Serge Evrard

Enhancing patient safety and quality of surgical cancer care: The French National Cancer Plans

Two National Cancer Plans (2003-2007 and 2009-2013) have been launched in France to organise the healthcare offer in order to enhance quality and safety. The current Cancer Plan(1) defines regulatory frameworks across the three major areas of cancer therapy: surgery, chemotherapy and radiotherapy. These regulatory frameworks are based on three pillars: transversal requirements for the quality of care; establishment of minimal thresholds for institutions and technical criteria that are required for each type of cancer surgery. Based on adherence to these requirements and following a process of continuous assessment, institutional accreditations (currently being allocated in 2010) will be given for a period of 5 years.

Parenchymal sparing surgery for colorectal liver metastases: The need for a common definition

BACKGROUND The definition of parenchymal sparing surgery (PSS) for colorectal liver metastases (CRLM) diverges requiring a clarification of the concept. METHOD A consecutive series of patients were treated by PSS for their CRLMs, either by resection or intra-operative ablation (IOA), whenever possible a one-stage surgery and minimal usage of portal vein embolization. Post-operative complications were the primary endpoint with a special focus on post-operative liver failure. RESULTS Three hundred and eighty-seven patients underwent a PSS out of which 328 patients received a median of 9 pre-operative cycles of chemotherapy. One hundred and twenty-eight patients had a major resection, combined with IOA in 137 patients and IOA alone in 50 cases. The 5yr-overall survival was 50.3%. There was no difference in post-operative complications between minor and major resections, validating our PSS definition based on the Tumor burden/Healthy liver ratio and not just the retrieved volume. CONCLUSIONS PSS is defined as a high ratio of tumoral burden per specimen retrieved while favoring one-stage surgery approach. Our series, using combined resections and IOAs, matches this definition well. Furthermore, complications were correlated neither to chemotherapy nor to liver-induced toxicities, contrary to extended hepatectomies.

Le chirurgien et la maladie métastatique

For a long time, metastatic disease was a prohibited zone for surgeons locked into their roles in controlling primary non-disseminated tumours. However, this has changed at the end of the 20th century with the apparition of effective chemotherapies and targeted therapies. Since then, surgeons have been able to treat hepatic, pulmonary, peritoneal and brain metastases. The more chemotherapy progresses and controls disease, the more surgeons can operate on residual disease. With this final surgery acting on the defined perimeter of systemic treatment efficacy, it appears to offer gains in progression-free survival. Gains in overall survival have not yet been demonstrated. Further, new technologies should enable surgeons to reduce the lower limits of their fields of action, increasing their therapeutic perimeters. Metastatic disease constitutes a unique model of therapeutic synergy that can be accredited to multidisciplinary strategy.