Sequential pathologic staging of untreated non-Hodgkin's lymphomas by laparoscopy and laparotomy combined with marrow biopsy

Abstract

In a selected series of 119 patients with non-Hodgkin's lymphoma apparently limited to lymph nodes or to primary extranodal sites, two sequential combined surgical diagnostic procedures (laparoscopy plus needle marrow biopsy and laparotomy plus open marrow biopsy) were performed to compare their relative merits in the detection of occult extranodal disease. The final anatomic extent of disease was also correlated with two histopathologic classifications (Rappaport and Kiel). After the first combined procedure, which also included one or more splenic biopsies, 22% of patients showed liver infiltration, 29% splenic infiltration and 17% bone marrow involvement. After the second combined procedure, which was performed in 80 patients with negative histologic findings in the liver on laparoscopy and in the bone marrow on needle biopsy, liver involvement was documented in five patients (6%) while splenic infiltration was detected in eight additional cases. The open iliac crest biopsy revealed an infiltrated marrow in only two patients (3%). Laparotomy also detected other occult sites of lymphoma in abdominal nodes and in the small intestine (total 38%). Thus, most patients with stage IV disease were documented through laparoscopy plus needle marrow biopsy (89%) while laparotomy was mainly useful for a more complete definition of nodal and splenic involvement. The difference of extranodal infiltration between nodular and diffuse pattern already evident in the Rappaport classification (21% vs 41%) becomes even more pronounced in the Kiel classification in which follicular lymphomas belong to only one cytologic type, the centroblastic-centrocytic subgroup. The diffuse histiocytic subtype of the Rappaport classification as well as the immunoblastic lymphoma of the Kiel classification revealed both a remarkably low incidence of extranodal invasion (17% vs. 23%) despite their high biological malignancy.