THE ROLE OF INITIAL LAPAROTOMY AND 2ND-LOOK SURGERY IN THE TREATMENT OF ABDOMINAL B-CELL NON-HODGKINS-LYMPHOMA OF CHILDHOOD - A REPORT OF THE BFM GROUP

The aim of this study was to determine the role of surgery in the trea tment of abdominal B-cell non-Hodgkin's lymphomas (B-NHL) in children. We analyzed the effect of surgical variables of initial laparotomy an d second-look surgery on event-free survival (EFS) of 177 patients wit h abdominal B-NHL enrolled into the three consecutive multicenter tria ls NHL-BFM 81, NHL-BFM 83, and NHL-BFM 86. The therapy regimen was com parable in all 3 trials as well as the overall outcome of the patients . Patients with stage II and complete resection received 3 courses of therapy (4 in trial NHL-BFM 81), patients with stage II not resected, stage III, and stage IV received 6 courses of therapy (8 in trial NHL- BFM 81). An initial laparotomy was performed in 161 patients, in 59 of them as an urgent procedure. Complete resection of the abdominal prim ary was performed in 43 patients, 40 of them had a localized bowel tum or. The probability of EFS (pEFS) at 5 years is 95 %, 69 %, 62 %, and 67 % for patients with complete resection, subtotal resection (n = 36) , partial resection (n = 21), or biopsy only (n = 61), respectively. C omplete resection was achieved in 30 out of 40 patients with stage II, but only in 12 of 113 and 1 of 24 patients with stage III and IV resp ectively. pEFS at 5 years according to stage and completeness of resec tion is as follows: stage II complete resected 97 %; stage II not comp lete resected 100 %; stage III/IV complete resected 92 %; stage III/IV not complete resected 63 %. The rate of postoperative complications ( n = 20) was 19 % after incomplete resections and 7 % in patients with a biopsy only. Two patients suffered from relapse along a former drain age tube channel. Second-look surgery was performed in 60 patients. Th e intraoperative findings corresponded to the preoperative findings of ultrasonography and/or computed tomography in 88 % of the cases. The rate of failures after the second-look operation was 9 of 27 patients without residual tumor, 4 of 25 patients with residual tumors containi ng only necrotic tissue, and 5 of 8 patients with active residual lymp homa. Our conclusions are: For patients with localized bowel tumors co mplete removal is of advantage allowing a reduced chemotherapy. Howeve r, no major functional impairment is justified since an equally good p rognosis is achieved with intensified chemotherapy. In patients with e xtended disease, a biopsy only is recommended; debulking procedures ar e to be avoided. Drainage tubes are not to be used. If the diagnosis c an be established from examination of effusions or the bone marrow, a laparotomy should be avoided so that chemotherapy can be started witho ut delay. Even in patients presenting as a surgical emergency a preope rative ultrasonography should be performed in order to give the surgeo n valuable information for planning the appropriate procedure. Second- look surgery is not needed in addition to ultrasonography or CT for de tection of residual tumors after initial chemotherapy. However, a seco nd-look operation is still of value in order to identify those patient s with vital residual tumors who may benefit from an intensified treat ment.