Hodgkin's Disease

THE etiology, symptoms, prognosis, and pathology of Hodgkin's disease have been thoroughly covered by many writers, particularly Yates and Raine, Bunting, and others. I am chiefly concerned with the accompanying osseous changes and the treatment. I am quite sure that the incidence of bone involvement in Hodgkin's disease is much higher than the literature would lead us to believe. As we become more thorough in our examinations, insisting upon complete radiologic investigation of the skeleton, more and more will we find osseous involvement. At the present writing, it is impossible to give statistics on the frequency with which bony changes occur. One cannot rely on the figures quoted in the older literature—the autopsies were not complete, and thorough X-ray examinations were not made. It has occurred to us in the study of our cases that there is a similarity between bone metastases following carcinoma and bone changes in Hodgkin's disease. Review of the bones usually attacked by carcinomas and Hodgkin's disease shows them to be parallel. As is true in carcinoma, so in Hodgkin's disease also, the vertebræ, ribs, pelvis, and femora most frequently show changes. These findings lead us to believe that the disease invades areas rich in red marrow. The cases we have examined revealed no changes in the bones distal to the elbows or knees. We know that there is an absence of red marrow in these bones after puberty. We are also aware that metastasis from carcinoma is relatively infrequent in these same bones. These observations have furnished material for speculation, so that we ask the question, “Are the diseases similar in their methods of bone invasion?” It is true, as far as we know, that Hodgkin's disease starts in the lymphatics, for a long period remaining confined to them. To admit these facts tends to discourage any further theorizing. However, we were not content to drop the subject and, on further investigation, found cases diagnosed as carcinoma of the lymph glands of the cervical region, proven by biopsy, with definite areas of metastasis in the ilium. It seems unlikely that the disease spread to the ilium by way of the lymphatics. It seems more reasonable and more probable that the extension was hematogenous. We are bearing in mind Handley's2 work in which he presents the theory that cancer is disseminated by permeation of the lymphatics. Handley believed that metastasis occurred by extension of the tumor cells through the deep fascial lymphatics. It seems reasonable to assume that carcinoma of the breast might easily spread to the adjacent structures by way of the lymphatics, but the possibility of carcinoma of the breast metastasizing to the proximal third of the femur, by way of the lymphatics, does not seem reasonable or likely. The hematogenous route seems more accessible and plausible. Von Recklinghausen3 holds that tumors spread through the blood stream into the bone marrow.