Palliative surgery for gastric cancer

Most patients with gastric carcinoma have a disease that is too advanced for radical surgery. A Review was made of 13,175 cases of gastric carcinoma registered at the Birmingham Cancer Registry during the period of 1960-1969. Of the patients, 79.6% had disease that was not radically resected, and few of these patients survived to 2 years. Those who had a palliative resection or bypass had the lowest 30-day mortality rate when compared to all other palliative measures (P less than 0.001). Furthermore, palliative resection gave the best survival in the presence of both locally advanced and metastatic disease (P less than 0.001). This suggests that the best palliative procedure for those with a disease unsuitable for radical surgery is a resection.     

Palliative surgery of soft tissue sarcoma

Despite an increasing trend towards early diagnosis of breast cancer,patients still present with locally advanced disease. Also, in some patients chemotherapy will fail, and local and regional recurrence will occur. This article outlines options for palliative care for such patients.     

Palliative surgery for brain metastases of malignant melanoma.

Forty patients with melanoma brain metastases were treated by surgery. Single brain metastases were found in 32 cases and multiple in eight. The most frequent tumor location was the frontal and frontoparietal lobes. Neurological improvement was observed in 25 patients and surgical mortality rate was less than 5%. The median survival time for all patients was 8 months. When patients with multiple cerebral metastases were excluded the median survival time was 13 months. The 3- and 5-year survival was 25% and 15%, respectively. Seventeen patients with extracerebral metastases received treatment and were without known extracerebral tumor at the time of brain metastases diagnosis. These patients had a median survival time that did not significantly differ from those without occurrence of extracerebral metastases. Quality of life as judged by Karnofsky index was improved after surgery and maintained on an acceptable level for the remaining time of survival.     

胰腺癌:姑息性手术治疗(旁路术/切除术)

Objective:We compare the outcome of palliative pancreaticoduodenectomy and palliative surgical bypass in patients with advanced pancreatic carcinoma in our hospital. Recent published related articles are also reviewed. Methods:A respective analysis was performed comparing the perioperative parameters and outcome of 20 patients who underwent pancreaticoduodenectomy with a gross suspected cancer residue and 30 patients who underwent a surgical bypass, all of the patients were diagnosed as in advanced stages intra-operatively. Results:The two groups were comparable with patient characteristics, including age, gender, initial symptoms and concomitant major organ diseases. Tumors are similar in size and intra-operatively diagnosed as in advanced stages in both groups. All of the patients in the resection group were microscopically proved having cancer residue. One postoperative mortality occurred in the resection group (5%), zero in the bypass group (P ＞ 0.05). Overall complications were significantly higher in the resection group (30% vs. 0, P ＜ 0.01), including 2 patients developed Acute Respiratory Distress Syndrome (ARDS), zero in the bypass group (P ＜ 0.01); hemorrhage and transfusions in the resection group were much more than that in the bypass group (P ＜ 0.05). Hospital stay after resection was significantly longer than bypass (20 vs. 12 days, P ＜ 0.01). Hospital fee after resection was 4 times more than after bypass (median 61.500 vs. 15. 300 yuan, P ＜ 0.01). Survival was significantly longer after resection (median 12.2 vs. 7.1 months, P ＜ 0.01). Conclusion:Our results show that palliative resection in advanced pancreatic carcinoma lengthens the survival time of the patients, but this is paid for significantly higher complications than bypass.     

Palliative surgery of metastatic bone disease: A review of 83 cases

Of a total of 83 patients with metastatic bone disease, surgery was performed in 17 cases at the prefracture stage, in 54 cases after complete fracture and in 10 cases to decompress the spinal cord. Positive short-term results were obtained in 75% of cases. 7 patients presented mild complications. In 2 cases, the patients had to be reoperated. 55% of the patients were still alive after 6 months, 31% after 12 months and 10% after 2 years.     

Palliative radiotherapy

Radiotherapy is often used for the palliative treatment of advanced cancer. Although each cancer is unique in its histology and natural history, there are several scenarios that repeatedly challenge physicians. Specifically, skeletal metastases, spinal cord compression, brain metastasis, bronchial obstruction, and vena cava obstruction are regularly encountered. This review will discuss the diagnosis and treatment of these common important situations.     

Palliative therapy

There are a wide variety of palliative treatments for esophageal cancer. The aim of most treatments is to maintain oral food intake, which should stabilize or even improve quality of life. Stent placement is currently the most widely used treatment modality for palliation of dysphagia from esophageal cancer. Stent placement offers a rapid relief of dysphagia, however, the rate of complications (late hemorrhage) and recurrent dysphagia (stent migration, tumor overgrowth) is relatively high. The scientific evidence to advocate the use of anti-reflux stents for the prevention of gastro-esophageal reflux is currently too low. Photodynamic therapy is mostly used in North America; however, due to the high costs of the treatment, the long-lasting side effects and the necessity of repeated treatments, it is not an ideal treatment for palliation of malignant dysphagia. Nd:YAG laser is a relatively effective and safe treatment modality, although laser treatment is also expensive, technically difficult and requiring repeated treatment sessions at 4-6 weeks intervals. Single dose brachytherapy compares favorably to stent placement in long-term effectiveness and safety. Effective treatment strategies are probably 12 Gy given in one fraction or 16 Gy given in two fractions. Palliative chemotherapy offers response rates in recent trials (including partial and complete responses) ranging from 35% to 50%. Whether palliative chemotherapy also results in a survival benefit is not established yet. For clinical trials on palliation of esophageal cancer, the measurement of quality of life is an important outcome measure. The cancer-specific EORTC QLQ-C30 and the esophageal cancer-specific EORTC-OES-18 are validated measures for establishing quality of life status. For the future, a multimodality approach with stent placement or brachytherapy in combination with chemotherapy may be indicated.     

Palliative Viszeralchirurgie

Despite constant improvements in diagnostics and cancer therapy, numerous patients with malignant tumors present with advanced tumor stages with local infiltration and/or distant metastasis at the time of initial diagnosis. Many of these patients only qualify for palliative therapy. Surgery plays a pivotal role in different interdisciplinary palliative treatment strategies. In the present review, the surgical therapy options for the treatment of different tumor entities are discussed. Moreover, the therapy of peritoneal carcinomatosis including peritonectomy in combination with intraperitoneal and systemic chemotherapy is reviewed.     

Palliative gastroenterology

Continuous improvements in endoscopic imaging and accessories have opened up a field of interventional endoscopy. This highly technical offshoot of gastroenterology uses not just standard endoscopic techniques but also newer endoscopic ultrasound (EUS) imaging or fluoroscopic monitoring to facilitate procedures that were once performed either surgically or percutaneously, if at all. This review will update the role of these novel procedures that can be used to assist in the palliative care of patients whose malignancies involve the gastrointestinal tract. The emphasis will be on those palliative interventions that are used to overcome intestinal obstruction in the gastrointestinal tract and restore luminal patency. The role of EUS-guided celiac plexus neurolysis to assist in pain control, especially in patients with pancreatic malignancies, will also be detailed.     

Hope Is Palliative

The authors reflect on the palliative value of hope when dealing with illness.“May I call you?” our mother asked via text message. It was Black Friday—a day when the masses awaken early, descend on stores in droves, and search for bargains. I asked if we could talk later.“Ok, just wanted to ask you about Gram. She’s very yellow today.”We discussed this change in appearance by telephone. Our elderly grandmother was battling a viral infection and later developed a skin rash, so we hoped for an autoimmune hemolytic anemia or other benign cause of her painless jaundice. Those two words, a verbal “one-two punch,” invoke doom in anyone familiar with them, given their association with advanced pancreatic cancer and its poor outcomes.In the emergency department later that morning, a computed tomography scan revealed a mass growing in the head of her pancreas. Hospital admission was arranged, and additional imaging was ordered. A young gastroenterologist, consulted to obtain tissue, suggested the possibility of a diverticulum instead. He explained this could become filled with food and compress the biliary system. Evaluation via endoscopic retrograde cholangiopancreatography (ERCP) was suggested for diagnosis. The ERCP was performed the next day and confirmed the presence of a mass. Brushings were obtained, but the physician, impressed by the endoscopic findings, diagnosed pancreatic cancer shortly after the procedure was complete. Unfortunately, we were told, no aggressive treatment options were available. Within 24 hours of admission, the palliative care service was consulted, and discharge planning began.The palliative care team was a single physician who had worked previously as a general surgeon. After reviewing the images, he was not convinced of the inevitability of death. He suggested that the disease was localized to the pancreas and urged our family to seek the opinion of an experienced surgeon. Desperate for hope, we embraced this uncertainty. Arrangements were made for a second opinion at an academic medical center 100 miles from our home. An endoscopic ultrasound scan would be performed in the morning, the case would be discussed at a multidisciplinary tumor board, and then the surgeon would share the recommendations in the afternoon.“Too much to text but not bad news.”The ultrasound scan was complete. The expert endoscopist suggested that autoimmune pancreatitis, a nonmalignant entity that mimics pancreatic cancer, might be the culprit. Instead of surgery, radiation, and cytotoxic chemotherapy, she would be expected to recover with a short course of steroids. Overwhelmed by this benign possibility, our mother leaped from her chair and hugged the attending gastroenterologist. The fellow-in-tow, surprised by this unexpected outburst, cried. Laboratory tests were ordered for autoimmune pancreatitis but ultimately returned negative. The surgeon outlined the risks and benefits of a robotically assisted Whipple. His optimism was clear: the intent was to eradicate all disease—to cure. The surgery was scheduled for the last week of December.Over the holidays, our family converged in snowy northwestern Pennsylvania from warmer climates thousands of miles away. A preoperative positron emission tomography scan was negative, and the plans for surgical resection were confirmed. Our grandmother made the holiday meal and, on Christmas day, served lasagna and dipped Italian Wedding Soup as she had done for years. We relished each other’s company and chatted for hours; all of us content to ignore the 800-lb gorilla. After the leftovers were eaten, and the dishes were washed and put away, the out of town visitors began to leave. We wished her luck with her surgery instead of saying goodbye.The lone update came in the form of a group text message: “Everything still quiet. OR nurse Nancy just stopped by to say they were still going. Doctor very intent on what he is doing. Still maneuvering robot. Lots of soft tissue to get through. Probably be until dinner time before he’s all done.”Shortly before supper, the surgeon emerged from the operating room, convened the family, and declared the operation successful. In the days that followed, she walked with physical therapy, used the incentive spirometer, and ate meals. After 2 days, she left the intensive care unit and, on postoperative day 7, was discharged from the hospital. She had exceeded everyone’s expectations. The pathologic report showed locally advanced pancreatic adenocarcinoma with 1 of 13 positive regional lymph nodes and negative surgical margins. Chemotherapy could be considered and would boost the chance of cure. If ever there was a time to be hopeful, it was now.“Hi love…. You up yet?” read the pre-7 a.m. text messages from our mother. In the telephone calls that followed, we learned that our grandmother had died early that morning, less than 2 weeks after hospital discharge. She had had a sudden onset of back pain and chills followed by irregular breathing. Was it a pulmonary embolus? A myocardial infarction? An infection? The possibilities seemed so academic and so trivial. It was over.This new development was difficult to accept after she had done well with surgery and was cured (or nearly cured) of her disease. In our zeal to hope for the best outcome, had we overlooked the risks inherent to a major operation? In retrospect, the surgeon’s confidence as he described the curative operation left little room for us to be dubious. The risks seemed miniscule compared with the consequences of withholding curative therapy in the setting of an aggressive cancer. Refusing surgery meant accepting death, an option we admonished weeks before when we left the community hospital. The stakes were high, and we agreed to move forward.For us, proceeding meant a transition from health care providers to health care consumers and anxious family members. In this new role, we came to appreciate that the path to cancer survivorship, although well-trodden, is not easy. Patients who elect to receive curative therapy must also consent to the risks associated with it and accept its long-term physical and psychological sequelae. Even with the best medical care, delivered under the most favorable circumstances, cures are not guaranteed. When remissions vanish and cancer relapses, particularly in elderly patients, some might question the appropriateness of aggressive therapy over less intensive measures. In light of our grandmother’s unfavorable outcome, several of us were left questioning whether our decision to pursue aggressive therapy was appropriate.After careful consideration, we recognized that adopting a curative approach to our grandmother’s cancer improved her quality of life during the final weeks. Although this strategy conflicts with prevailing views on resource allocation and end of life care, it allowed our grandmother and our family to look forward to a life after cancer. Surgery and chemotherapy meant that she would be a part of future family gatherings, enjoy a few more Sunday mornings, and savor the warm days of spring after the long winter. For our family, too, the surgery represented hope. It was the difference between wishing her well with surgery instead of saying “goodbye” over the Christmas holiday. There was never a need for hospice. Although selfish, we were relieved not to witness the natural history of pancreatic cancer unfold in our loved one. Her death, although unexpected, was brief and painless—for all of us.From the palliative care physician to the endoscopist and surgical oncologist at the tertiary academic center, the hope we were given was a much more potent form of palliation than any medicine or surgery. It allowed us to view the diagnosis as an obstacle that could be overcome. Death was once again allowed to slip into the realm of uncertainty, and we enjoyed our time together. Although limited, this was time spent unencumbered by a deadly disease.As providers, many of us can recall discussions with our patients and their families in which we have tried to paint a grim picture in the setting of a poor prognosis. In oncology, these are the patients with progressive, widely metastatic disease after third- line chemotherapy and those with leukemia refractory to salvage chemotherapy. Outside of oncology, these patients are a heterogeneous group: those with end-stage heart or liver disease, patients with progressive, irreversible cognitive decline, and individuals who are poor candidates for optimal therapies. Should not these patients and their families, despite their poor prognosis and impending death, have hope? And hope for what? Hope for a spontaneous remission or cure? Hope for a miraculous response to a new therapeutic agent? “Having hope,” as one patient recently said, “beats the hell out of sitting around thinking about dying.”When we talk with our patients and their families about an illness and its likelihood of cure, let us endeavor to be honest, but careful not to eliminate hope. Having been on both sides of the disease, we now recognize that hope has a very poignant palliative value.