Tumor resection of a local recurrence or a metastasis may be appropriate. Soft tissue tumors may result in difficult wound problems because of pain, ulceration, or fistula formation causing odor, discharge, or bleeding. Examples include ulcerating breast tumors; eroding head and neck
tumors; enterocutaneous or perineal fistulas draining bile, stool, or urine; and bulky axillary or inguinal nodal metastases causing progressive lymphedema and limited function. Surgical resection, if negative margins can be obtained, may result in significantly improved quality of life. The patient may already have had several attempts at local tumor control which may increase the complexity and potential morbidity of any planned local resection. For example, resection of a tumor through irradiated tissue may require the transfer of a soft tissue and/or muscle flap from an unirradiated area. Resection of recurrent anal cancer after failed chemo-radiation may require a two-team approach, where the surgical oncologist removes the tumor and a plastic surgeon fills the perineal defect with a gracilis or rectus abdominis muscle soft tissue flap.

For the patient who presents with metastatic disease, surgery may be an important part of gaining control of the local disease even if cure is not possible. Once a tumor has infiltrated a nerve root, surgery is unlikely to be helpful, so palliative surgical intervention may be warranted to prevent difficult symptoms despite distant metastases. Radical palliative resections such as esophagectomy, pancreaticoduodenectomy (4), and pelvic exenteration have been described for the purposes of local symptom control (5, 6). In select patients, improvements in quality of life can be dramatic even if survival is not lengthened.

Surgical resection should generally not be performed unless a complete resection can be achieved, as the tumor will simply recur. For some tumors, however, incomplete or debulking resections are appropriate, such as for slow-growing tumors (e.g., metastatic carcinoid or thyroid cancer), or when effective antitumor therapy can be given postoperatively to treat the residual tumor (ovarian cancer).

Amputation may be necessary for extremity lesions such as soft tissue sarcomas and melanomas. It is usually a secondary procedure after failed limb-conserving therapy; unless it is absolutely necessary for palliation of pain, fungation or prevention of major hemorrhage. Amputation should be avoided in the presence of metastatic disease (7).

Surgical resection is effective if the tumor causing the obstruction can be resected with negative margins even in the presence of metastatic disease. This is generally most applicable to obstructions of the gastrointestinal tract (8). Retrospective studies support palliative gastric resection for the relief of symptoms (9). Small or large bowel obstructions occur in 5–43% of patients with advanced primary or metastatic intra-abdominal malignancy. Symptoms include abdominal cramping and pain, nausea and vomiting, and constipation. The passage of liquid stool does not rule out obstruction, as it may be due to overflow. Peritonitis suggests a strangulated bowel loop or perforation and is an indication for emergency surgery. If there is a history of malignancy or previous surgery, a nasogastric tube is initially inserted for decompression. A computed tomography (CT) scan of the abdomen is recommended if the obstruction does not resolve to determine the site(s) and type of obstruction. Surgical resection is most effective if there is one site of obstruction. Benign causes of obstruction are found in 3–48% of patients with a history of malignant disease, and the postoperative mortality is similar (10%) to those patients without a history of malignancy. The most common causes of nonmalignant obstruction include adhesions, internal herniation (perhaps around a stoma), and radiation enteritis. Patients with multiple sites of obstruction in the small bowel usually have carcinomatosis. Symptoms of obstruction in these patients are often multifactorial and are rarely an acute event, alternating between complete and partial obstruction (10). The results of surgery for patients with carcinomatosis are poor and considerable clinical skill must be exercised by the surgeon in deciding whether or not the patient would benefit from an attempt at a surgical resection (8). Good prognostic factors include the following:

Poor prognostic criteria include the following:

Malignant bowel obstruction in the large colon is usually due to one site of obstruction, and patients will often benefit
from a surgical procedure. The tumor should be resected if possible, but a bypass or stoma will also provide effective symptom relief.

Several enteroenterostomies to bypass areas of obstruction may be performed in the small and large bowel if resection is not possible to restore intestinal continuity. If this is not possible, a diverting ostomy may be performed proximal to the obstructed segment. Patients require at least 100 cm of small bowel to maintain nutrition without parenteral supplementation, and proximal stomas may case postoperative complications due to high fluid outputs. In the large bowel, a colostomy will relieve unresectable distal colonic obstruction, but will not prevent bleeding, pain, and discharge from the retained tumor.

Obstructions of the biliary tree are managed by percutaneous biliary drainage with or without stent placement, endoscopic stent placement or with a surgical bypass procedure. While internal–external percutaneous drains offer easy access in case of tube blockage, many patients do not like having an external tube to care for. Endoscopic stenting is effective, but may block, often resulting in readmission due to sepsis and requiring stent changes every few months. Four randomized trials comparing endoscopic stent insertion versus surgical bypass allow some broad conclusions to be made (12). Both techniques are effective in initial drainage of the biliary tree and improvement of symptoms. Endoscopic stenting has a lower early morbidity and mortality rate compared to surgical bypass, and therefore is more suitable for sick and debilitated patients. However, late complications of cholangitis and recurrent jaundice are high with endoscopic stenting, so repeat procedures may be required every 3–6 months. Patients expected to live longer than 6 months may therefore be more suitable for surgical bypass.

Percutaneously placed gastrostomy tubes may be placed to relieve obstructive symptoms for patients with bowel obstruction due to carcinomatosis who are not candidates for surgical bypass. This will avoid the uncomfortable long-term placement of a nasogastric tube in patients unfit for surgery.

Ureteric obstruction due to pelvic malignancy may be relieved by percutaneous placement of nephrostomy catheters and is highly successful in relieving the pain of obstruction and returning renal function to normal. However, the role of treatment of ureteric obstruction in palliative patients is not defined and will vary according to the performance status and wishes of the patient. The results for most patients are quite poor, yet there are those for whom intervention will result in several months of productive life in which to accomplish expressed goals. In one retrospective study of patients with advanced malignancy, 86% of patients had significant cancer-related symptoms after endoscopic or percutaneous diversion and 51% required repeat interventions. Furthermore, the average survival was 5 months, with 50% of that time spent in hospital (13). In another study, 58% required a second procedure after internal drainage, but useful life was achieved in 84% of patients (14). Indications for intervention include bilateral hydronephrosis, unilateral ureteric obstruction with renal insufficiency, or pyelonephritis. Contraindications include asymptomatic patients unless the function of the contralateral kidney is of concern, or patients with rapidly progressive disease for which no other therapy is planned.

Local ablation using laser, electrocautery, cryotherapy, or photodynamic therapy can provide immediate relief of symptoms in easily accessed areas such as the trachea, esophagus, and rectum (2, 15, 16). These modalities are generally applied through a rigid or flexible endoscope with or without general anesthesia, and results of obstruction are generally equivalent, achieving relief of symptoms in most patients with minimal morbidity. Because obstruction recurs within weeks due to tumor regrowth, the time between treatments can be extended if the ablation is followed by the insertion of a stent or by intraluminal radiation. Endoscopic dilatation is effective in the esophagus, with a low complication rate (perforation in 5%), but must also be repeated every 3–4 weeks.

Stenting is becoming an effective option for palliation. Stents range from a rigid tube, placed with a rigid endoscope, to self-expanding wire stents inserted by flexible endoscopy or radiologic guidance. Covered wire stents reduce the incidence of tumor in-growth, but are associated with an increased incidence of migration and occlusion. Stents can be placed in the bronchus, duodenum, esophagus, bronchus, biliary tree, and colon; the site of obstruction must be relatively short and fixed.

Malignant ascites is defined as clinically evident and abnormal fluid accumulation within the abdominal cavity associated with a disseminated malignancy in the absence of hepatic cirrhosis (21). Most of patients with intra-abdominal malignancy will accumulate fluid in their abdomen due to a variety of processes, including vascular and lymphatic compression from liver metastases, portal hypertension from tumor infiltration of the liver parenchyma, decreased protein levels from cancer cachexia and malnutrition, and secretion by peritoneal tumor deposits (22). Cancers of the ovary, pancreas, breast, colon, and rectum, and of unknown origin are the most common causes of malignant ascites in palliative patients (21, 22). Malignant cells within the ascitic fluid can be identified by cytology in only 60% of patients, despite this criterion being considered the gold standard for diagnosis (23); the diagnosis is confirmed when intra-abdominal cancer is identified by radiologic imaging, laparotomy, or laparoscopy. Although patients with ovarian cancer live significantly longer than patients with other tumors because of the availability of more
effective anticancer therapies, the development of malignant ascites generally heralds a poor prognosis. As fluid builds up, patients will experience increased abdominal girth causing discomfort, anorexia, nausea, early satiety, dyspnea, and fatigue. For 15–71% of these patients, the increasing intra-abdominal pressure due to massive fluid accumulation causes significant symptoms which significantly affects their quality of life (21). Massive swelling of the entire lower half of the body is common when hepatic metastases compress the inferior vena cava (IVC syndrome), and may cause patients to be bedridden.

Medical therapy, such as a diuretic and restriction of sodium and fluid intake, may be helpful for central ascites. Repeated therapeutic paracentesis (percutaneous drainage) is most commonly used. Up to 5 liters of fluid may be drained at one time through a needle in the abdominal wall. Patients may require drainage two to three times per week, and often become very symptomatic prior to drainage. Peritoneovenous shunts, constructed of a plastic drainage tube with one end in the abdominal cavity and the other end inserted into the jugular vein, are now rarely used in malignant ascites because of a 25–49% complication rate (e.g., blockage, infection) and a high 30-day mortality rate (24). More recently, permanent indwelling peritoneal catheters, similar to peritoneal dialysis catheters, have been used (25, 26, 27). Percutaneous catheters can be managed by nurses or caregivers at home, which is important as patients become less mobile near the end of their lives (28). In patients with IVC syndrome causing severe ascites and anasarca, radiologic placement of expandable metallic IVC stents provide significant relief (29).