Embryologically based resection of cervical cancers: a new concept of surgical radicality

An ontogenetic approach to gynecologic malignancies

Abstract

Ontogenetic anatomy is the mapping of body compartments established during early embryologic development, particularly well demarcated in the adult pelvis. Traditional cancer surgery is based on wide tumour excision with a safe margin, whereas the ontogenetic theory of local tumour spread claims that local dissemination is facilitated in the ontogenetic compartment of origin, but suppressed at its borders in the early stages of cancer development. Optimal local control of cancer is achieved by whole compartment resection with intact margins following ontogenetic “planes”. The principles embodied in this hypothesis are most convincingly supported by the results of the implementation of total mesorectal excision in rectal cancer, and more recently, by innovative surgical approaches to gynaecologic malignancies. The high resolution contrast of MR, accurately delineating pelvic fascial compartments, makes it the best imaging modality for gynaecologic cancer surgery planning following these principles, but requires interpretation of imaging anatomy from a different perspective.

Teaching Points

• Ontogenetic anatomy refers to mapping of embryologically determined body compartments.

• Ontogenetic theory claims tumour growth is not isometrical, but rather compartment permissive.

• Ontogenetic principles are highly supported by the outcome results of total mesorectal excision.

• Innovative gynaecologic cancer surgery approaches based on ontogenetic theory show promising results.

Laparoscopic radical hysterectomy in cervical cancer as total mesometrial resection (L-TMMR): a multicentric experience

OBJECTIVE

To analyze the feasibility of total mesometrial resection by laparoscopy (L-TMMR) in a multicentric series of early stage cervical cancer.

METHOD

We prospectively evaluated a consecutive series of cervical cancer patients with pre-operative FIGO stages IA2-IB1 at the Catholic University in Rome and in Campobasso and the Charitè University in Berlin. All cases were assessed at pre-operative MRI scan and clinically confirmed by investigation under anesthesia, adhering strictly to the FIGO criteria. The surgical and post-surgical data were collected.

RESULTS

104 women with cervical cancer were admitted between July 2013 and August 2014 and among them 71 patients with pre-operative FIGO stages IA2-IB1 were treated with L-TMMR. One laparotomic conversion was registered. The median operative time was 260min (120-670min), estimated blood loss was 100cm(3) (25-900cm(3)), and the median length of hospital stay was 6days (2-26days). We observed 8 intra-operative complications including a vascular injury of the left internal iliac vein that caused conversion, 6 vesical injuries and 1 ureteral injury managed laparoscopically. Two vescico-vaginal fistula and one hemoperitoneum were observed as major post-operative complications (4.2%).

CONCLUSION

L-TMMR can be safely performed in selected cervical cancer patients. Further larger prospective trials are needed to evaluate the oncological outcome of patients undergoing this surgical procedure.