Prognostic factors for subdiaphragmatic involvement in clinical stage I-IIsupradiaphragmatic Hodgkin's disease: A retrospective analysis of the GHSG

Background: Staging laparotomy and splenectomy were routinely performed in patients with early-stage Hodgkin's disease (HD) qualifying for radiotherap y alone to determine the exact extent of disease. However, staging laparoto my is associated with a considerable number of side effects, warranting mor e sophisticated diagnostic procedures and new therapy strategies. We retros pectively analyzed patients undergoing staging laparotomy to identify preth erapy risk factors predicting the probability of abdominal disease and to d efine high-risk groups that might benefit from staging laparotomy and subse quent stage-adjusted treatment. Patients and methods: Between February 1988 and January 1993, 391 patients with CS I-II supradiaphragmatic Hodgkin's disease underwent staging laparot omy and splenectomy according to the treatment policy of the German Hodgkin 's Lymphoma Study Group (GHSG) for early stages of Hodgkin's disease. Univa riate and multivariate analysis of pretherapeutic clinical characteristics were performed in an attempt to predict staging laparotomy results and to i dentify risk groups. Results: Of the 391 patients, 81 (21%) had subdiaphragmatic disease. Eighte en percent were upstaged to PS III and three percent to PS IV. By a multiva riate model the following parameters were independent risk factors for posi tive surgical staging: left cervical involvement (P < 0.001), mediastinal i nvolvement (P < 0.009), Karnofsky performance status (P < 0.004) and histol ogy (P < 0.04). In our analysis gender (P < 0.08) and ESR (P < 0.06), often described as of high prognostic value, was not significant. The presence o f systemic symptoms, number of involved areas and clinical stage were not a ssociated with abdominal disease, as described in several former publicatio ns. To define high-risk groups, which comprise at least 15% of patients of the cohort and have a risk of subdiaphragmatic involvement of > 35%, combinatio ns of only two or three of the predictive factors were analyzed. With respe ct to these criteria the following subgroups of patients were identified as having a high risk for subdiaphragmatic disease (> 35%): a) left cervical lymph node involvement and no mediastinal involvement (n = 98, observed ris k 36%); b) no mediastinal involvement and MC/LD histology (n = 113, observe d risk 40%). Conclusions: We conclude that initial clinical characteristics are predicti ve for occult abdominal involvement in early clinical stages of Hodgkin's d isease. The impact of these risk factors on future therapeutical strategies have to be evaluated.