The role of splenectomy in the management of advanced Hodgkin's disease

Routine laboratory tests in relation to spleen size and tumour involvement in untreated Hodgkin's disease

A number of routine laboratory tests were studied in 39 untreated patients with Hodgkin's disease with respect to size and tumour involvement of the spleen. Eighteen patients with tumour-engaged spleens had lower total lymphocyte counts and IgG and IgM levels than patients with non-involved spleens. However, no significant differences in these respects were found between patients with tumour-involved spleens weighing less than 500 g and patients without splenic tumour involvement. Hemoglobin values were inversely and reticulocyte counts positively correlated with the weight of involved spleens. Remaining laboratory variables under study, e.g. total granulocyte counts, platelet counts, ESR and liver enzymes, were not associated with the size or tumour involvement of the spleen. It may be concluded that routine laboratory tests yield no specific information as to splenic tumour involvement or size.

On the size and tumor involvement of the spleen in Hodgkin's disease

Fifty-four untreated patients with Hodgkin's disease (HD) subjected to splenectomy were studied with respect to preoperatively assessed spleen size compared to postoperative findings. Before splenectomy, nine patients had "normal sized" spleens, 18 patients had spleens weighing greater than or equal to 200 g and 14/39 spleens were tumor-involved. Nine patients had "enlarged" but unpalpable spleens. Eight of these weighed greater than 200 g and 3/9 spleens showed tumor involvement. Six patients with preoperatively palpable spleens showed tumor involvement, their spleens weighed greater than 660 g. The results confirm the inaccuracy of non-invasive procedures in prediction of spleen size and tumor involvement in HD.

The potential benefits of therapeutic splenectomy for patients with Hodgkin's disease and non-Hodgkin's lymphomas

Thirty-four patients with Hodgkin's disease and non-Hodgkin's lymphoma underwent therapeutic splenectomies to improve hematologic tolerance for chemotherapy. The mean age was 40 years; there were 16 males and 18 females. Fourteen had Hodgkin's disease, 19 had non-Hodgkin's lymphoma, and 1 had malignant histiocytosis. Nineteen had palpable splenomegaly, 19 had marrow involvement and 20 had splenic involvement by lymphoma. The following data were analyzed before and after splenectomy: mean white blood cell count (WBC) and platelet count on planned first day of cycle, delay ratio of chemotherapy delivery and percent maximal dose rate. Thirteen patients had non-Hodgkin's lymphoma, splenomegaly and positive bone marrow and showed significant benefit in all of the aforementioned parameters. Of the patients with prior irradiation, only those who completed their radiation greater than six months prior to splenectomy showed benefit. Ten patients had Hodgkin's disease, negative bone marrow and no splenomegaly. This group showed significant improvement in mean platelet count but more limited benefit in delay ratio and percent maximal dose rate. Thus, selected patients with lymphoma who are experiencing delays in chemotherapy because of poor count tolerance may benefit from splenectomy.

The liver in Hodgkin's disease--II. Histopathologic findings

Histopathologic findings in 459 liver biopsies performed in 308 patients with Hodgkin's disease were reviewed. Typical Hodgkin infiltrates were found in only 11/459 biopsies (2.4%) and infiltrates suspect for Hodgkin's disease in only 8/459 (1.7%), whereas unspecific changes were more common. Lymphocytic infiltration was seen in 47% of the biopsies and focal necrosis in 19%. No correlation could be demonstrated between unspecific changes and clinical characteristics, including prognosis.

Splenectomy for hypersplenism in malignant lymphomas

Splenectomy has been performed in advanced malignant lymphomas in an effect to correct haematological cytopaenias in 41 patients since 1975. In both Hodgkin's disease and a variety of non-Hodgkin's lymphomas the operation has been associated with a high percentage of haematological correction (90 per cent overall). In many of these patients the haematological defect had prevented or led to the cessation of treatment and in those cases where chemotherapy was resumed after splenectomy worthwhile remission was achieved in 87.5 per cent of patients. There was no postoperative deaths and morbidity was considered acceptably low. We conclude that splenectomy is a valuable adjunct to treatment in advanced malignant lymphomas and should be considered at the first suggestion of splenic overactivity and reduced bone marrow reserves.

Clinical studies on the correlation between immunologic status and total gastrectomy combined with splenectomy

The influence of splenectomy on the immunologic status of stomach cancer patients was studied. Eight gastric cancer patients having undergone total gastrectomy combined with splenectomy were evaluated immunologically. Peripheral lymphocyte counts were depressed and continued to be so in splenectomized patients. PHA-induced lymphocyte blastogenesis decreased rapidly after total gastrectomy with splenectomy and thereafter increased gradually. PHA skin test seemed to take almost the same time course. These recoveries to the normal range were observed 4 weeks after operation. In 10 other patients who had undergone total gastrectomy with splenectomy for gastric cancer and had been recurrence-free for more than 6 months, peripheral lymphocyte and T lymphocyte counts significantly increased compared with 7 cases having undergone total gastrectomy only, though no difference was seen in both PHA skin test and PHA-induced lymphocyte blastogenesis between the 2 groups.

[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.

Clinical and surgical staging of Hodgkin's disease

Staging laparotomy was performed in 36 patients with Hodgkin's disease. The surgical procedure changed the stage in 14 cases or 36% and also revealed subdiaphragmatic disease in 14 patients. Mixed cellularity and nodular sclerosis were the main histopathological types, contributing 44% and 42%, respectively, of the whole material. Postoperative complications occurred in 8 cases (22%)--none was fatal. The average hospital stay was 9.5 days, the longest being 22 days.

The Value and Present Indications of Staging Laparotomy in Hodgkin's Disease

From December 1971 to December 1976 224 patients with Hodgkin's disease underwent diagnostic laparotomy and splenectomy under a multidisciplinary protocol of treatment. In 149/224 (66.5%) the clinical stage of the disease was confirmed, whereas in 75/224 (33.5%) it was modified after surgery. In 7.6% of the patients (17/224) there were postoperative complications. One patient died of myocardial infarction. The rate of complications in the last 100 cases was 5%. Preoperative patient selection, excluding those definitely in stage IV, is of relevance, and it can be done by iliac crest biopsy and laparoscopy. Although a better exploitation of some diagnostic procedures (lymphangiography, laparoscopy) and the expanding use of chemotherapy may reduce in the future the need for staging laparotomy and splenectomy, diagnostic laparotomy is still indicated for the selection and preparation of patients for radiation therapy in stages I, II and III.

Tissue diagnosis in lymphomas

An accurate histological diagnosis is sometimes difficult to achieve in the lymphoma patient. This problem is accentuated by incorrect choice of noded for biopsy or mishandling of tissues, either at surgery or during the fixative process. Practical guidelines are suggested to help minimize these problems.

Siderosis of lymph nodes patients with Hodgkin's disease

Lymph nodes removed from 28 untreated patients with Hodgkin's disease all contained markedly increased amounts of hemosiderine, whether or not they were histologically involved in the disease. This finding was particularly striking in patients with the nodular sclerosis type of disease. Abnormal deposits of iron were also noted frequently in lymph nodes containing metastatic carcinoma, lymphoma of non-Hodgkin's type, and reactive hyperplasia, but in each case, with the exception of metastatic squamous cell carcinoma, the amount was significantly less than seen in Hodgkin's disease. The findings suggest that in patients with Hodgkin's disease and perhaps in those with other disorders in which abnormal tissue retention of iron underlies sideropenic anemia, lymph nodes are an important site of iron retention.