Usefulness of lymphography in childhood neoplasia

Restatement of Lymphography in Childhood: Experience with 413 Consecutive Patients in Ten Years

From January 1969 to June 1978, 413 children under 15 years of age underwent lymphography at the Istituto Nazionale Tumori of Milan. Successful lymphatic cannulation was accomplished in 97.7% (769/787) of the sites where it was attempted. No major or permanent complications were encountered. In those children undergoing biopsy of opacified lymph nodes, the lymphographic-histologic correlation was 94.5% (104/110). This study has shown that lymphography in childhood can be as readily performed as in the adult and that its diagnostic accuracy is acceptable. As in adults, it is useful in treatment planning, evaluating results of therapy, and detecting a recurrent tumor.

Lymphography in Childhood Cancer

Lymphographic investigations were done in 139 children (84 males and 55 females). Up to the age of 10 years the examination was performed in anesthesia; after that age suitable sedation only was given. The radiographic pattern of the lymph node involvement in this type of tumor is the same in children as in adults. Peculiar patterns were observed in neuroblastoma and in Ewing's sarcoma. 78 patients (57.4%) were suffering from systemic disease and 59 (41.9%) from solid tumors; in 2 cases the clinical diagnosis of tumor was not borne out by the histologic findings. In 35.3% of the cases with Hodgkin's disease and in 29% of supradiaphragmatic reticuloendothelial sarcoma lymphography revealed subdiaphragmatic lymph node involvement. In the stage III and IV patients lymphography was always pathologic. Pathologic lymph nodes were found in 3/10 patients with lymphoma arising in Waldeyer's tonsillar ring. Metastases were present in 40/59 of the cases of solid tumor (68.9%); the incidence of metastases was especially high in neuroblastoma (20/24), in rhabdomyosarcoma (4/5) and in tumors of the gonades (7/9). 16 cases were operated on; 2 false positives were found for lymph nodes in which there was pronounced reactive inflammatory hyperplasia.

Experiment with 659 consecutive lymphograms in children

Between 1963 and January 30, 1975, 659 children under 16 years of age were referred for bipedal lymphography at the Institut Gustave-Roussy. Approximately one-third were under 5 years of age. The vast majority had documented malignant disease. Successful bilateral lymphatic cannulation and lymph nodd opacification were accomplished in 86.7% of all children. Another 11.6% had successful unilateral lymphograms, which usually provided sufficient information to be considered as diagnostic stldies. In only 1.7% of all children was the study unsuccessful bilaterally. Lymphatic cannulation failure rates progressively decreased as the child increased in age. There were five "allergic" reactions (0.75%), one of which was considered life-threatening, and one instance (0.15%) of a transient neurological deficit. No permanent sequelae or deaths were attributed to the lymphogram.

Comparison of Radiological Findings in Children with Hodgkin's Disease and Non-Hodgkin's Lymphomas at Disease Presentation

From January 1968 to March 1975, 115 patients with malignant lymphomas, all aged under 15 years, were admitted to the Istituto Nazionale Tumori of Milan: 57 had Hodgkin's disease (mean age 9.7 yrs) and 58 non-Hodgkin's lymphomas (mean age 7.7 yrs). In this group of consecutive unselected and untreated patients the incidence of lesions radio-logically evident at disease presentation was comparatively evaluated in relation to histology. 36 cases underwent a subsequent diagnostic laparotomy with splenectomy. Chest X-ray was performed in all patients. It proved to be pathologic in 44 % of patients with Hodgkin's disease (mediastinal adenopathies were present in all cases). Pulmonary lesions were documented in 5 %, pleural in 2 % and skeletal in 2 %. Lymphography showed retroperitoneal involvement in 16 % with Hodgkin's disease and in 29 % with malignant lymphomas; radiological findings were confirmed by laparotomy in 35/36 cases. Skeletal survey proved to be abnormal in only 2 % of Hodgkin's compared to 18 % of non-Hodgkin's lymphomas. All lesions were clinically symptomatic. Intestinal involvements (small bowel and colon), which were always symptomatic, were present in 15 patients with non-Hodgkin's lymphoma (26%). IVP showed direct involvement of kidneys in 2 patients with non-Hodgkin's lymphoma. The comparison of radiological findings in the two groups of patients confirm that non-Hodgkin's lymphomas have a more aggressive initial spread: 43 % of patients were classified as stage IV at disease presentation. At the same time, our data prove that some of these diagnostic tools are of scant use when performed as a screening procedure for occult lesions.

The staging of Hodgkin's disease in children reviewed

The accurate staging of Hodgkin's disease is of greater importance in children than in adults, because the deleterious effects of extensive radiation therapy and of prolonged multiple-agent chemotherapy are of greater significance in this age group. The physician concerned with Hodgkin's disease in children must separate those aspects of developments in this field which are applicable to the pediatric age group from the relatively large adult experience. Isotope scanning is effective in demonstrating disseminated disease in pediatric patients. Lymphangiograms are useful, but are more difficult to perform and to interpret in children. When laparotomy is performed in children with clinical Stage I, II, or III Hodgkin's disease, stage will be altered (upward or downward) in approximately 40% of children subjected to the procedure. As growth retardation, skeletal deformity, and secondary neoplasia follow radiotherapy in children, the major function of the laparotomy is to delineate the extent of the disease and thus define appropriate limitations of therapy.

Lymphomas of Children: Lymphography and Diagnostic Laparotomy in the Planning of Treatment

104 cases of malignant lymphoma in children are considered and the value of lymphography and laparotomy for the purpose of correct staging is demonstrated. 83 patients underwent lymphography and 19 laparotomy. These investigations definitely resulted in significant changes in staging.