Treatment of subdiaphragmatic Hodgkin's disease: Is radiotherapy alone appropriate only for inguino-femoral presentations?

PURPOSE: Evaluate the role of staging laparotomy, and the impact of disease subsites on treatment outcome, for sub-diaphragmatic Hodgkin's Disease. METHODS AND MATERIALS: Between 1966 and 1989, 23 patients with Hodgkin's disease limited to sites below the diaphragm were treated at the Royal Adelaide Hospital. The high male:female ratio (2:8), low proportion of nodular sclerosis subtype (26%), and older age (mean = 40) relative to supra-diaphragmatic Hodgkin's disease is consistent with most other series. Thirteen patients underwent staging laparotomy. Initial treatment consisted of radiation therapy alone in 11, chemotherapy alone in 7, and combined modality therapy in 4 patients. This data was then combined with other published series over the last decade, to analyse relapse patterns and treatment results in relation to initial site(s) of disease. RESULTS: The overall, disease specific, and progression free 5 (and 10) year survival rates were 69%, 81%, and 58% respectively. There was no statistically significant effect of staging laparotomy on any of these parameters. Combining these results with those in the literature revealed an unacceptable relapse rate for patients with disease outside of the inguino-femoral region treated with inverted-Y radiation therapy alone. CONCLUSIONS: For the majority of patients with sub-diaphragmatic Hodgkin's disease, staging laparotomy can be avoided. Inverted-Y radiation therapy should only be used for inguino-femoral presentations.