The value of laparotomy and splenectomy in the staging of Hodgkin's disease

The current practice of lymphography: a survey in the age of computed tomography

A postal survey has revealed a reduction in the practice of lymphography in several hospitals where body computed tomography (CT) is available. Nowhere in this country has this reduction been quite so marked as in East Anglia, where very few lymphograms are now performed. Some of the factors which may be responsible are assessed; in particular, the introduction of body CT.

The evolution and summary results of the Stanford randomized clinical trials of the management of Hodgkin's disease: 1962-1984

This is a summary report of the Stanford randomized clinical trials of the management of Hodgkin's disease, initiated in 1962. There have been four major changes in the treatment protocols during this 22 year period. Between 1962-67, 132 patients with CS I, II and III disease were enrolled on various radiation trials. Between 1968-74, 367 patients were enrolled on studies primarily evaluating the role of adjuvant MOPP chemotherapy. Between 1974-80, variations in the chemotherapy regimen and the sequences of the combined modality programs were studied. The current studies, initiated in 1980, have enrolled 102 patients, and test a new mild adjuvant chemotherapy, VBM, (vinblastine, bleomycin and methotrexate) and utilizes ABVD in combined modality and alternating regimens. During the two decades of these studies, involving more than 800 patients, the initial remission rate and duration and the survival of all patients treated have progressively improved.

Comparison of 99Tcm lymphoscintigraphy and lymphangiography in patients with malignant lymphomas

Comparison of abdominal lymphoscintigraphy with 99Tcm microcolloid and conventional lymphangiography in 38 patients with malignant lymphomas showed 62 per cent agreement when the results were classified as normal, doubtful and abnormal. The present scintigraphic method seems to be sufficiently safe and accurate as a screening test, without significant side effects and associated with little patient discomfort.

Selective hemisplenectomy for Hodgkin's disease

Schellong's recommendation to do a selective splenectomy in Hodgkin's disease supported by our retrospective histological findings in biopsies of lymph nodes and spleens of 25 patients. In addition, we recommend a hemisplenectomy instead of a splenectomy in cases of involvement of the lymph nodes at the pancreatic tail and at the hilus of the spleen. Hemisplenectomy, which is not a more difficult or more time-consuming operation, provides more security in judging an invasion of the spleen.

Prognostic significance of the number of involved areas in the early stages of Hodgkin's disease

An analysis of 1059 patients with clinical stage (CS) I and II Hodgkin's disease was undertaken to determine the prognostic significance of the number of involved sites. In this group of patients the number of involved lymph node areas was highly correlated with the probability of dissemination of occult disease. In the subgroup of patients with involvement of two lymph node sites (CS II2) approximately 50% demonstrated occult dissemination on the other side of the diaphragm as evidenced by subsequent relapse in the untreated subdiaphragmatic region. However, only 15% to 20% of this group had unsuspected disease in regions other than the spleen or the paraaortic lymph nodes. In CS I and II2 supradiaphragmatic patients, who underwent a staging laparotomy, splenic involvement was a powerful prognostic indicator. When the spleen was not involved, less than 10% of patients had disease elsewhere below the diaphragm, whereas, when the spleen was involved as many as 40% of patients had additional subdiaphragmatic sites involved. In the subgroup with three or more lymph node areas involved (CS II3), the proportion of patients with extension of disease on the other side of the diaphragm, as evidenced by later relapse was also about 50%. But in these patients, unlike the CS II2 patients, analysis of relapse patterns showed that occult disease had already disseminated to the pelvic nodes or to extra nodal sites. Furthermore, splenic involvement was of much less prognostic significance because CS II3 patients who did not demonstrate splenic involvement at staging laparotomy had similar relapse incidence and similar relapse patterns as those with positive spleens.

Staging laparotomy and splenectomy in early Hodgkin's disease. No therapeutic benefit

In a prospective randomized study of treatment for early-stage Hodgkin's disease presenting above the diaphragm, 76 patients had staging by laparotomy (Group I) and 28 had staging by closed techniques (Group II). Treatment consisted of involved-field radiotherapy alone (44 patients), involved-field radiotherapy followed by chemotherapy (38 patients), total nodal radiotherapy alone (15 patients), or total nodal radiotherapy followed by chemotherapy (seven patients). On presentation, both groups had similar clinical features and similar treatment distribution. With similar follow-up (87 months), no significant differences in remission or survival were observed between Groups I and II: remission 59 versus 68 percent; survival 74 versus 92 percent; p value 0.27 and 0.09, respectively. Multiple areas of relapse were more frequently observed in Group I (11 of 32 had relapse) as compared with Group II (none of nine had relapse, p less than 0.082). In Group I, relapse in the abdomen was observed as an isolated event or as part of disseminated relapse in 12 percent of patients compared with 3 percent (one patient) in Group II with abdominal relapse alone. Seven patients in Group I and two patients in Group II died with Hodgkin's disease. Six other patients in Group I died with complete remission of non-Hodgkin's lymphoma (one patient), leukoencephalopathy (one patient), sepsis during chemotherapy (two patients), myocardial infarction (one patient), and cerebrovascular accident (one patient). Three other patients in this group had other secondary malignancies successfully controlled (histiocytic lymphoma, squamous cell carcinoma of the cervix, and malignant schwannoma). No second primary lesions or death with complete remission were observed in Group II. Staging laparotomy with splenectomy in early-stage Hodgkin's disease did not improve the duration of remission or survival or decrease the number of abdominal relapses compared with closed staging.

The place of staging laparotomy in the management of Hodgkin's disease

The results of laparotomy and splenectomy in 225 patients with Hodgkin's disease are presented. The investigation changed the staging of the disease in 35% of patients. It carried no mortality and a low morbidity. It is concluded that the procedure provides information unobtainable accurately by other means and that it should be carried out in adult patients of both sexes and all histological subgroups who have clinical Stage I and II disease.

The EORTC treatment of early stages of Hodgkin's disease: the role of radiotherapy

Since 1964, the European Organisation for Research and Treatment of Cancer has conducted three subsequent clinical trials on clinical Stages (CS) I + II Hodgkin's disease (HD) in which 1059 patients have been entered. The first trial compared regional radiotherapy (RT) with mantle field or inverted Y, versus the same RT followed by a weekly injection of vinblastine for 2 years. The relapse free survival (RFS) and overall survival (S) were higher in patients treated by RT and chemotherapy (CT). This benefit, however, was significant only in patients with a mixed cellularity histologic type. The second trial compared the therapeutic efficacy of splenic irradiation versus splenectomy and found that in both arms, RFS and S were identical. Moreover, it was found that splenic involvement was correlated with an increased incidence of relapse in extranodal sites and in non irradiated lymphatic areas. In this trial, CT was given only to patients with poor histologic types, mixed cellularity or lymphocytic depletion. In the third trial, staging laparotomy was performed only to further delineate a good prognostic group which could be treated by RT alone. In this limited treatment group, there was no difference in RFS and S between mantle field and mantle field + para-aortic RT. In the extensive treatment group, total nodal irradiation (TNI) was compared with RT + MOPP. The RFS was slightly lower in the TNI arm, but there was no significant difference in S. The data of the 3 trials underline the importance of prognostic factors in the choice of optimal treatment and show that their significance depends upon the type of treatment. Multivariate statistical analyses showed that the main prognostic factors, which can help to identify the subsets of patients who can be treated by RT alone, are (1) systemic symptoms and elevated erythrocyte sedimentation rate (ESR), (2) the number of involved lymphatic areas, and (3) staging laparotomy. Extended RT (mantle + para-aortic + spleen treatment) gives satisfactory results in patients without systemic symptoms and/or elevated ESR and one or two involved sites, whereas TNI or combined modality treatment becomes mandatory for patients with 3 or more involved sites or splenic involvement and/or systemic symptoms. With proper adjustment of the irradiated volume, a very large proportion of CS I + II patients can be best treated by RT alone.

Experiences from the National Danish Hodgkin's Study Group (LYGRA) with respect to diagnosis, classification and treatment of Hodgkin's disease

From September 1971 to April 1983, 1200 patients with newly diagnosed Hodgkin's disease were admitted to the centres which had founded LYGRA (the Danish Hodgkin's Study Group), to undergo uniform staging procedures and treatment. Present problems concerning staging, treatment, and complications, such as the risk of pneumococcal infection following splenectomy, the loss of fertility, and the risk of secondary malignancies, in particular leukaemia, are discussed.

Evaluation of the surgical aspects of staging laparotomy for Hodgkin's disease in children

Experience with 72 children in which the type of staging laparotomy recommended by the Intergroup Hodgkin's Disease in Childhood Study (IHDCS) was employed (1967-1981) is reviewed. Laparotomy altered the stage in 35% of these patients including advance in stage (I-II to III-IV) in 24 patients, and reduction in stage (III to II) in one patient. In adults, Stage III disease is divided into III1 and III2 on the basis of the presence or absence of lower abdominal node involvement; and prognosis is significantly better in III1. Nine patients from two additional institutions were included in a special study of Stage III disease. This included 22 children in III1 and 11 children in III2. Although the children with Stage B (systemic symptoms) disease were concentrated in III2, none of the measured difference between these two groups were significant. No fatal postsplenectomy sepsis has been noted since the use of pneumococcal vaccine and prophylactic penicillin became standard.

The liver in Hodgkin's disease--I. Clinico-pathological relations

A retrospective analysis of staging results from 308 patients with Hodgkin's disease (HD) was performed in order to relate clinico-pathological findings with respect to the liver to other staging results and to prognosis. Thirty-four patients had clinically enlarged liver, 80 had increased serum-enzyme levels indicating possible liver damage, but only 10 patients had biopsy-proven histologic evidence of HD in the liver (7 primary biopsies, 3 re-biopsies). Among the prognostic correlations not only advanced stage and liver infiltrates were connected to poor prognosis, but also--even in early stages--elevated serum enzyme values (S-GOT and alkaline phosphate).

Is staging laparotomy for Hodgkin's disease still justified?

The records of 50 consecutive patients who underwent staging laparotomy for Hodgkin's disease were reviewed. Preoperative clinical stages were as follows: stage I, 12 patients; stage II, 20 patients; and stage III, 18 patients. The accuracy of preoperative lymphangiography, confirmed pathologically, was 80 percent. Early experience with computed axial tomographic scanning is promising. The stages of 20 patients (40 percent) were changed by laparotomy, and their treatment was altered as a result. Fourteen patients were upstaged and 6 downstaged. Patient who were upstaged to stage IIIB and IV received chemotherapy; those downstaged to stage I and II received radiotherapy only. Sixty-seven percent of patients with preoperative constitutional symptoms (class B) had positive findings at laparotomy, compared with only 28 percent of patients without such symptoms (class A). Patients with mixed cellularity or lymphocyte-depleted histology were more likely to have positive findings at laparotomy. There were four complications and operative deaths. We conclude that staging laparotomy retains a useful role in the diagnosis and management of Hodgkin's lymphoma.

Computed tomography, ultrasound and lymphography in the diagnosis of malignant lymphoma

Lymphographic findings were compared with the results at histopathology in 42 laparotomized patients with malignant lymphoma. Of 12 patients with lymphographically suggested lesions in normal-sized lymph nodes, only one had pathologic changes at histologic examination. Computed tomography gave a better idea of the extent of the disease than lymphography. Moreover, CT had an equal diagnostic accuracy as lymphography for demonstrating enlarged para-aortic lymph nodes. CT should therefore be able to replace lymphography in examination of malignant lymphoma. Ultrasound had the same diagnostic accuracy as CT regarding the upper and middle abdomen but not in the lower abdomen. Ultrasound is of special value in thin patients and when guided needle biopsy is required.

Morphometrical analysis of T- and B-cell compartments of spleens in Hodgkin's disease

One possible explanation for the defective cellular immunity in Hodgkin's disease is an abnormal distribution of T lymphocytes. To study this possibility a morphometric analysis of T- and B-areas in non involved and involved spleens of patients with Hodgkin's disease was undertaken. We found that in involved spleens a significant reduction of the T dependent area could be demonstrated. We concluded that this reduction is caused by an abnormal distribution of T lymphocytes in the spleen and may partly explain the defects in cellular immunity. In addition, the absence of overlap between the T/B area ratios of involved and non-involved spleens suggests, that a prediction on involvement of spleen can be made by morphometrical analysis of a small, random taken non-involved area.

Management of neoplasms of the head and neck in children. II. Malignant tumors

The otolaryngologist who treats children must have knowledge of the neoplasms that can occur in childhood. Such tumors are usually mesenchymal in origin and may be benign or malignant. Diagnosis and management of the more common benign tumors are undertaken by the otolaryngologist because local excision is generally curative. The proper treatment of malignant lesions requires a more extensive, multidisciplinary team, which includes a pediatric oncologist, diagnostic and therapeutic radiologist, and pathologist, in addition to the otolaryngologist. This article outlines the types of malignant neoplasms that occur in childhood and discusses current approaches to therapy.

Extralymphatic Hodgkin's disease. Prognosis and response to therapy

Three hundred eighteen patients with pathologic stage IA and IB, IIA and IIB, and IIIA Hodgkin's disease who entered into Stanford University Medical Center randomized trials comparing radiation therapy alone to radiation therapy plus six cycles of adjuvant chemotherapy were evaluated. Of these, 54 patients had extralymphatic (E) lesions. There were five relapses among these patients (9 percent), not different from the 37 relapses among the remaining 264 patients (14 percent) with Hodgkin's disease confined to the lymphatic system. Actuarial survival and freedom from relapse were not significantly different for patients with or without extralymphatic disease. The survival of patients with extralymphatic disease was similar whether they received radiation therapy alone or radiation therapy plus chemotherapy.

Staging laparotomy in Hodgkin's disease

A surgeon's experience in staging laparotomy for Hodgkin's disease over an eight-year period is reviewed. The laparotomies concerned were the vast majority of such staging procedures done in this regional centre over this period. A relatively large series of staging operations performed by one surgeon has thus been accumulated and demonstrates the value of experience, and in the light of the allows questioning of the need for some of the steps considered to be basic to staging laparotomy. In the 19 cases reviewed, staging laparotomy altered the method of management in 44%.

Complications from staging laparotomy for Hodgkin disease

Nonspecific complications from staging laparotomy are usually related to general anesthesia or abdominal exploration. Specific complications for the procedure do exist: intubation difficulties during administration of anesthesia to patients with untreated mediastinal disease, sepsis in up to 20% of patients, depending on stage of disease and intensity of postoperative chemotherapy and radiotherapy, arterial and possibly venous thromboemboli from extensive retroperitoneal node dissection, pancreatitis, small bowel obstruction from adhesions to node biopsy sites, operative mishaps, subphrenic abscesses, and bleeding from liver biopsies. Certain patient subpopulations are at especially high risk for some of these complications and their identification and possible measures to minimize such problems are proposed.

Is staging laparotomy of therapeutic value in patients with supradiaphragmatic Hodgkins's disease, clinical stage IA-IIA?

Between 1968 and 1972, 123 patients with clinical stage (CS) IA and IIA Hodgkin's disease were seen. Staging laparotomy was introduced in June 1970. The impact of staging laparotomy on the prognosis has been evaluated by comparing the treatment results before and after the introduction of this procedure. The patients were treated only on the basis of CS before staging laparotomy, and mainly on the basis of pathological stage (PS) after the introduction of this procedure. Patients with stage IA to IIIA disease received radiotherapy alone with the extended field techniques, while patients with stage IVA disease had combination chemotherapy. After an observation time of 7 years there was no difference in survival between the two groups. The relapses occurred earlier in the patients treated after the introduction of staging laparotomy. It is known that the survival is unaffected by staging laparotomy in the patients with Hodgkin's disease CS IA and IIA.

Human-human hybridomas producing monoclonal antibodies of predefined antigenic specificity

We report the establishment of human-human hybridomas producing monoclonal antibody of predefined antigenic specificity. The U-266 human myeloma cell line was incubated in the presence of 8-azaguanine, and a rapidly growing, 8-azaguanine-resistant, hypoxanthine/amethopterin/thymidine (HAT) medium-sensitive mutant line, U-266AR1, was selected. These cells were fused with lymphoid cells from uninvolved spleens removed at staging laparotomy from patients with untreated Hodgkin's disease who had been previously sensitized to the chemical allergen 2,4-dinitrochlorobenzne. Hybrid cell cultures growing in HAT medium were screened for IgG production. Positive cultures were selected and their supernatants were tested in a solid-phase radioimmunoassay for reactivity with dinitrophenyl hapten coupled to bovine serum albumin. Cultures producing specific antibody were subcloned and expanded, and their antibody products were shown to be monoclonal by biosynthetic labeling and sodium dodecyl sulfate/polyacrylamide gel electrophoresis.

A new effective four-drug combination of CCNU (1-[2-chloroethyl]-3-cyclohexyl-1-nitrosourea) (NSC-79038), vinblastine, prednisone, and procarbazine for the treatment of advanced Hodgkin's disease

Five hundred and sixty-six patients with either Stage III or IV Hodgkin's disease were prospectively randomized to test whether CCNU and/or vinblastine are more effective than mechlorethamine and/or vincristine with procarbazine and prednisone. The combination of CCNU, vinblastine, procarbazine, and prednisone (CVPP) was shown to be a highly effective program with a complete response frequency of 69%. The use of CCNU as part of the induction program was also shown to be the most significant determinant of prolonged remissions (P = .025). Reduced vomiting and neurotoxicity, as well as the oral administration, were the chief advantages of the CVPP as compared with MOPP. These factors resulted in improved patient and physician compliance. The MVPP regimen was also shown to be a highly effective regimen with a complete response frequency of 73% in patients without prior exposure to chemotherapy. However, the induction regimens containing vinblastine were associated with a significantly higher frequency of fatal hematopoietic toxicities than the induction regimens containing vincristine (P = .05). This higher frequency was almost exclusively seen in the elderly or in patients previously treated with both chemotherapy and radiotherapy. At this time, the remission durations maintained by vinblastine with periodic reinforcement are longer when compared with vinblastine maintenance alone (P = .06), but there is no corresponding increase in survival.

Prognostic effect of early diagnostic splenectomy in Hodgkin's disease: a randomized trial

A randomized trial is reported which evaluates the effect of early diagnostic splenectomy on the prognosis of patients with Hodgkin's disease (HD) and uncertain prognosis. This was started in January 1973 and concluded in April 1979. Sixty-seven patients were entered in the study and 31 were randomized for splenectomy. All patients except 2 received total nodal irradiation, excluding the splenic and hepatic areas. After 40 months' observation there was no difference between the groups in respect of survival and the number of recurrences. However, relapses occurred earlier in the splenectomized patients. Pneumococcal septicaemia was recorded in 2 splenectomized patients. It is concluded that prognosis is not improved by diagnostic splenectomy in HD patients with uncertain prognosis and treated with total nodal irradiation.

Results of surgical staging in Hodgkin's disease

The results of surgical staging in Hodgkin's disease in 107 patients under the care of one surgeon over an 8-year period are presented. The inaccuracy of clinical staging is re-emphasized as 43 per cent of patients had their disease stage altered by surgical staging. Lymphangiography correctly predicted the presence of intra-abdominal disease in only 70 per cent of patients. Spleen size was not an indication of involvement, and furthermore the spleen was involved by disease in the absence of nodal involvement in 6 patients. In 2 cases mesenteric nodes were involved in the absence of pancreatic or coeliac nodal involvement. As a consequence of surgical staging many patients received a more extensive field of radiotherapy, and 18 per cent of patients were treated by combination chemotherapy instead of radiotherapy. There was no hospital mortality and a low operative morbidity following surgical staging. At present surgical staging is an essential part of the overall strategy of management of patients with Hodgkin's disease.

Hodgkin's disease: unfolding concepts concerning its nature, management and prognosis

The evolution of our concepts concerning the fundamental nature and natural history of Hodgkin's disease is reviewed. Recent evidence establishes that it is indeed a malignant neoplasm, albeit a curious one, the giant cells of which display aneuploid karyotypes, often with marker chromosomes indicating their clonal derivation, and the functional and surface marker properties of cells of the mononuclear phagocyte series. The disease tends initially to spread by contiguity from one lymph node chain to others with which direct lymphatic channel communications exist. Essentially all patients, even those with limited disease, have some degree of impairment of cell-mediated immunity, apparently due to inhibition of T-lymphocyte function. Lymphangiography, computed tomography, and laparotomy with splenectomy have greatly improved the accuracy of clinical staging. Total lymphoid megavoltage radiotherapy and/or multidrug combination chemotherapy now permit the eradiction of disease of all stages, resulting in a dramatic improvement in prognosis and an increasing frequency of permanent cure of this once inevitably fatal condition.

Staging laparotomy in Hodgkin's disease

Staging laparotomy (multiple liver and lymph node biopsies and splenectomy) was performed at the North Carolina Baptist Hospital in 123 patients with Hodgkin's disease. There were no deaths. Wound, pulmonary, intra-abdominal or urinary tract complications developed in 17 patients. Of those complications, one case each of pelvic abscess, subphrenic abscess, small bowel obstruction, staphylococcal peritonitis and subphrenic hematoma required a major intra-abdominal operation. The patients were classified on the basis of histopathology; nodular sclerosis--40, mixed cellularity--44, lymphocyte predominant--24, lymphocyte depleted--13, and undetermined--2. The pathological stage following laparotomy was unchanged from the clinical stage in 62%, reduced in 15%, and advanced in 23%. Subsequent therapy, therefore, was altered in 38% of the patients. Lymphangiography, done in 108 patients, showed lymph node involvement in 46 patients and no involvement in 62 patients. Of those lymphangiographic findings, 79% were confirmed histopathologically, 19% were falsely positive, and 1.8% were falsely negative. There were positive findings of Hodgkin's disease in the spleen in 42% of patients. The staging laparotomy continues to be a valuable tool in the staging and treatment of Hodgkin's disease.

Staging laparotomy in Hodgkin's disease

Staging laparotomy is a useful procedure as long as regional radiotherapy continues to be the primary modality of treatment for early Hodgkin's disease. However, many oncologists have extended the indications for systemic chemotherapeutic agents. Studies are in progress to evaluate the effectiveness of chemotherapy alone for all patients with B symptoms as well as for those with stages I and II disease associated with large mediastinal masses or lymphocyte depletion histology. If therapeutic practices change significantly in the future, there may be fewer indications for careful staging. The natural history of treatment of cancers in a sophisticated therapeutic environment is that more careful staging is required to utilize the vast array of therapies being developed to improve prognosis. In all likelihood staging laparotomy in some form will continue to be a part of the management scheme for patients with Hodgkin's disease.

Morbidity and mortality after surgery in patients with disseminated or locally advanced cancer receiving systemic chemotherapy

All postoperative complications and mortality were analyzed in a diverse group of patients operated upon by the authors during a ten-year period. These patients shared only two common factors: 1) known locally advanced or disseminated cancer, and 2) systemic chemotherapy within three weeks (either pre- or postoperatively) of major surgery. One hundred eighty-six operations were performed on 175 patients. The overall mortality in this series was 2.2% (four patients), with a complication rate of 5.9% (11 patients). Despite the known detrimental effects of widespread cancer and cytotoxic agents on wound healing, appropriate surgical intervention can be accomplished with an acceptable mortality and morbidity in patients with locally advanced or disseminated cancer who are receiving systemic chemotherapy.

Computerised tomographic (CT) abdominal scanning in Hodgkin's disease

Thirty-nine patients with Hodgkin's disease (HD) with little or no clinical evidence of abdominal disease were investigated by abdominal CT scanning. The results were compared with those of bipedal lymphography and laparotomy and splenectomy. In the assessment of para-aortic lymph nodes, CT scanning and lymphography were of equal efficacy in determining the presence or absence of disease (87 and 79% respectively). Although CT scan could occasionally demonstrate disease in nodes in areas other than the retroperitoneum, its value was limited by its inability to detect involvement of nodes which were not significantly enlarged. CT assessment of splenic HD was unreliable, focal deposits being detected in only one of the 11 spleens involved. In this selected group of patients, CT scan had little advantage over lymphography in the description of disease extent. However, CT scan would appear to be the investigation of choice in patients with suspected abdominal relapse because of the more frequent presence of disease in sites not seen on lymphography. When treatment decisions are dependent on accurate knowledge of distribution of disease, CT scanning cannot yet effectively replace staging laparotomy and splenectomy as the means of achieving this information.

Hodgkin's disease: the pendulum swings. Knox lecture, Royal College of Radiologists, 1977

There has been a profound change in the attitude of the medical profession towards patients with Hodgkin's disease. Until recently the disease was regarded, quite incorrectly, as inevitably fatal. Nowadays it is frequently assumed that it is constantly curable, which also a totally erroneous view. However, there has been an enormous improvement in the management of patients with all stages of the disease, so much so that further improvements without the production of excessive complications are becoming increasingly difficult to achieve. The author reviews the background to the present situation including some of the studies organised by the British National Lymphoma Group, which may be producing results which could be of benefit for patients. Some measures are discussed which may offer hope of improving even further the situation for the patient, without increasing risks from treatment.

Hepatic Hodgkin's disease without involvement of the spleen

A patient with Hodgkin's disease, who at laparotomy had liver involvement with no evidence of Hodgkin's disease in the spleen, is reported. Rare alternate lymphaticovenous anastomoses exist that may lead to liver involvement in the absence of splenic involvement.

[Biopsy of para-aortic lymphnodes in patients with malignant lymphomas (author's transl)]

In treatment of malignant lymphomas exploratory laparotomy with splenectomy, liver and lymphnodes biopsy is necessary in order to individualize appropriate management. The surgeon must make maximal effort to obtain lymphnodes for histological examination. The surgical anatomy of the retroperitoneum in space of abdominal aorta and the biopsy procedure of paraaortic lymphnodes were described. The literature was reviewed.