10.1245/ASO.2005.03.016
Annals of Surgical Oncology 12:1084-1089 (2005)
© 2005 Society of Surgical Oncology
Effectiveness of Palliative Procedures for Intra-Abdominal Sarcomas
Jen Jen Yeh, MD,
Samuel Singer, MD,
Murray F. Brennan, MD and
David P. Jaques, MD
Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10021
Correspondence: Address correspondence and reprint requests to: David P. Jaques, MD; E-mail: jaquesd{at}mskcc.org.
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ABSTRACT
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Background: Nearly half of patients with intra-abdominal (retroperitoneal, visceral, or pelvic) sarcoma undergo more than one operation. When the objective shifts from cure to palliation, the clinical quandary of doing no harm and maximizing benefit is magnified. Knowledge of the effectiveness of a procedure at achieving its palliative intent, as well as its attendant morbidity and mortality, is therefore paramount during this deliberation.
Methods: A retrospective review was performed of all patients with a diagnosis of intra-abdominal sarcoma who underwent a palliative procedure between 1982 and 2003. A procedure was defined as palliative if it was explicitly performed to relieve symptoms.
Results: Ten percent (112 of 1084) of patients with a diagnosis of intra-abdominal sarcoma underwent a total of 156 palliative procedures. The most frequent system for which a palliative procedure was performed was gastrointestinal (68 of 156; 44%). Overall, 71% of patients had improvement of symptoms 30 days after the operation, whereas only 54% of patients remained symptom free after 100 days. Although 54% of gastrointestinal tract obstructive symptoms were successfully relieved at 30 days, only 23% of patients remained symptom free at 100 days. The overall operative morbidity was 29%, and postoperative mortality was 12%. Patients undergoing procedures intended to palliate gastrointestinal obstruction encountered the greatest morbidity (19 of 40; 48%).
Conclusions: Successful palliation of many symptoms associated with advanced intra-abdominal sarcoma may be achieved. However, even in highly selected patients, the progressive and pervasive nature of the disease limits the opportunity to attain sustained relief for gastrointestinal obstructive symptoms.
Key Words: Palliative • Sarcoma • Intra-abdominal • Gastrointestinal symptoms • Retroperitoneal sarcoma
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INTRODUCTION
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A comprehensive report1 published by the Institute of Medicine in 2001 has helped bring awareness of improving palliative care for the dying cancer patient to the forefront. This report highlighted a lack of practice guidelines for palliative care. In the past, palliative and noncurative procedures have not been well defined, and studies have focused on morbidity and mortality rather than symptom relief and improvement of quality of life.2 More recently, efforts have been made to better define palliative surgery and its attendant goals.3,4 In addition, prospective studies have begun to scrutinize the effectiveness of procedures performed with explicit palliative intent.5,6
Nearly half of patients with intra-abdominal (retroperitoneal, visceral, or pelvic) sarcoma undergo more than one operation. In patients with recurrent retroperitoneal soft tissue sarcoma, approximately 40% have disease that is incompletely resected or unresectable.7,8 The likelihood of complete resection decreases after each recurrence. In a study of 245 patients with retroperitoneal liposarcoma, 74% of patients who underwent incomplete resections were symptomatic, most of whom experienced pain as the dominant symptom.9 Seventy-five percent of patients with symptoms who underwent an incomplete resection experienced successful postoperative relief.
Patients with recurrent intra-abdominal sarcoma may require not only resection of the abdominal mass to alleviate symptoms such as pain, but also additional procedures secondary to complications related to the recurrence. No study to date has provided a detailed examination of the effectiveness of palliative procedures required in patients with intra-abdominal sarcoma.
Knowledge of the effectiveness of a procedure at achieving its palliative intent, as well as its attendant morbidity and mortality, is paramount when the objective shifts from cure to palliation. The clinical quandary of doing no harm and maximizing benefit is magnified in this situation as the primary intent shifts from prolonging life to optimizing quality of life.
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METHODS
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A retrospective review of a prospective database was performed of all patients with a diagnosis of intra-abdominal sarcoma (retroperitoneal, visceral, and pelvic) who underwent a palliative procedure between July 1, 1982, and December 31, 2003. A procedure was defined as palliative if it was explicitly performed to relieve symptoms or improve quality of life as stated in the chart record during the preoperative evaluation by the primary surgeon. For patients with multiple symptoms, the dominant symptom was recorded. Any procedure performed for the purpose of palliation was included, including interventional radiological, endoscopic, and operative procedures.
Postprocedure mortality was defined as (1) death within 30 days of surgery or radiological or endoscopic procedure or (2) in-hospital death. Complications were defined according to strict criteria set forth by surgical secondary events guidelines at Memorial Sloan-Kettering Cancer Center10 and were defined as follows: grade 1 complications were those that required no or minor interventions, such as oral antibiotics; grade 2 complications were those that required moderate interventions, such as intravenous medications; grade 3 complications were those that required hospital admission or surgical or radiological interventions; grade 4 complications were those that produced a chronic disability; and grade 5 complications resulted in death. Evidence of symptom improvement was evaluated at 30 and 100 days from the patient record. In addition, durability of symptom relief was illustrated by using symptom-free survival (SFS). SFS was defined as the time period during which the patient had improvement or relief of symptoms after a specific procedure. This time period ended at death or when a new or recurrent symptom occurred. SFS was evaluated for each palliative procedure performed.
Upper gastrointestinal tract (UGI) symptoms were defined as symptoms thought to be proximal to the ligament of Treitz, such as reflux, regurgitation, and gastric outlet obstruction. Mid/lower gastrointestinal tract (LGI) symptoms were defined as those thought to be distal to the ligament of Treitz.
SFS was analyzed by using the log-rank test and was graphically compared by using the Kaplan-Meier product method. Fisher’s exact test was used for comparison of two groups of categorical variables, and the Pearson 
2 test was used for more than two groups. A Mann-Whitney test was used to compare nonparametric groups.
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RESULTS
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Demographics
Nine-hundred eleven patients were treated who had a diagnosis of intra-abdominal sarcoma. Of these, 112 patients underwent 156 palliative procedures. Thirty (27%) patients had more than one procedure. There were 58 women and 54 men; the median age was 54 years. Eleven patients were lost to follow-up. The median follow-up was 10 months (range, 0–117 months).
The most common tumor types in patients undergoing palliative procedures for intra-abdominal sarcoma were liposarcoma and gastrointestinal (GI) stromal tumor (Table 1
). The most common category of symptoms requiring palliation was GI obstruction, followed by pain and bleeding (Table 2). One hundred twenty-eight operative and 28 nonoperative procedures were performed (Table 3). Eighty-three percent (129/156) of procedures were performed for intra-abdominal symptoms.
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TABLE 3. Operative and nonoperative procedures performed in patients with intra-abdominal sarcoma requiring palliation
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Morbidity and Mortality
There were 46 complications (29%) in the 156 procedures performed. The severity of complications is illustrated in Tables 4 and 5. The periprocedural mortality was 12% (13 of 112). The median length of stay was 9 days (range, 0–95 days).
There were significantly more complications in the operative (45 of 129; 35%) compared with the nonoperative (1 of 27; 4%) group (P = .001; Tables 4
and 5). There was no association between tumor type and the type or frequency of complications. The most frequent (11 of 21; 52%) complications, including one death, occurred with operations involving large- and small-bowel resections with anastomoses. Three patients who underwent a colostomy without a concomitant resection had no complications.
Patients who presented with symptoms of GI obstruction encountered the greatest number and severity of complications. There were 19 (48%) complications in 39 procedures performed for obstruction. Most procedures were performed for symptoms of LGI obstruction. The complication rate in procedures performed to palliate LGI obstructive symptoms was 60% (18 of 30), with 8 (27%) of grade 3 severity and 5 (17%) perioperative deaths.
The median length of stay was also significantly longer in this cohort compared with patients with other symptoms (Table 6). Patients who received palliative treatment for symptoms of GI obstruction had a median length of stay of 15 days (range, 2–76 days) compared with 8 days (range, 0–95 days) for patients who did not present with GI obstruction (P < .001).
Durability of Symptom Relief
The median duration of symptom relief was 150 days (Fig. 1). The median survival after the procedure was 15 months, with a median follow-up for survivors of 17 months. Symptom categories that were most successfully relieved with a palliative procedure were hepatobiliary symptoms, pain, and bleeding (Table 2).
Although 71% (72 of 101) of patients experienced relief of their symptoms 30 days after a palliative procedure, this was durable at 100 days for only 54% (55 of 101). Three patients died during this period but did experience relief of their symptoms. This decrease in durability was attributable to 25 (25%) patients who developed new symptoms and 18 (18%) patients who experienced recurrent or persistent symptoms until death. Twelve patients died with no relief of symptoms (Fig. 2).
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FIG. 2. Durability of symptom relief for patients undergoing palliative procedures for intra-abdominal sarcoma at 30 days (A) and at 100 days (B).
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Relief of GI obstructive symptoms was least successful, with a median SFS of 44 days (range, 0–992 days). Patients who presented with symptoms of UGI obstruction had a median SFS of 17 days (range, 0–457 days), and those with symptoms of LGI obstruction had a median SFS of 26 days (range, 0–992 days). Durability of relief at 30 and 100 days was significantly worse when compared with patients presenting with other symptoms. SFS was 60% at 30 days for patients with GI obstruction and 87% for those without. At a follow-up of 100 days, SFS decreased to 25% for patients with GI obstruction, compared with 70% for those without (Fig. 3). The decrement in durability of symptom relief at 100 days was attributable to the development of new symptoms (Tables 7 and 8). For symptoms of UGI obstruction, 44% (four of nine) of procedures provided no relief or only limited relief of <30 days. Although 63% (19 of 30) of procedures performed to relieve LGI obstructive symptoms achieved short-term relief at 30 days, only 27% (8 of 30) achieved ongoing relief at 100 days because of the development of new symptoms.
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FIG. 3. Durability of relief of gastrointestinal (GI) obstructive symptoms compared with other symptoms after palliative procedures for intra-abdominal sarcoma (n, number of procedures).
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TABLE 7. Durability of relief at 30 days of gastrointestinal obstructive symptoms after palliative procedures for patients with intra-abdominal sarcoma
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TABLE 8. Durability of relief at 100 days of gastrointestinal obstructive symptoms after palliative procedures for patients with intra-abdominal sarcoma
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DISCUSSION
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Operative or nonoperative interventions for palliative intent involve a tenuous balance between the probability of improving quality of life and the possibility of introducing significant morbidity and mortality. The preoperative discussion between the physician and the patient and his or her family should encompass the value of achieving relief of the targeted symptom, as well as the attendant morbidity threshold at which such a procedure will be performed.11
This report demonstrates that successful palliation of many symptoms associated with advanced intra-abdominal sarcoma may be achieved when patients are selected carefully. Similar to a previous prospective analysis of 1022 palliative procedures for advanced cancer of all types performed in a single year, in which symptom resolution or improvement was achieved in 80% at 30 days,5 71% of patients in the current study experienced relief of symptoms within 30 days after a palliative procedure. Contrary to many palliative procedures for other tumors or sites, this is most often achieved by the requirement for resection of the intra-abdominal mass. This adds particular importance to the preoperative assessment of extent of disease and resectability.
A multitude of physician and patient factors enter the decision to undertake a procedure for palliative intent. This report supplies general aides for this decision-making process in patients with intra-abdominal sarcoma. Although 70% to 75% of symptoms are consistently relieved in carefully selected patients,9 it is valuable to be aware of the relevant costs and benefits. Hospital length of stay, procedure-related morbidity and mortality, and durability are all concerns that need to be addressed during this deliberation process.
Although 71% of patients achieved symptom relief at 30 days, with an attendant procedure morbidity of 29% and mortality of 12%, the durability was limited for nearly half secondary to the occurrence of major new or recurrent symptoms or death by 100 days. Patients with documented obstructive GI symptoms were the most challenging. Those with UGI. obstructive symptoms experienced short-lived relief: 44% of patients had persistent or recurrent symptoms, and 22% had new symptoms by 30 days. Comparatively better outcomes were achieved with palliating LGI obstructive symptoms by 30 days. However, more than half of these patients experienced new symptoms by 100 days. The progressive and pervasive nature of the disease limits the opportunity to attain long-term relief for GI obstructive symptoms.
Not fully represented in this article are patients with unresectable intra-abdominal sarcoma who experience symptoms but do not undergo an intervention either because of patient preference or because their symptoms, often combined with poor performance status, preclude a rational attempt at resolution. The progressive and pervasive nature of this disease limits the opportunity to attain long-term relief for GI obstructive symptoms. Nonetheless, the compelling indications will make this a major consideration for the patient and surgeon.
Received for publication March 3, 2005.
Accepted for publication July 20, 2005.
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REFERENCES
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- Foley KM, Gelbrand H. Improving Palliative Care for Cancer. Washington, DC: National Academy Press, 2001.
- Miner TJ, Jaques DP, Tavaf-Motamen H, Shriver CD. Decision making on surgical palliation based on patient outcome data. Am J Surg 1999;177:150–4.[CrossRef][Medline]
- McCahill LE, Krouse RS, Chu DZ, et al. Decision making in palliative surgery. J Am Coll Surg 2002;195:411–22; discussion 422–3.[CrossRef][Medline]
- McCahill LE, Krouse R, Chu D, et al. Indications and use of palliative surgery—results of Society of Surgical Oncology survey. Ann Surg Oncol 2002;9:104–12.[Abstract/Free Full Text]
- Miner TJ, Brennan MF, Jaques DP. A prospective, symptom related, outcomes analysis of 1022 palliative procedures for advanced cancer. Ann Surg 2004;240:719–26; discussion 726–7.[Medline]
- McCahill LE, Smith DD, Borneman T, et al. A prospective evaluation of palliative outcomes for surgery of advanced malignancies. Ann Surg Oncol 2003;10:654–63.[Abstract/Free Full Text]
- Lewis JJ, Leung D, Woodruff JM, Brennan MF. Retroperitoneal soft-tissue sarcoma: analysis of 500 patients treated and followed at a single institution. Ann Surg 1998;228:355–65.[CrossRef][Medline]
- Jaques DP, Coit DG, Hajdu SI, Brennan MF. Management of primary and recurrent soft-tissue sarcoma of the retroperitoneum. Ann Surg 1990;212:51–9.[Medline]
- Shibata D, Lewis JJ, Leung DH, Brennan MF. Is there a role for incomplete resection in the management of retroperitoneal liposarcomas? J Am Coll Surg 2001;193:373–9.[CrossRef][Medline]
- Martin RC II, Brennan MF, Jaques DP. Quality of complication reporting in the surgical literature. Ann Surg 2002;235:803–13.[CrossRef][Medline]
- Miner TJ, Jaques DP, Shriver CD. A prospective evaluation of patients undergoing surgery for the palliation of an advanced malignancy. Ann Surg Oncol 2002;9:696–703.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
