Staging laparotomy in Hodgkin's disease. Further evidence in support of its clinical utility

Hepatic Enzymes in Hodgkin's and non Hodgkin's Lymphoma

Serum alkaline phosphatase levels in patients with Hodgkin's and non-Hodgkin's lymphoma were studied. The findings were correlated with clinical stage, particularly hepatic involvement, and histologic findings. Serum levels of other hepatic enzymes (SGOT, 5′N and γGT) were also measured. The usefulness of these studies for clinical staging was described, as well as speculation on the observed differences in Hodgkin's and non-Hodgkin's patients.

Infection among 210 patients with surgically staged Hodgkin's disease

To determine the incidence and types of infections in Hodgkin's disease, particularly those related to the overwhelming pneumococcal sepsis syndrome, 210 consecutive patients with previously untreated Hodgkin's disease who underwent staging laparotomy with splenectomy from March 1968 to October 1979 were reviewed. For 178 patients (85 percent) alive at the end of the study, the mean follow-up time was 68.1 months. Eighty-two serious infections occurred among 59 (28 percent) of the patients; 47 (57 percent) serious infections were microbiologically documented and 35 (43 percent) were clinically documented. Forty-seven microbiologically documented serious infections occurred in 34 patients and consisted of 23 episodes of pneumonia, 10 cases of bacteremia, seven wound infections, two cases of disseminated herpes zoster, one subphrenic abscess, and four miscellaneous infections. Microbiologically documented serious infections occurring during initial treatment or remission had lower incidences of leukopenia (29 versus 58 percent) (p = 0.09) and death (11 versus 53 percent) (p = 0.005) than those occurring after relapse of Hodgkin's disease. Of the microbiologically documented serious infections, 76 percent were associated with a predisposing factor(s) (leukopenia, postoperative state, steroids, peripheral neuropathy, leukemia), of which 34 percent were fatal. Microbiologically documented serious infections unassociated with a predisposing factor were never fatal, including the only episode of pneumococcal sepsis in the series. In contrast to microbiologically documented serious infections, only 14 percent of clinically documented serious infections (versus 38 percent) were fatal. The overwhelming pneumococcal sepsis syndrome and other infections thought to be associated with the asplenic state are uncommon problems in patients with Hodgkin's disease after splenectomy.

Anatomical substages of stage III Hodgkin's disease: implications for staging, therapy, and experimental design

Twenty-three patients with pathologic stage III Hodgkin's disease were classified with respect to the presence or absence of symptoms (III-A, III-B), the presence or absence of splenic involvement (IIIS+, IIIS-) and anatomic substage--the extent of disease within the abdomen (III1, III2). Stage III1 disease included disease limited to the upper abdomen, i.e., spleen, splenic node, celiac node, and/or portal node. All other more extensive disease was classified as stage III2. Symptoms and splenic involvement did not predict either disease-free survival or survival. However, 5 year actuarial disease-free survival was significantly better in III1 patients as compared to III2 patients (77% vs. 13%, p less than .001). Eight of nine stage III2 patients receiving total nodal radiotherapy alone relapsed. When considered along the previous studies of anatomic substage, these findings suggest that patients in stage III1 and III2 should receive different therapeutic approaches. Analysis of therapeutic results in stage III patients must consider anatomic substage.

Morbidity of staging laparotomy in Hodgkin's disease

The morbidity of exploratory laparotomy and splenectomy in Hodgkin's disease was determined at three institutions--a university hospital, a major university affiliated hospital and a large community hospital. Of the 90 patients who underwent exploratory laparotomy, 33 (37%) sustained a major or minor complication within two weeks of surgery. Seventeen patients (19%) sustained a minor complication and 16 patients (18%) a major complication. There was no mortality. A higher complication rate occurred in patients more than 28 years of age (p = 0.01), and in patients with advanced clinical stage when age was controlled (p = 0.05). We suggest that prior to performing an exploratory laparotomy in a given patient, the necessity of the procedure be weighed against its potential hazards.

The therapeutic implications of splenic involvement in stage IIIA Hodgkin's disease

In an effort to determine the most appropriate initial therapy for patients with stage IIIA Hodgkin's disease, a comparative analysis was undertaken of 13 pathologically staged IIIA Hodgkin's disease patients whose abdominal disease was localized to the spleen (IIIsA); 17 IIIA patients with spleen and abdominal lymph node involvement (IIIs+n+A) and 44 stage IIA patients. The three groups were treated concurrently with either extended field irradiation alone or limited field irradiation followed by MOPP chemotherapy. Relapse rates after irradiation alone were 17% for the IIIsA patients; 63% for the IIIs+n+A patients and 25% for the stage IIA patients. Following therapy with irradiation and chemotherapy no relapses occurred among the IIIsA and IIIs+n+A patients while 2/16 (13%) stage IIA patients relapsed. After irradiation alone stage IIIs+n+A patients had a significantly shorter remission duration and survival than the stage IIA patients (p = 0.03 and 0.002, respectively) but remission duration and survival were similar for the IIIsA and IIA patients. When therapy was irradiation and chemotherapy no significant differences in remission duration or survival were noted for the three groups. The most common sites of relapse for the IIIs+n+A patients were extralymphatic (60%) while no extralymphatic relapse have occurred among the IIIA patients (p less than 0.02). The only relapse among the IIIsA patients was at an extralymphatic site. These data have shown that patients with IIIsA Hodgkin's disease have a similar prognosis to stage IIIA disease but after therapy with irradiation along stage IIIs+n+A patients have a poorer prognosis. Combined irradiation and chemotherapy should, therefore, be considered for stage IIIs+n+A Hodgkin's disease when abdominal nodal disease cannot be included in the initial radiation port.

The treatment of Hodgkin's disease: emphasizing programs at the Clinic Center, National Institutes of Health

During the past 10--15 years there has been a dramatic improvement in the prognosis of patients with Hodgkin's diases. More than 80% of all patients now will live 5+ years, many of them free from disease. The well-recognized immediate complications of therapy discussed above, are insignificant compared to the tremendous improvement in patients' survival. The fact that they now probably will survive long enough to potentially be at risk of such long-term complications is a testament to the efficacy of modern-day aggressive therapy.

False positive lymphography in Hodgkin's disease: a histologic-lymphadenographic correlation

A series of 99 consecutive patients having a staging laparotomy for Hodgkin's disease was reviewed. Negative lymph nodes removed during the laparotomy were correlated with lymphograms reported as positive or suspicious. Four patients had large nodes with a prominent hilar area or irregular cortical fat deposits. In two other patients a cluster of small lymph nodes accounted for the radiologic misinterpretation.

Infections in 92 splenectomized patients with Hodgkin's disease. A clinical review

Infections that occurrred in 92 previously untreated patients with Hodgkin's disease were reviewed from the time of laprotomy and splenectomy. Pneumonias occurred in nine patients with urinary tract infections in twelve during the immediate postoperative period. Severe bacterial infections did not occur in any patients during initial radiation therapy, adjuvant chemotherapy (stages I through IIIA), initial intensive chemotherapy (stages IIIB and IV) or during remission. Severe infections occurred in eight profoundly granulocytopenic patients with recurrent Hodgkin's disease. Streptococcus (Diplococcus) pneumoniae and Hemophilus spp infections were distinctly uncommon during the remission period. Herpes zoster, however, was very common developing in 22 of 92 (24 per cent) patients. Predisposing factors to herpes zoster included sex (female more than male), therapy (radiation plus chemotherapy more than chemotherapy alone), and age (less than 30 years of age more often than 30 to 50 years of age). Severe infection was uncommon in these patients except in ascociation with specific predisposing factors such as the immediate postoperative state of prolonged granulocytopenia associated with recurrent Hodgkin's disease or its therapy. Splenectomy per se did not affect either the incidence or the severity of infection during this period of 12+ months of observations per patient.

The significance of abnormal circulating cells in patients with Hodgkin's disease

Buffy coat preparations of peripheral blood from two patients with Stage IVB Hodgkin's disease, 33 patients with Hodgkin's disease undergoing complete staging including laparotomy, 12 normal controls and eight patients with viral upper respiratory infections were examined for the presence of abnormal cells. Primitive histiocytic cells were seen in the two patients with IVB disease and in two patients with IIIB disease all of whom proved to be refractory to chemotherapy. Reed-Sternberg cells were seen in one IVB patient. Large cells with basophilic, agranular cytoplasm and moderately convoluted nuclei often with a perinuclear halo and nucleoli were detected in 30 of 35 patients with Hodgkin's disease, five of eight patients with viral infections but in none of 12 normal controls. Other abnormal large cells with round nuclei, occasional prominent nucleoli, grey to lightly eosinophilic cytoplasm and diffuse granulation were seen almost exclusively in Hodgkin's disease. There was no correlation between histology, stage, splenic involvement, skin test positivity and response to therapy with the presence or frequency of either of these cell types. This observation suggests that these cells are more likely to be 'reactive' rather than malignant. It is unusual for abnormal histiocytic cells to circulate in Hodgkin's disease and their presence may be a poor prognostic sign. The presence of other types of large atypical cells is not indicative of either haematogenous spread of Hodgkin's disease or of poor prognosis after treatment with radiotherapy alone.