Tonsillectomy and Hodgkin's disease: the lymphoid tissue barrier

Cancer risk following surgical removal of tonsils and adenoids - a population-based, sibling-controlled cohort study in Sweden

BACKGROUND

Removal of tonsils and adenoids is among the most common surgical procedures worldwide. Evidence of increased risk of cancer following such surgery is, however, inconclusive.

METHODS

We conducted a population-based, sibling-controlled cohort study of 4,953,583 individuals in Sweden with a follow-up during 1980-2016. History of tonsillectomy, adenotonsillectomy, and adenoidectomy was identified from the Swedish Patient Register whereas incident cases of cancer during follow-up were identified from the Swedish Cancer Register. We used Cox models to calculate hazard ratios (HR) with 95% confidence intervals (CI) of cancer in both a population and a sibling comparison. The sibling comparison was used to assess the potential impact of familial confounding, due to shared genetic or non-genetic factors within a family.

RESULTS

We found a modestly increased risk for any cancer following tonsillectomy, adenoidectomy, or adenotonsillectomy in both the population (HR 1.10; 95%CI 1.07-1.12) and sibling (HR 1.15; 95%CI 1.10-1.20) comparisons. The association did not differ greatly by type of surgery, age at surgery, or potential indication for surgery, and persisted more than two decades after surgery. An excess risk was consistently observed for cancer of the breast, prostate, thyroid, and for lymphoma in both population and sibling comparisons. A positive association was observed for pancreatic cancer, kidney cancer, and leukemia in the population comparison whereas a positive association was observed for esophageal cancer in the sibling comparison.

CONCLUSIONS

Surgical removal of tonsils and adenoids is associated with a modestly increased risk of cancer during the decades following the surgery. The association is unlikely attributed to confounding due to shared genetic or non-genetic factors with a family.

Tonsillectomy and the incidence of various types of cancer

A potential connection between tonsillectomy and the development of various cancer types has repeatedly been reported in the scientific literature, but many studies have contradicted these observations. Thus, we have no clear evidence, neither to firmly support nor to refute the above-mentioned connection. Here, I suggest that the main reason for the lack of clearer evidence is that the investigations have so far mainly used incorrect sample groups. I propose that individual differences in the tonsils' involvement in immune reactions should be taken into account to solve this long-standing puzzle.

Tonsillitis, tonsillectomy and Hodgkin's lymphoma

It has been debated whether the reported increased risk of Hodgkin's lymphoma (HL) after tonsillectomy could be due to some underlying factor rather than the surgery itself. We studied whether not only tonsillectomy but also tonsillitis was associated with HL. This nationwide cohort study included all Danish residents during 1977-2001. Information on a diagnosis of tonsillitis, tonsillectomy, or HL was obtained from national registries. During 124 million person-years we observed 2,988 HL patients of whom 58 were tonsillectomized (most with preceding tonsillitis) and 14 were diagnosed with only tonsillitis at more than 1 year before HL diagnosis. Tonsillectomy was associated with a significantly increased HL risk in persons under 15 years of age as follows: 1-4 years after tonsillectomy, relative risk (RR) = 3.9 [95% CI: 1.4-11; n = 4]; >5 years after tonsillectomy, RR = 3.5 [1.4-8.5; n = 5]. No young cases of HL occurred among persons diagnosed with only tonsillitis. In contrast, 1-4 years after a hospital diagnosis of tonsillitis without subsequent tonsillectomy we found an increased HL risk in persons aged 15 years or above as follows: 15-34 years of age at HL diagnosis, RR = 3.5 [1.6-7.7; n = 6]; 35+ years, RR = 5.9 [2.2-16; n = 4]. Age at tonsillitis or tonsillectomy did not modify HL risk within the 3 age strata. An increased HL risk was found both after tonsillectomy and after an isolated diagnosis of tonsillitis. These results suggest that tonsillitis is a risk factor for HL and not that, as previously reported, only the surgical removal of tonsils is a risk factor.

[Tonsillectomy in 2005]

During the past years, the number of tonsillectomies (only palatine tonsils are taken off) has decreased, indications for surgery have changed. A multi-disciplinal group of paediatricians tried to elaborate the state of the art in the field. Tonsils are the first line defense of high respiratory tract. The immune functions of their lymphoid tissue are multiple: mucosal antigens capture, presentation to lymphocytes, antigens specific proliferation of lymphocytes T and B, differentiation of lymphocytes in effectors lymphocytes and immune lymphocytes. Epithelial cells on the tonsils' surface express non-specific defense. These facts explain partly tonsils' hypertrophy. Tonsillectomy has no general immune consequences. In 2002, in France, 75,000 tonsillectomies were realized, of which 90% were in children. Tonsil's hypertrophy is the major indication, mandatory when sleep apnoeas exist. The main historical tonsillectomy indication for recurrent tonsillitis should decrease due to a more precise diagnostic (rapid test at bed site), an efficient antibiotics therapy and better care for pain. Other indications are scarce. Surgery, feasible from 9 months of age, requires a brief general anaesthesia and has very few contra-indications. The technique, operator dependent, relies on his experience. The only potentially severe complication is an haemorrhage due to scab fall between the eighth and twelfth days. It requires explanation and a written note given to parents. The possibility of lack of feeding and voice modification, usually transitory, should be known. Multiple consequences of tonsillectomy especially allergy have been alleged. Since the years 1980, it is well established that pre-existing allergy or asthma are not a contraindication. More, its deleterious impact on allergic children has not been demonstrated. Last, a gain of weight post-tonsillectomy is possible and could become a risk if excessive.

Complications of tonsillectomy and adenoidectomy

Adenotonsillectomy is generally safe surgery, but surgeons should be cognizant of potential complications and be prepared to manage them. Postoperative hemorrhage usually responds to local measures or cautery but can be life-threatening. Preoperative screening of coagulation profiles appears unnecessary. Anesthetic risks have declined with modern techniques, but airway risks, aspiration, and pulmonary edema are possible. Nasopharyngeal valving may be altered by velopharyngeal incompetence or nasopharyngeal stenosis. Sore throat, otalgia, fever, dehydration, and uvular edema are more common postoperative complaints. Less common complications include atlantoaxial subluxation, mandible condyle fracture, infection, eustachian tube injury, and psychological trauma. The prevalence, management, and strategies for avoidance of these are discussed.

Risk of Hodgkin's disease subsequent to tonsillectomy: a population-based cohort study in Sweden

Although some studies have linked excess of Hodgkin's disease (HD) to tonsillectomy, the findings have not been consistent. In particular, risk of HD by age at tonsillectomy has not been fully evaluated, despite the notable change in immunologic function of the tonsils between childhood and adulthood. To evaluate the risk of HD and other lymphomas, associated with tonsillectomy according to age at surgery, a population-based cohort study was conducted. Using nationwide Swedish hospitalization records, 55,169 patients undergoing tonsillectomy with/without adenoidectomy (T/A) were identified during the period 1964-1983. By linkage with the nationwide Total Population, Migration, Cancer and Causes-of-Death registries, these patients were followed up for as long as 25 years. After exclusion of the first post-operative year, a total of 533 first primary-cancer cases was identified between 1965 and 1989. Small excess risk was observed for HD (20 cases, SIR = 1.4, 95% CI 0.9-2.2). HD risk was more pronounced among patients tonsillectomized before age 12 (7 observed vs. 1.7 expected, SIR = 4.1, 95% CI 1.6-8.4), but declined significantly with older ages at T/A. While our data suggest a small increase in HD among all patients undergoing T/A and a significant excess for those under age 12 at surgery, we cannot exclude the possibility that the excess may be due to factors underlying the disorders that led to surgery.

Epstein-Barr virus in pediatric Hodgkin disease: age and histiotype are more predictive than geographic region

Epidemiologic studies have implicated Epstein-Barr virus (EBV) in the great majority (80%-100%) of Hodgkin disease (HD) cases in South American countries, versus only 30%-40% in the United States and other industrialized countries. Other EBV-related malignancies are known to be geographically localized, including nasopharyngeal carcinoma in south China and Burkitt lymphoma in equatorial Africa. Some studies, however, have suggested that age and histiotype, rather than geographic region, are the major determinants of the association between EBV and HD. To further characterize this relationship in children, we matched 26 cases of pediatric Hodgkin disease from south Brazil and 26 cases from the U.S.-forhistiotype and age. The Brazilian children (22 males, 4 females) had a median age of 9 years, while the median age of the U.S. group (11 males, 15 females) was 7.5 years. Formalin-fixed, paraffin-embedded biopsy material was examined for EBV early RNA1 (EBER1) expression by in situ hybridization. This antigen was detected solely in Reed-Sternberg cells or their variants in positive samples. The same proportion of cases was positive (15/26 or 58%) in both groups of children. After adjustment for histiotype and age, the association between EBV and HD remained independent of geographic location, but was more frequent in children aged < or = 10 years at diagnosis. These findings support the multiple-etiology hypothesis for Hodgkin disease.

Serum immunoglobulin E levels in children with chronic tonsillitis

Serum immunoglobulin E (IgE) levels were estimated by ELISA in 50 children with chronic tonsillitis before and after tonsillectomy. When compared with the control group, mean serum IgE concentration was found to be significantly higher in children with chronic tonsillitis (P less than 0.001). After tonsillectomy the levels returned to normal.

The role of nasopharyngeal lymphoid tissue

Nasal-associated lymphoid tissue (NALT), which comprises paired lymphoid organs in the nasopharynx of rodents, is the principal mucosal lymphoid tissue of the respiratory tract. As described in this review, NALT bears certain similarities to the Peyer's patches of the intestine but the two differ remarkably in morphology, lymphoid migration patterns and the binding properties of their high endothelial venules (HEV).

Hodgkin's disease in adults: association with social factors and age at tonsillectomy. A case-control study

The relationship between socio-economic characteristics, previous tonsillectomy, family history of cancer and risk of Hodgkin's disease (HD) was investigated in a case-control study. One hundred and sixty patients, aged 15-78, with histologically confirmed HD, and 185 hospital controls were interviewed. A statistically significant decrease in risk of HD was observed among subjects with large sibship size (RR = 0.63, C.I. 0.46-0.86) and among those who underwent tonsillectomy prior to the age of 10 (RR = 0.46, C.I. 0.22-0.94). High educational level was associated with an increased risk of HD (RR = 6.68, C.I. I.94-23.08). Analysis by age-group (15-39 yrs and 40 yrs or more) confirmed the role of high educational level as a risk factor in both young and old subjects, while the protective effect of tonsillectomy at an early age seems to be confined to young subjects. Analysis by histological subtype showed a statistically significant decrease in risk of HD in large sibship size for both nodular sclerosis (NS) and mixed-cell subtypes; the role of education and tonsillectomy was observed only for NS. These data confirm the role of social factors in HD risk and suggest a protective effect of tonsillectomy performed early in life that needs to be confirmed in larger population-based studies.

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.

Viral etiology of testicular tumors

Testicular carcinoma and Hodgkin's disease are among the most frequent malignancies afflicting young men in the 15 to 39-year age group. These malignancies share other epidemiological characteristics as well, including multiple histological tumor types, higher rates of occurrence in white, urbanized populations and upper social classes, relative infrequency among black populations, low but definite familial occurrence and an early geographically acquired lifetime risk irrespective of later migration. Both diseases are increasing in this country. This epidemiological similarity suggests exposure to an infectious agent early in life. The Epstein-Barr virus is known to be oncogenic and neonatal exposure with early infection is believed to be associated with Burkitt's lymphoma in African children. High titers of antibodies to the Epstein-Barr virus capsid antigen also have been reported in a series of studies comparing patients with Hodgkin's disease and controls. Because testicular cancer is epidemiologically similar to Hodgkin's disease and, therefore, might be expected to manifest similar Epstein-Barr virus findings, we performed a viral screen (Epstein-Barr virus, cytomegalovirus, and hepatitis A and B viruses) on blood samples from 56 consecutive patients with clinical stage I germ cell tumors of the testis who had received no active therapy after orchiectomy. Our results show a high incidence (80 per cent) of previous exposure to Epstein-Barr virus and support the hypothesis of a possible infectious origin for testicular carcinoma.

Acquired disorders affecting the immune system and non-Hodgkin's lymphoma

A case-control study was undertaken to determine whether a prior history of a variety of acquired disorders affecting the immune system was associated with an increased risk of non-Hodgkin's lymphoma. Cases were identified over a 4-year period (1976-1979) at the Johns Hopkins Hospital and individually matched to hospital controls on age, sex, race, and year of diagnosis. For the 109 cases and matched controls who were traced and interviewed, positive associations suggesting an increase in risk were not detected. Instead, there was a suggestion of an inverse relationship. Odds ratios (ORs) were consistently less than 1 for associations between non-Hodgkin's lymphoma and several chronic infectious diseases (OR = 0.65, 95% CI = 0.35, 1.20), chronic inflammatory diseases (OR = 0.88, 95% CI = 0.43, 1.79), autoimmune disorders (OR = 0.80, 95% CI = 0.19, 3.76), and allergic disorders (OR = 0.77, 95% CI = 0.45, 1.32). A statistically significant protective association was found for surgical removal of lymphoid tissue (OR = 0.50, 95% CI = 0.27, 0.91). Adjustment for potentially confounding variables did not change these results. These findings do not support the previously anecdotally reported impression that disorders producing a chronic antigenic stimulus are associated with the development of non-Hodgkin's lymphoma.

Epidemiologic comparison of cancer of the testis and Hodgkin's disease among young males

In 1970 the epidemiologic similarities between Hodgkin's disease and multiple sclerosis were first described, suggesting that a common agent or agents might be involved in their etiology. The hypothesis proposed at that time was that the agents followed the paralytic polio model: widespread infection with an agent of low pathogenicity at an early age, resulting in acquired immunity in later life. Lack of early infection results in the disease appearing in adulthood, with severe repercussions. This article extends the paralytic polio model to include testicular carcinoma, since the epidemiologic similarities between it and Hodgkin's disease are striking. Specifically, the authors compare age at clinical onset, histologic type, time trends, race, socioeconomic status, geographic variation, occupation, and familial aggregation. It is suggested that the possibility of common etiologies involved in the pathogenesis of these two cancers be tested further by epidemiologic, clinical, or laboratory studies.

Hodgkin's disease presenting with rectal symptoms in a homosexual male. A case report and review of the literature

A 33-year-old homosexual man presented with complaints of rectal discharge and tenesmus. There was no evidence of organomegaly or lymphadenopathy. Biopsy of a rectal mass revealed Hodgkin's disease. The literature of rectal Hodgkin's disease is reviewed, and the possible relationship of this unusual case to the recent outbreak of other unusual malignancies in homosexual males is discussed.

Unilateral tonsillectomy--indications and results

Seventy-six cases of unilateral tonsillectomy performed over the last 20 years are reported. The average age was 3.75 years. Fifty per cent had adenoidectomy. A review of their case notes and of 54 questionnaires returned by parents, asking their opinion of the change in symptoms before operation and two years after operation, showed that they could be allotted into three groups: Group 1 35 cases (65 per cent) had dramatic improvement in the symptoms of allergy, colds, otitis, sore throats, eating, meat eating and sleep. Group 2 of nine cases (17 per cent) had considerable improvement in most symptoms. Group 3 of 10 cases (18 per cent) had minimal improvement. Post-tonsillectomy hypertrophy of the remaining tonsil occurred within two to four years in nine cases, necessitating removal. Four (11 per cent) in Group 1, (22 per cent) in Group 2, and three (30 per cent) in Group 3. The three secondary tonsillectomies in Group 3 gave good results in two cases. In five cases the other tonsil was removed six to 15 years later. This series of cases has demonstrated that a tremendous decrease in incidence of throat and upper respiratory tract infection in young children, apparently prone to infection can occur in over 80 per cent of cases following unilateral tonsillectomy, in spite of the continued presence of the remaining large tonsil.(ABSTRACT TRUNCATED AT 250 WORDS)

Tonsillectomy: A Prognostic Factor in Hodgkin's Disease?

The clinical features and course of Hodgkin's disease (HD) were investigated in 160 previously tonsillectomized patients and compared with 375 nontonsillectomized ones. In both groups, sex, social class, histologic type, stage and symptoms were almost identically distributed. Tonsillectomized patients showed a higher incidence of initial cervical forms (p < 0.05) and more frequently developed the disease under 35 years of age (p < 0.001), thus also reflecting the different policies of the otolaryngologists in the past few decades. Moreover, the tonsillectomized patients enjoyed a significantly better survival (p ≈ 0.01) than the nontonsillectomized ones. Adjusted survival curves for age and site of initial involvement proved that the favorable prognostic value of tonsillectomy was not due to the altered distribution of these 2 factors in the 2 groups; in addition, an earlier diagnosis in tonsillectomized patients could be excluded. The favorable effect of tonsillectomy in HD patients might be related specifically to the reduced portion of immunologically reacting oropharyngeal lymphoid tissue remaining after tonsillectomy. A decreased output of the specific immune-complexes, which are responsible for the disease, according to Vianna's theory, might be hypothesized in tonsillectomized patients.

A procedure for investigating cancer cluster reports

Cancer clusters are described as epidemiologic leads to environmental determinants of cancer. A historical perspective of cancer cluster reports is offered with comments on the various investigative methods. A specific, systematic protocol for responding to cancer cluster reports is offered with a detailed example. Suggestions for decision making and comments on statistical analysis are also offered. Emphasis is placed on the participant interview and on the use of non-case data.

Tonsils and adenoids: why the dilemma?

Enlarged tonsils and adenoids have been implicated in dentofacial development and in the developing facial configuration. The growth pattern and the role of these lymphoid tissues are controversial, as are the benefits to be gained by their surgical removel. The diagnosis of enlarged tonsils and adenoids and of mouth breathing is not based on well-defined criteria.

Serum immunoglobulins in patients with chronic tonsillitis

In this work, the serum immunoglobulin (IgG, IgA, IgM and IgD) levels were determined in ten patients with chronic tonsillitis. The serum immunoglobulins were estimated before and two months after tonsillectomy, using the radial immuno-diffusion method. Ten normal individuals with intact tonsils were chosen as a control group. The patients had elevated serum levels of IgG and IgA. These high levels may be due to repeated antigenic stimulation. The IgM and IgD were not significantly higher than in the normal controls. The serum IgG level did decrease significantly following tonsillectomy; the other three immunoglobulins were reduced, but insignificantly. The fall in immunoglobulins may be due to a reduction in the antigenic load, to the removal of immunoglobulin-producing tissue, or to alteration in the oropharyngeal pathogenic bacteria. Tonsillectomy does not seem to compromise immunological integrity or the immunoglobulin-producting apparatus. Estimations of the serum immunoglobulin, or simply of IgA, may help us to select those candidates for adeno-tonsillectomy who will have a good prognosis, or at least to exclude those with an underlying sub-clinical immunodeficiency disease.

Carcinoma of the larynx in an 11-year-old boy with late cervical metastasis: report of a case with a ten-year follow-up

An 11-year-old boy with laryngeal carcinoma underwent a partial laryngectomy. Subsequently, a cervical metastatic node developed eight months following a tonsillectomy; a radical neck dissection was performed. The patient has remained free of disease over a ten-year follow-up period. In our review of the English literature, no similar case report was found. The potential relationship of tonsillectomy to alterations in local T cell-mediated immune response is discussed.

Tonsillectomy and autoantibodies in patients with habitual tonsillitis

Tonsillectomy is virtually a routine operation now for ENT surgeons, but its immunological evaluation is still obscure. We have carried out an investigation in 57 patients who visited our clinic, with reference to autoantibodies by the immunofluorescence technique. We found autoantibodies at a higher frequency after tonsillectomy than before tonsillectomy in the young age group. There are studies that report close correlation of autoantibodies and malignancy. Since there are few reports that mention the relationship of the presence of autoantibodies and tonsillectomy, we have emphasized here careful follow-up of the patients from this standpoint.

T and B lymphocyte rosettes in tonsils of atopic and non-atopic children

This investigation was carried out to determine the immunological function of the human tonsils, especially the role of lymphocytes of atopic and non-atopic children. An E- and EAC-rosette forming technique is introduced, with semiquantitative evaluation of T and B lymphocytes in the peripheral blood of 56 normal subjects, 28 atopic and 5 non-atopic children of both sexes and different ages. The percentage of T and B lymphocytes in removed palatine tonsils in 28 atopic and 5 non-atopic children was calculated. The percentage of rosette-forming cells in E and EAC suspensions appeared to be independent of age and sex. The percentage of T lymphocytes in peripheral blood was significantly higher than in the palatine tonsils, whereas the percentage of B lymphocytes was significantly higher in the tonsils of atopic and non-atopic children than in the peripheral blood. The mean percentage of B lymphocytes in the tonsils of atopic children was significantly higher than in non-atopic children. The percentage of B lymphocytes was found to be significantly higher in hypertrophic than in small tonsils. Also, in the tonsils with adhesions there was a statistically significantly higher percentage of EAC rosettes than in the tonsils free of adhesions. The percentage of T lymphocytes was statistically significantly higher in the small tonsils.

Tonsillectomy and immune responses

Immune response were examined in 10-year-old boys just before and one month after tonsillectomy, and in young male adults tonsillectomized 10 years earlier. All the parameters studied were found to be quite normal.

A note on the so-called Lennert's lymphoma (lympho epithelioid cellular lymphoma) concerning its disease entity

Two cases of so-called Lennert's lymphoma, which is characterized by massive infiltrations of focally aggregated epithelioid cells, are presented. Since this lesion was particularly emphasized by LENNERT and MESTDAGH in 1968, the major conflicting issue has been focussed on its precise disease entity whether this is an independent or already-established lymphoproliferative disorder. Based on our experiences, we are rather inclined to regard this lesion to be "a curious histologic variant of an already-established disease entity". In order to investigate its precise disease entity and also in view of a possible significance of the presence of epithelioid histiocytes in the lymph nodes and of tonsillar involvement in relation to immunocompetence of the patients, further accumulation of similar cases is required.

Epidemiology of hodgkin's disease in the young

Many features of Hodgkin's disease (HD) among adolescents and young adults suggest that it has an infectious etiology. However, the proposal that HD is a contagious disease which can be transmitted by patients or their close contacts has not been substantiated. An alternative infectious disease model is suggested by analogy with paralytic poliomyelitis (PP). For both diseases, the peak age of incidence is delayed as living conditions improve. For both, increased risk is associated with higher social class and small family size. Like PP, HD may be a rare manifestation of a common infection with the probability of disease development increasing as age at infection is delayed. This analogy is supported by the report that the risk of HD is higher for persons who had a low frequency of childhood infectious diseases. If this model is valid, HD patients represent no hazard to their contacts. However, the incidence of HD among young adults may increase in the coming decade because of the current high standard of living and small family size.

A study of serum IgA levels in children undergoing tonsillectomy

Earlier work has suggested that up to 25% of children undergoing tonsillectomy because of recurrent sore throats are relatively deficient in IgA immunoglobulin and that they do less well after the operation than 'normal' children. Measurements of serum immunoglobulin levels were carried out in 96 children undergoing tonsillectomy for recurrent sore throats. Levels of IgA, IgM and IgG were found to be similar to those in healthy children, 7-29% of those studied had 'low' IgA serum levels. There was a significant relationship between serum IgA levels and the age of the child. No relationship could be established between IgA levels and pre- or postoperative clinicaal state of the children. Low IgA serum levels are probably the result of delayed immunological maturation rather than a true immunodeficient state. IgA estimations, therefore, have no bearing on selection for operation or the prognosis after operation.

A small cluster of Hodgkin's disease

Nine cases of Hodgkin's disease and one of acute lymphoblastic leukaemia occurred in 1972-5 in an area of less than 1 km. Clinical, social, and drug histories provided no relevant information, and definite patient-to-patient contacts before the onset of disease were not established. There was a higher incidence of malignant neoplasms in first-degree relatives of the patients than in those of a small control group living in the same area. There was no apparent reason for this cluster of cases, but geographical, climatic, and entomological studies are being carried out.

Basic concepts in Hodgkin disease

The following is an example of a typical case of Hodgkin's disease, which illustrates the use of clinical and pathologic staging procedures. A 40-year-old man had fever and swelling of the left side of the neck for two weeks. Physical examination showed enlargement of the left supraclavicular and left axillary lymph nodes but no hepatosplenomegaly. Biopsy of the affected lymph nodes showed Hodgkin's disease, mixed cellularity type. A chest roentgenogram, lymphangiogram. 67Ga scan, and results of bone marrow biopsy of the right iliac crest were normal. The clinical stage was classified as IIB2. (Subscript 2 indicates the number of regions of lymph node involvement. The patient subsequently underwent laparotomy. The spleen weighed 150 gm and contained microfoci of Hodgkin disease. Biopsy of an upper para-aortic lymph node at the L-1 showed involvement by Hodgkin disease, but specimens from either lobe of the liver, lower para-aortic and iliac lymph nodes, and left iliac crest did not. The pathologic stage was therefore classified as IIIN+H-S+M- Polychemotherapy was prescribed.

Hodgkin's Disease, tonsillectomy and family size

The association of tonsillectomy and Hodgkin's disease was investigated by comparison of 136 young adult patients with their 315 siblings and 78 spouses. On the basis of a case-spouse comparison, the risk ratio of Hodgkin's disease among tonsillectomized persons was 3.1 (1.5 to 7.7, 95 per cent confidence limits); on the basis of a case-sibling comparison it was 1.4 (0.8-2.6). The case-sibling analysis was repeated according to sibship size, and increased risk of disease was associated with tonsillectomy only within the 37 sibships of size two. A similar variation of risk ratio with sibship size was found in data from a prior study. The range of the association implies that the relation beteeen tonsillectomy and Hodgkin's disease either is noncausal or is complex and modified by family size. Risk of Hodgkin's disease was found to increase as a sibship size decreased, suggesting that a cause of Hodgkin's disease is correlated with childhood social class.