Hodgkin's disease: problems of staging

Assessment of Liver and Spleen Involvement in Hodgkin's Disease

Prognosis and proper treatment in Hodgkin's disease (HD) are strictly related to staging accuracy: liver and spleen involvement is of particular importance in this regard. We have evaluated, in 113 consecutive patients, the accuracy of clinical parameters to detect histologically documented HD involvement by comparing hepatosplenomegaly, liver function tests, liver and spleen scan, inspection of liver and spleen surface at laparoscopy with histologic findings. Our data suggest that of all the parameters studied, laparoscopy has the highest sensitivity and specificity values (about 100 %). Laparoscopy may precede laparotomy as a staging procedure in HD and may give, in patients not submitted to laparotomy whatever the reasons, very reliable information.

Hodgkin's disease of the liver; prognosis and possible indications for radiotherapy

A retrospective analysis of 56 patients presenting with Hodgkin's disease involving the liver between 1970 and 1984 revealed a 10-year survival probability of 44%. The actuarial 10-year continuous progression free survival was 42%. Presentation variables predicting for relapse in the liver included hepatomegaly (P less than 0.025) or focal lesions on isotope, ultrasound or CT scan (P less than 0.01). These factors may define a context for investigation of adjuvant hepatic irradiation following chemotherapy.

Primary pulmonary Hodgkin's disease

Primary pulmonary Hodgkin's disease is a rare but distinct entity, to be distinguished from nodal Hodgkin's disease and from lymphomas involving the lung secondarily. Sixty-one cases have now been reported in the world's literature. This lymphoma affects women more frequently than men, and typically involves the superior portions of the lungs. Radiologically, it appears as a solitary mass or multinodular disease; inhomogeneity or cavitation of these lesions are common. Since the presentation of this disease is nonspecific, and as noninvasive tests are rarely revealing, diagnosis requires an open thoracotomy and lung biopsy. Factors which correlate with a poorer prognosis include "B" symptoms, bilateral disease, multilobe involvement, penetration of the pleura, and cavitation. The staging and treatment of these lymphomas according to the extent of pulmonary involvement are recommended, as radiotherapy or combination chemotherapy may be effective in appropriately selected patients.

The radiology of lymphoma

The development of new imaging techniques over recent years has improved the accuracy with which the extent of the disease can be demonstrated in patients with lymphoma. These methods either complement or replace existing conventional radiological methods such as plain films, bariums, intravenous urograms or lymphography. CT in particular, and to a lesser extent ultrasound and radionuclides, now plays an important part in helping the clinician to manage patients with lymphoma. It is impractical and unnecessary to use all available imaging studies. More than ever, close co-operation between the clinician and radiologist is essential to derive the maximum amount of information from the studies and to use the techniques effectively and appropriately. This chapter has reviewed the advantages and limitations of each imaging method, stressing the role of each in staging the lymphomas and in monitoring response to treatment. The common radiological appearances of the effects of lymphoma on each organ system have been described. The possible contribution that other techniques may make in the future has been discussed.

Abnormal coagulation results in patients with Hodgkin's disease

Case records of 177 patients admitted with Hodgkin's disease were reviewed to assess the frequency and significance of coagulation abnormalities. Prolongation of the prothrombin time, activated partial thromboplastin time, or thrombin time occurred in 56 patients, 32 percent of all evaluable cases. The most frequent clotting abnormalities involved the prothrombin time, which was increased in 43 patients (24 percent). Prothrombin time prolongation correlated with bulky or advanced disease as defined by stage (p = 0.001), constitutional symptoms (p less than 0.0001), massive mediastinal involvement (p = 0.02), and elevated alkaline phosphatase levels (p less than 0.0001). Abnormal coagulation test results followed the course of disease, normalizing with tumor regression and reappearing during relapse. Despite the surprising incidence of abnormal coagulation results, bleeding complications were reported in only two cases. Patients undergoing invasive procedures in the presence of clotting abnormalities fared no worse than those in whom procedures were cancelled. There is no evidence that complete staging evaluation should be comprised because of these abnormal test values. Extensive hematologic testing revealed no single mechanism to explain the coagulation factor disorders found in Hodgkin's disease.

A retrospective evaluation of mediastinal tomograms, isotope liver scans, and isotope bone scans in the staging and management of patients with lymphoma

The influence of mediastinal tomograms and isotope scans of liver and bone on the initial staging and management of patients with lymphoma has been studied. There appears to be only a small role for these investigative procedures, and it is suggested that considerable savings in time and money can be made by a more judicious use of these techniques.

Glioblastoma of the brainstem associated with Hodgkin lymphoma

This case of Hodgkin lymphoma associated with glioblastoma multiforme is, as far as we know, unique. The possible implications of this association and of HL associated in 3 known cases with meningioma are discussed.

Indications for and morbidity associated with operative staging in patients with lymphoma

Operative staging of patients with lymphoma has made an important contribution to the more accurate planning of treatment of this disease. Concomitant improvements in therapy have led to an increase in 5 year survival, particularly in patients with Hodgkin's disease. Nevertheless, considering risk versus benefit, several groups of patients might be spared increased morbidity from postoperative infection by restricting the operation to patients with stage I non-Hodgkin's lymphoma and to patients with Hodgkin's disease, stages I to III, without B symptoms. Groups having a greater risk of infection include all patients with non-Hodgkin's lymphoma and patients with Hodgkin's disease and B symptoms in whom operation is indicated. These exclusions from operative staging may not apply if accurate definition of the extent of disease is essential to evaluation of a new therapeutic program being assessed by a prospective randomized clinical trial.

Management of Hodgkin's disease in a patient with sickle cell anemia

A right periauricular swelling developed in a 21-year-old woman with sickle cell anemia. The mass was removed and revealed Hodgkin's disease of the lymphocyte predominance type. While preparing the patient for a staging laparotomy, an allo-anti-Kell and an allo-antic-C were identified in the patient's sera. The patient's direct antiglobulin test was positive and an auto-anti-e was eluted from the patient's erythrocytes. The patient was treated with nine courses of MOPP therapy given over a nine-month period. The clinical and therapeutic implications for the management of patients with sickle cell anemia and lymphoproliferative disorders are discussed.

Reassessment of prognostic factors in stage IIIA and IIIB Hodgkin's disease treated with MOPP and radiotherapy

Prognostic factors have been re-evaluated for 88 patients with Stage III Hodgkin's disease to see if they have remained significant on a long-term basis. Treatment had consisted of two cycles of MOPP followed by radiotherapy to the mantle, abdomen, and pelvis; all patients had achieved complete remission. Case material was grouped according to the presence of absence of mediastinal disease. Five-year survivals for Stage IIIA and IIIB patients were 85 and 80%; corresponding disease-free survivals were 76 and 73%. Significant prognostic factors include age, histopathology, and extent of abdominal disease, but the relative importance of these factors differs for the mediastinal and nonmediastinal patients. Modifications of current treatment policy for both mediastinal and nonmediastinal patients are discussed in relation to the prognostic factors.

Skeletal lesions in Hodgkin's disease. Review of literature and case reports

Skeletal lesions in Hodgkin's disease can be due to different underlying causes. Reports on bone changes in Hodgkin's disease are reviewed and compared with two of our patients. The first patient, a fourteen year old girl with Hodgkin's disease, staged IV B, had skeletal involvement at the time of diagnosis. The other patient developed, three and a half years after the onset of the disease, bone lesions which might have been thought to be a manifestation of Hodgkin's disease. But by bacteriologic and histologic studies salmonella osteomyelitis could be proven.

Arterial embolus as a complication of staging laparotomy

Staging laparotomy is widely utilized in the management of selected patients with Hodgkin disease. The local trauma produced by extensive en bloc periaortic node removal for detection of subdiaphragmatic disease may predispose the patient to arterial thromboembolic events. This procedure seems undesirable and unnecessary especially in patients known to have lymphocyte-depleted and mixed-cellularity-type disease or in those found to have splenic involvement by intraoperative sectioning. These patients will often have microscopic tumor in their random needle and wedge liver biopsies taken at surgery; extensive periaortic tissue sampling is therefore unnecessary. A further concern is that such patients are likely to receive postoperative steroid chemotherapy, which has been associated with a hypercoagulative state.

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.

Breast carcinoma: treatment failures in "early" and "late" disease

Review of 86 autopsied cases of disseminated breast carcinoma showed that the scatter in survival time and pattern of metastatic distribution was similar in those with and without node involvement at operation. There were tumour cells in the efferent vessels in 86% of cases with tumour-bearing nodes, this factor being thus associated with a "late" carcinoma, one in which latent metastatic spread was present at the time of operation. While one cannot distinguish between an "early" tumour confined to the breast, and a potential treatment failure in which tumour emboli may have passed the nodes without colonizing them, the present findings indicate that such a distinction may be real.

[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.