Laparotomy and splenectomy in the staging of untreated patients with Hodgkin's disease

Ultrasonography of Hodgkin's disease in the liver and spleen

Ultrasound findings of 39 spleens and 68 livers in which histology was obtained at laparotomy or autopsy within a month of the examination and four livers in which abnormalities were found clinically by other methods during long-term follow-up were reviewed to evaluate the various sonographic appearances and the accuracy in detecting involvement of the spleen and liver. Only one out of 17 positive spleens had definite ultrasonic focal lesions. Not only small splenic Hodgkin's foci but also larger ones were overlooked. Of 10 positive livers, six showed diffuse inhomogeneity throughout the liver, two showed multiple, well-defined, echo-poor lesions but two showed no significant ultrasonic abnormality even in retrospect. No correlation was found between the type of Hodgkin's disease and the ultrasonic appearance of involved livers. Ultrasonic examination, however, could differentiate other liver abnormalities, such as fatty changes, a cyst and a thrombosed haemangioma from infiltration of Hodgkin's disease. In one case, splenic lesions became echogenic following-chemotherapy.

The decision to perform staging laparotomy in symptomatic Hodgin's disease

This study defines patients with symptomatic Hodgkin's disease for whom risks of staging laparotomy (LAP) outweigh benefits conferred by accurate knowledge of stage. From a database of more than 900 pathologically-staged patients, probabilities of pathological stage are calculated for combinations of basic findings and lymphangiogram results. Decision-making thresholds are defined at which results of treatment after LAP, taking operative mortality into account, are equivalent to immediate treatment appropriate to clinical stage. These thresholds are substantially altered by varying LAP mortality estimates, by assigning a false negative rate to LAP, and by considering uncertainty in treatment results. Fifty-four combinations of findings are described for which immediate therapy with MOPP is justified; total nodal irradiation (TNI) is never indicated in B patients without prior LAP staging. Analysing 94 B patients who had LAP showed an appreciable number might have been spared this, particularly when uncertainty in treatment results is considered. With 0.03 (=3%) uncertainty in treatment, and 1% LAP mortality, LAP was not indicated in one in seven patients; nearly one third of patients should have immediate treatment with 3% LAP mortality. Threshold analysis can define those patients for whom risks of LAP outweigh benefits.

[Diagnostic value of clinical methods in the staging of abdominal Hodgkin's disease (author's transl)]

Explorative laparotomies were carried out on 68 patients with Hodgkin's disease in the University Hospital of Marburg from 1969 through 1978. These laparotomies were preceded by clinical examination, abdominal sonography in 27 cases, lymphography in 55 cases, scintigraphy of liver and spleen in 58 cases, and radiographic examinations of the intestinal tract in 18 cases. Sonography revealed a greater accuracy (90%) for splenic involvement than scintigraphy (74%); the results of sonography and scintigraphy of the liver were comparable. For the detection of para-aortal lymphomas ultrasound and lymphography can be regarded as complementary methods. Our results are compared with findings in the literature on abdominal sonography (n = 50), scintigraphy of liver and spleen (n = 185), and lymphography (n = 465) carried out before explorative laparotomy for lymphogranulomatosis. There was a better correlation for the systemic symptoms of the 68 patients with the clinical stage than with the pathologic stage. The importance of diagnosing different groups, e.g. in stage III, is stressed.

Hodgkin's disease

During the past two decades, new approaches to the diagnosis and treatment of Hodgkin's disease have contributed to improved rates of survival and probable cure. Currently, patients with Hodgkin's disease are treated according to the stage and symptoms of their disease. The degree of certainty necessary for determining stage depends on the potential effectiveness of the therapeutic options available in a given case. Certain cases have been identified where treatment with a single modality has been disappointing, and the use of both radiotherapy and chemotherapy may be considered for these. Such decisions can be made only by evaluating the effectiveness of salvage after relapse following single-modality treatment and assessing the added hazards of initial treatment with both modalities.

Hodgkin's disease: radiotherapeutic management at a cancer oriented community hospital

Seventy-eight patients with Hodgkin's disease were treated with radiation therapy between July 1966 and July 1976 (30 Stage I, 28 Stage II, 20 Stage III). The mean follow-up period is greater than 5 years. 90% of Stage I, 86% of Stage II, 65% of Stage III, and 82% (64/78) of all patients are NED after radiotherapy alone. Since laparotomy option (1970) 89% (50/56) of patients are NED. Fourteen patients were failures. Chemotherapy "rescued" 6 of 14. Seven have died, 1 is alive with disease, and 1 died of leukemia. Absolute survival is 90% (70/78). Failures were more frequent in patients with unfavorable histological types (9/14), and Stage III disease, primarily IIIS+ or B category (7/14). Sites of failures were mainly extranodal, primarily lung (10/14) and bone (2/14), and are consistent with hematogenous dissemination. Laparotomy performed in 41 patients identified unsuspected splenic involvement in 9 cases (22%), but was a distinct failure in confirming most "small node" positive lymphangiograms. Two patients developed acute myelocytic leukemia, both while NED 5 years posttherapy. One patient had also received adjunctive MOPP. There has been no impairment in the quality of survival that could be directly attributed to radiotherapy.

Intensive investigation in management of Hodgkin's disease

Ninety-eight patients with clinically localised Hodgkin's disease underwent laparotomy and splenectomy to determine the extent of microscopic spread. In 68 patients the procedure was carried out for untreated disease apparently confined above the diaphragm. Abdominal disease cannot be confidently excluded on the basis of non-invasive investigation at presentation. Clinical assessment of splenic disease was unreliable unless gross splenomegaly was present. Pedal lymphography was accurate in assessing para-aortic and iliac disease but of no value in assessing other intra-abdominal lymph node involvement, including that of the mesenteric lymph node. Trephine bone marrow biopsy findings were normal in all patients before surgery, and only one patient was found to have diseased bone marrow by Stryker-saw biopsy at operation. Liver disease was identified at operation in nine patients, some of whom were asymptomatic with clinically undetectable splenic and nodal disease. Detailed clinical staging failed to detect disease in one-third of patients who underwent laparotomy. These studies show that if radiotherapy is to remain the treatment of choice for disease truly localised to lymph nodes a detailed staging procedure, including laparotomy and splenectomy, remains essential. The value of this potentially curative treatment is considerably diminished in the patient who has been inadequately staged.

A case of primary lymphoma of the liver

A case of primary malignant lymphoma of the liver is described. Presenting with epistaxis, he died in hepatic encephalopathy with an intractable bleeding post-bulbar duodenal ulcer.

Staging of Hodgkin's disease: a surgical perspective

Staging laparotomy, consisting of splenectomy and biopsies of liver, lymph nodes, and bone marrow, is a very useful adjunct in the workup of a patient with Hodgkin's disease. In this series of 400 patients, 1.0 per cent required reoperations for complication, 3.7 per cent had major complications, and 14.0 per cent had minor complications from the operation. Further evidence of Hodgkin's disease was discovered in 42.0 per cent of the cases and a change from the clinical to the pathologic stage occurred in 27.5 per cent of these cases. The surgeon's task in the treatment of Hodgkin's disease and other malignant diseases is to document and mark the areas of involvement so that accurate and appropriate therapy can be given, while morbidity and mortality are minimized.

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.

Complications of abdominal exploration and splenectomy in staging children with Hodgkin's disease

Until alternate diagnostic methods are discovered, the staging procedure seems to be the most reliable method to establish the presence or absence of abdominal involvement in Hodgkin's disease. Our experience with staging laparotomy in 22 children raises serious questions as to both the risk of operation and the prognostic value of a negative abdominal exploration. Routine use of the staging laparotomy may not be justified in clinical Stage IA patients with lymphocyte-predominant cell type. Because of the hazards and limitations of the staging procedure, vigorous attempts would seem to be indicated to identify subcategories of patients in whom the likelihood of intraabdominal involvement is so small as to negate the value of surgical staging.

Experience with clinical and operative staging of Hodgkin's disease in children

Accurate staging is critical for the proper treatment of Hodgkin's disease. In the past 5 yr, 60 children with Hodgkin's disease were staged by celiotomy which included splenectomy and biopsy of liver, retroperitoneal lymph nodes, and bone. Fifty children underwent staging celiotomy at initial diagnosis (Group I). Ten others were staged surgically because of suspected reactivation of disease diagnosed and treated before current staging methods were employed (Group II). Forty-one of 50 children in Group I had Stage I or II disease, seven Stage III, and two Stage IV. As a result of operation, therapy was altered in seven children. Three had a higher stag e and four a lower stage than that suspected by clinical evaluation, including two with liver involvement. Of the two patients in Group II, celiotomy revealed unsuspected splenic disease in seven, including one with liver involvement. Celiotomy and splenectomy were well tolerated and no long-term complications have been noted (average follow-up 2 yr). Forty-nine of 50 children in Group I and six of ten in Group II are alive without disease. No cases of sepsis attributable to splenectomy have been observed.

A combined modality approach to the treatment of Hodgkin's disease. Preliminary results of a prospectively randomized clinical trial

Eighty-seven previously untreated patients with pathologic Stage IA, II (A or B), or IIIA Hodgkin's disease were randomized over a 48-month period to receive either megavoltage extended field radiotherapy alone or megavoltage radiotherapy limited to involved lymph node sites (including at least an upper mantle field) followed by combination chemotherapy with nitrogen mustard, vincristine, prednisone, and procarbazine (MOPP). Four patients (4.6%) failed to achieve remission with initial radiotherapy. Seventy-two evaluable patients have currently completed therapy. Ten of 41 patients achieving remission with radiation alone have relapsed, compared to only 1 of 31 receiving radiation plus chemotherapy. Seven patients have died, 3 of whom failed to achieve remission with initial radiotherapy. The other 4 had Stage IIIA disease treated with radiation alone. Severe myelosuppression occurred infrequently during chemotherapy, and neither serious infections nor second neoplasms have observed. Although these preliminary results are encouraging, longer followup is required to determine the ultimate effects of combined modality therapy on survival and long-term complications.

Role of liver scanning in the diagnosis of hepatic metastases

Liver scanning is quite useful in detecting metastases, particularly when none are suspected clinically, and obviates the need for more elaborate and expensive examinations in about half the cases in the series analyzed here.