Staging of Hodgkin's disease: a surgical perspective

Individual risk of abdominal disease in patients with stages I and II supradiaphragmatic Hodgkin's disease. A rule index based on 341 laparotomized patients

A multivariate analysis of the prognostic factors for clinical Stages I and II supradiaphragmatic Hodgkin's disease was carried out with a logistic regression model in 341 patients. The proportion of patients with positive staging laparotomy was greater in males, in individuals with several sites involved, mixed cellularity (MC) or lymphocyte depletion (LD) histologic types, systemic symptoms, or in patients with lower cervical involvement and higher erythrocyte sedimentation rate (ESR), serum copper, and LDH levels. Histology, presence of systemic symptoms (fever and sweats), and number of involved nodal regions were independent predictors of positive laparotomy. Mediastinal involvement is correlated to a significantly lower risk of positive laparotomy. Based on these observations, the individual risk for each patient of occult abdominal disease has been defined.

Predicting the risk of abdominal disease in Hodgkin's lymphoma. A multifactorial analysis of staging laparotomy results in 255 patients

There were 425 consecutive patients treated for Hodgkin's disease at this Medical Center from 1943 to 1983. Of these, 255 patients underwent a staging laparotomy and had complete preoperative clinical records. Overall, 35% had a change in stage (24% were upstaged, 11% downstaged). Twenty-nine per cent of clinical stage I patients were upstaged; 31% of stage II patients were upstaged, while less than 1% were downstaged; and four per cent of stage III patients were upstaged while 44% were downstaged. The diagnostic laparotomy yielded involvement in the spleen in 71% of patients with abdominal involvement, in the periaortic lymph nodes in 41%, in the liver in 11%, and the bone marrow in seven per cent. Only 12% of the 135 patients with negative laparotomies subsequently relapsed in the abdomen after a mean follow-up of 4.8 years. A multifactorial analysis was performed to identify dominant factors predicting the risk for abdominal disease. The factors best predicting abdominal involvement in stage I and II patients were: antecedent symptoms (greater than or equal to 2, 1, 0; p less than 0.00001), histological type [nodular sclerosing (NS) less than lymphocyte-predominant (LP) less than mixed cellularity (MC) less than lymphocyte-depleted (LD); p = 0.0009], and sex (females less than males, p = 0.01). The clinical stage (I vs. II), the site of lymphoma presentation, and the age and race of the patient did not have significant predictive value for the risk of abdominal disease after the other factors were accounted for. A mathematical model was derived for identifying dominant prognostic factors for predicting the risk of abdominal disease in an individual patient setting. The lowest risk patients were asymptomatic females with NS histology (6%) or LP histology (8%), while the highest risk patients were men with multiple symptoms and either MC histology (85%) or LD histology (93%). This information can be useful in making clinical decisions in Hodgkin's lymphoma patients, especially those at an increased risk for surgery.

The staging of Hodgkin’s disease revisited

The conventional staging of Hodgkin's disease (HD) including lymphangiography and staging laparotomy with splenectomy is well-known and commonly utilized. However, recent data on new imaging modalities (e.g. ultrasound, computed tomographic scanning) and prognostic factors (e.g. size of the mediastinal mass, extent of splenic involvement, etc.) suggest that a more rational approach to staging based on treatment considerations is now possible. In addition, careful restaging of patients in apparent remission, including surgical evaluation in selected patients, is also important. In this paper, these new concepts of the staging of HD are reviewed.

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.

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.

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.

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.

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.

Staging laparotomy in Hodgkin's disease

Staging laparotomy was performed at the University of Virginia Medical Center on 111 patients with Hodgkin's disease. The operation included multiple liver and lymph node biopsies and, excepting three patients, splenectomy. The histopathology was reviewed and the 111 patients were classified as follows: nodular sclerosis, 74; mixed cellularity, 28; lymphocyte predominance, 7; and undetermined, 2. There were no deaths. Wound, pulmonary or urinary tract complications occurred in 11 patients. One case of postoperative thrombophlebitis occurred and in another case small bowel obstruction developed, and resolved without reoperation. The pathologic stage (PS) following laparotomy was unchanged from the clinical stage (CS) in 64%, reduced in 20%, and advanced in 16%. The therapy, however, was altered in 38% of the patients. Lymphangiography in 103 patients was interpreted as showing lymph node involvement in 38, equivocal involvement in 11, and no involvement in 54. Among the 92 examinations reported as either positive or negative, 77% were confirmed histopathologically, 21% were falsely positive, and 2% were falsely negative. The spleen was positive for Hodgkin's disease in 39% of cases, and in these patients with positive spleens there was no reason to suspect intra-abdominal involvement preoperatively in 21%.