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Abstract
Introduction/Background*Palliative surgery for advanced cancer involves complex decision-making - to identify ethical dilemmas in consideration of attitudes and factors influencing case selection. In general, this includes preservation of patient choice and informed consent regarding realistic outcomes balanced with surgical risk and morbidity. Further patient individualised factors include age and performance status, comorbidities, tumour grade and extent and symptom severity.
Methodology We present a 44-year-old otherwise fit and well female whom previously underwent complete resection of leiomyosarcoma. Subsequent imaging identified lung metastases, pelvic nodal disease and further avid pelvic mass managed with chemotherapy. Despite complete distant disease resolution, pelvic progression led to bilateral ureteric stenting and nephrostomy insertion, with enactment of Do Not Attempt Cardiopulmonary Resuscitation directive (DNACPR), palliative care and hospice input.
Result(s)*Multidisciplinary team recommendation was for palliative debulking surgery due to significant symptom profile and pain in view of potential resectability despite visceral involvement. The patient underwent midline laparotomy, modified posterior en-bloc exenteration, right ureteric resection and reimplantation with psoas hitch and stent replacement, bladder repair, primary ileo-ascending colon anastomosis, Hartmann’s procedure and end sigmoid colostomy. The patient made an uneventful recovery with a normal postoperative retrograde cystogram and whilst histopathology reported involvement of bowel mucosa and serosa, clear margins were achieved.
Conclusion*Palliation aims to relieve suffering and support quality of life for seriously ill patients and their families, alongside life-prolonging and curative surgical treatments. We report on this case to highlight the value of radical and multiple resections of sarcoma in younger patients as well as the value of the surgical multidisciplinary team in achieving clear resection margins. We recognise a shift from cancer elimination to symptom elimination. Palliative care need not be synchronous with end of life care; an illustration of which is that the DNACPR was withdrawn in our patient’s case. Whilst impact on survival may be limited, we emphasise the value in continuing to explore all treatment options and further delineate the balance between provision of false hope versus not giving up hope.