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Philosophy

The Leipzig School of Radical Pelvic Surgery was established in 2005 with the objective to provide insights concerning locoregional tumor spread deduced from embryonic development and to demonstrate their translation into a new principle of surgical radicality for the treatment of lower female genital tract cancer.

 

Principle of conventional cancer surgery

​Principle of conventional cancer surgery: Wide tumor excision and staging lymph node dissection

Traditional surgery for local cancer control is based on functional topographic anatomy confounded by empirical dissection artefacts and on the model of isotropic tumor permeation. The clinical practice translated from these principles is wide tumor excision, i.e. the resection of the tumor with a metrically defined circumferential tissue margin free of neo- or dysplastic lesions. However, that treatment may cause considerable morbidity. Moreover, despite R0 resection, local recurrences that often indicate a poor prognosis may occur in up to 50 percent. Although fundamental for the concept of surgical tumor treatment, the prognostic robustness of margin width could never be demonstrated.
Regional lymph node dissection is performed for nodal staging. In case of proven metastases surgical treatment alone is regarded insufficient for tumor control and adjuvant (chemo)radiation is recommended. Postoperative radiation therapy may reduce locoregional relapses of gynecologic malignancies but overall survival is not improved. Instead, treatment morbidity is significantly increased and a great proportion of patients is overtreated.

Embryonic development and malignant progression

The ontogenetic cancer field model of locoregional tumor spread

Progressive steps in metazoa development generate increasingly specified tissue domains. Before cell type determination, they comprise the expanding habitats of multiple cell types whose stem cells can transdifferentiate into each other. Populations of determined cell types are confined to topographically defined compartments further segregating into subcompartments and finally zones of the mature organism.
The cancer field model considers cancer progression as despecification of transformed stem cells in the mature organism with a competent adaptive immune system. The tissues for potential local tumor propagation, the cancer fields, represent the mature derivatives of the founder tissue domains in reverse sequence. Thus, an order of cancer is established. The topologic relationship between the local tumor extent and the mature tissues of sequential developmental steps determines ontogenetic tumor stages (oT).

The regional lymph nodes executing peripheral immune tolerance for their tributary tissues provide additional permissive sites for discontinuous tumor spread, especially for epithelial neoplasms. Since the lymph nodes are invariably connected to their tributary regions through afferent lymphatics and exhibit common tissue antigens, the potential regional propagation field can be identified for each local cancer field of the individual neoplasm. This topographic link of a cancer field to its intercalated and basin lymph nodes allows ontogenetic nodal staging (oN) in addition to the ontogenetic tumor staging.

Redefining cancer surgery

​Cancer field resection and therapeutic lymph node dissection

Clinical translation of these insights resulted in cancer field resection and therapeutic lymph node dissection based on ontogenetic anatomy mapping the body with regard to development. Cancer field resection preserves tissue of adjacent compartments of different embryonic origin despite close proximity to the neoplasm. Based on the model of ontogenetic cancer fields, total mesometrial resection (TMMR), extended mesometrial resection (EMMR), vulvar field resection (VFR) and laterally extended endopelvic resection (LEER) with therapeutic lymph node dissection (tLND) for the therapy of cervical, vulvar and vaginal cancer have been developed. These new surgical procedures achieve excellent locoregional tumor control without adjuvant radiotherapy at minimized treatment-related morbidity.

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