Posttransplant lymphoproliferative disorder (PTLD) is a complication of solid organ transplantation and is associated with Epstein-Barr virus (EBV). Recently, EBV-related PTLD was defined as probable PTLD or proven PTLD. Probable PTLD involves significant lymphadenopathy, hepatosplenomegaly, or other end-organ manifestations, without a histological diagnosis, together with significant EBV DNAemia. Proven PTLD is the detection of EBV-encoded proteins in a tissue specimen, together with symptoms and/or signs originating from the affected organ. Probable PTLD after pediatric liver transplantation has not been well documented. Therefore, here, we aimed to describe cases of five pediatric patients with probable PTLD after liver transplantation, who were successfully treated with preemptive immunosuppression reduction with or without rituximab. All five patients (age range, 1-4 years; two girls and three boys) had EBV DNAemia. Three patients developed probable PTLD within 12 months of transplantation. Further, three patients had a significantly high EBV viral load, but the other two patients with lymphadenopathy and end-organ manifestation had a relatively low EBV viral load. Early onset pediatric PTLD with significant EBV DNAemia is almost universally EBV-related. Biopsy was not performed in any patient due to the relative inaccessibility of the lesion and young age of the patients. If the patient's symptoms are too mild, if excisional biopsy is too difficult to perform, or if the patient is too sick to undergo an invasive procedure, initiating preemptive treatment without a histological diagnosis could be the treatment option.

A pathological diagnosis of a lesion in the ureteral wall is often attended with a difficulty. We report a case of a 54-year-old man who presented a thickening of the ureteral wall and diffuse swelling of paraaortic lymph nodes diagnosed as a non-Hodgkin lymphoma by a laparoscopic needle biopsy. This is a safe and useful technique by which target tissues can be surely obtained.

Lymphadenopathy-identified incidentally during computed tomography (CT) mandates a tissue diagnosis. When percutaneous techniques are not possible, surgical tissue diagnosis becomes necessary. Laparotomy is the current gold standard; however a laparoscopic approach offers many potential benefits.

This institutional review board (IRB)-approved study evaluated all patients undergoing laparoscopic retroperitoneal lymph node biopsy from 2001 to 2007 at the Cleveland Clinic. Patient records were retrospectively reviewed for age, sex, pathologic diagnosis, conversion to laparotomy, and perioperative complications.

A total of 30 cases were reviewed. In this group, 67% were males and 33% were female; mean age was 48 years. Ten patients underwent mesenteric lymph node sampling and 20 (67%) underwent retroperitoneal tumor resection. There were four (17%) conversions and no complications. Lymphoma was the most common pathologic finding.

Laparoscopic lymph node biopsy is a safe effective alternative to open surgical biopsy.

Ultrasound or computed tomography-guided percutaneous lymph nodes biopsy often do not supply sufficient tissue for the histopathologic diagnosis of a lymphoma. Laparoscopic lymph node biopsy (LLB) has the advantage of obtaining the entire lymph node and avoiding the invasivity and all the possible complications of a laparotomy. The aim of the present study is to assess the safety and diagnostic accuracy of the LLB in intra-abdominal lymphoma. Between April 1999 and October 2005, 36 LLB were performed in 35 patients to rule out or to follow the progression of a lymphoma. The clinical outcome and the pathology reports were analyzed retrospectively. A conversion to laparotomy was necessary in 2 cases due to intraoperative difficulties (5.8%). No major postoperative complications or mortality occurred. Mean hospital stay was 2.1 days. In 9 patients, LLB was performed to follow a possible progression of the lymphoma, whereas in 26 patients it was used to establish a diagnosis. Two repeated LLB were necessary to achieve a correct diagnosis in 1 patient. Fourteen patients had non-Hodgkin lymphoma, 6 patients had Hodgkin lymphoma, 9 patients presented an infiltration by primitive or metastatic tumors, and 7 patients had benign lymphadenopathy. In 97% of the cases, LLB supplied the necessary information for the correct diagnosis, classification, and subsequent therapeutic decisions. In conclusion, LLB is a safe and effective procedure. Its diagnostic accuracy is superior to percutaneous techniques. LLB can be proposed as the procedure of choice to sample deep lymphatic tissues in patients with intra-abdominal lymphadenopathy at a very low morbidity rate and as an outpatient procedure in selected cases.

Laparo- or retroperitoneoscopic biopsy was performed for five male patients with retroperitoneal lymph node swelling of unknown origin. Previous core needle biopsies were useless or inapplicable in all patients. A laparoscopic approach was used for two patients, with a retroperitoneoscopic approach for the remaining three patients. Sufficient specimens for not only pathological diagnosis but also further examinations such as immunophenotyping or DNA analysis were safely obtained. Convalescence was satisfactory and all patients were treated appropriately according to the resulting diagnosis. This technique should be performed by urologists, who are more familiar with laparo- or retroperitoneoscopic approach targeting retroperitoneal organs.

Although primary gastrointestinal (GI) lymphomas are an infrequent occurrence and represent 1%-4% of the malignant tumors of the GI tract, secondary involvement of the GI tract by lymphoma is not uncommon. Several controversies remain about the prognostic stratification and the optimal treatment modalities for these lymphomas. A crucial component of answering these questions is an accurate and complete characterization of the tumor. The currently used World Health Organization classification of hematologic malignancies requires integration of morphologic, immunophenotypic, and genotypic features to define a disease type. Through the use of a representative case we highlight how this information is used for the appropriate diagnosis of a GI lymphoma. We also discuss the clinical features, including radiologic and endoscopic findings in patients presenting with a GI lymphoma. The review is a pathologist's perspective on what to do when suspecting a lymphoma of the GI tract.

Evaluation of the sensitivity and specificity of fine needle aspiration of retroperitoneal masses and lymph nodes in gynecologic oncology.

Retrospective study of 101 punctures administered to 84 patients aged 23-86 years. The method's sensitivity and specificity were evaluated by clinical follow-up.

A satisfactory sampling was obtained in 89.1% of punctures, and a cytological diagnosis was made in 88.1%. The size of the lymph nodes punctured was less than 14 mm in 46.5%. This test has a sensitivity of 87.5%, specificity of 88.9%, positive predictive value of 98%, negative predictive value of 53.3%, and accuracy of 87.7%. Four patients presented complications: pain (2), hematoma (1), and right ureteral perforation (1).

The fine needle aspiration technique has excellent positive predictive value and low morbidity. As a method of visualization, CT-scan, in combination with lymphography, allows the location of small lesions and the definition of their internal structures. The weak negative predictive value of fine needle aspiration might be correctible by laparoscopy-directed biopsy, and its potential is clearly ensured by the development of techniques for locating sentinel lymph nodes.

To assess the efficacy of laparoscopy in the diagnosis of intra-abdominal lymphoma.

The medical records of patients with suspected primary or recurrent lymphoma who underwent laparoscopy between March 1991 and March 2003 were reviewed. Demographic, clinical, operative, and pathologic data were collected. The feasibility, safety, and effectiveness of the laparoscopic procedure were assessed.

Laparoscopic biopsy was attempted in 94 patients. In 78 patients (83%), the procedure was completed laparoscopically. Conversion to laparotomy was undertaken in 16 patients (17%), most commonly because of inadequate exposure, insufficient tissue, or postoperative adhesions. Among the 69 cases of lymphoma, 55 (80%) were diagnosed via laparoscopy only, 9 (13%) via laparotomy, and 5 (7%) with later procedures. Of the remaining 25 patients, 7 had nonlymphoma disease (4 occult carcinomas, 1 multiple myeloma, 1 epithelioid leiomyosarcoma, and 1 neuroblastoma), and 18 had benign lymphadenopathy (no evidence of lymphoma with a mean follow-up of 53 months). The laparoscopic procedure resulted in false-negative results in 6 patients (6%). The mean hospital stay for patients having a laparotomy was 6 days (range, 3-10 days); the remaining patients were all outpatients. The only Intraoperative laparoscopic complication was hemorrhage that required laparotomy. This event occurred in a patient with a previously undiagnosed neuroblastoma.

Laparoscopic lymph node biopsy safely provides adequate tissue for full histological evaluation on an outpatient basis in most patients with intra-abdominal lymphoma.

Laparoscopy seems to be playing an emerging role in the management of lymphoproliferative diseases. The aim of this study was to prospectively analyze personal experience evaluating the role and limits of laparoscopy in the management of lymphomas. From July 1993 to December 2000, 131 consecutive patients were referred to our institution for primary diagnosis (group A, n = 70), suspected relapse (reassessment) (group B, n = 54), or staging/restaging of lymphoproliferative diseases (group C, n = 7). Diagnostic and/or operative laparoscopy was performed in all patients. To assess the accuracy of laparoscopy, the results were analyzed according to the indications for surgery. In all, 128 procedures were completed laparoscopically (95.5%). Conversion was required in 7 cases (5.1%). Causes of the conversions were severe obesity (body mass index 62.5), uncontrolled intraoperative bleeding (HIV+), nondiagnostic tissue sampling (2 cases), perisplenic inflammation and perisplenic abscesses (3 cases). The results of this study highlight the safety of diagnostic and staging laparoscopy and laparoscopic splenectomy in patients with lymphoproliferative diseases (major complications 2.9%, perioperative mortality 0%). In all, 96.4% of patients from group A and 100% of patients from group B were treated on the basis of laparoscopic findings. No false negative diagnosis occurred. Laparoscopy may become the "gold standard" in the management of lymphoproliferative disease in the following settings: for the differential diagnosis of hepatic and/or splenic focal lesions; when percutaneous needle biopsy fails and/or genetic analysis is needed for therapeutic decision; for the primary diagnosis and abdominal staging of patients with diffuse retroperitoneal lymphadenopathy in the absence of peripheral lymphadenopathy; for cases of abdominal restaging after concurrent chemoradiotherapy and in cases of suspected relapse when percutaneous biopsy is not technically possible; and for patients with lymphoproliferative disease when splenectomy is required. Marked splenomegaly with perisplenic inflammatory reaction and lymphadenopathy in HIV+ patients should be considered possible causes of failure of the laparoscopic approach.