The Importance of Staging Laparotomy in Pediatric Hodgkin’s Disease By Christopher K. Breuer, Nancy J. Tarbell, Peter M. Mauch, Howard J. Weinstein, Mary Morrissey, Donna Neuberg, and Robert C. Shamberger zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPO Boston, Massachusetts zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJ 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 pathologi- cal 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 tomog- raphy 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. Post- splenectomy 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 war- ranted for the majority of pediatric patients with Hodgkin’s disease if treatment will be guided by stage. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Copyright o 1994 by zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA W .B. Saunders Company INDEX WORDS: Hodgkin’s disease, staging laparotomy. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA T HE ROUTINE USE of staging laparotomy for Hodgkin’s disease (HD) is controversial. At our institution, because the stage of disease determined the treatment strategy, staging laparotomy and sple- nectomy were generally recommended between 1969 and 1991 for patients with clinical stage (CS) I, II, or III HD. In an effort to avoid the morbidity and mortality associated with staging laparotomy, investi- gators have compared CS with pathological stage (PS) to see if CS could accurately predict and therefore replace PS.rm8 They discovered that restag- ing (either upstaging or downstaging) occurred in 25% to 40% of the patients studied, thereby reaffirm- ing the utility of staging laparotomy. However, studies Journal of Pediatric Surgery, Vol 29, No 8 (August), 1994: pp 1085-l 089 have identified subgroups of patients with HD for whom CS is a more accurate predictor of PS.le4 The purpose of this study was to assess the impact of the staging laparotomy on the rate of upstaging and downstaging, the rates of restaging in various sub- groups, the morbidity and mortality from staging laparotomy, and the pathological findings in upstaged patients. MATERIALS AND METHODS Between April 1969 and December 1991. staging laparotomy was performed as part of the routine diagnostic evaluation in 247 pediatric patients presenting with supradiaphragmatic HD at the Joint Center for Radiation Therapy (JCRT), the Dana-Farber Cancer Institute, and the Children’s Hospital in Boston, Massachu- setts. Our population consisted of 150 males (61%) and 97 females (39%). The mean age was 15 years (range, 3 to 18 years). Thirty-seven percent of the patients were less than 13; 63% were between 13 and 18 years of age. One quarter of the patients presented with B symptoms; the others did not have B symptoms. Because staging laparotomy was not routinely recommended for stage IV HD, most of our patients (82%) presented with CS I or II disease; only 18% had CS III or IV disease. Twelve percent of patients had lymphocyte-predominant (LP) histology. The other 88% had nodular sclerosing (63%). mixed cellularity (24%). or lymphocyte-depleted (1%) tissue types. In all patients, clinical staging was determined by history, physical examination, blood counts and chemistries, and chest radiography. Patients with mediastinal or hilar adenopathy had whole lung tomography or computed axial tomography (CT) scans of the chest. The number of sites involved above the diaphragm was determined using the Ann Arbor Classification Guide1ines.g Bipedal lymphangiography (LAG) was performed in 145 pa- tients, and abdominal CT scans were obtained for 70 patients. Fifty patients (20%) did not have LAG or an abdominal CT scan before undergoing staging laparotomy. These patients were staged before the availability of CT scanning, and, because of age, would have required general anesthesia to complete the LAG. HD was staged as CS III or IV for any of the following reasons: positive abdominal CT scan result (nodes > 2 cm in size), positive From the Departments of Surgery, Radiation Therapy, Pediatrics (Division of HematologylOncology), and Statistics, Children’s Hospi- tal, Dana Farber Cancer Institute, and the Joint Center,for Radiation Therapy, Haward Medical School, Boston, MA. Presented at the 1993 Annual Meeting of the Section on Surgery of the American Academy of Pediatrics, W ashington, DC, October 29-31, 1993. Address reprint requests to Robett C. Shamberger, MD, Department of Sutgety, Childrens Hospital, 300 Longwood Ave, Boston, MA 02115. Copyright o I994 by W . B. Saunders Company 0022- 3468194/2908- 0027$03.O O lO 1085