| Ch 7 | Page 10 / 12 | |
| Cancer surgery |
Palliative surgery | |
A pathological fracture (due to metastasis) will consolidate over a similar duration as for normal fractures, provided that the fracture is sufficiently immobilised.
On the other hand, an osseous metastasis does not imply imminent patient death. However, it could imply considerable physical decline for the patient (bed immobilisation, risk of bedsores, dependency on the family circle, frustration faced with incapacity). Vigorous treatment is therefore of great help.
Rapid surgical repair of pathological fractures is therefore recommended when feasible and when it offers prompt patient mobilisation.
Some examples:
- femoral neck fracture (total hip prosthesis),
- fracture of femoral or humeral diaphysis (central medullar nail),
- vertebral collapse(corporeal cementoplasty).
The presence of a prosthesis is not a contraindication for radiotherapy.
When rachis metastases occur (osseous or meningeal metastases) with medullar compression (paraparesia or paraplegia), the ideal delay for surgical treatment is less than 24 hours. After 24 hours, vascular damage due to medullar compression renders possible movement recovery uncertain. Thus, the diagnosis of medullar compression should be treated as an emergency and the patient should immediately be referred to a surgeon for decompression and fixation. Complementary radiotherapy may also be useful.
If the delay is too long, then the patient will suffer from long painful and upsetting agony which could have been avoided (the patient’s death cannot be avoided however its dreadful conditions can).
The apparition of prefracture pains is another surgical emergency: the bone is damaged to such an extent that every movement is painful and the risk of complete fracture is very high. A surgical procedure for preventive consolidation could be associated with other measures such as localised radiotherapy or morphine treatment.
Derivation surgery may be carried out when the tumour becomes an obstacle either for respiratory, digestive or urinary tracts.
Some examples:
- tracheostomy (occasionally in emergency) for head and neck or thyroid cancers,
- colostomy for an occlusion in relation to digestive or ovarian tumours,
- gastrostomy to feed a patient with oesophageal or head and neck cancer,
- ureterostomy or other urinary diversion for bladder, prostate or gynaecological tumours,
- cranial shunts for intracranial hypertension.
The major psychological trauma consecutive to such a surgical procedures should be prevented via a clear and comprehensive explanation to the patient (and his/her family) of the remaining body function potential. These procedures should therefore not be performed too late (when body function damage is such that useful repair is no longer possible) or too early (before possible patient acceptance).
Sometimes, tumour excision, even if it is not satisfactory in terms of survival, may be useful if involving uncomplicated postoperative recovery and requiring limited hospitalisation: the quantity of recurrence-free life and quality of life should be promoted.
Since they are more easily accepted by patients, it is also possible to carry out internal derivations:
- either via a surgical approach,
- or via a percutaneous approach,
- or by endoscopy,
- or by endovascular method.
The use of such prosthesis should therefore bring together various specialities in order to offer the most appropriate relief to patients: a clear evaluation of these methods by retrospective studies and quality of life questionnaires should be made in order to determine the most suitable solution.
The implantation of an oesophageal prosthesis using endoscopy, of an ureteral prosthesis by a percutaneous puncture or during cystoscopy, and the use of a colic prosthesis or a venous stent for protecting the patient from a superior cave syndrome are all very useful 'palliative surgical procedures'.
A surgical procedure can also be proposed not to cure but to improve the patient's comfort.
Tumour necrosis is very frequent around developed disease and, not only painful, its odour, bleeding and ugliness can also be very unpleasant for the patient and his/her family. Certain particularly neglected tumours have left us with horrifying pictures.
A simple excision can offer comfort and cleanliness: mastectomy, resection of an intestinal tumour despite hepatic metastases or derivation for fistulae.
It consists in the ablation of an endocrine gland whose secretion is known to favour tumoral development.
In practice only two locations are concerned: breast carcinoma (for which a surgical ovariectomy or pelvic irradiation may be proposed) or prostate carinoma (for which bilateral surgical castration may be proposed).
The psychological trauma for the patient should be prevented through thorough and attentive explanations.
However, most often, in order to avoid such explanations, the physician will prefer to treat medically (anti-hormone products: anti-androgens or anti-estrogens, chemical castration by a LH-RH analogue - see chapter on hormonotherapy). The results are identical although the cost is much higher.
 |
