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Long-term morbidity after staging laparotomy for Hodgkin lymphoma
Journal of Pediatric Surgery 52 (2017) 1430–1432
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Long-term morbidity after staging laparotomy for Hodgkin lymphoma☆,☆☆ Inna Lobeck a, Beth Rymeski a, Karen Burns b, Rajaram Nagarajan b, Judy Correll b, Debra Kent b, Roshni Dasgupta a,⁎ a b
Division of Pediatric and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States Cancer and Blood Diseases Institute, Cincinnati Childrens Hospital Medical Center, Cincinnati, OH USA
a r t i c l e
i n f o
Article history: Received 20 September 2016 Received in revised form 21 November 2016 Accepted 28 November 2016 Key words: Hodgkin lymphoma Survivorship Secondary malignancy Staging laparotomy Pediatric cancer
a b s t r a c t Background: A large cohort of Hodgkin lymphoma (HL) survivors exist. With patients transitioning from pediatric to adult care, practitioners should be aware of potential complications. The aim of this study was to describe the long-term complications of patients who had staging laparotomy for the treatment of HL. Methods: After institutional review board approval, a retrospective review of hospital records at our institution was performed. Data extracted included demographics, treatment course and long-term postoperative complications. Results: 24 patients with HL underwent staging laparotomy from 1971 to 1994 with median follow-up of 27.9 years. Six (33%) had intraabdominal disease. Three patients (17%) required four repeat laparotomies for bowel obstruction. Of these, one had radiation to the inguinal region for local control, one had mantle radiation. Five patients developed a second malignancy. There were no documented cases of postsplenectomy sepsis. Other late effects that were unlikely related to surgery included pulmonary fibrosis (4), heart failure (2), hypothyroidism (4), and dysphagia (3). One patient died of metastatic adenocarcinoma. Conclusions: Long-term follow-up of patients who underwent staging laparotomy for HL revealed an increased incidence of repeat laparotomy and secondary malignancy. This underscores the importance of a high index of suspicion and screening in this population. Level of Evidence: Level III. © 2017 Elsevier Inc. All rights reserved.
Physicians treating long-term cancer survivors should be aware of potential complications which may manifest years after surgical treatment of disease. With improved patient survivorship and transition of care from childhood to adulthood, the implications of previous staging procedures may be missed. Hodgkin lymphoma (HL) is a B cell proliferative malignancy that accounts for 7000 new cases annually in the United States [1]. The prognosis of disease relies on accurate staging to direct management. In 1969, Glatstein et al. [2] introduced staging laparotomy including liver biopsy, lymph node biopsy of the celiac, portal, para-aortic, splenic, mesenteric and iliac nodes and splenectomy for the evaluation of HL. This quickly became the standard of care for the staging of intraabdominal disease and was used to determine the extent of disease, per the Children's Oncology Group [3].
☆ The authors have nothing to disclose. This study was unfunded. ☆☆ Type of Study: Retrospective comparative study. ⁎ Corresponding author at: Cincinnati Children's Hospital Medical Center, MLC 2023, 3333 Burnet Ave, Cincinnati, OH 45229, United States. Tel.: +1 513 636-4371; fax: +1 513 636 7657. E-mail address: [email protected] (R. Dasgupta). http://dx.doi.org/10.1016/j.jpedsurg.2016.11.047 0022-3468/© 2017 Elsevier Inc. All rights reserved.
The once-fatal disease now reaches a 98% long-term survival rate [1]. With increasing numbers of HL survivors in the United States currently long-term complications of operative staging and therapy can cause significant adverse events affecting quality of life for survivors. With the advent of more advanced imaging and presence of morbidities associated with surgery, such as cardiac arrest, wound infection, hemorrhage, abscess, pulmonary emboli, pneumonia, sepsis and small bowel obstruction [4] open surgical staging is no longer used for abdominal HL. Despite recent advances in care, physicians treating long-term survivors of HL should be aware of potential high risk complications. With improved patient survivorship of HL and transition of care from childhood to adulthood, the implications of previous staging procedures may be missed. A large subgroup of HL survivors exists that has undergone previous operative staging procedures and requires close followup for possible long-term complications. Although staging laparotomies are no longer the standard of care, because of the large number of patients who once underwent staging laparotomy, practitioners taking care of HL survivors should be aware of long-term complications of this procedure and have a high index of suspicion for these complications. Sequelae of operative staging, such as overwhelming postsplenectomy infection (OPSI) and small bowel obstruction, have been previously described in the literature [5]. In this investigation,
I. Lobeck et al. / Journal of Pediatric Surgery 52 (2017) 1430–1432
we aimed to identify key late complications in patients who underwent open surgical staging as a part of their initial evaluation of the disease. 1. Methods After institutional review board (IRB) approval of experimental protocol, the medical records of 95 consecutive patients with pathologically confirmed HL at Cincinnati Children's Hospital Medical Center were identified through a database of patients in the cancer survivor clinic. Patients younger than 18 years who had undergone surgical laparotomy for staging between 1971 and 1994 were included in the study. Patients who followed up in the long-term survivorship clinic, at least 5 years postoperatively, were included in the study. Of the 95 patients with HL, 24 patients met inclusion criteria. Data collected included patient demographics, adjuvant therapy, clinic notes, operative interventions and long-term postoperative complications. 2. Results 2.1. Patient characteristics 24 patients underwent staging laparotomy for HL between 1971 and 1994. The average patient age at laparotomy was 14.45 ± 5.02 years, with an equivalent number of males and females. The average followup within the long-term survivorship clinic was 29 ± 6 years. Most patients (n = 21, 87.5%) underwent splenectomy as a part of surgical staging with intraabdominal disease seen in six patients (25%). Postoperatively, 12 patients (50%) required chemotherapy and 17 (70.8%) required radiation therapy. Postoperative staging is demonstrated in Table 1. 2.2. Patient complications No mortalities were identified as a result of surgical complications. One patient however, expired from metastatic adenocarcinoma to the small bowel (unknown primary), 25 years after staging laparotomy for HL. Bowel obstruction, secondary to adhesions, was seen in three patients (12.5%) who required repeat laparotomy, with one patient requiring two laparotomies. Of the three patients requiring laparotomy, two had undergone radiation, with one patient undergoing radiation to the inguinal region (7500 cGy) for local control and the other with mantle radiation (2100 cGy). There were no episodes of bowel obstruction in the 71 patients who did not undergo initial staging laparotomy. Five patients (20.8%) experienced secondary malignancies including breast cancer (n = 3), metastatic adenocarcinoma with unknown primary (n = 1) and bone malignancy (n = 1). Of these, four underwent radiation therapy alone, and one underwent both radiation and chemotherapy. Four patients (three males, one female) experienced posttreatment infertility. There were no documented cases of OPSI, all patients were vaccinated preoperatively and all postsplenectomy patients received prophylactic antibiotics for at least two years postoperatively.
Table 1 Hodgkin lymphoma patient staging. Hodgkin lymphoma staging Stage
n
Ia Ib IIa IIb IIIa IIIb
3 1 4 2 7 1
1431
3. Discussion HL is a curable malignancy with a significant cohort of survivors now facing complications from initial staging and therapy. Most patients who underwent surgical staging have now transitioned out of pediatric acute care oncologic care and a large majority are cared for solely by primary adult care providers. Survivors of HL may have late effects secondary to surgical staging procedures, chemotherapy and radiation treatment. Recognition of these potential complications is essential. Ongoing care in survivorship clinics, such as seen in our institution, provides the best model for early recognition of specific morbidities faced by this unique group of patients. The most important prognosticating factor for HL is clinical stage [1]. Staging laparotomy with splenectomy was historically, widely accepted for the diagnosis and staging of HL. This modality provided excellent diagnostic accuracy of abdominal disease and provided the opportunity to avoid chemotherapy. In a review of staging laparotomy by Multani and Grossbard [4] however, a combined short- and long-term mortality rate of 0.3%–1% was found with major morbidities (cardiac arrest, wound infection or dehiscence, pulmonary embolism, pneumonia, sepsis, small bowel obstruction etc) seen in 3%–18% of patients and minor morbidities (atelectasis, urinary tract infections, prolonged ileus) in 6%–19%. Likewise, staging laparotomy presents risks including postoperative infections, delay of therapy, OPSI and increased risk of leukemia [4]. Recent advances in imaging, along with increasing evidence of procedural risks, have directed management away from open staging procedures [6,7]. Studies have indicated that laparoscopic staging of HL is effective and safe with reduced postoperative morbidity as compared to staging laparotomy [7,8]. Although these advances have reduced the role of open surgical staging, there remains a large population of patients who are at risk for the long-term complications of staging laparotomy. This is the first study to examine long-term complications in a longitudinal cohort of HL survivors. In long-term follow-up, patients in our cohort had a significantly increased incidence of repeat laparotomy for bowel obstruction. This is noted to be 3–4-fold higher than the expected rate of postlaparotomy bowel obstruction which is between 3% and 5% [9]. In 1994, Jockovich et al. [5] found an inverse relationship between age and bowel obstruction. Their investigation determined that 27% of patients who were 15 years or younger at the time of staging laparotomy developed this complication with 6.8% requiring repeat laparotomy. Our examination of pediatric patients receiving staging laparotomy had a similarly high incidence of bowel obstruction (12.5%), suggesting that clinicians should have a high index of suspicion for this complication in patients who underwent staging laparotomy and splenectomy for HL as children. It should be noted that 17/24 patients with staging laparotomy also had radiation as a part of their treatment protocol. No patient however had abdominal radiation, so we do not believe this to have played a major role in development of bowel obstruction. Secondary malignancies have also been reported in patients with HL who underwent staging laparotomy. A previous study by Mauch et al. [10] found 9% of patients to have secondary malignancies including non-Hodgkin lymphoma, leukemia, multiple myeloma and solid tumors, for which the most significant risk factor included the combination of radiation and chemotherapy. In our study, 20.8% of patients developed a secondary malignancy after treatment for HL, with the majority undergoing radiation therapy alone. Similarly to Mauch's findings, the most common solid tumor seen in our cohort was breast. Previous investigations have cited OPSI as being the most serious infectious complication of the staging procedure [5]. Because of the lack of opsonins, in cases where staging laparotomy involved splenectomy, patients were more susceptible to overwhelming sepsis by encapsulated organisms. A review of post-laparotomy complications by Jockovich et al. [5] found a 6.8% incidence of OPSI. Interestingly, they found that 11% of patients who received the pneumococcal vaccine after splenectomy developed OPSI, despite appropriate immunization. Other studies have determined the risk of
1432
I. Lobeck et al. / Journal of Pediatric Surgery 52 (2017) 1430–1432
bacterial sepsis to be between 1.5% and 9% [11–13]. This risk is amplified in children undergoing aggressive chemotherapeutic regimens [11]. In our investigation, no cases of OPSI were seen, despite 20-year follow-up though we acknowledge that this is a devastating complication that should be recognized quickly in postsplenectomy patients. Staging laparotomy is no longer widely utilized for HL, as studies have shown no significant difference in remission or survival between staging with open laparotomy and staging through noninvasive means [14–16]. However, because of the long history of laparotomy with splenectomy being the standard of care for staging in HL, there remains a large population of long-term survivors who underwent surgical staging for HL and are now being cared for in the adult medical system. This care is often through primary care providers who may not have extensive knowledge of pediatric staging and treatment procedures. This study underscores the value of long-term follow-up and participation in oncologic survivorship clinics as an important tool to prevent morbidity. Practitioners should maintain a high index of suspicion for late effects both of surgery and medical treatment. References [1] Kelly K. Hodger. Lymphoma in children and adolescents, improving the therapeutic index. Blood 2015;126(22):2452–8. [2] Glatstein E, Guernsey JM, Rosenberg SA, et al. The value of laparotomy and splenectomy in the staging of Hodgkin's disease. Cancer 1969;24(4):709–18.
[3] Leibenhaut MH, Hoppe RT, Efron B, et al. Prognostic indicators of laparotomy findings in clinical stage I–II supradiaphragmatic Hodgkin's disease. J Clin Oncol 1989; 7(1):81–91. [4] Multani PS, Grossbard ML. Staging laparotomy in the management of Hodgkin's disease: is it still necessary? Oncologist 1996;1(1 & 2):41–55. [5] Jockovich M, Mendenhall NP, Sombeck MD, et al. Long-term complications of laparotomy in Hodgkin's disease. Ann Surg 1994;219(6):615–21 [discussion 621-4]. [6] Lacher MJ. Routine staging laparotomy for patients with Hodgkin's disease is no longer necessary. Cancer Invest 1983;1(1):93–9. [7] Baccarani U, Carroll BJ, Hiatt JR, et al. Comparison of laparoscopic and open staging in Hodgkin disease. Arch Surg 1998;133(5):517–21 [discussion 521-2]. [8] Martinet O, Bettschart V, Scholl B, et al. Value of laparoscopic staging for Hodgkin disease. Surg Laparosc Endosc Percutan Tech 2000;10(5):335–7. [9] Grant HW, Parker MC, Wilson MS, et al. Adhesions after abdominal surgery in children. J Pediatr Surg 2008;43(1):152–6 [discussion 156-7]. [10] Mauch PM, Kalish LA, Marcus KC, et al. Second malignancies after treatment for laparotomy staged IA-IIIB Hodgkin's disease: long-term analysis of risk factors and outcome. Blood 1996;87(9):3625–32. [11] Donaldson SS, Glatstein E, Vosti KL. Bacterial infections in pediatric Hodgkin's disease: relationship to radiotherapy, chemotherapy and splenectomy. Cancer 1978; 41(5):1949–58. [12] Chou MY, Brown AE, Blevins A, et al. Severe pneumococcal infection in patients with neoplastic disease. Cancer 1983;51(8):1546–50. [13] Taylor MA, Kaplan HS, Nelsen TS. Staging laparotomy with splenectomy for Hodgkin's disease: the Stanford experience. World J Surg 1985;9(3):449–60. [14] Bergsagel DE, Alison RE, Bean HA, et al. Results of treating Hodgkin's disease without a policy of laparotomy staging. Cancer Treat Rep 1982;66(4):717–31. [15] Kaplan HS. Hodgkin's disease: unfolding concepts concerning its nature, management and prognosis. Cancer 1980;45(10):2439–74. [16] Gomez GA, Reese PA, Nava H, et al. Staging laparotomy and splenectomy in early Hodgkin's disease. No therapeutic benefit. Am J Med 1984;77(2):205–10.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Long-term morbidity after staging laparotomy for Hodgkin lymphoma☆,☆☆ Inna Lobeck a, Beth Rymeski a, Karen Burns b, Rajaram Nagarajan b, Judy Correll b, Debra Kent b, Roshni Dasgupta a,⁎ a b
Division of Pediatric and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States Cancer and Blood Diseases Institute, Cincinnati Childrens Hospital Medical Center, Cincinnati, OH USA
a r t i c l e
i n f o
Article history: Received 20 September 2016 Received in revised form 21 November 2016 Accepted 28 November 2016 Key words: Hodgkin lymphoma Survivorship Secondary malignancy Staging laparotomy Pediatric cancer
a b s t r a c t Background: A large cohort of Hodgkin lymphoma (HL) survivors exist. With patients transitioning from pediatric to adult care, practitioners should be aware of potential complications. The aim of this study was to describe the long-term complications of patients who had staging laparotomy for the treatment of HL. Methods: After institutional review board approval, a retrospective review of hospital records at our institution was performed. Data extracted included demographics, treatment course and long-term postoperative complications. Results: 24 patients with HL underwent staging laparotomy from 1971 to 1994 with median follow-up of 27.9 years. Six (33%) had intraabdominal disease. Three patients (17%) required four repeat laparotomies for bowel obstruction. Of these, one had radiation to the inguinal region for local control, one had mantle radiation. Five patients developed a second malignancy. There were no documented cases of postsplenectomy sepsis. Other late effects that were unlikely related to surgery included pulmonary fibrosis (4), heart failure (2), hypothyroidism (4), and dysphagia (3). One patient died of metastatic adenocarcinoma. Conclusions: Long-term follow-up of patients who underwent staging laparotomy for HL revealed an increased incidence of repeat laparotomy and secondary malignancy. This underscores the importance of a high index of suspicion and screening in this population. Level of Evidence: Level III. © 2017 Elsevier Inc. All rights reserved.
Physicians treating long-term cancer survivors should be aware of potential complications which may manifest years after surgical treatment of disease. With improved patient survivorship and transition of care from childhood to adulthood, the implications of previous staging procedures may be missed. Hodgkin lymphoma (HL) is a B cell proliferative malignancy that accounts for 7000 new cases annually in the United States [1]. The prognosis of disease relies on accurate staging to direct management. In 1969, Glatstein et al. [2] introduced staging laparotomy including liver biopsy, lymph node biopsy of the celiac, portal, para-aortic, splenic, mesenteric and iliac nodes and splenectomy for the evaluation of HL. This quickly became the standard of care for the staging of intraabdominal disease and was used to determine the extent of disease, per the Children's Oncology Group [3].
☆ The authors have nothing to disclose. This study was unfunded. ☆☆ Type of Study: Retrospective comparative study. ⁎ Corresponding author at: Cincinnati Children's Hospital Medical Center, MLC 2023, 3333 Burnet Ave, Cincinnati, OH 45229, United States. Tel.: +1 513 636-4371; fax: +1 513 636 7657. E-mail address: [email protected] (R. Dasgupta). http://dx.doi.org/10.1016/j.jpedsurg.2016.11.047 0022-3468/© 2017 Elsevier Inc. All rights reserved.
The once-fatal disease now reaches a 98% long-term survival rate [1]. With increasing numbers of HL survivors in the United States currently long-term complications of operative staging and therapy can cause significant adverse events affecting quality of life for survivors. With the advent of more advanced imaging and presence of morbidities associated with surgery, such as cardiac arrest, wound infection, hemorrhage, abscess, pulmonary emboli, pneumonia, sepsis and small bowel obstruction [4] open surgical staging is no longer used for abdominal HL. Despite recent advances in care, physicians treating long-term survivors of HL should be aware of potential high risk complications. With improved patient survivorship of HL and transition of care from childhood to adulthood, the implications of previous staging procedures may be missed. A large subgroup of HL survivors exists that has undergone previous operative staging procedures and requires close followup for possible long-term complications. Although staging laparotomies are no longer the standard of care, because of the large number of patients who once underwent staging laparotomy, practitioners taking care of HL survivors should be aware of long-term complications of this procedure and have a high index of suspicion for these complications. Sequelae of operative staging, such as overwhelming postsplenectomy infection (OPSI) and small bowel obstruction, have been previously described in the literature [5]. In this investigation,
I. Lobeck et al. / Journal of Pediatric Surgery 52 (2017) 1430–1432
we aimed to identify key late complications in patients who underwent open surgical staging as a part of their initial evaluation of the disease. 1. Methods After institutional review board (IRB) approval of experimental protocol, the medical records of 95 consecutive patients with pathologically confirmed HL at Cincinnati Children's Hospital Medical Center were identified through a database of patients in the cancer survivor clinic. Patients younger than 18 years who had undergone surgical laparotomy for staging between 1971 and 1994 were included in the study. Patients who followed up in the long-term survivorship clinic, at least 5 years postoperatively, were included in the study. Of the 95 patients with HL, 24 patients met inclusion criteria. Data collected included patient demographics, adjuvant therapy, clinic notes, operative interventions and long-term postoperative complications. 2. Results 2.1. Patient characteristics 24 patients underwent staging laparotomy for HL between 1971 and 1994. The average patient age at laparotomy was 14.45 ± 5.02 years, with an equivalent number of males and females. The average followup within the long-term survivorship clinic was 29 ± 6 years. Most patients (n = 21, 87.5%) underwent splenectomy as a part of surgical staging with intraabdominal disease seen in six patients (25%). Postoperatively, 12 patients (50%) required chemotherapy and 17 (70.8%) required radiation therapy. Postoperative staging is demonstrated in Table 1. 2.2. Patient complications No mortalities were identified as a result of surgical complications. One patient however, expired from metastatic adenocarcinoma to the small bowel (unknown primary), 25 years after staging laparotomy for HL. Bowel obstruction, secondary to adhesions, was seen in three patients (12.5%) who required repeat laparotomy, with one patient requiring two laparotomies. Of the three patients requiring laparotomy, two had undergone radiation, with one patient undergoing radiation to the inguinal region (7500 cGy) for local control and the other with mantle radiation (2100 cGy). There were no episodes of bowel obstruction in the 71 patients who did not undergo initial staging laparotomy. Five patients (20.8%) experienced secondary malignancies including breast cancer (n = 3), metastatic adenocarcinoma with unknown primary (n = 1) and bone malignancy (n = 1). Of these, four underwent radiation therapy alone, and one underwent both radiation and chemotherapy. Four patients (three males, one female) experienced posttreatment infertility. There were no documented cases of OPSI, all patients were vaccinated preoperatively and all postsplenectomy patients received prophylactic antibiotics for at least two years postoperatively.
Table 1 Hodgkin lymphoma patient staging. Hodgkin lymphoma staging Stage
n
Ia Ib IIa IIb IIIa IIIb
3 1 4 2 7 1
1431
3. Discussion HL is a curable malignancy with a significant cohort of survivors now facing complications from initial staging and therapy. Most patients who underwent surgical staging have now transitioned out of pediatric acute care oncologic care and a large majority are cared for solely by primary adult care providers. Survivors of HL may have late effects secondary to surgical staging procedures, chemotherapy and radiation treatment. Recognition of these potential complications is essential. Ongoing care in survivorship clinics, such as seen in our institution, provides the best model for early recognition of specific morbidities faced by this unique group of patients. The most important prognosticating factor for HL is clinical stage [1]. Staging laparotomy with splenectomy was historically, widely accepted for the diagnosis and staging of HL. This modality provided excellent diagnostic accuracy of abdominal disease and provided the opportunity to avoid chemotherapy. In a review of staging laparotomy by Multani and Grossbard [4] however, a combined short- and long-term mortality rate of 0.3%–1% was found with major morbidities (cardiac arrest, wound infection or dehiscence, pulmonary embolism, pneumonia, sepsis, small bowel obstruction etc) seen in 3%–18% of patients and minor morbidities (atelectasis, urinary tract infections, prolonged ileus) in 6%–19%. Likewise, staging laparotomy presents risks including postoperative infections, delay of therapy, OPSI and increased risk of leukemia [4]. Recent advances in imaging, along with increasing evidence of procedural risks, have directed management away from open staging procedures [6,7]. Studies have indicated that laparoscopic staging of HL is effective and safe with reduced postoperative morbidity as compared to staging laparotomy [7,8]. Although these advances have reduced the role of open surgical staging, there remains a large population of patients who are at risk for the long-term complications of staging laparotomy. This is the first study to examine long-term complications in a longitudinal cohort of HL survivors. In long-term follow-up, patients in our cohort had a significantly increased incidence of repeat laparotomy for bowel obstruction. This is noted to be 3–4-fold higher than the expected rate of postlaparotomy bowel obstruction which is between 3% and 5% [9]. In 1994, Jockovich et al. [5] found an inverse relationship between age and bowel obstruction. Their investigation determined that 27% of patients who were 15 years or younger at the time of staging laparotomy developed this complication with 6.8% requiring repeat laparotomy. Our examination of pediatric patients receiving staging laparotomy had a similarly high incidence of bowel obstruction (12.5%), suggesting that clinicians should have a high index of suspicion for this complication in patients who underwent staging laparotomy and splenectomy for HL as children. It should be noted that 17/24 patients with staging laparotomy also had radiation as a part of their treatment protocol. No patient however had abdominal radiation, so we do not believe this to have played a major role in development of bowel obstruction. Secondary malignancies have also been reported in patients with HL who underwent staging laparotomy. A previous study by Mauch et al. [10] found 9% of patients to have secondary malignancies including non-Hodgkin lymphoma, leukemia, multiple myeloma and solid tumors, for which the most significant risk factor included the combination of radiation and chemotherapy. In our study, 20.8% of patients developed a secondary malignancy after treatment for HL, with the majority undergoing radiation therapy alone. Similarly to Mauch's findings, the most common solid tumor seen in our cohort was breast. Previous investigations have cited OPSI as being the most serious infectious complication of the staging procedure [5]. Because of the lack of opsonins, in cases where staging laparotomy involved splenectomy, patients were more susceptible to overwhelming sepsis by encapsulated organisms. A review of post-laparotomy complications by Jockovich et al. [5] found a 6.8% incidence of OPSI. Interestingly, they found that 11% of patients who received the pneumococcal vaccine after splenectomy developed OPSI, despite appropriate immunization. Other studies have determined the risk of
1432
I. Lobeck et al. / Journal of Pediatric Surgery 52 (2017) 1430–1432
bacterial sepsis to be between 1.5% and 9% [11–13]. This risk is amplified in children undergoing aggressive chemotherapeutic regimens [11]. In our investigation, no cases of OPSI were seen, despite 20-year follow-up though we acknowledge that this is a devastating complication that should be recognized quickly in postsplenectomy patients. Staging laparotomy is no longer widely utilized for HL, as studies have shown no significant difference in remission or survival between staging with open laparotomy and staging through noninvasive means [14–16]. However, because of the long history of laparotomy with splenectomy being the standard of care for staging in HL, there remains a large population of long-term survivors who underwent surgical staging for HL and are now being cared for in the adult medical system. This care is often through primary care providers who may not have extensive knowledge of pediatric staging and treatment procedures. This study underscores the value of long-term follow-up and participation in oncologic survivorship clinics as an important tool to prevent morbidity. Practitioners should maintain a high index of suspicion for late effects both of surgery and medical treatment. References [1] Kelly K. Hodger. Lymphoma in children and adolescents, improving the therapeutic index. Blood 2015;126(22):2452–8. [2] Glatstein E, Guernsey JM, Rosenberg SA, et al. The value of laparotomy and splenectomy in the staging of Hodgkin's disease. Cancer 1969;24(4):709–18.
[3] Leibenhaut MH, Hoppe RT, Efron B, et al. Prognostic indicators of laparotomy findings in clinical stage I–II supradiaphragmatic Hodgkin's disease. J Clin Oncol 1989; 7(1):81–91. [4] Multani PS, Grossbard ML. Staging laparotomy in the management of Hodgkin's disease: is it still necessary? Oncologist 1996;1(1 & 2):41–55. [5] Jockovich M, Mendenhall NP, Sombeck MD, et al. Long-term complications of laparotomy in Hodgkin's disease. Ann Surg 1994;219(6):615–21 [discussion 621-4]. [6] Lacher MJ. Routine staging laparotomy for patients with Hodgkin's disease is no longer necessary. Cancer Invest 1983;1(1):93–9. [7] Baccarani U, Carroll BJ, Hiatt JR, et al. Comparison of laparoscopic and open staging in Hodgkin disease. Arch Surg 1998;133(5):517–21 [discussion 521-2]. [8] Martinet O, Bettschart V, Scholl B, et al. Value of laparoscopic staging for Hodgkin disease. Surg Laparosc Endosc Percutan Tech 2000;10(5):335–7. [9] Grant HW, Parker MC, Wilson MS, et al. Adhesions after abdominal surgery in children. J Pediatr Surg 2008;43(1):152–6 [discussion 156-7]. [10] Mauch PM, Kalish LA, Marcus KC, et al. Second malignancies after treatment for laparotomy staged IA-IIIB Hodgkin's disease: long-term analysis of risk factors and outcome. Blood 1996;87(9):3625–32. [11] Donaldson SS, Glatstein E, Vosti KL. Bacterial infections in pediatric Hodgkin's disease: relationship to radiotherapy, chemotherapy and splenectomy. Cancer 1978; 41(5):1949–58. [12] Chou MY, Brown AE, Blevins A, et al. Severe pneumococcal infection in patients with neoplastic disease. Cancer 1983;51(8):1546–50. [13] Taylor MA, Kaplan HS, Nelsen TS. Staging laparotomy with splenectomy for Hodgkin's disease: the Stanford experience. World J Surg 1985;9(3):449–60. [14] Bergsagel DE, Alison RE, Bean HA, et al. Results of treating Hodgkin's disease without a policy of laparotomy staging. Cancer Treat Rep 1982;66(4):717–31. [15] Kaplan HS. Hodgkin's disease: unfolding concepts concerning its nature, management and prognosis. Cancer 1980;45(10):2439–74. [16] Gomez GA, Reese PA, Nava H, et al. Staging laparotomy and splenectomy in early Hodgkin's disease. No therapeutic benefit. Am J Med 1984;77(2):205–10.