Surgical staging of abdominal involvement in unselected patients with Hodgkin's disease

Diagnostic Cell Pathology in Lymph Nodes Diseases

The investigation is based on the cytological findings in imprints, stained by the modified Papanicolaou E.A. 50 method, of 190 lymph nodes, of which 10 were normal 60 with benign diseases, 58 with malignant lymphomas and 62 with metastases. The cytological data were controlled by and correlated with histological sections. Touch preparations of lymph nodes do not present technical difficulties, are rapidly prepared and are always satisfactory. Cytological details are much better preserved and more recognizable than in histological sections but little information on lymph node organization is yielded. Imprints do not replace tissue diagnoses or even frozen sections, but under certain circumstances they may supply sufficient data for immediate diagnostic purposes, such as findings of metastatic malignant tumor cells or of Reed-Sternberg cells and their variants in lymph nodes during laparatomy for the staging of Hodgkin's disease. In addition to their supplementary diagnostic as well as teaching value, touch preparations allow minute caryological observations in malignant lymphomas. Peculiar basic nuclear structures in both well and poorly differentiated lymphocytic lymphomas and two different nuclear types in histiocytic lymphoma are described. The variations and frequency of several cell types (reticulum cells, lymphocytes, histiocytes, Reed-Sternberg and lacunar cells) in Hodgkin's disease are described and correlated with the histologic type.

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).

Role of Computed Tomography in Staging and Management of Gastrointestinal Lymphoma

Twenty-six computed tomography (CT) examinations in 18patients with histologically proven gastrointestinal lymphomas are reported. Fourteen CT examinations were performed at the time of initial presentation, the others being performed during the course of the disease. CT did not help in the diagnosis of the disease but it is effective in assessing the extent and thus the stage of the disease. A normal CT scan during follow up is associated with good prognosis. CT may be of help in planning treatment, especially radiotherapy. It is an investigation easily tolerated by patients and can be used in circumstances where other investigations would be impossible.

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.

Contiguous pattern spreading in patients with Hodgkin's disease

BACKGROUND

In 1966, Rosenberg and Kaplan hypothesized that Hodgkin's disease (HD) arises at a discrete primary site and subsequently spreads in a predictable manner via functionally contiguous lymph nodes. However, their results were not statistically evident. It was our aim to describe the spreading in the lymphatic system more precisely and to confirm their postulate.

METHODS

Between 1971 and 1992, 297 patients underwent pathological staging for HD. Our subsequent evaluation was restricted to the 236 cases with cervical involvement (65 bilateral, 80 dextral and 91 sinistral), those with lymph nodes on the right side (65 + 80 = 145) being analyzed separately from those with tumours on the left (65 + 91 = 156). Spreading via the lymphatic system was assessed by scoring of the number of involved and uninvolved nodes in six regions, which are functionally contiguous in the lymph system but not necessarily anatomically neighboured. The number of 'gaps' (i.e. missed nodes) observed according to a systematic spreading model was compared with that expected (probability model) if a random course had been followed.

RESULTS

Of the 156 patients with left cervical HD, 117 (75%) had para-aortic or spleen involvement, 90 (58%) had mediastinal involvement, 65 (42%) had right cervical involvement, 50 (32%) had axillary involvement and 23 (15%) had inguinal involvement. Of the 145 patients with right cervical HD, 112 (77%) had mediastinal involvement, 89 (61%) had para-aortic or spleen involvement, 65 (44%) had left cervical involvement, 44 (30%) had axillary involvement and 16 (11%) had inguinal involvement. In patients with left or right cervical lymph nodes, the proportions observed with gaps in the spreading were 37 and 27% (SE 7%), respectively, whereas the corresponding values of gaps expected in a probability model if a random course of spreading had been followed would have been 84 and 73% (P = 0.0001 and 0.0001, respectively).

CONCLUSION

Our data support the concept that HD spreads in a predictable manner via functionally contiguous lymph nodes. In patients with right cervical lymph nodes, HD spreads via the upper mediastinum and pulmonary hila to the upper abdominal nodes and the spleen. In those with left cervical tumours, HD spreads directly to the abdomen (bypassing the mediastinum), then upward again via the pulmonary hila and upper mediastinum to the neck region (bilateral involvement) and from here it proceeds to the axillary nodes. Finally the inguinal nodes are involved.

Hodgkin's disease: historical perspective and clinical presentation

In conclusion, emphasis has shifted from a progressive increase in the weight of treatment to the reduction of management aggressiveness for some subsets of patients by taking advantage of clinical presentation and risk factors. The first period was based on the philosophy that extensive work-up can help to minimize treatment. The goal has become to avoid unnecessary invasive techniques. With better knowledge of the late effects and causes of death, there is now a consensus that management should be modulated according to the individual characteristics of the patient. The aim of further studies will be to progress in the identification of the various subsets of HD and to introduce new therapeutic modalities as effective but less toxic than the present ones. This approach requires for each subset of patients a rigorous assessment of the long-term cost and benefit of the various therapeutic modalities used for treatment of HD.

Radiation therapy in clinical stage I and II Hodgkin's disease. The Princess Margaret Hospital Lymphoma Group

A review of the Princess Margaret Hospital experience over the last 20 years in treating clinically staged patients with stage I and II Hodgkin's disease was performed to analyse the impact of patient selection and extended field radiation on relapse and survival. Of the 878 patients with stage I and II Hodgkin's disease, 521 with clinical stages I and II received radiation alone as the initial treatment. The actuarial survival for all stage I and II patients was 85.1% at 5 years and 76.2% at 10 years, and for clinically staged patients treated with radiation alone, 87.2 and 77.6%, respectively. The relapse-free rate (RFR) for all clinical stage I and II patients treated with radiotherapy (RT) alone was 70.1% at 5 years and 65.8% at 10 years. Significant prognostic factors for RFR and survival included age, stage and histology. In addition, the extent of radiation was identified as an independent prognostic factor for survival as well as for relapse. The RFR for those treated with involved field RT was 58.4% at 5 years and 50.5% at 10 years; for patients treated with mantle RT, 69.9 and 65.6%, and those treated with extended field RT 77.4 and 75.8%, respectively. In a highly selected group of patients with no adverse features, i.e. with stages IA-IIA, lymphocyte predominant or nodular sclerosis histology, erythrocyte sedimentation rate < 40, age < 50, no large mediastinal mass, and no E-lesions--the policy of mantle RT (M) and extended field RT (EF) produced comparable 5-year relapse-free rates (M, 84.9%; EF, 87.1%; P = 0.53). We conclude that a policy of treatment selection based upon clinicopathological prognostic factors and the use of extended field RT confers excellent results in the treatment of clinical stage I and II Hodgkin's disease.

Detection of a systemic effect of malignancy in vivo by magnetic resonance imaging

In animals bearing tumors prolongation of spin lattice relaxation time (T1) has been detected in vitro in organs not directly affected by the malignancy. This has been termed the "Systemic Effect." In this study the possible existence of such an effect in the liver, muscle and fat of humans with lymphoma has been investigated. In vivo T1 measurements were made using a low field strength (0.08 Tesla) magnetic resonance imager. The mean liver T1 for 19 lymphoma patients with normal liver histology was 206 ms, compared with a mean of 191 ms for 61 volunteers (p less than 0.0001). Among these patients prolongation of liver T1 was related to the extent of disease elsewhere in the body. For 23 patients with Hodgkin's disease (HD) examined at the time of diagnosis, liver T1 was significantly correlated with other known markers of disease extent or activity (alkaline phosphatase level, erythrocyte sedimentation rate and the presence of systemic symptoms). No such correlations were observed among 25 patients with non-Hodgkin's lymphoma (NHL). Muscle and fat T1 was measured in 26 patients with lymphoma, 14 patients with acute leukemia and 88 volunteers. Seven of the patients with lymphoma and 2 of those with leukemia had muscle T1 values above the range observed for volunteers. Similarly, 3 patients with lymphoma and 1 with leukemia had prolonged fat T1. These findings indicate that a systemic effect of malignancy on T1 is detectable in a proportion of humans with lymphoma or leukemia.

Detection of liver involvement in Hodgkin's disease

Liver involvement with Hodgkin's disease is determined at our institution by a combination of wedge biopsy and needle biopsy at the time of staging laparotomy. This retrospective study was undertaken to determine whether the wedge or the needle biopsy method is the more accurate. All staging laparotomies (n = 116) during the period 1972-1986 were reviewed. Twelve patients were found to have liver involvement with Hodgkin's disease; 2 had had wedge biopsies only and ten had had both wedge and needle biopsies. In all ten with both wedge and needle biopsies, the wedge biopsies were positive for liver involvement, but in only five were the needle biopsies positive. This study indicates that wedge biopsy is the more accurate method for detecting liver involvement in these patients, and we believe it should always be a part of the staging laparotomy for Hodgkin's disease.

Low field strength magnetic resonance imaging of the spleen: results from volunteers and patients with lymphoma

Low field strength (0.08 Tesla) magnetic resonance imaging (MRI) of the spleen with spin lattice relaxation time (T1) measurement was performed on a total of 79 healthy volunteers and 62 patients with lymphoma. Inhomogeneity was observed on the T1 images of the spleen from 25 volunteers. This was therefore considered a normal variant. The normal range of spleen T1 at 0.08 Tesla was established (362-420 msec). No influence of age on spleen T1 was detected. The range of T1 values observed in males and females was similar, although the mean spleen T1 for females was significantly longer than that for males. The sensitivity of T1 measurement for the detection of lymphoma in the spleen was poor, particularly for patients with Hodgkin's disease. In a minority of untreated patients, however, a spleen T1 value outside the normal range may indicate the presence of lymphoma in the spleen. A significant decrease in spleen T1 following treatment was observed in 9 patients who underwent serial scanning.

Combined modality in Hodgkin's disease. Comparison of six versus three courses of MOPP with clinical and surgical restaging

Between 1972 and 1979, 121 patients with Hodgkin's disease (clinical Stages IInA, IB, IIB, and III) were treated by two different, successive, therapeutic protocols. The first group received six MOPP (mechlorethamine, vincristine, procarbazine, prednisone) cycles before radiotherapy, whereas the second group received only three MOPP cycles before irradiation. A total of 118 patients underwent surgical restaging with splenectomy before irradiation. Clinical criteria used in defining complete remission were verified by surgical restaging. Three MOPPs were just as effective as six MOPPs when combined with radiotherapy in achieving complete remission and in treating occult splenic disease. Following extended-field irradiation, complete remission rates were 96% for three MOPPs versus 94% for six MOPPs. The actuarial survival rates, 4 years after therapy completion, were 89% for three MOPPs and 94% for six MOPPs, with a relapse-free survival rate of 88% and 96.6%, respectively.

Primary splenic presentation of malignant lymphoma and related disorders. A study of 49 cases

The diagnosis of malignant lymphoma presenting as an initial splenic manifestation may go unrecognized as such when peripheral lymph nodes are not enlarged and when results of bone marrow biopsies are negative. Tissues from 49 patients, ranging in age from 15 to 78 years, in whom the original diagnosis of malignant lymphoma and related conditions was made at splenectomy, were classified as: diffuse small lymphocytic (20), diffuse large cell (11), diffuse small cleaved (5), diffuse large cell, immunoblastic (5), follicular small cleaved cell (3), and follicular mixed small cell and large cell (2). Two additional spleens, diagnosed as acute blastic leukemia, were initially confused with malignant non-Hodgkin's lymphoma by light microscopy. One patient presented with Hodgkin's disease confined to the spleen. For the non-Hodgkin's lymphoma group, parameters of age, sex, splenic weight (range, 226-4000 g), lymph node, bone marrow, or liver involvement did not adversely influence prognosis. Abdominal lymph nodes were positive in 31 of 37 patients having splenic hilar and/or abdominal lymph nodes available for review. Of 29 patients with adequate follow-up, 7 died of disease, 5 were free of disease at 3 years, 2 were free of disease at 5 years, 2 were alive with disease at 3 years, 4 were alive with disease at 5 years, and 9 died from second malignancies, unknown, or unrelated causes. Six of the 7 patients who died of lymphoma were classified as large cell (four diffuse large cell and two diffuse large cell, immunoblastic), with a mean 2-year survival. One patient died of leukemia. Those lymphomas classified as low grade behaved in an indolent fashion. The morphologic diversity of these cases emphasizes the need for the initial recognition and correct classification of lymphomas which present in the spleen, since survival is best determined according to histologic type.

Ultrasonography of Hodgkin's disease in the liver and spleen

Ultrasound findings of 39 spleens and 68 livers in which histology was obtained at laparotomy or autopsy within a month of the examination and four livers in which abnormalities were found clinically by other methods during long-term follow-up were reviewed to evaluate the various sonographic appearances and the accuracy in detecting involvement of the spleen and liver. Only one out of 17 positive spleens had definite ultrasonic focal lesions. Not only small splenic Hodgkin's foci but also larger ones were overlooked. Of 10 positive livers, six showed diffuse inhomogeneity throughout the liver, two showed multiple, well-defined, echo-poor lesions but two showed no significant ultrasonic abnormality even in retrospect. No correlation was found between the type of Hodgkin's disease and the ultrasonic appearance of involved livers. Ultrasonic examination, however, could differentiate other liver abnormalities, such as fatty changes, a cyst and a thrombosed haemangioma from infiltration of Hodgkin's disease. In one case, splenic lesions became echogenic following-chemotherapy.

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.

Chemotherapy--radiotherapy association in Hodgkin's disease, clinical stages IA, II2A: results of a prospective clinical trial with 166 patients

One hundred sixty-six patients with clinical stages IA, II2A Hodgkin's disease were treated between April 1972 and December 1976 with three courses of multiagent chemotherapy (methylchlorethamine, vincristine, procarbazine, prednisone) followed by mantle irradiation--excluding mediastinum for those with initial upper cervical presentation and absence of mediastinal involvement--or inverted Y radiotherapy. None had staging laparotomy. With a follow-up of 12--84 months, median 40 months, the overall survival is 93.5% and the overall relapse-free survival 89.9%. Eight patients died, three of them with evident disease. Ten patients relapsed; four are now free of disease after retreatment. With chemotherapy-radiotherapy sequence, staging laparotomy is not indicated. Results and side effects of this treatment strategy are compared with those of other treatment policies.

Results of surgical staging in Hodgkin's disease

The results of surgical staging in Hodgkin's disease in 107 patients under the care of one surgeon over an 8-year period are presented. The inaccuracy of clinical staging is re-emphasized as 43 per cent of patients had their disease stage altered by surgical staging. Lymphangiography correctly predicted the presence of intra-abdominal disease in only 70 per cent of patients. Spleen size was not an indication of involvement, and furthermore the spleen was involved by disease in the absence of nodal involvement in 6 patients. In 2 cases mesenteric nodes were involved in the absence of pancreatic or coeliac nodal involvement. As a consequence of surgical staging many patients received a more extensive field of radiotherapy, and 18 per cent of patients were treated by combination chemotherapy instead of radiotherapy. There was no hospital mortality and a low operative morbidity following surgical staging. At present surgical staging is an essential part of the overall strategy of management of patients with Hodgkin's disease.

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.

Computed tomography (CT) in the staging of patients with Hodgkin's Disease: a report on 136 patients

One hundred and thirty-six patients with biopsy proven Hodgkin's disease (HD) had conventional staging investigations and CT carried out at presentation. CT did not detect 20 out of 24 positive spleens and did not detect disease at 16 involved lymph node sites proven at laparotomy. In 60 cases in whom lymphography was performed, CT detected all disease shown by lymphography and showed additional disease in 13 other cases (three within the lymphogram area). In 43 patients CT was the only investigation of the abdomen that could be performed and identified 31 unexpected areas of disease in this group. CT altered the stage of the patients in 16% of cases compared with 8% (lymphography) and 34% (laparotomy). The importance of CT as a baseline investigation for the subsequent monitoring of the complete remission of all known disease is discussed, and the routine use of CT when available as the primary non-invasive staging investigation of the abdomen in HD is recommended.

Computerised tomographic (CT) abdominal scanning in Hodgkin's disease

Thirty-nine patients with Hodgkin's disease (HD) with little or no clinical evidence of abdominal disease were investigated by abdominal CT scanning. The results were compared with those of bipedal lymphography and laparotomy and splenectomy. In the assessment of para-aortic lymph nodes, CT scanning and lymphography were of equal efficacy in determining the presence or absence of disease (87 and 79% respectively). Although CT scan could occasionally demonstrate disease in nodes in areas other than the retroperitoneum, its value was limited by its inability to detect involvement of nodes which were not significantly enlarged. CT assessment of splenic HD was unreliable, focal deposits being detected in only one of the 11 spleens involved. In this selected group of patients, CT scan had little advantage over lymphography in the description of disease extent. However, CT scan would appear to be the investigation of choice in patients with suspected abdominal relapse because of the more frequent presence of disease in sites not seen on lymphography. When treatment decisions are dependent on accurate knowledge of distribution of disease, CT scanning cannot yet effectively replace staging laparotomy and splenectomy as the means of achieving this information.

[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.

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.

Splenectomy for undiagnosed splenomegaly

During the 9-year period 1968-76 116 splenectomies were performed at the General Hospital, Nottingham. Of these, 13 (11 per cent) were undertaken for unexplained splenomegaly. In 6 patients a diagnosis was established by the operative procedure (2 with sarcoidosis, 2 splenic cysts, 1 Gaucher's disease and 1 haemangiosarcoma). Histological examination of the excised spleens in the remaining 7 patients showed no specific features. Two of these patients benefited considerably from removal of very large spleens. Another patient died from lymphosarcoma which was diagnosed 21 months after splenectomy. In the remaining 4 patients with mild to moderate splenomegaly, there were no real diagnostic or therapeutic advantages. It is concluded that splenectomy should always be considered in patients with unexplained moderate or gross splenomegaly but it may not be helpful in the patient whose spleen is only midly enlarged.

Computed tomography of abdomen in staging and clinical management of lymphoma

During July 1976 to Demember 1977, 150 patients with Hodgkin's disease and 138 with non-Hodgkin's lymphoma were examined by computed tomography (CT). In 45 cases 50 repeat examinations were conducted. Concurrent laparotomy and lymphography were performed on 68 and 56 patients respectively. The overall incidence of false-positive CT examinations as confirmed by laparotomy was 7.4%. In 18 patients with non-Hodgkin's lymphoma in the abdomen there was good correlation between the two techniques. Of the 50 patients with Hodgkin's disease who underwent laparotomy, 17 had splenic disease and 14 minimally enlarged lymph nodes in 20 areas; CT, however, detected only four diseased spleens and five minimally enlarged lymph nodes. Nevertheless, CT often detected enlarged lymph nodes missed by lymphography and was 23% more efficient than lymphography in detecting unsuspected disease. CT also detected unsuspected disease in patients with relapse of lymphoma. CT may replace other non-invasive investigations of abdominal disease in patients with lymphoma and give a reliable guide to prognosis. It does not, however, eliminate the need for laparotomy in staging Hodgkin's disease.

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.

Hodgkin's disease: radiotherapeutic management at a cancer oriented community hospital

Seventy-eight patients with Hodgkin's disease were treated with radiation therapy between July 1966 and July 1976 (30 Stage I, 28 Stage II, 20 Stage III). The mean follow-up period is greater than 5 years. 90% of Stage I, 86% of Stage II, 65% of Stage III, and 82% (64/78) of all patients are NED after radiotherapy alone. Since laparotomy option (1970) 89% (50/56) of patients are NED. Fourteen patients were failures. Chemotherapy "rescued" 6 of 14. Seven have died, 1 is alive with disease, and 1 died of leukemia. Absolute survival is 90% (70/78). Failures were more frequent in patients with unfavorable histological types (9/14), and Stage III disease, primarily IIIS+ or B category (7/14). Sites of failures were mainly extranodal, primarily lung (10/14) and bone (2/14), and are consistent with hematogenous dissemination. Laparotomy performed in 41 patients identified unsuspected splenic involvement in 9 cases (22%), but was a distinct failure in confirming most "small node" positive lymphangiograms. Two patients developed acute myelocytic leukemia, both while NED 5 years posttherapy. One patient had also received adjunctive MOPP. There has been no impairment in the quality of survival that could be directly attributed to radiotherapy.

Morbidity of staging laparotomy in Hodgkin's disease

The morbidity of exploratory laparotomy and splenectomy in Hodgkin's disease was determined at three institutions--a university hospital, a major university affiliated hospital and a large community hospital. Of the 90 patients who underwent exploratory laparotomy, 33 (37%) sustained a major or minor complication within two weeks of surgery. Seventeen patients (19%) sustained a minor complication and 16 patients (18%) a major complication. There was no mortality. A higher complication rate occurred in patients more than 28 years of age (p = 0.01), and in patients with advanced clinical stage when age was controlled (p = 0.05). We suggest that prior to performing an exploratory laparotomy in a given patient, the necessity of the procedure be weighed against its potential hazards.

An evaluation of intraabdominal involvement in Hodgkin disease

An analysis of the staging procedure in 80 patients with histologically confirmed Hodgkin disease was performed at Tata Memorial Hospital, Bombay. There was a marked male preponderance. The mixed cellularity type of Hodgkin disease is the commonest histological variety (47.5%) and has the highest incidence of subsequently proven generalized disease (76%). The lymphocytic predominant variety was the next most common (27.5%) and was present as unsuspected disease in 45% of cases. Systemic symptoms were associated with advanced disease in 57% of clinical IB and 73% of clinical IIB cases. Splenic involvement was histologically confirmed in 41% of cases with stage I disease and 52% of cases with stage II disease and was associated with liver involvement in two cases. A lymphogram was performed, in addition, prior to the laparotomy in 40 cases and the lymphogram-laparotomy concordance was approximately 72% in our series. This stresses the importance of a staging laparotomy.

Are pelvic irradiation and routine staging laparotomy necessary in clinically staged IA and IIA Hodgkin's disease?

Thirty-nine patients with clinically staged IA and IIA Hodgkin's disease were treated with mantle plus paraaortic/splenic irradiation between 1968 and 1975. All patients had supradiaphragmatic presentations, and none had staging laparotomies. With a follow-up time of 1 to 9 years, mean 4.3 years, the overall relapse-free survival is 92% (100% for stage IA and 89% for stage IIA). The absolute relapse-free 5-year survival is 91% There were no pelvic recurrences. These data show that routine staging laparotomy and pelvic irradiation are not indicated for clinically staged IA and IIA Hodgkin's disease with supradiaphragmatic presentation. The criteria for staging laparotomy in early-stage Hodgkin's disease are discussed.

Lymphography as a guide during laparotomy in Hodgkin's and non-Hodgkin's lymphomas

Lymphography of 123 newly diagnosed patients with lymphoma was followed by staging laparotomy without intra-operative abdominal roentgenography. These patients were retrospectively evaluated for residual abnormal nodes with postoperative abdominal roentgenography. Sixteen patients with pathologically normal nodes at laparotomy had residual lymphographically abnormal nodes at postoperative roentgenography. Nine patients received less extensive irradiation than they would have if the remaining abnormal nodes had been biopsied and found to contain tumor. Two had shortened survivals as an apparent consequence.

Intensive investigation in management of Hodgkin's disease

Ninety-eight patients with clinically localised Hodgkin's disease underwent laparotomy and splenectomy to determine the extent of microscopic spread. In 68 patients the procedure was carried out for untreated disease apparently confined above the diaphragm. Abdominal disease cannot be confidently excluded on the basis of non-invasive investigation at presentation. Clinical assessment of splenic disease was unreliable unless gross splenomegaly was present. Pedal lymphography was accurate in assessing para-aortic and iliac disease but of no value in assessing other intra-abdominal lymph node involvement, including that of the mesenteric lymph node. Trephine bone marrow biopsy findings were normal in all patients before surgery, and only one patient was found to have diseased bone marrow by Stryker-saw biopsy at operation. Liver disease was identified at operation in nine patients, some of whom were asymptomatic with clinically undetectable splenic and nodal disease. Detailed clinical staging failed to detect disease in one-third of patients who underwent laparotomy. These studies show that if radiotherapy is to remain the treatment of choice for disease truly localised to lymph nodes a detailed staging procedure, including laparotomy and splenectomy, remains essential. The value of this potentially curative treatment is considerably diminished in the patient who has been inadequately staged.

A case of primary lymphoma of the liver

A case of primary malignant lymphoma of the liver is described. Presenting with epistaxis, he died in hepatic encephalopathy with an intractable bleeding post-bulbar duodenal ulcer.

Staging of Hodgkin's disease: a surgical perspective

Staging laparotomy, consisting of splenectomy and biopsies of liver, lymph nodes, and bone marrow, is a very useful adjunct in the workup of a patient with Hodgkin's disease. In this series of 400 patients, 1.0 per cent required reoperations for complication, 3.7 per cent had major complications, and 14.0 per cent had minor complications from the operation. Further evidence of Hodgkin's disease was discovered in 42.0 per cent of the cases and a change from the clinical to the pathologic stage occurred in 27.5 per cent of these cases. The surgeon's task in the treatment of Hodgkin's disease and other malignant diseases is to document and mark the areas of involvement so that accurate and appropriate therapy can be given, while morbidity and mortality are minimized.