered directly to the target tumor by selective cannulation of the feeding artery. This method facilitates increased chemotherapy dose to the tumor. ^,

Radioembolization or selective internal radiation therapy (SIRT) enables delivery of high-dose brachytherapy (BT) to hepatic malignancies by the selective injection of yttrium-90 microspheres, used in the setting of hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM). ^, This treatment exploits the finding that arterial supply to liver tumors is different to normal liver tissue, which is supplied by the portal vein system. There is low penetration of the beta particles from yttrium-90 (approximately 2.5 mm in human tissues), so necrotizing effects are localized.

Thermal ablation techniques involve placement of a specially designed probe/electrode into the center of a lesion, usually under ultrasound (US) +/− CT guidance. The device is connected to an energy source able to generate extremes of temperature to cause irreversible tumor necrosis, ranging from microwave or radiofrequency ablation (RFA) in excess of 60°C to cryotherapy using argon gas under pressure to create subfreezing temperatures. ^{, ,} Chemical ablation has also been described using absolute alcohol and phenol, although thermal ablation is more commonly performed. A 0.5–1.0-cm zone of coagulation necrosis around the lesion is required to enable a tumor-free margin. Because RFA relies on electrical current flow, effective tissue/tumor heating is reduced by adjacent blood vessels >3 mm due to heat sink effect. Microwave ablation can include larger treatment volumes (up to 8 cm diameter), provides optimal heating of cystic masses, causes less pain, and has less heat sink effect than RFA.

Overall, thermal ablative therapies (primarily RFA and microwave) are the preferred treatment option for small lesions, with chemoembolization therapy preferred for larger lesions.

Esophagus

Esophageal carcinoma is the eighth most common cancer worldwide and sixth most common cause of cancer death. ^, Despite recent improvements in treatment and modest survival gains, overall 5-year survival for esophageal cancer remains disappointing at around 17%. Patients with inoperable local disease fare even worse with less than 3% of patients surviving 5 years. The majority of symptoms from advanced esophageal cancer can now be palliated with nonsurgical techniques and, as such, palliative surgery in the form of resection or bypass is rarely performed.

The most troublesome symptoms of incurable esophageal cancer, namely, dysphagia and bleeding, can be alleviated using less invasive methods. Esophageal self-expanding stents (SES), BT, external beam radiotherapy, and endoscopic recannulation techniques are highly effective as unimodal or multimodal therapy and are well tolerated by patients. A 2014 Cochrane Review confirmed that the combination of BT with self-expanding metal stent insertion or radiotherapy should be used as the preferred options for palliative management of dysphagia. Meta-analysis has shown that metallic stents are superior to plastic stents. Patients have been reported to do badly with tumors requiring stents more than 12 cm in length.

BT provides a less instant relief of dysphagia than SES but is associated with a better quality of life (QOL) and survival. The optimal dose is unknown but 8–20 Gy in single or double doses is common. SES can be placed endoscopically often without the need for esophageal dilatation.

Malnutrition is common with advanced esophageal cancer due to malignant dysphagia and the catabolic state. Percutaneous gastrostomies (PEG) and radiologically inserted gastrostomies (RIG) can be placed and permit bolus feeding. The author prefers placement of a PEG tube at the time of esophageal stenting. Occasionally if the esophageal lumen is completely occluded, a surgical gastrostomy or feeding jejunostomy may be required. This can be placed via laparotomy or laparoscopy.

Stomach

Gastric carcinoma represents the second leading cause of cancer-related death worldwide. Despite improvements in overall survival, the majority (60%–70%) of patients diagnosed with gastric cancer present with advanced stages. Bleeding is the most important adverse event caused by locally advanced gastric cancer. Other major complications are gastric outlet obstruction (GOO) and malnutrition.

Hemorrhage and obstruction may often be controlled by endoscopic intervention or with radiotherapy, perforation almost always requires surgical intervention. The effect of palliative surgery in patients with advanced gastric cancer on QOL is unknown. Currently two prospective randomized multicenter trials (RENAISSANCE/Flot5, SURGIGAST) are assessing the role of combined chemotherapy and surgery for patients suffering from stage IV gastric cancer.

Complications due to peritoneal carcinomatosis, i.e., stenosis, bleeding, or perforation, have to be treated considering tumor mass, distribution and localization, performance status, nutritional status, and overall prognosis. Potential surgical therapeutic approaches include small bowel resection, stoma formation, bypass surgery, or PEG placement to drain gastric and small bowel fluid.

If bleeding is significant and cannot be controlled by endoscopic intervention, or if bleeding recurs more than once following endoscopic treatment, the following options remain:

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  Angiography and selective embolization of the bleeding vessel (angiography is only capable to visualize bleedings of 1 mL/min or more; the stomach is perfused via five different arteries limiting the chances of successful embolization)

  
  
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  Palliative gastrectomy

  
  
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  Palliative radiation

In a meta-analysis comparing endoscopic stenting to gastroenterostomy, stenting was found to be associated with higher clinical success, a shorter time to starting oral intake, reduced morbidity, a lower incidence of delayed gastric emptying, and a shorter hospital stay, while there was no significant difference between the two methods for severe complications or 30-day mortality. Surgical gastroenterostomy, however, appears to allow for longer symptom-free survival.

In some patients, insertion of a jejunal feeding tube (percutaneous endoscopic jejunostomy, PEJ) is the only option to maintain enteral nutrition. In patients with an otherwise untreatable GOO, palliative placement of a PEG is indicated to drain gastric fluid (venting PEG). Palliative (partial) gastrectomy may prolong survival by as much as 3 months when compared with a bypass procedure. This comes with a significant risk of morbidity and mortality and should therefore only be performed in selected cases.

Although gastrectomy remains a successful intervention for GOO related to gastric cancer, endoscopic stenting might be a preferable option for patients with limited life expectancy or where surgery is not possible. There are, however, no data on QOL outcomes postendoscopic stenting and the technology of duodenal stenting seems to lag behind that of biliary stents, and thus laparoscopic or open gastric bypass remains an important consideration.

Radiation has been associated with good palliation in gastric cancer causing obstruction with symptom control rates of 80% in a small series and has the advantage of also controlling bleeding.

Pancreas

Approximately 80% of newly diagnosed patients with pancreatic adenocarcinoma cannot benefit from a curative strategy. When the diagnosis of unresectable disease is made, nonsurgical endoscopic approaches should be prioritized in order to keep hospital stay as short as possible without delaying systemic chemotherapy. If an unresectable disease is diagnosed at laparotomy, an appropriate palliative surgical treatment should be considered to prevent biliary and enteral obstruction, as well as pain exacerbation due to tumor invasion. A more aggressive approach toward palliative resection can be justified only in specific circumstances. Hepatic metastases constitute a contraindication for resection of pancreatic adenocarcinoma. With treatment, median survival for locally advanced inoperable disease approaches 12 months in contemporary clinical trials and 6–8 months for metastatic disease.

The assessment of life expectancy in pancreatic cancer is difficult. Jamal et al . developed a symptom-based score (McGill-Brisbane Symptom Score, MBSS), which can be assessed during the first interview. They reported four symptoms independently predicting poor survival and weighted them regarding their influence on survival:

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  Weight loss >10% (8 points)

  
  
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  Pain (5 points)

  
  
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  Jaundice (4 points)

  
  
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  Smoking (4 points)

A low score (0–9 points) predicted an overall median survival of 14.6 months versus 6.3 months in the patient group with a high score (12–21 points).

Patients with an estimated survival of less than 6 months benefit more from interventional stent placement in terms of morbidity and length of hospital stay. Patients with a life expectancy exceeding 6 months may benefit from a more lasting solution with a decreased need for reinterventions over time. In these patients, a surgical bypass procedure should be performed, especially if the diagnosis of unresectable disease is made at laparotomy. These patients will benefit from double bypass procedures as this approach can reduce the incidence of GOO and obstructive jaundice. The double bypass procedure including gastrojejunostomy does not increase postoperative morbidity compared with biliary bypass alone. The retrocolic gastrojejunostomy is associated with a lower rate of postoperative delayed gastric emptying. Some authors reported 20% morbidity and 4% mortality rates after palliative biliary bypass surgery. ^,

A Cochrane Review published in 2014 addressed the question whether resection of the pancreas with involved vessels (locally advanced pancreatic cancer) provides better outcome than palliative treatment alone. This review identified some evidence that pancreatic resection increases survival and decreases costs compared with palliative treatment for selected patients (40% survival in resection group vs. 0% in palliative treatment group at 3 years follow up).

At diagnosis, approximately one-third of pancreatic cancer patients complain of pain and 90% of them experience severe pain at end-stage disease. Therefore any good palliation must focus on pain management in order to improve QOL. Percutaneous and/or intraoperative neurolysis should always be attempted for pain relief.

Biliary Tract/Liver

Most liver resections should be undertaken with curative intent. In the palliative setting, they are undertaken with two main aims, either to prolong survival or for symptom control. Cholangiocarcinomas are the main indication for surgical palliation, in the form of a biliary-enteric bypass. Neuroendocrine tumors (NETs) are the predominant indication for palliative liver resection. Cytoreductive liver resections for NETs can be associated with enhanced survival and can relieve symptoms caused by the mechanical effects of the tumor and hormone secretion.

The alleviation of biliary obstruction is preferable prior to instituting systemic therapy, if possible. Stenting endoscopically or percutaneously is an effective and less invasive option than surgical bypass, having been shown to have fewer short-term complications, although a higher reocclusion rate.

Studies have failed to demonstrate any significant difference in overall survival between patients with hilar cholangiocarcinomas who undergo surgical and nonsurgical procedures to relieve biliary obstruction, and percutaneous, endoscopic, and combined biliary stents should be regarded as first-line palliative treatment. The most common surgical approach for the palliation of hilar cholangiocarcinoma is a biliary-enteric bypass to segment III. For those patients in whom a segment III bypass is not feasible, a right-sided cholangiojejunostomy may be undertaken. The preferred procedure to achieve surgical palliation for patients with distal cholangiocarcinoma depends on the exact site of the tumor but is either a hepaticojejunostomy or choledochojejunostomy. It has long been recognized that these bypasses yield superior results compared with those involving the gall bladder or duodenum. Concomitant gastrojejunostomy as a prophylactic measure to avoid GOO is now recommended by most authors.

Unresectable gall bladder cancer is associated with a dismal survival of approximately 2–5 months, and nonsurgical methods of palliation should therefore be chosen in the vast majority of patients.

More than 80% of patients with liver metastases from NETs cannot undergo curative resection. The management of these patients remains controversial. The main aims of palliative liver resections for NETs are to improve symptoms (and associated QOL) and facilitate the effect of nonoperative treatments. Palliative resections for neuroendocrine liver metastases (NELM) can also confer a survival benefit. Most authors advocate cytoreductive hepatic surgery when at least 90% of the bulk of the tumor can be resected, which is very likely to yield a successful outcome. The current literature, however, does not provide evidence from randomized trials in order to definitely assess the role of cytoreductive surgery in these patients.

Small and Large Bowel and Rectum

Less than 3% of gastrointestinal malignancies arise from the small bowel. Malignant small bowel obstruction carries a poor prognosis, and usually survival is not expected to exceed 1 year. ^, Within the multitude of disease processes that can lead to malignant small bowel obstruction, patients with primary colorectal cancer appear to have better survival and palliation when treated with surgical intervention. In the palliative setting, intestinal bypass or stoma formation needs to be considered. A high-output stoma carries significant risks for the patient and an intestinal bypass should always be preferred for the treatment of a nonresectable malignant small bowel obstruction.

The estimated median survival of patients with inoperable malignant bowel obstruction (MBO) is 1 month with a 6-month survival of less than 8%. A patient fit for surgery should only have a short trial of conservative management followed by surgery. Surgery should result in a definitive diagnosis, radical resection of the obstructing lesion, or bypass formation.

Considering overall data of invasive measures in metastatic colorectal cancer, there are no statistically significant differences between median survival of patients treated with resection surgery (11–22 months) and of patients treated with intervention without tumor resection (7–22 months). The median survival of patients receiving only best supportive care does not exceed 2–3 months. Studies involving a series of surgical cases of MBO have shown a 30-day mortality of 25% (9%–40%), postsurgical morbidity of 50% (9%–90%), a rate of reobstruction of 48% (39%–57%), and a median survival of 7 months (2–12 months). ^{, ,} Age, advanced disease, malnutrition, and poor performance status are considered factors for poor prognosis even in cases where surgery may technically be possible. ^,

Malignant colonic obstruction in a patient not suitable for surgery can often be managed effectively with a self-expanding colonic stent, under fluoroscopic guidance. ^, With this method, stents can be inserted into the rectum and distal sigmoid but with combined colonoscopic guidance stents can also be placed into the proximal colon. Colonic stenting has a high success rate (80%–100%) with good symptomatic relief and improved QOL. There is no difference in mortality and morbidity rates compared with surgery, but the advantage of stenting is a shorter hospital stay with shorter procedure time and less blood loss. The most common complications of this technique are immediate or delayed perforation (4.5%), migration (11%), and obstruction (12%).

Palliative medical treatment of inoperable MBO is multimodal and based on the combined use of glucocorticoids, antiemetics, antisecretors, and potent analgesic opioids. Due to their antiemetic action and reduction of mucosal edema, glucocorticoids are indicated in the initial phases of this complication and may increase the rate of spontaneous resolution. Antiemetics of choice are neuroleptics (haloperidol). Antagonists of 5-HT ₃ receptors are effective for controlling emesis in the treatment of MBO, even in cases where the patient’s response to other antiemetics is insufficient.

There is considerable debate regarding the risks and benefits of elective resection of the primary tumor in asymptomatic patients with clearly incurable disease. The rationale for this approach is threefold. First, it may prevent development of acute complications during the lifetime of the patient, which is now significantly longer. In patients with metastatic colorectal cancer where the primary tumor remains in situ and there are no symptoms, only 11%–14% experience morbidity related to the primary tumor that may require surgical or nonsurgical intervention such as stenting or radiotherapy. Second, primary tumor resection may prevent treatment complications such as hemorrhage or perforation that arise due to the use of the anti–vascular endothelial growth factor (VEGF) agent bevacizumab. Third, primary resection may improve the efficacy of systemic treatment and prolong survival. There are, however, conflicting data on the survival benefit of primary tumor resection and no prospective randomized trials, although recent retrospective studies have suggested a survival benefit. It is likely that carefully selected patients benefit from primary tumor resection followed by systemic therapy. Nonetheless, until the results of ongoing randomized trials are published, this patient population remains undefined.

Abnormal volume of fluid in the peritoneal cavity as a result of cancer is termed malignant ascites and develops in up to 50% of cases. Common underlying neoplasms include breast, ovarian, gastric, pancreas, and colon cancer, with up to 20% of unknown primary. ^, Associated life expectancy is short (less than 4 months); only in breast and ovarian cancer is survival usually longer. Single drainage of ascites with nontunneled catheters is effective but if left in place long term these can cause complications, such as infection (35%), accidental removal, leakage (20%), and occlusion (30%). As a result, tunneled catheters are preferred for longer-term management of malignant ascites. ^,

Brain and Vertebral Column

Modern neurosurgery is much less invasive than even two decades ago, and it is much easier to tip the balance in favor of intervention for symptom reduction. Autopsy studies suggest that 20%–25% of cancer patients have brain metastases. Eight to ten percent of adults with cancer will develop symptomatic brain metastases. There is some evidence supporting the treatment of up to three metastases, and for palliation of raised intracranial pressure or neurologic deficit, a large metastasis may be removed even if the magnetic resonance imaging (MRI) reveals other smaller asymptomatic lesions.

While there is still debate regarding the influence of surgery on survival of glioblastoma, it can be very useful for palliation of symptoms, including headache and neurologic deficit. ^{, ,} Surgery will usually provide better palliation for accessible tumors in noneloquent areas, but radiosurgery (linear accelerator, Gamma knife) can be very useful for treating deep-seated tumors or those in eloquent areas.

Ventriculoperitoneal shunting can provide dramatic palliation of symptoms of raised intracranial pressure with minimal morbidity. In some cases, where there are malignant cells in the cerebrospinal fluid (CSF), there is a risk of peritoneal seeding as well as shunt blockage. In this situation, endoscopic third ventriculostomy is a minimally invasive procedure that can provide similar palliation.

Epidural spinal cord or cauda equina compression from metastatic disease can have a significant negative effect on QOL. Treatment by posterior laminectomy often fails. Minimally invasive surgery (MIS) techniques provide a compromise better suited to palliation of pain and neurologic deficit. Using a combination of neuronavigation and MIS techniques, tumors can often be decompressed through the pedicle, and fixation can then be inserted percutaneously.

Head and Neck

The complexity of care in the terminal period of life with head and neck cancer (HNC) results in the admission of many patients. A recent study reported that more than 50% of patients were hospitalized in their last month of life due to bleeding (17%), pain (9%), breathing difficulties (9%), swallowing difficulties (9%), inability to cope (6%), and fracture (3%).

Cancer of the head and neck often requires treatment to provide patients with adequate voice use and the ability to swallow. Endoluminal debulking of pharyngeal and laryngeal lesions can provide good palliation, avoiding the need for a tracheostomy and allowing patients to undergo palliative chemotherapy or radiotherapy, or to buy time for definitive palliative surgery. The use of laser allows clean, hemostatic tumor removal or debulking.

Weight loss and malnutrition are major problems in patients with advanced HNC, with more than half having significant weight loss and cachexia, and approximately 20% of all cancer-related deaths caused by cachexia. ^, Cancer cachexia is different from starvation and is associated with preferential loss of muscle over adipose tissue, increased proteolysis and lipolysis, increased metabolic activity of the liver, and increased production of acute-phase proteins.

Pleura, Chest Wall, Lung, and Mediastinum

The main indications for thoracic surgical palliation in primary and secondary thoracic malignancies are:

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  Cardiorespiratory compromise secondary to a malignant pleural effusion and/or pericardial effusion

  
  
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  Pulmonary metastases from extrathoracic primary malignancy

  
  
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  Pain resulting from chest wall tumors

  
  
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  Sepsis resulting from obstructive bronchogenic malignancy

Malignant pleural mesothelioma is an almost-always fatal tumor, and palliative platinum-based chemotherapy is the standard of care. A recent Cochrane Review addressed the question whether the use of radical multimodality therapy with extrapleural pneumonectomy would provide better survival. This review does not support the use of radical multimodality therapy over routine clinical care. In patients with malignant pleural mesothelioma it is therefore recommended that videoscopic talc pleurodesis and insertion of a tunneled indwelling pleural catheter are the most appropriate forms of palliation.

Overwhelmingly, malignant pleural effusion is the main indication for surgical palliation in thoracic malignancy. It is generally accepted that pleurodesis should not be attempted if the predicted survival of the patients is less than 3 months.

If, on postdrainage plain chest x-ray, the lung reexpands completely, full pleural apposition can be achieved and any intervention to affect a pleurodesis will have a high likelihood of success. If the lung fails to reexpand fully, this indicates entrapment by a malignant pleural rind and any attempt to achieve a pleurodesis will have a high failure rate.

The most effective surgical treatment option for malignant pleural effusion is that of a videoscopic talc pleurodesis. This procedure requires general anesthesia, double-lumen endotracheal intubation, and positioning of the patient in the lateral decubitus position. Sterile talc is insufflated to effectively cover all areas of the visceral and parietal pleura. The standard dose is 5–10 g. A chest drain is inserted and should be removed when less than 150 mL of pleural fluid is produced over a period of 24 h. This usually occurs at 48–72 h postsurgery. The success rate of a talc pleurodesis has been reported to be greater than 75%.

Talc slurry (talc mixed with normal saline 5 g talc: 50–100 mL sterile normal saline), instilled via an intercostal catheter, is a useful technique for achieving pleurodesis in patients not fit for or declining surgical intervention. This technique can be performed on the ward. The talc slurry is instilled via the intercostal catheter and the tube clamped. The patient is then positioned on each side in the supine position for approximately 20 min and then in the upright position, leaning left and right for a further 20 min. The procedure results in acute pleuritis and can be quite painful. Adequate analgesia should be provided to the patient. The author prefers to add local anesthetic agents to the talc slurry. Thoracoscopic talc pleurodesis has a significantly higher success rate than talc slurry (80% vs. 60%). The effectiveness of talc slurry compared with a permanent indwelling pleural catheter is comparable.

For patients with failed videoscopic pleurodesis where significant symptomatic benefit is achieved by pleural drainage, a permanent indwelling tunneled pleural catheter may be the most effective option.

Malignant pericardial effusions can be effectively managed in the acute setting by percutaneous drainage via an ultrasound-guided catheter introduced using Seldinger technique. For long-term management a pericardial window can be formed videoscopically on the left or right side.

Breast

Women with metastatic breast cancer face remote disease as their dominant cause of death, but many will have concurrent locoregional relapse. Often a standard mastectomy technique with carefully planned skin excision can remove a symptomatic, ulcerating cancer with primary closure of the skin and subcutaneous tissues. Vacuum-assisted closure (VAC) dressings are the currently preferred dressing for split-skin grafting postmastectomy. Latissimus dorsi (LD) myocutaneous flaps are the simplest option for new skin and soft tissue. They can be mobilized and rotated into a postmastectomy defect with relatively little surgical morbidity. An LD flap provides robust skin and muscle coverage, which allows postsurgical radiotherapy to be performed.

In many cases axillary dissection to level III of the axilla can be a very important palliative surgical procedure. In the era of sentinel lymph node biopsy as standard therapy for early breast cancer, palliative completion axillary dissection is an important surgical tool. The contraindications to resection of axillary disease are involvement of the axillary artery and brachial plexus.

Patients often survive for considerable periods with stage IV breast cancer. In these patients, the majority of the tumor burden will often be the primary cancer in the breast or axilla. Retrospective studies have suggested improved survival for patients who have the primary malignancy resected in the presence of confirmed metastatic disease. This view, however, is not entirely supported by a recent Cochrane Review. Tosello et al. did not identify evidence from randomized trials to make definitive conclusions on the benefits and risks of breast surgery associated with systemic treatment for women diagnosed with metastatic breast cancer.

The bone is the most common site for breast cancer metastases. Low-volume, bone-only disease is relatively common and often responds well to systemic therapy, particularly endocrine agents. Indications for surgery are lack of response to therapy, local pain, fracture, or high potential of fracture in weight-bearing long bones.

Thyroid Gland

Anaplastic thyroid carcinoma (ATC) is one of the most aggressive solid neoplasms with a median survival of 6 months after diagnosis. It most commonly presents as a large, firm thyroid mass causing hoarseness, vocal cord paralysis, dysphagia, cervical pain, and dyspnea. Most cancer-related deaths are due to rapid locoregional growth; therefore therapeutic efforts should be concentrated here. These patients are often best managed by multimodal therapy, including surgery and external beam radiation therapy (EBRT) ± chemotherapy. Due to its poor prognosis, aggressive approaches in metastatic ATC should be used sparingly. In cases of inoperability, neoadjuvant EBRT and/or chemotherapy should be considered, possibly rendering the tumor suitable for surgery. As there is a high risk of relapse after response to EBRT ± chemotherapy, surgery should be performed when feasible in these cases. There is no indication for tumor debulking with gross positive margins.

Tracheostomy for airway compromise is technically challenging and has a high rate of healing complications, which can delay EBRT. It should be considered in cases of impending airway obstruction, not as a prophylaxis. Most patients requiring a tracheostomy have aggressive disease with a poor prognosis. It may relieve airway distress but provides minimal prolongation of life.

Adrenal Gland

Adrenal incidentalomas may be found in 4%–7% of abdominal CT scans. Up to 5% of these will be adrenocortical carcinomas (ACC), and 2.5% will be metastatic cancers. An endocrine syndrome can be found in 60% of ACC, most commonly Cushing syndrome (50%), virilization (<10%), or a combination of both (25%). ACC are very rare malignant tumors (1–2 per million per year). In the presence of metastatic lesions, the 5-year survival drops from approximately 60% to below 20%, and survival is usually less than 13 months. Debulking mainly serves to control tumor-related endocrine syndromes.

To diagnose a malignant pheochromocytoma (PCC), the presence of local invasion and distant metastasis is needed, and such lesions are not curable. Up to 25% are part of a hereditary syndrome, most commonly multiple endocrine neoplasia and von Hippel-Lindau. Treatment options for malignant PCC include surgery (the mainstay of treatment), metaiodobenzylguanidine (MIBG) radiotherapy, and systemic antineoplastic therapy. There are no randomized controlled trials to determine which nonsurgical treatment is more effective. If the PCC is not resectable, tumor debulking is considered a mainstay of treatment, palliating the hypersecretory state. However, its role is unclear in asymptomatic, low-secreting tumors.

Urology

The most commonly performed palliative urologic procedures are ureteric stenting and fulguration of bleeding bladder and prostate tumors. As cystectomy carries greater morbidity than radiotherapy, it should be considered only if there are no other options of palliative diversion (nephrostomy, ileal conduit). Ureteric stents may not always be able to overcome the compressive forces, and nephrostomy tubes may be the only palliative option.

Up to one-third of cases with renal cell carcinoma (RCC) will present with synchronous metastatic disease. Cytoreductive nephrectomy has potential QOL benefits as it may reduce bleeding, pain from clot colic, as well as paraneoplastic symptoms. Patients who underwent cytoreductive nephrectomy also have better survival.

The gold standard treatment for organ-confined ureteric or renal pelvis transitional cell carcinoma (TCC) is nephroureterectomy. Patients with synchronous or metachronous metastatic disease have poor outcomes. For metastatic bladder TCC, the current standard of care involves a transvesical debulking of the bladder tumor with adjuvant chemotherapy and radiotherapy. However, palliative cystoprostatectomy (men) or anterior pelvic exenteration (women) remains an option for patients with significant local symptoms such as uncontrollable hemorrhage.

Most patients with lymph node-positive prostate cancer will ultimately fail treatment. While many urologists are reluctant to perform radical prostatectomy (RP) in patients who are lymph node-positive, there is evidence of improved cancer-specific and overall survival in those who undergo RP. Thus RP is an important component of multimodal strategies of lymph node-positive prostate cancer.

Gynecology

Epithelial ovarian cancer, which accounts for >90% of all ovarian malignancies, is advanced at diagnosis in approximately 70% of cases. Primary cytoreductive surgery is still the mainstay of therapy for its assumed benefit in three main areas:

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  Physiological benefits of removing bulky tumor masses, particularly ovarian and omental disease, improving gut function and decreasing ascites.

  
  
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  Improved tumor perfusion and increased growth fraction increasing the likelihood of response to chemotherapy and decreasing the potential for developing drug resistance.

  
  
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  Immunologic benefits as large tumor masses appear to have an immunosuppressive function.

There also appears to be a role for repeat surgical cytoreduction in patients with recurrent disease.

The incidence of bowel obstruction in patients with ovarian cancer is 25%–50%, and the life expectancy of patients with bowel obstruction in ovarian cancer is 4 months. There are no definite prognostic factors to predict the outcome of surgery in patients with MBO, and the management of these patients remains controversial. Kucukmetin et al . confirmed in a Cochrane Review that there is evidence in support of palliative surgical management to prolong survival in patients suffering from bowel obstruction due to ovarian cancer.

Cancer of the cervix is the most common gynecologic cancer worldwide, with the incidence being much higher in third world countries without a screening program. Locally advanced or metastatic cervical cancer is usually primarily treated with chemoradiation rather than radical hysterectomy. When cervical cancer recurs centrally in a radiated field, pelvic exenteration may offer the only hope of cure. However, there may also be a role for palliative exenteration in certain cases of cervical cancer complicated by vesico- or colovaginal fistulae. A Cochrane Review published in 2014, however, did not find evidence from which to determine whether exenterative surgery is better, equivalent to, or worse than nonsurgical treatment in women with recurrent gynecologic cancers (excluding recurrent ovarian cancer). Recurrent cervical cancer may also present with ureteric obstruction. Retrograde stenting is often appropriate, but if this is not technically feasible, strong consideration must be given to the appropriateness of percutaneous nephrostomy in patients whose poor prognosis or symptoms from pelvic tumor may make a less traumatic demise from renal failure a kinder option.

Large ovarian tumors, either primary or secondary from other sites (particularly gastrointestinal tract and breast), may cause local pressure effects resulting in pain, bloating, abdominal distension, and problems with gut function. Even if the removal of the ovarian tumor does not prolong survival, there is a role to debulk them to improve the patient’s QOL for the time they have left.

Recurrent ascites is a common complication in patients with advanced gynecologic malignancies, especially recurrent ovarian cancer. Repeated paracentesis may be required, and this can be a great inconvenience to patients. A tunneled peritoneal catheter drainage system (radiologic or surgical insertion is possible) can be used for repeated drainage of ascitic fluid in the community setting.

Orthopedics

The aim of palliative orthopedic treatment is to alleviate pain and restore mobility and dignity to patients suffering with terminal cancer.

The majority of metastatic bone lesions encountered are lytic in nature. Lysis is not due to direct tumor destruction. It occurs via the release of cytokines, causing recruitment of osteoclasts. This is thought to occur as part of the metastatic cell binding.

Treatment for patients with metastatic bone disease (MBD) is primarily palliative, with the goals of limiting pain and rapidly restoring function. Renal and thyroid carcinoma lesions may be highly vascular. Embolization is advisable to decrease the risk of bleeding. This should be performed even if closed techniques such as intramedullary nailing are to be employed.

Typically, clinicians have a tendency to underestimate the patients’ life expectancy. The following features of MBD are associated with a better prognosis:

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  Primary tumor breast, prostate, myeloma, or lymphoma

  
  
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  Solitary skeletal metastasis

  
  
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  Absence of visceral metastasis

  
  
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  Absence of pathological fracture

In the lower-limb intramedullary nailing is the treatment of choice. In the femur the use of long cephalomedullary nails is recommended. These maximize the amount of bone protected and reduce the need for reoperation. Controversy exists in the surgical management of diaphyseal lesions in the humerus. The surgical options are either intramedullary nailing or plate stabilization. There is no consensus within the literature, and surgeons should use the technique they feel most comfortable with.

The femur and specifically the hip are disproportionately overrepresented in the frequency of long bone MBD locations. Up to 75% of all surgery for MBD is performed in the hip. In the proximal femur, lesions that cross the intertrochanteric line proximally should be treated with arthroplasty.

Conclusions

Palliative surgery remains a challenging area of surgery with limited evidence to support therapeutic decision-making. Significant symptom relief can be achieved through close cooperation between different care providers and surgical (sub-) specialists. Early postoperative morbidity and mortality are high and this needs discussion with patients, family, and other members of the care team. Less traumatizing and minimal invasive approaches should always be preferred to reduce time spent in hospital and to avoid delays of palliative radio- and/or chemotherapy. Every decision in this area of surgery needs to be made with profound and humble respect for the person who is dying and their family.

Key Points

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  Every surgeon should have a good understanding of the options and limitations of palliative surgery.

  
  
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  30-day mortality in palliative surgery is as high as 30%.

  
  
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  Treatment decisions should be made in an MDT setting.

  
  
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  Brain metastases, Karnofsky index less than 50%, severe pain, dyspnea, high LDH, and leukocytosis are indicators of a poor prognosis.

  
  
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  Endoscopic stenting +/- BT is the preferred option for management of malignant dysphagia.

  
  
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  Palliative gastrectomy for stage IV gastric cancer is currently under investigation.

  
  
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  Complications of unresectable pancreatic cancer should be managed with nonsurgical endoscopic/radiologic approaches.

  
  
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  If unresectable pancreatic cancer is found at surgery a double bypass procedure should be performed.

  
  
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  Locally advanced pancreatic cancer is best palliated with resection.

  
  
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  Endoscopic, percutaneous, and combined stents are the first line of palliative treatment for malignant biliary obstruction.

  
  
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  Malignant small and/or large bowel obstruction should be managed surgically (bypass/stoma/resection) in a patient fit for surgery.

  
  
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  Malignant colonic obstruction in patients not fit for surgery is best managed with a colonic stent.

  
  
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  Asymptomatic patients with stage IV colorectal cancer benefit from primary tumor resection followed by systemic therapy.

  
  
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  Malignant ascites indicates a life expectancy of less than 4 months (excluding breast and ovarian cancer).

  
  
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  Tunneled catheters are optimal for management of malignant ascites and malignant pleural effusion (if pleurodesis fails).

  
  
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  Palliative resection of up to three brain metastases is justified.

  
  
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  Radiosurgery (Gamma knife, linear accelerator) is suitable for deep-seated tumors or those in eloquent areas.

  
  
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  Videoscopic talc pleurodesis is the most effective treatment for malignant pleural effusions.

  
  
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  Radical multimodality therapy of malignant pleural mesothelioma is not superior to palliative platinum-based chemotherapy plus pleurodesis.

  
  
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  Primary cytoreductive surgery is the mainstay of therapy for advanced ovarian cancer.

  
  
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  Palliative surgery for bowel obstruction due to ovarian cancer prolongs patient survival.