Limited Value of Lymphangiography in Hodgkin's Disease

The following generalizations are commonly accepted as forming the basis for rational therapy in Hodgkin's disease: (a) cure depends on the deliverance of an adequate dose of radiation to all involved tissues; (b) retroperitoneal extensions of apparently localized disease may be clinically silent; (c) lymphangiography will demonstrate clinically silent retroperitoneal extensions in a large percentage of cases (2–5, 7–9); (d) lymphangiography is mandatory for defining the proper treatment volume in curative therapy of Hodgkin's disease (4, 5, 7–9). A review of the lymphangiograms in 71 cases of Hodgkin's disease at Walter Reed General Hospital does not confirm statements c and d, however, but suggests that lymphangiography may be of little practical value in determining proper therapy. Since 1962, more than 250 lymphangiographic examinations have been performed at Walter Reed, over 100 in patients with proved Hodgkin's disease. Of these studies, 71 were available for review and met the criteria for inclusion in the present study. The criteria were kept as simple as possible and consisted of the following three items: (a) each case must have histologically proved Hodgkin's disease with confirmation by the Armed Forces Institute of Pathology; (b) each case must have had the lymphangiography performed as part of the initial staging procedure; (c) each case must have adequate clinical and laboratory information to allow staging of the patient by all parameters other than the lymphangiogram. The film studies were obtained and read independently by three radiologists without benefit of clinical history other than the diagnosis. These readings were then compared with each other and with the original reading of the resident who performed the study. There were thus four independent interpretations of the films. Both the immediate films and the twenty-four-hour follow-up films were carefully reviewed, but in general the diagnosis and the interpretation of the studies were based on the follow-up films. All disease suspected on the immediate study (angial phase) was confirmed on the twenty-four-hour lymph node phase, usually with more complete demonstration of the extent of the disease. There were no cases with unusual lymph flow, collaterals, shunts, or obstructive patterns which did not have obvious nodal disease on the twenty-four-hour follow-up films (Fig. 1). The criteria for positive diagnosis were enlargement of lymph nodes with maintenance of their outline and foamy or reticulated structure to the nodes (Fig. 2) (3, 5, 7, 8, 10).