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Staging laparotomy for Hodgkin's disease in children
Staging Laparotomy for Hodgkin’s Disease in Children Martin J. Bell, MD, St. Louis, Missouri Vita J. Land, MD, St. Louis, Missouri Jessie L. Ternberg, MD, St. Louis, Missouri
Staging laparotomy for the evaluation of patients with Hodgkin’s disease was first reported in 1969 [I], followed by several reports of this procedure in children with Hodgkin’s disease [2-41. In 1974 a survey of the members of the Surgical Section of the American Academy of Pediatrics [5] addressed itself primarily to the complications associated with splenectomy and laparotomy and concluded that the risk of the procedure was low. Recent reports, however, have cast doubt upon the safety of the procedure
W-4.
Also pertinent is the reliability of the procedure, since therapy and prognostic evaluation will, in part, be based upon information obtained from laparotomy. In particular, failure to find Hodgkin’s disease below the diaphragm, the “negative” laparotomy, must truly indicate an absence of disease as longterm observation is pursued. These issues prompted a review of our experience with staging laparotomy. Material and Methods Patient Data. From September 1969 through May 19’75, twenty-four children were treated for Hodgkin’s disease at St. Louis Children’s Hospital. Of these, twenty-one (15 male, 6 female; 20 white, 1 black) underwent staging laparotomy and form the patient group for this report. Of the three excluded patients, two underwent this procedure at other institutions, and one was stage IV with biopsy-proved pulmonary involvement at the time of initial evaluation. One child, initially seen with stage IIIB disease in 1970, was treated without laparotomy. In 1974 a recurrence in a cervical node prompted a staging procedure. Age of the patients ranged from 4.5 years to 15 years (mean, 11.2 years). Clinical Staging. Clinical staging was carried out, evaluating historical information, physical examination, and laboratory and radiographic data. Duration of symptoms ranged from two days to eight years. All twenty-one patients had lymphadenopathy (19 cervical, 2 inguinal). Ten of twenty-one patients had the appearance of adenopathy six months or longer before the diagnosis was established. Systemic symptoms were present at the time of diagnosis in six of twenty-one patients. These included fever, malaise, and weight loss. From the Departments of Surgery and Pediatrics, Washington University School of Medicine. and the St. Louis Children’s Hospital, St. Louis, Missouri. This work was supported in pat-lby mnt CA-05587 from the National Cancer Institute. Reprint requests should be addressed to Martin J. Bell, MD, Division of Pediatric Surgery, St. Louis Children’s Hospital, 500 South Kingshighway, St. Louis, Missouri 83110.
Chest radiographs were obtained in all patients, and in eleven children hilar, paratracheal, or mediastinal lymphadenopathy was described. Intravenous pyelogram was obtained in seventeen patients and revealed ureteral deviation in three. Inferior venacavogram was performed in four patients and was reported to be abnormal in one. Lymphangiography was carried out in fifteen patients and was abnormal in two. Other routine examinations included complete blood count, liver function studies, and bone marrow aspiration. Confirmation of the diagnosis was made by lymph node biopsy in all patients. Histologic evaluation of the tissue type was nodular sclerosing in twelve, lymphocyte-predominant in four, and mixed cellularity in five. On the basis of this data, clinical stage was assigned as follows: IA (8 patients); W(6); IIB(3); IIIB(3); and IVA(l). Laparotomy was then carried out in all patients, including those with systemic symptoms. Operative Technic. Exploration was carried out through vertical midline or paramedian incisions. The procedure included splenectomy, liver biopsy (both needle and wedge specimens were obtained), and lymph node biopsy. Lymph nodes were obtained from the iliac, paraortic (inferior and superior), mesenteric, and splenic hilar sites. Not every area was biopsied in each patient, and an average of three nodes was submitted per patient. Iliac crest marrow biopsy was also performed. In five of the six female patients oophoropexy was performed, placing the ovaries in the midline, one anterior and the other posterior to the uterus. One of these patients has since had a successful pregnancy. Results
Tissue containing Hodgkin’s disease was obtained in eight of the twenty-one patients. The spleen was the site of disease in all eight. Lymph nodes were positive in three of the patients. ?‘he liver biopsy was positive in one patient who was probable stage IVA by preoperative clinical staging. No positive marrows were obtained. Of the two patients with abnormal lymphangiograms, one had a “negative” laparotomy. Of the thirteen with normal lymphangiograms, four had positive laparotomies, but in all of these patients Hodgkin’s disease was identifiedin the spleen (4) and liver (l), with no abnormal nodes found. Abdominal Hodgkin’s disease was found in four of five patients who were stage B (symptomatic). Disease was present in an abdominal site in five patients with nodular sclerosing tissue type, three patients with mixed cellularity, and in no patients with lymphocyte-predominant histologic pattern.
The American Journal of Surgery
Staging Laparotomy for Hodgkin’s Disease in Children
Postoperative Complications. One child had intestinal obstruction on the fifth postoperative day, requiring lysis of adhesions and derotation of a twisted intestinal segment. A patient twelve years old at the time of staging and splenectomy had pneumococcal septicemia twenty-two months after diagnosis and initiation of therapy. This patient had a second septic episode fourteen months later with group A, beta-hemolytic streptococcus cultured from the blood. His Hodgkin’s disease was active at the time of both septic events and was being treated with chemotherapy. A second patient was treated for apparent septicemia in his community hospital seven months after laparotomy and splenectomy. He was four years old at the time of diagnosis and was receiving chemotherapy at the time of the septic episode. Both children recovered from these infections with appropriate antibiotic therapy. Stage Changes and Patient Status. On the basis of laparotomy findings, 29 per cent of patients in this series changed stage. This included five children whose stage was revised downward (2 patients from stage IIA to IIIA; 2 from IIB to IIIB; 1 from IA to IIIA), the procedure indicating more extensive disease than noted by clinical staging. One child’s staging, changed after treatment for cervical node recurrence, was revised upward (IIIB to IA). Of the five patients with downward revision, two have expired, one is living without evidence of recurrence six years after diagnosis, and two are currently in treatment with no evidence of active disease. Twelve patients with stage I or II disease underwent laparotomy with no biopsied sites found to contain Hodgkin’s disease. None of these patients have subsequently developed disease below the diaphragm, and all are living free of disease, with therapy based upon the staging procedure. Mean follow-up in this group at the time of this writing is forty-two months (range, 20 to 67 months). Two patients with clinical stage III and one with stage IV disease were found to have Hodgkin’s disease in abdominal sites. All three are living, one with persistent disease.
Comments
Hodgkin’s disease is relatively uncommon in the childhood years. Because of this, few institutions have accummulated large series of pediatric patients. Despite this limitation, certain conclusions may be drawn from this relatively small experience with respect to its applicability in children. In terms of safety, our experience shows that staging laparotomy does not subject the patient with Hodgkin’s disease to undue operative risk. Only one patient had a serious immediate postoperative VetlIme 133, May 1977
complication. The period of hospitalization was generally five to seven days. Two patients have had septic episodes, neither fatal. However, this does represent a 10 per cent incidence of this complication, and all patients are now placed on prophylactic penicillin after staging laparotomy. We do not believe that it is necessary to biopsy all major abdominal node groups in each patient. Indeed, an excessive number of node biopsies may tend to increase the incidence of immediate postoperative complications. The procedure described herein has yielded satisfactory tissue with which therapeutic decisions have been made, and has withstood a period of follow-up evaluation in excess of three years, during which time no patient developed abdominal disease after a “negative” laparotomy. Since the radiotherapeutic and chemotherapeutic modalities utilized in the treatment of Hodgkin’s disease are themselves associated with significant risk and complication, their use must be judiciously directed. We therefore conclude that staging laparotomy is a high-yield diagnostic procedure, which although it does incur a risk of postsplenectomy sepsis, continues to have an important place in the management of children with Hodgkin’s disease. Summary
Experience with staging laparotomy in twenty-one children has produced minimal immediate postoperative morbidity. Sepsis in two patients after discharge has prompted the long-term use of penicillin. Confirmation or revision of clinical staging by laparotomy has proved to be an accurate means of determining therapy and prognosis in children. References 1. Glatstein E, Guernsey J, Rosenberg S, Kaplan H: The value of laparotomy and splenectomy in the staging of Hodgkin’s disease. Cancer 24: 709, 1969. 2. Hays D, Hittle RE, lsaacs H Jr, Karon M: Laparotomy for the staging of Hodgkin’s disease in children. J Pediafr Surg 7: 517, 1972. 3. Hay DM, Karon M, lsaacs H, Hittle RE: Hodgkin’s disease: tech nique and results of staging laparotomy in childhood. Arch Surg 106: 507, 1973. 4. Filler RM, Jaffe N, Cassady JR, Traggis DG, Vawter GF: Experience with clinical and operative staging of Hodgkin’s disease in children. Jfediafr Surg 10: 321, 1975. 5. Rosenstock J, D’Angio G, Kieswetter W: The incidence of complications following staging laparotomy for Hodgkin’s disease in children. Am J Roentgenol Radium Ther Nucl h&d 120: 531.1974. 6. Lanzkowsky P, Karayalcin G, Shende A, Levy R: Complications of laparotomy and splenectomy in the stages of Hodgkin’s disease in children. Pediatr Res 9: 369, 1975. 7. Chilcote R. Baehner R: The incidence of overwhelming lnfectlon in children staged for Hodgkin’s disease (abstract). Proc Am Assoc Cancer Res and Am Sot C/in Oncology, 1975. 8. Wayne ER, Kosloske AM, Holton CP, et al: Complication of splenectomy and staging laparotomy in children with H&gkin’s disease. J Pediatr Surg 10: 677, 1975.
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Staging laparotomy for the evaluation of patients with Hodgkin’s disease was first reported in 1969 [I], followed by several reports of this procedure in children with Hodgkin’s disease [2-41. In 1974 a survey of the members of the Surgical Section of the American Academy of Pediatrics [5] addressed itself primarily to the complications associated with splenectomy and laparotomy and concluded that the risk of the procedure was low. Recent reports, however, have cast doubt upon the safety of the procedure
W-4.
Also pertinent is the reliability of the procedure, since therapy and prognostic evaluation will, in part, be based upon information obtained from laparotomy. In particular, failure to find Hodgkin’s disease below the diaphragm, the “negative” laparotomy, must truly indicate an absence of disease as longterm observation is pursued. These issues prompted a review of our experience with staging laparotomy. Material and Methods Patient Data. From September 1969 through May 19’75, twenty-four children were treated for Hodgkin’s disease at St. Louis Children’s Hospital. Of these, twenty-one (15 male, 6 female; 20 white, 1 black) underwent staging laparotomy and form the patient group for this report. Of the three excluded patients, two underwent this procedure at other institutions, and one was stage IV with biopsy-proved pulmonary involvement at the time of initial evaluation. One child, initially seen with stage IIIB disease in 1970, was treated without laparotomy. In 1974 a recurrence in a cervical node prompted a staging procedure. Age of the patients ranged from 4.5 years to 15 years (mean, 11.2 years). Clinical Staging. Clinical staging was carried out, evaluating historical information, physical examination, and laboratory and radiographic data. Duration of symptoms ranged from two days to eight years. All twenty-one patients had lymphadenopathy (19 cervical, 2 inguinal). Ten of twenty-one patients had the appearance of adenopathy six months or longer before the diagnosis was established. Systemic symptoms were present at the time of diagnosis in six of twenty-one patients. These included fever, malaise, and weight loss. From the Departments of Surgery and Pediatrics, Washington University School of Medicine. and the St. Louis Children’s Hospital, St. Louis, Missouri. This work was supported in pat-lby mnt CA-05587 from the National Cancer Institute. Reprint requests should be addressed to Martin J. Bell, MD, Division of Pediatric Surgery, St. Louis Children’s Hospital, 500 South Kingshighway, St. Louis, Missouri 83110.
Chest radiographs were obtained in all patients, and in eleven children hilar, paratracheal, or mediastinal lymphadenopathy was described. Intravenous pyelogram was obtained in seventeen patients and revealed ureteral deviation in three. Inferior venacavogram was performed in four patients and was reported to be abnormal in one. Lymphangiography was carried out in fifteen patients and was abnormal in two. Other routine examinations included complete blood count, liver function studies, and bone marrow aspiration. Confirmation of the diagnosis was made by lymph node biopsy in all patients. Histologic evaluation of the tissue type was nodular sclerosing in twelve, lymphocyte-predominant in four, and mixed cellularity in five. On the basis of this data, clinical stage was assigned as follows: IA (8 patients); W(6); IIB(3); IIIB(3); and IVA(l). Laparotomy was then carried out in all patients, including those with systemic symptoms. Operative Technic. Exploration was carried out through vertical midline or paramedian incisions. The procedure included splenectomy, liver biopsy (both needle and wedge specimens were obtained), and lymph node biopsy. Lymph nodes were obtained from the iliac, paraortic (inferior and superior), mesenteric, and splenic hilar sites. Not every area was biopsied in each patient, and an average of three nodes was submitted per patient. Iliac crest marrow biopsy was also performed. In five of the six female patients oophoropexy was performed, placing the ovaries in the midline, one anterior and the other posterior to the uterus. One of these patients has since had a successful pregnancy. Results
Tissue containing Hodgkin’s disease was obtained in eight of the twenty-one patients. The spleen was the site of disease in all eight. Lymph nodes were positive in three of the patients. ?‘he liver biopsy was positive in one patient who was probable stage IVA by preoperative clinical staging. No positive marrows were obtained. Of the two patients with abnormal lymphangiograms, one had a “negative” laparotomy. Of the thirteen with normal lymphangiograms, four had positive laparotomies, but in all of these patients Hodgkin’s disease was identifiedin the spleen (4) and liver (l), with no abnormal nodes found. Abdominal Hodgkin’s disease was found in four of five patients who were stage B (symptomatic). Disease was present in an abdominal site in five patients with nodular sclerosing tissue type, three patients with mixed cellularity, and in no patients with lymphocyte-predominant histologic pattern.
The American Journal of Surgery
Staging Laparotomy for Hodgkin’s Disease in Children
Postoperative Complications. One child had intestinal obstruction on the fifth postoperative day, requiring lysis of adhesions and derotation of a twisted intestinal segment. A patient twelve years old at the time of staging and splenectomy had pneumococcal septicemia twenty-two months after diagnosis and initiation of therapy. This patient had a second septic episode fourteen months later with group A, beta-hemolytic streptococcus cultured from the blood. His Hodgkin’s disease was active at the time of both septic events and was being treated with chemotherapy. A second patient was treated for apparent septicemia in his community hospital seven months after laparotomy and splenectomy. He was four years old at the time of diagnosis and was receiving chemotherapy at the time of the septic episode. Both children recovered from these infections with appropriate antibiotic therapy. Stage Changes and Patient Status. On the basis of laparotomy findings, 29 per cent of patients in this series changed stage. This included five children whose stage was revised downward (2 patients from stage IIA to IIIA; 2 from IIB to IIIB; 1 from IA to IIIA), the procedure indicating more extensive disease than noted by clinical staging. One child’s staging, changed after treatment for cervical node recurrence, was revised upward (IIIB to IA). Of the five patients with downward revision, two have expired, one is living without evidence of recurrence six years after diagnosis, and two are currently in treatment with no evidence of active disease. Twelve patients with stage I or II disease underwent laparotomy with no biopsied sites found to contain Hodgkin’s disease. None of these patients have subsequently developed disease below the diaphragm, and all are living free of disease, with therapy based upon the staging procedure. Mean follow-up in this group at the time of this writing is forty-two months (range, 20 to 67 months). Two patients with clinical stage III and one with stage IV disease were found to have Hodgkin’s disease in abdominal sites. All three are living, one with persistent disease.
Comments
Hodgkin’s disease is relatively uncommon in the childhood years. Because of this, few institutions have accummulated large series of pediatric patients. Despite this limitation, certain conclusions may be drawn from this relatively small experience with respect to its applicability in children. In terms of safety, our experience shows that staging laparotomy does not subject the patient with Hodgkin’s disease to undue operative risk. Only one patient had a serious immediate postoperative VetlIme 133, May 1977
complication. The period of hospitalization was generally five to seven days. Two patients have had septic episodes, neither fatal. However, this does represent a 10 per cent incidence of this complication, and all patients are now placed on prophylactic penicillin after staging laparotomy. We do not believe that it is necessary to biopsy all major abdominal node groups in each patient. Indeed, an excessive number of node biopsies may tend to increase the incidence of immediate postoperative complications. The procedure described herein has yielded satisfactory tissue with which therapeutic decisions have been made, and has withstood a period of follow-up evaluation in excess of three years, during which time no patient developed abdominal disease after a “negative” laparotomy. Since the radiotherapeutic and chemotherapeutic modalities utilized in the treatment of Hodgkin’s disease are themselves associated with significant risk and complication, their use must be judiciously directed. We therefore conclude that staging laparotomy is a high-yield diagnostic procedure, which although it does incur a risk of postsplenectomy sepsis, continues to have an important place in the management of children with Hodgkin’s disease. Summary
Experience with staging laparotomy in twenty-one children has produced minimal immediate postoperative morbidity. Sepsis in two patients after discharge has prompted the long-term use of penicillin. Confirmation or revision of clinical staging by laparotomy has proved to be an accurate means of determining therapy and prognosis in children. References 1. Glatstein E, Guernsey J, Rosenberg S, Kaplan H: The value of laparotomy and splenectomy in the staging of Hodgkin’s disease. Cancer 24: 709, 1969. 2. Hays D, Hittle RE, lsaacs H Jr, Karon M: Laparotomy for the staging of Hodgkin’s disease in children. J Pediafr Surg 7: 517, 1972. 3. Hay DM, Karon M, lsaacs H, Hittle RE: Hodgkin’s disease: tech nique and results of staging laparotomy in childhood. Arch Surg 106: 507, 1973. 4. Filler RM, Jaffe N, Cassady JR, Traggis DG, Vawter GF: Experience with clinical and operative staging of Hodgkin’s disease in children. Jfediafr Surg 10: 321, 1975. 5. Rosenstock J, D’Angio G, Kieswetter W: The incidence of complications following staging laparotomy for Hodgkin’s disease in children. Am J Roentgenol Radium Ther Nucl h&d 120: 531.1974. 6. Lanzkowsky P, Karayalcin G, Shende A, Levy R: Complications of laparotomy and splenectomy in the stages of Hodgkin’s disease in children. Pediatr Res 9: 369, 1975. 7. Chilcote R. Baehner R: The incidence of overwhelming lnfectlon in children staged for Hodgkin’s disease (abstract). Proc Am Assoc Cancer Res and Am Sot C/in Oncology, 1975. 8. Wayne ER, Kosloske AM, Holton CP, et al: Complication of splenectomy and staging laparotomy in children with H&gkin’s disease. J Pediatr Surg 10: 677, 1975.
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