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The Surgical Treatment of Hodgkin's Disease

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The Surgical Treatment of Hodgkin's Disease [CANCER RESEARCH 26 Part 1, 1254-1263, June 1966] The Surgical Treatment of Hodgkin's Disease GEORGE T. PACK AND DAVID W. MOLANDER The Pack Medical Foundation, New York, New York Summary matous, but it does not permit of detailed classification. If we stress this necessary minor surgery so strongly at this time, it is Re-evaluation of the role of radical surgery in the treatment of early Hodgkin's disease is proposed. The correct application for 3 reasons: (a) the incredible evidence that many physicians of surgical techniques for the diagnosis of Hodgkin's disease and in this present day ignore the presence of and do not remove an enlarged and obviously pathologic lymph node for biopsy, influ the treatment of complications and concurrent unrelated dis enced by the dangerous assumption that it is due to an inflam eases is elaborated. The acceptable indications and probable matory lymphadenitis; (6) some patients continue to be treated contraindications for radical extirpative dissection followed by a by irradiation and/or chemotherapy without histologie verifica full tumor dose of irradiation as the initial treatment of patients with unifocal Hodgkin's disease are discussed. tion of the diagnosis; (c) if such a lymph node were excised more frequently and earlier, the percentage of patients with Hodgkin's A significantly higher 10-year survival rate occurred in a limited number of patients with early Hodgkin's disease treated disease in unifocal Stage I would increase, thereby enlarging the opportunities for surgical treatment and greater curability initially with radical surgery and irradiation as compared with a group treated with irradiation only. Further re-examination of If suspicious peripheral lymph nodes do not exist, the surgeon may elect to perform an exploratory laparotomy to biopsy a this approach is justified. palpable mass of unknown character, although admittedly the majority of patients with retroperitoneal nodal Hodgkin's dis Introduction ease have definite enlargement of peripheral lymph nodes. In a series of 50 exploratory laparotomies for obscure abdominal In a legendary book on the natural history of Ireland, there diseases performed at the Memorial Hospital, only 4 were sub was purported to be a chapter listed in the table of contents as sequently labeled as futile in affording neither diagnosis nor "Snakes of Ireland," but on turning to the listed page number, the subject was disposed of with the laconic sentence: "There treatment (39). Thoracotomy is occasionally performed to biopsy a mediastinal or pulmonary mass of obscure nature. A prelimi are no snakes in Ireland." So today, some iconoclasts have inti nary scalene biopsy which reveals Hodgkin's disease would mated that "there is no surgical treatment of Hodgkin's disease" obviate the necessity for the more major thoracotomy since it and are inclined to refer all cases of this disease to the thera would offer presumptive evidence that the mediastinal lymph peutic disciplines of irradiation and chemotherapy. In the denial nodes were part of the same disease. of any indications for primary surgical treatment they could be 90% correct, but there are occasional settings in which surgical excision may serve beneficially as an ally of the more commonly Lymphangiographic Diagnosis employed modes of treatment (Table 1). It is essential not only to establish a definitive histologie diag nosis but also to determine by all possible means the probable Biopsy staging of the disease. In addition to radiographie visualization of chest and bones, medical surveys by physical examination, Three centuries have elapsed since Malpighi (20) in his "De blood counts and bone marrow studies, and scintigrams of bony Viscerum Structura" described the necropsy findings of nodular skeleton (radioactive fluorine-18) and liver (radioactive iodine- splenic lesions and lymphadenopathies characteristic of the 131 rose bengal), a minor surgical procedure known as lym- lymphoid disease to which we now apply the eponym, "Hodg phangiography may change the clinical staging of Hodgkin's dis kin's disease." Of the 7 cases originally described by Thomas ease from Stage I to Stage II. For example, by using a tiny No. Hodgkin in 1832 (14), only 3 would qualify today as truly repre 10 polyethylene catheter inserted into an intermetatarsal web sentative of the disease which bears his name. Regardless of lymphatic, made visible by a blue dye (alphazurine), a radio- specific signs and symptoms, the clinical diagnosis is never as paque liquid called Ethiodal (ethyl ester of iodized poppy seed accurate as a peripheral node biopsy. For the record, for future oil) is slowly injected by a small lymphangiogram pump [Ariel statistical evaluation, for the estimation of prognosis, for guid and Resnick (2)]. Visualization of the femoral, inguinal, iliac, ance in the choice of therapy, a biopsy is essential. It may be and paraaortic and paracaval nodes is achieved. Identification of accomplished most satisfactorily by the complete removal of a retroperitoneal Hodgkin's disease by this procedure has inhibited peripheral lymph node. Partial removal of a lymph node is us from performing groin dissections for erroneously labeled hazardous because the capsule is released and local spillage and unicentric disease (Stage I). Whenever the radiographie proce infiltration may occur. Aspiration biopsy is condemned; it may dure reveals a more advanced stage of this disease, Ariel has afford evidence to the pathologist that the lesion is lympho- continued the lymphatic infusion by substituting Ethiodal syn- 1254 CANCER RESEARCH VOL. 26 Downloaded from cancerres.aacrjournals.org on September 29, 2021. © 1966 American Association for Cancer Research. Surgical Treatment thesized with radioactive iodine-131 and administered therapy in TABLE 2 doses of 20-40 me (Fig. 1). HODGKIN'S DISEASE: INITIAL LYMPHADENOPATHY LymphadenopathyCervicalMediastinalAxillaryInguinalParaaorticMesenterioEpitrochlearPreauricularNasopharyngealMultipleTotalNo.ofpatients85524034161412622272%20.916.412.610.75.14.41.97.085.0 General Principles and Indications for Surgical Treatment Williams et al. (38) have wisely considered 4 different condi tions under which surgery may be helpful to the patient with Hodgkin's disease: (a) surgery for diagnosis: peripheral node biopsy, even laparotomy or thoracotomy; (6) surgery for concur rent unrelated diseases, e.g., appendicitis; (c) surgery for com plications directly and indirectly related to Hodgkin's disease, such as hypersplenism, or compression of the spinal cord or trachea; (d) surgery for the definitive treatment of Hodgkin's disease per se. EVALUATION OF PROGNOSTIC FACTORS IN THE INDIVIDUAL PATIENT.Before subjecting the patient with Hodgkin's disease to the rigors of major surgen-, the acceptable indications and in tiding a patient with advanced Hodgkin's disease over the the probable contraindications should be fully evaluated. The surgical procedure. factors deemed favorable from the standpoint of a good prog STAGEi OR PHASEi—UNICENTRICFOCUSOF HODGKIN'SDIS nosis are normal red blood cell and marrow cell counts; absence EASE.Stage I describes a unicentric focus of Hodgkin's disease of leukocytosis, leukopenia, eosinophilia, and thrombocyto- without constitutional symptomatology. In selected instances penia; lymphadenopathy localized to 1 region; early surgical within this group of patients, e.g., with either cervical, axillary, intervention for Stage I Hodgkin's disease; bulky local growth or groin lymphadenopathies, an initial surgical intervention may but remaining as a unicentric focus; and the histologie type of add many years to the life expectancy of the patient. If a surgi Hodgkin's disease with nodular sclerosis. Factors strongly sug cal attack cannot be applied, a no less aggressive approach with gesting that radical curative surgical efforts are contraindieated radiation therapy is indicated. In this stage of Hodgkin's disease, include the following states: rpimary abdominal Hodgkin's the best chance exists to prevent the malignant tumor from disease, Pel-Ebstein septic fever, fever concurrent with the very pursuing a progressive and, at times, intermittent and relent incipiency of the disease, splenomegaly, multiple regions of lessly malignant course. nodal involvement, severe pruritus, and antecedent acute infec Hodgkin's disease, as a disorder, may implicate the entire tion. Unfortunately, by the time the diagnosis is established reticuloendothelial system but, fortunately, may affect only a there are not too many patients free of 1 or more of the afore regional group of lymph nodes in its incipiency. In order of fre mentioned unfavorable factors. quency, the initial lymphadenopathies reported by our patients UNRELATED SURGICAL PROCEDURES IN PATIENTS WITH HODG- are as follows: cervical, mediastinal, axillary, inguinal, para- KIN'S DISEASE.Allthe usual unrelated surgical diseases and indi aortic, mesenteric, epitrochlear, preauricular, nasopharyngeal, cations which can afflict a group of otherwise normal people may and simultaneous multicentric regions (Table 2). The most funda occur in patients with Hodgkin's disease. Surgical procedures for mental concept here in the choice of future treatment is the cholelithiasis, appendicitis, lung abscess, bleeding ulcers, perfora realization that it may be a clinically localized disease and, tions of the gastrointestinal tract, even Cesaríansection for therefore, amenable to extirpative dissection (32). Such a uni dystocia must be done, employing
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