Splenectomy in Hodgkin's Disease for splenomegaly, cytopenias and intolerance to myelosuppressive chemotherapy

Indicazioni e Risultati Preliminari Della Laparotomia Diagnostica Nei Vari Tipi di Linfoma Maligno

From September 1970 to November 1971 83 unselected patients with malignant lymphomas (48 with Hodgkin's disease, 12 with lymphosarcoma and 23 with reticulum cell sarcoma) underwent diagnostic laparotomy with splenectomy and liver, retroperitoneal and mesenteric node biopsies. 19/83 cases (mostly referred from other hospitals) had received either local radiotherapy or a course of chemotherapy. In 79/83 with stages I, II and III the laparotomy was carried out to better define the extent of involvement below the diaphragm before therapy. In 4 patients with stage IV reticulum cell sarcoma (gastrointestinal involvement) laparotomy was indicated either because of bleeding (3) or because of bowel obstruction (1). Before sugery patients underwent accurate clinical, hematological, biochemical and radiological evaluation including scintiscan of liver as well as hepatic biopsy with Menghini's needle (table 1). After laparotomy patients were stages according to Rye's classification. The spleen was not removed in 3 cases because of technical difficulties. The overall incidence of splenic involvement (table 2) was found to be almost identical in Hodgkin's disease (29.5 %) and in lymphoreticular sarcomas (28.5%). The spleen was histologically positive in a high percent age of both groups of cases with disease above and below the diaphragm, as well as with lymphocyte depletion (7/14) and with systemic symptoms (78 %) in Hodgkin's disease (table 3). The mean weight of the involved spleen was 346 g (95–1050), that of the uninvolved spleen was 189 g (75–500). The overall incidence of histologic involvement of liver was (18.4%), 6.2% in Hodgkin's disease and 17.4 % in the group of lymphoreticular sarcomas (table 4). There were no patients with liver involvement without concomitant spleen involvement. When the patients with positive lymphangiograms and/or palpable spleen (1–3 cm below the costal margin) are excluded, diagnostic laparotomy detected occult intra-abdominal lesions in 13/48 (27 %) cases with Hodgkin's disease and, respectively, 5/35 (14.3 %) cases with lymphoreticular sarcomas (table 5). The overall incidence of occult lesions was 21.8%. Histology correlated with lymphography in 64/83 (77%) cases (table 6). In 3/4 patients with negative lymphography histologically abnormal nodes were found above LII. In 8/10 patients with positive lymphography and negative histology (5 sampled in lymphographically non suspicious area and 3 around the celiac axis) the post-laparotomy films confirmed the persistence of abnormal nodes. This was indirectly proved by an almost immediate progression in the para aortic lymph nodes in 1 case and by a marked regression in 7 cases after chemotherapy and/or radiotherapy. Since laparotomy is not infallible in removing abnormal nodes one should rely on lymphographic findings in case of discrepancy to plan the appropriate therapy. Complications secondary to laparotomy were minimal and transient. The indications and advantages of this new useful procedure in all types of malignant lymphomas are discussed (table 7).

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.

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.

[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.

Long term follow-up of combination chemotherapy-radiotherapy of stage III Hodgkin's disease: a Cancer and Acute Leukemia Group B study

The Cancer and Acute Leukemia Group B studied the effect of combination chemotherapy-radiotherapy on Stage III Hodgkin's disease. Chemotherapy consisting of 4 weekly doses of vinblastine and one dose of mechlorethamine hydrochloride was followed by no therapy (CT), radiation to involved fields (CTIF) or total nodal radiation (CTTN). Two other treatment arms included total nodal radiation alone (TN) or total nodal radiation followed by chemotherapy (TNCT). Maximum follow-up is ten years. Complete remission percentages were 36 (8/22) for CT, 71 (17/24) for CTIF, 100 (21/21) for CTTN, 86 (19/22) for TNCT and 89 (16/18) for TN. Disease-free survival in patients receiving radiation +/- chemotherapy is 23% (19/73) at 5 years, but even after 9 years relapses were observed in two patients. Forty-one percent of all patients are alive and 32% have survived for five years. Ability to administer adequate therapy was the main determined for response duration and survival. Factors influencing the outcome of the disease include histology, age, splenectomy, initial white blood cell count and performance status, whereas symptomatology, initial absolute lymphocyte count and sex played no role on survival.

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.

Splenic infarction and spontaneous rupture of the spleen after therapeutic embolization

Patients with major hematologic disorders who have hypersplenism and alterations in their immune mechanism are subject to a higher incidence of bacteremia after embolization procedures. In certain instances, these infectious complications can be fatal. Medical splenectomy for hematologic disorders is sometimes complicated by massive splenic infarction and spontaneous rupture; spontaneous rupture appears to be a function of both infarct size and underlying infectious complications. Prophylactic measures can be employed to avoid these complications after interventional splenic embolization.

Splenectomy for massive splenomegaly

Removal of a massively enlarged spleen is a challenging surgical problem that is associated with higher death and complication rates than the removal of smaller spleens. Older age, serious and chronic primary diseases, and associated cardiopulmonary abnormalities contribute to the morbidity and mortality. Most patients with massive splenomegaly have been treated with corticosteroid and/or antineoplastic drugs, which impair wound healing, hemostatic function, and host resistance. Precise surgical technic is especially important in these cases because of the susceptibility to postoperative hemorrhage. Ligation of the splenic artery via the lesser peritoneal sac before mobilization of the spleen is associated with lower intraoperative transfusion requirements than when the spleen is mobilized before the splenic artery is ligated.

Effects of nitrogen mustard and splenectomy on mouse bone marrow colony formation in vitro

Improved tolerance of splenectomized patients with Hodgkin's disease (HD) to radiotherapy and chemotherapy has been reported. The present study was undertaken to determine the effects of splenectomy and nitrogen mustard (NM) on colony-forming cells (CFC's) of bone marrow cells obtained from CF1 male mice by in bitro agar-gel technique. Splenectomized mice were given NM intraperitoneally on day 11. On day 15, they were sacrificed and the bone marrow was cultured with a source of colony-stimulating factor (CSF). Spleen extract was prepared by grinding spleens from CF1 mice. On the eighth day of incubation, significantly higher numbers of CFC's were found in splenectomized animals at 1% confidence level (F Test) compared with the nonsplenectomized animals. Both splenectomized and non-splenectomized mice had a greater colony response after NM (at 5% confidence level) than saline-treated controls. Maximum numbers of colonies were obtained in the nustard-treated asplenic animals. Splenic extract, as well as extracts from other organs, when added to the culture plates resulted in inhibition of colony formation. The significance of in vitro inhibition after addition of organ extract is uncertain.

Management of Hodgkin's and non-Hodgkin's lymphomas

These diseases of the lymphoreticular system with neoplastic alteration of the involved tissues represent different entities and show marked variability in their clinical manifestations, pathologic behavior, prognosis, and response to treatment. New diagnostic, histopathologic, and therapeutic concepts in the past decade have led to significant advances in the care and management of these patients, particularly those with Hodgkin's disease.

Thrombocytopenic purpura as the sole manifestation of a recurrence of Hodgkin's disease

A man with apparently quiescent Hodgkin's disease presented with acute severe isolated thrombocytopenic purpura. Splenectomy revealed macroscopic involvement with Hodgkin's tissue and cured the thrombocytopenia.