Residual or recurrent chest mass in pediatric Hodgkin's disease. A surgical problem?

Controversy surrounds the management of a residual chest mass in patients treated for Hodgkin's disease. Between 1971 and 1985, we treated 22 children, aged 7-18 years, with pathologically proven Hodgkin's disease. Nine had radiographic evidence of mediastinal and/or pulmonary involvement. Following treatment, a residual or new chest mass occurred in three patients, prompting surgical exploration. No histologic subtype of Hodgkin's disease predominated in this group. Two patients had received radiotherapy and chemotherapy, and one had received chemotherapy alone. The erythrocyte sedimentation rate (ESR), uniformly elevated at diagnosis, was normal prior to surgery in all three patients. Gallium scans, also uniformly positive at diagnosis, were negative in two patients but positive in a third, suggesting possible relapse. At operation, however, no patient had recurrent Hodgkin's disease. Pathologic findings were thymic fibrosis, mediastinal pseudocyst, and normal thymus, respectively. We conclude that a chest mass following treatment for Hodgkin's disease may be benign, particularly if disease markers such as ESR have normalized. Moreover, a positive gallium scan does not necessarily indicate recurrent Hodgkin's disease. Although surgical exploration is a prudent policy when there is persistent evidence of residual or recurrent chest mass, our experience suggests that immediate exploration is not mandatory and may be deferred for a period of close continued observation.