Assessment of Liver and Spleen Involvement in Hodgkin's Disease (original) (raw)

The Decision to Perform Staging Laparotomy in Symptomatic Hodgkin's Disease

British Journal of Haematology, 1980

This study defines patients with symptomatic Hodgkin's disease for whom risks of staging laparotomy (LAP) outweigh benefits conferred by accurate knowledge of stage. From a database of more than 900 pathologically-staged patients, probabilities of pathological stage are calculated for combinations of basic findings and lymphangiogram results. Decision-making thresholds are defined at which results of treatment after LAP, taking operative mortality into account, are equivalent to immediate treatment appropriate to clinical stage. These thresholds are substantially altered by varying LAP mortality estimates, by assigning a false negative rate to LAP, and by considering uncertainty in treatment results. Fifty-four combinations of findings are described for which immediate therapy with MOPP is justified; total nodal irradiation (TNI) is never indicated in B patients without prior LAP staging. Analysing 94 B patients who had LAP showed an appreciable number might have been spared this, particularly when uncertainty in treatment results is considered. With 0.03 (=3%) uncertainty in treatment results, and 1% LAP mortality, LAP was not indicated in one in seven patients; nearly one third'of patients should have immediate treatment with 3% LAP mortality. Threshold analysis can define those patients for whom risks of LAP outweigh benefits. The diagnosis of Hodgkin's disease often marks the beginning of a series of increasingly invasive diagnostic tests to determine the stage of the disease (Carbone et al, 1971). This intensive staging may include an intravenous pyelogram, percutaneous bone marrow and liver biopsies, a gallium scan, a lymphangiogram (LG), and computerized tomography; since the information from these tests cannot be completely relied upon because of appreciable false negative, and for some tests, false positive rates, the series often culminates in an exploratory laparotomy, with extensive lymph node sampling and splenectomy (LAP). After the patient is thus 'pathologically-staged', future treatment is planned. 'Low-cost' information known about the patient, such as age, sex and histological subtype, is not used in this staging process. Usually, diagnostic tests are continued until a satisfactory degree of certainty regarding the stage of the disease is achieved. This is justified by the belief that results of stage-specific

Spleen involvement in Hodgkin's lymphoma: assessment and risk profile

Annals of Hematology, 2003

Diagnostic laparotomy is no longer routinely performed in Hodgkin's lymphoma and noninvasive diagnosis of spleen involvement remains uncertain. In order to assess the probability of splenic involvement based on clinical parameters, we retrospectively analyzed data on patients of the German Hodgkin's Lymphoma Study Group (GHSG) who underwent staging laparotomy and for whom splenic weight and size were available. Our study included 376 patients with Hodgkin's lymphoma who underwent staging laparotomy and splenectomy according to the treatment policy of the GHSG between February 1981 and January 1993. Univariate and multivariate analyses of pretherapeutic clinical characteristics and splenic weight were performed in order to predict the probability of splenic involvement. Computed tomographic (CT) images of 25 patients were available and used to correlate radiological splenic size and pathological splenic weight.

Clinical and Surgical Staging of Hodgkin's Disease

Upsala Journal of Medical Sciences, 1979

Staging laparotomy was performed in 36 patients with Hodgkin's disease. The surgical procedure changed the stage in 1 4 cases or 36 % and also revealed subdiaphragmatic disease in 1 4 patients. Mixed cellularity and nodular sclerosis were the main histopathological types, contributing 4 4 % and 4 2 %, 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.

Prognostic significance of the number of involved areas in the early stages of Hodgkin's disease

Cancer, 1984

An analysis of 1059 patients with clinical stage (CS) I and I1 Hodgkin's disease was undertaken to determine the prognostic significance of the number of involved sites. In this group of patients the number of involved lymph node areas was highly correlated with the probability of dissemination of occult disease. In the subgroup of patients with involvement of two lymph node sites (CS 112) approximately 50% demonstrated occult dissemination on the other side of the diaphragm as evidenced by subsequent relapse in the untreated subdiaphragmatic region. However, only 15% to 20% of this group had unsuspected disease in regions other than the spleen or the paraaortic lymph nodes. In CS I and 112 supradiaphragmatic patients, who underwent a staging laparotomy, splenic involvement was a powerful prognostic indicator. When the spleen was not involved, less than 10% of patients had disease elsewhere below the diaphragm, whereas, when the spleen was involved as many as 40% of patients had additional subdiaphragmatic sites involved. In the subgroup with three or more lymph node areas involved (CS II3), the proportion of patients with extension of disease on the other side of the diaphragm, as evidenced by later relapse was also about 50%. But in these patients, unlike the CS 112 patients, analysis of relapse patterns showed that occult disease had already disseminated to the pelvic nodes or to extra nodal sites. Furthermore, splenic involvement was of much less prognostic significance because CS II3 patients who did not demonstrate splenic involvement at staging laparotomy had similar relapse incidence and similar relapse patterns as those with positive spleens.

The importance of staging laparotomy in pediatric Hodgkin's disease

Journal of Pediatric Surgery, 1994

0 The findings of 247 pediatric patients who presented with supradiaphragmatic Hodgkin's disease and underwent staging laparotomies between April 1969 and December 1991 were reviewed to assess the importance of the staging laparotomy in pediatric Hodgkin's disease. A change in stage occurred in 25% of the cases reviewed. Fifty of the 202 (25%) clinical stage (CS) I or II patients were upstaged to pathological stage (PS) Ill or IV, and 12 of the 45 (27%) clinical stage Ill or IV patients were downstaged to pathological stage I or II. Possible risk factors for positive surgical staging, including gender, age, presence or absence of B symptoms, extent of involvement above the diaphragm, and histological type, were used to define subgroups of patients. Three statistically significant subgroups of patients with less than a 10% chance of restaging were identified. These groups included CS I and II patients with lymphocyte-predominant histology, CS I females, and CS Ill and IV females with nonlymphocyte predominant histology. These subgroups represent 24% of the cohort. Because CS is an accurate predictor of PS in these groups, treatment could be based solely on CS. The impact of radiographic imaging techniques on correctly predicting pathological stage was assessed. The rates of restaging for individuals with lymphangiography or computed axial tomography were not statistically different from those of patients without these radiographic studies. Therefore, abdominal imaging is not a substitute for surgical staging. No mortality and 2.8% morbidity occurred from staging laparotomy. Postsplenectomy sepsis and small bowel obstruction were the most common complications. Ninety-six percent of upstaged patients had splenic involvement, and 54% had positive nodal involvement. The spleen was the only site involved in 42% of patients. In conclusion, staging laparotomy is warranted for the majority of pediatric patients with Hodgkin's disease if treatment will be guided by stage. Copyright o 1994 by W.B. Saunders Company INDEX WORDS: Hodgkin's disease, staging laparotomy.

How to restrict liver biopsy to high-risk patients in early-stage Hodgkin's disease

Annals of Hematology, 2000

Liver biopsy is an invasive diagnostic method for detecting liver involvement (LI) in Hodgkin's disease (HD). The aim of this retrospective study was to determine and evaluate a method for restricting liver biopsy to a subset of patients. Between 1988 and 1994, a total of 2016 patients with HD were treated within the HD4-6 study protocol of the German Hodgkin's Lymphoma Study Group (GHSG). We investigated the predictive power of abdominal ultrasound (US) and computed tomography (CT), as well as of various clinical factors related to LI, using univariate and multivariate methods. LI occurred in 4.9% of all patients (99/ 2016) and in 3.0% of those who, if LI were disregarded, would have been included in clinical stages I and II. In multivariate analysis the presence of LI was significantly associated with splenic involvement or infradiaphragmatic involvement, absence of mediastinal involvement, serum alkaline phosphatase (SAP) level over 230 units/l, and age over 40 years. We used these factors to define a risk score for LI. LI is very rare in patients who would otherwise be in clinical stages I or II, but knowledge of LI is important because it has therapeutic consequences. With our risk score, liver biopsy is indicated for approximately one quarter of these patients otherwise in clinical stages I or II.