Postchemotherapy staging laparotomy in Hodgkin's disease.

Seventeen patients with Hodgkin''s disease who had a staging laparotomy (SL) within 2 months of the completion of initial chemotherapy are presented. Only 1 patient had a positive laparotomy. Postchemotherapy SL allows any residual active disease to be assessed, but the incidence of positive finding may be small, and such findings are unlikely to alter subsequent management. SL following chemotherapy is therefore not recommended either for patients in clinical remission or for patients with evidence of relapsed disease.     

The relevance of a staging laparotomy for Hodgkin's disease in India.

A retrospective analysis of 328 cases of Hodgkin's Disease (HD) subjected to a staging laparotomy at the Tata Memorial Hospital, Bombay, India, from 1974 to 1986 was undertaken to assess its relevance to our setup. Eighty percent of the patients were from clinical stages (CS) I and II, 38% with lymphocyte predominance (LP), and 41% with mixed cellularity (MC) histologies. Staging laparotomy was positive in 60% cases overall, including 50% from CS IA and IIA, 68% from CS IB and IIB, and 53% and 67%, respectively, from LP and MC histologies. Splenic involvement was seen in 54% cases. Operative complications were encountered in 2% of cases and deaths in two cases only. In view of the high propensity for abdominal spread, only selected CS IA and IIA cases would merit a staging laparotomy within which, nearly 50% cases with a negative yield could be offered radical segmental irradiation alone for cure. The majority of our patients would, however, require combination therapy.     

Early supradiaphragmatic Hodgkin's disease. High-dose gallium scanning obviates the need for staging laparotomy

Experience with 16 sequential patients with Stage IA/IIA supradiaphragmatic Hodgkin's disease who had no evidence of intra-abdominal disease using high-dose gallium and computerized tomography scanning is reported. Subsequent staging laparotomy also was negative in all these patients and did not alter management decisions. It is suggested that high-dose, whole-body gallium scanning and other noninvasive staging procedures give reliable data for therapeutic decisions.     

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.     

The staging of Hodgkin's disease

The approach to staging patients with Hodgkin's disease has changed over the last 20 years. Although careful physical examination, chest radiograph, and bipedal lymph-angiogram remain the mainstays of the clinical evaluation, computed tomography (CT) scanning of the chest and abdomen is rapidly gaining acceptance as a useful ancillary procedure. In addition, the initial enthusiasm for the staging laparotomy and splenectomy as a necessary part of the staging evaluation is now coming into question. Recent studies raise legitimate concerns about this procedure's overall impact upon survival as well as the potential long-term consequences of splenectomy. Select situations do exist, however, where a staging laparotomy remains appropriate. An approach to the staging of newly diagnosed Hodgkin's disease is suggested and supported by recent studies of this disease.     

Results and complications of staging laparotomy in hodgkin's disease

Between 1969 and 1983, 123 patients with Hodgkin's disease underwent a staging laparotomy. The stages of 34 (27%) patients were changed by laparatomy. Twenty-nine patients (23%) were upstaged, five (4%) down-staged. The most considerable change was found in stage III. The accuracy of preoperative lymphangiography was 85%. The postoperative complication rate was 15%. There were no operative deaths. The staging laparotomy for Hodgkin's disease is a reliable procedure, and allows less aggressive therapy in selective groups.     

The role of restaging laparotomy in Hodgkin's disease

The role of restaging laparotomy (RL) in Hodgkin's disease was studied in 41 patients. Two patients were in clinical stage I, 16 in clinical stage II, 13 in clinical stage III and 10 in clinical stage IV. Eight cases had previously received radiation therapy alone, 26 chemotherapy and 7 combined chemo-, and radiotherapy. The patients were divided into 2 groups, depending on the results of the preoperative clinical reevaluation. Group 1 included 20 patients with suspicion of persistent disease; in 6 (30%) RL was positive. Group 2 consisted of 21 cases with clinical appearance of complete response; RL was positive in one case (4.7%). The results of the comparison confirm the high rate of false positive findings in CT and lymphography. RL appears as a valuable procedure in patients with positive or doubtful clinical findings at reevaluation after radical therapy, in order to reduce the risk of unnecessary treatment.     

The pathological findings following laparotomy in Hodgkin's disease

The pathological findings in 50 patients with Hodgkin''s disease following laparotomy for diagnostic purposes are described. Forty-four patients had laparotomy before treatment and within a few months of the original diagnosis, while 6 patients had delayed laparotomies. The Rye histological classification was applied to the original lymph node biopsy, the abdominal lymph node and Hodgkin''s tissue in the spleen. The variation in appearance both of these tissues and of the liver biopsies is discussed.     

Liver and spleen scintigraphy in staging Hodgkin's disease

Liver–spleen scintigraphy is a useful adjunctive procedure in the diagnosis and staging of Hodgkin's disease. Scintigraphy is easily obtained for both the patient and the physician. It usually directs attention to a liver or spleen involved with the disease by revealing organomegaly with or without defects in concentration of radioactive colloid. The information may be diagnostic. Patients are presented who were studied with lymphangiography, diagnostic laparotomy with splenectomy, and liver–spleen scintigraphy among other tests for staging. The routine use of liver–spleen scintigraphy is recommended in the diagnosis and management of Hodgkin's disease.     

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.