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.
Highlights
Ontogenetic anatomy is based on the establishment of compartments during early embryologic development by lack of mixing of proliferating groups of cells—anlagen or primordia—at demarcated boundaries, which can be identified at certain sites in the adult body, for example the pelvis [1]
Three trials based on the ontogenetic theory of local tumour spread using total mesometrial resection (TMMR) extended mesometrial resection (EMMR) and laterally extended endopelvic resection (LEER) for the treatment of cervix cancer, included a total of 367 patients stages I-B to II-B
Ontogenetic anatomy emerges as an alternative to classic anatomy, focusing on embryologically defined compartments and External urogenital sinus (Anlagen: Superficial urogenital sinus-genital folds complex)
Summary
Ontogenetic anatomy is based on the establishment of compartments during early embryologic development by lack of mixing of proliferating groups of cells—anlagen or primordia—at demarcated boundaries, which can be identified at certain sites in the adult body, for example the pelvis [1]. Its validity was established for rectal cancer long before its description, with the implementation of total mesorectal excision which improved local control far more than had been anticipated [2, 3]. MR imaging has already been established as the method of choice for local staging in rectal and gynaecologic cancer due to its high contrast resolution It allows tumour localization and delineation with great precision, and compartment delimitation through the identification of pelvic fascia and ligaments that constitute most of the ontogenetic compartment boundaries of the adult pelvis. The second part of the paper corresponds to the reinterpretation of gynaecologic anatomy based on MR imaging, as relevant for oncologic surgery planning and in accordance with the theory principles, with some added example cases
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