Indicazioni e Risultati Preliminari Della Laparotomia Diagnostica Nei Vari Tipi di Linfoma Maligno

Abstract

From September 1970 to November 1971 83 unselected patients with malignant lymphomas (48 with Hodgkin's disease, 12 with lymphosarcoma and 23 with reticulum cell sarcoma) underwent diagnostic laparotomy with splenectomy and liver, retroperitoneal and mesenteric node biopsies. 19/83 cases (mostly referred from other hospitals) had received either local radiotherapy or a course of chemotherapy. In 79/83 with stages I, II and III the laparotomy was carried out to better define the extent of involvement below the diaphragm before therapy. In 4 patients with stage IV reticulum cell sarcoma (gastrointestinal involvement) laparotomy was indicated either because of bleeding (3) or because of bowel obstruction (1). Before sugery patients underwent accurate clinical, hematological, biochemical and radiological evaluation including scintiscan of liver as well as hepatic biopsy with Menghini's needle (table 1). After laparotomy patients were stages according to Rye's classification. The spleen was not removed in 3 cases because of technical difficulties. The overall incidence of splenic involvement (table 2) was found to be almost identical in Hodgkin's disease (29.5 %) and in lymphoreticular sarcomas (28.5%). The spleen was histologically positive in a high percent age of both groups of cases with disease above and below the diaphragm, as well as with lymphocyte depletion (7/14) and with systemic symptoms (78 %) in Hodgkin's disease (table 3). The mean weight of the involved spleen was 346 g (95–1050), that of the uninvolved spleen was 189 g (75–500). The overall incidence of histologic involvement of liver was (18.4%), 6.2% in Hodgkin's disease and 17.4 % in the group of lymphoreticular sarcomas (table 4). There were no patients with liver involvement without concomitant spleen involvement. When the patients with positive lymphangiograms and/or palpable spleen (1–3 cm below the costal margin) are excluded, diagnostic laparotomy detected occult intra-abdominal lesions in 13/48 (27 %) cases with Hodgkin's disease and, respectively, 5/35 (14.3 %) cases with lymphoreticular sarcomas (table 5). The overall incidence of occult lesions was 21.8%. Histology correlated with lymphography in 64/83 (77%) cases (table 6). In 3/4 patients with negative lymphography histologically abnormal nodes were found above LII. In 8/10 patients with positive lymphography and negative histology (5 sampled in lymphographically non suspicious area and 3 around the celiac axis) the post-laparotomy films confirmed the persistence of abnormal nodes. This was indirectly proved by an almost immediate progression in the para aortic lymph nodes in 1 case and by a marked regression in 7 cases after chemotherapy and/or radiotherapy. Since laparotomy is not infallible in removing abnormal nodes one should rely on lymphographic findings in case of discrepancy to plan the appropriate therapy. Complications secondary to laparotomy were minimal and transient. The indications and advantages of this new useful procedure in all types of malignant lymphomas are discussed (table 7).