and lateral chest radiographs. Mediastinal adenopathy may be quantitated by a measurement of the maximum width of the mediastinal mass divided by the maximum «rathoracic diameter (near the level of the diaphragm), shown in Figure 70-1. When this ratio exceeds 1 the disease is defined as bulky.” A computed tomogra- phy (CT) scan of the chest provides ancillary information regarding the extent of intrathoracic disease and assists in treatment planning.” ‘The retroperitoneal lymph nodes are evaluated best by bipedal lymphography (Fig, 70-2). The lymphogram re- vveals abnormalities not only in size of lymph nodes but also in their internal architecture. The sensitivity, speci- ficity, and overall accuracy of the lymphogram are 85%, 988%, and 95%, respectively.”' The lymphogram is espe- cially helpful for subdiaphragmatic presentations. Unfor- tunately, skill in the performance and interpretation of this examination is diminishing, and access to the study generally is not available outside major academic centers. An abdominal and pelvic CT scan should be obtained: however, the CT scan is less sensitive, specific, and accu- rate (65%, 92%, and 87%, respectively) for detection of disease in the retroperitoneal nodes than is the Iympho- gram.™ Even in the spleen, where the risk for discase is high, the CT scan has an overall accuracy rate of only 58%. The CT scan is also less useful than the lymphogram for purposes of identification of isolated abnormal nodes for the surgeon (if a laparotomy is contemplated), ra tion therapy treatment planning, and subsequent follow. up evaluation, Nevertheless, the abdominal CT scan serves as an important complement to the lymphogram FIGURE 70-1, The mediastinal mass ratio (MMA). The ratio is defined as the maximum single Norizontal mediastinal mass measurement divided by the maximum intrathoracic diameter (usually near the diaphragm). In this instence, MMA is 13.0 + 28.0, 0.46. a Cuapter 70: Hopckin’s Disease / 1965, FIGURE 70-2. Example of a positive lymphogram. In this bipedal ymphogram, the nodes throughout the left side (paraaottic, common iliac, and external iliac) are all involved, ‘demonstrating generalized enlargement and a foamy inter- nal architect tern. Compare with the nodes opacilied ‘on the right (paracaval, common iliac, and extemal iliac), all ‘of which appear normal. for its ability to occasionally identify disease in the upper abdomen or spleen The value of gallium scanning depends on the quality of the study and the skill of the interpreter. High-dose gallium with single photon emission computed tomogra. phy (SPECT) provides the most valuable images. This nique may be most helpful in evaluation of the medi- astinum. especially in detection of residual disease after treatment.” Approximately two thirds of patients who have positive restaging gallium scans after completion of ‘chemotherapy experience a subsequent relapse, compared with fewer than 20% of those with negative studies. 2-fluoro-2-deoxy-D-glucose (18FDG) positron emission tomography (PET) is being explored as another imaging ‘modality. but additional data are required before any judg. ment can be made regarding its utility Magnetic resonance imaging (MRI) may be an alterna: tive to chest or abdominopelvie CT scanning for initial staging." In addition, MRI scanning may prove to be as useful as gallium imaging in the evaluation of possible1977 CHAPTER 70: HODGKIN'S DISEASE FIGURE 70-11. (A) Diagnostic chest radiograph of a patient with a large mediastinal mass before any treatment. The patient received 12 weeks of chemotherapy and then was referred for consolidative irradiation. (B) Consolidative irradiation field to treat the mediast m and bilateral supraciavicular regions. The fields are designed to treat the remaining residual mediastinal abnormality Subdiaphragmatic Stage I or IE Disease Approxim: ly 10% of patients with stage lor II Hodg- kin’s disease present with involvement limited to sub diaphragmatic sites.” Lymphography is very helpful for management decisions. Patients with stage Vin femoral presentations, especially with lymphocyte pre dominance histology, do not require a staging laparotor Treatment to the inverted Y (with or without the sple: may be sufficient. Ifthe iliac nodes are involved, « st laparotomy may be performed to define appropriate ther apy more precisely. Alternatively. a full inverted-Y and spleen field may be treated, followed by prophylact treatment to the mantle oF minimantle. If involvement of the paraaortic nodes is detected-by imag bone marrow biopsy should be performed, and treatment studies, programs should be analogous to those for stage Ill dis ease, because the spleen is involved in approximately 40% of cases.” In general, the outcome of treatment for patients with subdiaphragmatic disease is equivalent to that for patients with supradiaphragmatic diseave Stage IIA Disea tA orable subgroup of stay. Patients with st Only the most those with anatomic substage IH, and eithe only limited splen neous: group MIA patients volved sple be considered for treatment with irradiation alone. This sup comprises one third of patients with stage IA disease. Because a staging laparotomy is essential to iden lify this favorable subgroup and staging lap being performed less frequently. these patients infrequently in clinical practice » further If a staging laparotomy is performed but selection criteria are used. lon 435 to GO have been reported for stage HA.” * It fo anatomic subst patients are selected accordi extent of splenic involve to 80% may be achieved with irradiation alon Neverth roup of patients with yent, relapse-free rates of 7. pelvic irradiation) less, in clinical practice even this favorable st MIA aise: e often is eated with combined-modality therapy Most patients with stage IIIA disease may be trea effectively with combined-modality therapy. The paran ters of irradiation and chemotherapy vary in programs at different centers. Most report rates of 80% to 906 Few data exist re ¢ the use of chemotherapy aline IIA Hoilgkin’s disease, Althou we IITA disease are included 1 some series. their out in stag patients wit st rately fram that of th 1c MIB or IV disease nthe United King up of patients with series have been reported dom. The dru MVPP pelphalan, vinblastine. procarbavine. and predni1988 / PRINCIPLES AND PRACTICE OF RADIATION ONCOLOGY TABLE 71~1. Diagnostic workup for non-Hodgkin's lymphoma GENERAL History, including systemic symptoms (unexplained fever, night sweats, weight loss >10% of body weight) Physical examination: Special attention to lymphatic sites, ‘organomegaly; For palpable lymph nodes; note and record number, size, location, shape, texture, and mobility Mirror examination of pharynx and oral cavity SPECIAL TESTS. Standard Bilateral iliac crest bone marrow biopsy Review of slides by expert hematopathologist Cytologic evaluation, if any effusion present Complementary Peritoneoscopy with liver biopsy RADIOGRAPHIC STUDIES Standard Posteroanterior and lateral chest fiims CT scans of abdomen and pelvis; CT scans of chest and neck if disease is present tsotopie bone scan Complementary * Gallium sean Upper gastrointestinal or small bowel series when clinically indicated CT scan of brain when clinically indicated LABORATORY STUDIES Standard Complete blood count (including platelet count, reticulocyte count), blood chemistres (including blood urea nitrogen, creatinine, uric acid levels), urinalysis LDH, liver function tests, including serum alkaline Phosphatase “Brymoye tener Sedimentation rato Serum electrophoresis, Baseline T3, T4, TSH if neck irradiation is to be used CT, computed tomography; LOH, lactate dehydrogenase; 3, triiodothyronine; T4, thyroxine; TSH, thyroid-stimulating, hormone. (LDH); imaging tests; and a bone marrow biopsy. The ‘minimum imaging investigations include chest radiogra- phy and computed tomography (CT) scanning of the ab- domen and pelvis.'* Some GI extranodal lesions not visi- ble on barium studies are visible on CT scans. CT scans are best for identifying mesenteric lymph node involve- ment (Fig. 711A). Use of CT scans enables proper deh nition of tumor volume and dose-limiting normal struc- tures (kidneys and liver) and enhances treatment planning, with the use of a simulator and therapy computer (Fig. 71-18). CT scan of the thorax reveals abnormalities in 7% to 30% of patients with initially normal chest radio- graphs and additional abnormalities in 254 of those with abnormal chest radiographs." Appropriate imaging tests should be performed to delineate the extent of extra- nodal disease, its size, its invasiveness, and its effect on other organs. In uncertain cases, a cytologic examination of an effusion or a needle biopsy of a suspicious lesion, may help to clarify disease extent. The specificity = sensitivity of Iymphangiography in expert hands hay been reported to exceed those of CT.” However, wit improvements in CT technology and the increased use of chemotherapy in early-stage disease, the overall value of lymphangiography has diminished."°* Magnetic ‘reso. nance imaging (MRI) is useful to delineate the extent of disease in soft tissues, but itis especially useful in illus: trating the extent of bone, extradural, and brain involve- ment. The use of gadolinium enhances MRI imaging ig the central nervous system. Approximately 75% to 83% of patients with NHL have uptake of gallium, depending, on the histology. Gallium scanning, especially high-dose gallium (10 mCi) combined with single photon emission, FIGURE 71-1. (A) CT scan showing mesenteric and retro- peritoneal disease at the lavel of he renal hilum. (6) isodose Curve from a muttifield radiation treatment plan to provide an idealized tumor dose of 45 Gy to the defined target vol ume, with lesser dose to the Iver volume (median 30 Gy) and to the kidneys (median 20 Gy).