Medical and Pediatric Oncology 12:244-246 (1984)

Hodgkin’s Disease Presenting in Epitrochlear Nodes

Anthony Yu, MD, and Alan D. Steinfeld, MD

Two cases of Hodgkin’s Disease (HD) pre- senting in epitrochlear nodes are described, and compared to four similar cases gleaned from the literature. The nodular sclerosis type of HD was present in 5 of the 6 patients. Of the four patients staged with laparotomy, two

had infradiaphragmatic disease. A treatment approach using radiation alone for patients with disease limited to the epitroclear region is presented, and anatomical considerations of the treatment technique are given

Key words: epitrochlear nodes, Hodgkin’s disease, lymphoma

INTRODUCTION

The frequency with which Hodgkin’s disease presents in various anatomical areas has been documented. Cer- vical and supraclavicular nodes are most commonly in- volved, followed in frequency by axillary and medias- tinal nodes [2,8].

Lymph nodes in the epitrochlear area are rarely in- volved with Hodgkin’s disease, and then usually as part of more widespread disease. In Dorfman’s series [l] of 185 patients, only three (1.6%) had epitrochlear adeno- pathy during their illness. Of the 149 patients reported by Landberg and Larsson [2,3], two had involvement of epi- trochlear nodes. By comparison, involvement of the epi- trochlear nodes by nodular lymphoma, particularly as a site of relapse, has been reported in 23 % of patients [9].

In recent years, several authors have presented iso- lated case reports of Hodglun’s disease presenting in the epitrochlear region. Two of these patients had no other evidence of tumor [3,4] and in two other patients, the epitrochlear node was the initial manifestation of more advanced disease [5,6].

Two additional cases of Hodgkin’s disease presenting in epitrochlear nodes are described. The diagnostic and therapeutic implications of this clinical situation will be discussed.

Fig. 1. AP X-ray of film of left elbow of Case 1. Note discrete epitrochlear nodes.

CASE 1 From the Department of Radiation Oncology, St. Vincent Hospital, Worcester, Massachusetts (A.Y.) and the Department of Radiation Oncology, New York University Medical Center, New York (A.S.)

Address reprint requests to Alan D. Steinfeld, MD, Department of Radiation Oncology, NYU Medical Center, 566 First Avenue, New

A 12-year-’ld girl painless left epitrochlear nodules- An x-ray film of the area &owed four distinct

and Hodgkin’s disease, tKKhhr sclerosing type was found. Work-up

(Fig‘ ‘1. They were

revealed a normal chest X-ray, lymphangiogram, IVP, York City, NY 10016.

0 1984 Alan R. Liss, Inc.

Hodgkin’s Disease in Epitrochlear Nodes 245

dose was given to the right axillary and supraclavicular regions in 18 treatments.

The patient has been followed regularly for 4 years with no evidence of disease.

CBC, and blood chemistries. One month after excision of the epitrochlear nodes she was admitted for staging laparotomy. At this time, a 2-cm left axillary node was found. It was removed at the time of laparotomy. The axillary node contained Hodgkin’s disease, but the sam- pled infradiaphragmatic nodes, liver, spleen, and bone marrow were free of disease.

She was treated on a protocol for stage IIA disease. The left epitrochlear area received 3,500 rads in 20 treatments over 4 weeks. Additionally, a mantle type field was used to deliver 3,500 rads to the cervical, supraclavicular, axillary, and mediastinal areas. She is free of disease 3.5 years after treatment.

CASE 2

A 40-year-old white man was admitted to the Malcolm Grow USAF Medical Center for staging and treatment of Hodgkin’s disease. Six weeks prior to referral, he noted a painless mass in the right epitrochlear area. Initial outpatient evaluation revealed no evidence of trauma or infection in the right hand. There was no history of fever, night sweats, or weight loss. Excisional biopsy was per- formed 2 weeks after initial presentation. Two nodes, each measuring approximately 1.5 cm, were removed. Histological examination revealed Hodgkin’s disease, mixed cellularity type.

A complete physical examination produced normal results. The patient underwent further staging which in- cluded gallium scan, liver/spleen scan, lymphangiogram, and bone marrow aspiration, all of which were normal. A laparotomy revealed no evidence of tumor. The patient was staged as IA.

Treatment consisted of cobalt radiation to the right epitrochlear area. A 4,000-rad midline dose was deliv- ered in 20 treatments via parallel opposed portals to the right epitrochlear area. In addition, a 3,600-rad midplane

DISCUSSION

The epitrochlear nodes are located along the basilic vein, 2-4 cm above the medial condyle of the humerus. There is usually one node, measuring a few millimeters in diameter, though two, or rarely three, nodes may be found. The efferent lymphatics from this group ascend superficially to the mid-upper arm, and then penetrate the fascia to join deep lymphatic trunks. At this point, deep (brachial) nodes may be found. The ascending deep lymphatic trunks then follow the main arteries and rarely have nodes situated along their course. They empty into the lymphatics and nodes associated with the axillary vein v11.

The prospect of cure in Hodgkin’s disease is corre- lated with the extent of the tumor at the time of initial diagnosis. The staging laparotomy has been shown to be of value, in patients with supradiaphragmatic stages I and II disease, in identifying areas of occult subdiaphragmatic tumor. In a Stanford series, 95 patients with stage I disease underwent staging laparotomy [ 101. Eighty-five patients presented with supradiaphragmatic disease, and 10 patients presented with inguinal-femoral nodes. There were no cases of epitrochlear adenopathy. Of 95 patients, 24 (25 %) had occult abdominal disease at laparotomy. The positive laparotomies were confined to the patients who presented with disease above the diaphragm. Of the nine patients who presented with axillary disease, four had tumor found in the spleen or splenic hilar nodes.

The incidence of abdominal involvenient in patients with epitrochlear Hodgkin’s disease appears to be of

TABLE I. Primary Epitrochlear Hodgkin’s Disease*

Clinical Lapa- Pathological Author Histology stage rotomy stage RX Outcome

Firth NS I None NA Regional RT NED 2 years Berman et a1 [4] NS I None NA Combination

chemotherapy NED 14 months Weiss and Jenkins [6] MC I + I11 (spleen) TNI + MOPP NED 3 months Sacks and Saab [7] MC I + IV (spleen) Not stated ?

(liver) Case 1 NS IIa - I1 Mantle RT

Case 2 MC I - I Involved field RT 4 years

*MC = mixed cellularity; NS = nodular sclerosis; NA = not applicable; RT = radiation therapy; MOPP = nitrogen mustard, vinicristine, prednisone, procarbazine; TNI = total nodal irradiation; NED = no evidence of disease. aPatient presented with epitrochlear node. An axillary node was found several weeks after presentation, at the time of staging laparotomy.

epitrochlear area 3 1/2 years

246 Yu and Steinfeld

magnitude similar to that of patients with primary axil- lary disease. Table I summarizes the patients presenting with epitrochlear Hodgkin’s disease found in the litera- ture and the two cases in this report. Two of the four patients who underwent staging laparotomy had occult disease in abdominal organs. While both of these patients had an unfavorable histology (Mixed Cellularity) (MC) another patient with MC histology had a negative laparotomy .

Adequate treatment for patients with solitary epi- trochlear Hodgkin’s disease cannot be definitely decided upon from these few cases. However, it appears reason- able to consider such a presentation analagous to cases of high cervical node. In such instances, locoregional radia- tion in appropriately selected patients has been shown to be highly effective [12], patients who do develop more widespread disease being salvageable with radiation and/ or chemotherapy [13]. With the ability to salvage these patients, the need for staging laparotomy in such presen- tation has been questioned [ 14,151. The occasional pres- ence of lymph nodes along the course of efferent lymphatics connecting the epitrochlear and axillary re- gions suggests that the radiation field used should cover the course of these vessels. Since treatment of the axillary nodes carries so little morbidity and since this area may be difficult to evaluate, it is reasonable to include this area as well.

ACKN OW LE DCM E N T S

The authors gratefully acknowledge the secretarial as- sistance of Ms. Robin Fowler.

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