Shear Wave Elastography of the Lumbar Multifidus Muscle in Patients With Unilateral Lumbar Disk Herniation.

OBJECTIVES: To assess lumbar multifidus muscle stiffness in patients with unilateral lumbar disk herniation (LDH) causing nerve root compression using shear wave elastography (SWE). METHODS: Thirty-three patients with unilateral subarticular LDH (L3-L4, L4-L5, and L5-S1) causing nerve root compression, diagnosed by magnetic resonance imaging, were enrolled in the study. Exclusion criteria were bilateral or multilevel LDH confirmed on magnetic resonance imaging, bilateral leg symptoms, and patients with a history of any spinal operation, malignancy, trauma, infection, spondylolisthesis, severe lateral recess stenosis, spinal canal stenosis, and substantial comorbidities. Two observers separately evaluated the multifidus muscle using SWE. Shear wave elastographic examinations of the muscle were performed slightly below the herniation using the spinous process of the vertebra as a landmark. The stiffness of the muscle between affected and normal sides was compared. Moreover, the correlation between the stiffness and duration of the symptoms and the correlation between the stiffness and severity of the nerve compression were also calculated. RESULTS: The mean stiffness values of the multifidus muscle on the affected side (mean ± SD: observer 1, 14.08 ± 3.57 kPa; observer 2, 13.70 ± 4.05 kPa) were significantly lower compared to the contralateral side (observer 1, 18.81 ± 3.95 kPa; observer 2, 18.28 ± 4.12 kPa; P < .001). The muscle stiffness had a moderate negative correlation with the duration of the symptoms and the severity of the nerve compression (observer 1, r = -0.535; observer 2, r = -0.458; P < .001). CONCLUSIONS: The multifidus muscle on the ipsilateral side of the LDH showed reduced stiffness values, and stiffness values were negatively correlated with the disease duration and severity of the nerve compression. Further studies might reveal the potential role of SWE of the multifidus muscle in determining clinical outcomes and assessing effectiveness treatment in patients with LDH.

Evaluation of the Tibial Nerve with Shear-Wave Elastography: A Potential Sonographic Method for the Diagnosis of Diabetic Peripheral Neuropathy.

Purpose To evaluate the value of shear-wave elastography (SWE) in the detection of diabetic peripheral neuropathy (DPN) of the tibial nerve. Materials and Methods This study was approved by the institutional review board, and written informed consent was obtained from all study participants. The study included 20 diabetic patients with DPN (10 men, 10 women), 20 diabetic patients without DPN (eight men, 12 women), and 20 healthy control subjects (nine men, 11 women). The tibial nerve was examined at 4 cm proximal to the medial malleolus with gray-scale ultrasonography and SWE. The nerve cross-sectional area (in square centimeters) and the mean nerve stiffness (in kilopascals) within the range of the image were recorded. Inter- and intrareader variability, differences among groups, and correlation of clinical and electrophysiologic evaluation were assessed with intraclass correlation coefficients, the Mann Whitney U test, and the Wilcoxon signed rank test. Results Between diabetic patients with and diabetic patients without DPN, mean age (60 years [range, 38-79 years] vs 61 years [range, 46-75 years], respectively), mean duration of diabetes (10 years [range, 1-25 years] vs 10 years [range, 2-26 years]), and mean body mass index (31.4 kg/m2 [range, 24.7-48.1 kg/m2] vs 29.8 kg/m2 [range, 22.9-44.0 kg/m2]) were not significantly different. Diabetic patients without DPN had significantly higher stiffness values on the right side compared with control subjects (P < .001). Patients with DPN had much higher stiffness values on both sides compared with both diabetic patients without DPN (P < .001) and healthy control subjects (P < .001). A cutoff value of 51.0 kPa at 4 cm proximal to the medial malleolus revealed a sensitivity of 90% (95% confidence interval [CI]: 75.4%, 96.7%) and a specificity of 85.0% (95% CI: 74.9%, 91.7%). Conclusion Tibial nerve stiffness measurements appear to be highly specific in the diagnosis of established DPN. The increased stiffness in subjects without DPN might indicate that the nerve is affected by diabetes. © RSNA, 2016 Online supplemental material is available for this article.

Corkscrew Collateral Vessels in Buerger Disease: Vasa Vasorum or Vasa Nervorum.

PURPOSE: To investigate the origin of "corkscrew" collateral vessels around the occluded popliteal artery in patients with Buerger disease by Doppler ultrasound (US) and magnetic resonance (MR) imaging in tandem with digital subtraction angiography (DSA). MATERIALS AND METHODS: Between January 2013 and June 2015, 42 patients diagnosed with Buerger disease were identified retrospectively. Patients in whom occlusion of the popliteal artery was found on DSA of the lower extremity were subjected to Doppler US and MR imaging prospectively. Fifteen of 42 patients were identified as having the required characteristics, of whom 10 participated in the present study. RESULTS: Ten patients with occlusion of the popliteal artery were selected for inclusion, and 12 lower limbs of these patients were investigated. The study cohort comprised one woman and nine men with a mean age of 41 years ± 10 (standard deviation; range, 39-58 y). Corkscrew collateral vessels identified on DSA examinations were also identified on secondary imaging (Doppler US and MR imaging) in all patients except one in whom the popliteal artery was reconstituted after short-segment occlusion. The origin of the corkscrew collateral vessels was identified as the vasa nervorum of the tibial nerve in nine patients. CONCLUSIONS: Data from the present study suggest that corkscrew collateral vessels at the knee level in patients with Buerger disease originate from the vasa nervorum of the tibial nerve rather than the vasa vasorum of the popliteal artery if the latter is occluded.

Is There Any Difference Between Seminomas and Nonseminomatous Germ Cell Tumors on Shear Wave Elastography? A Preliminary Study.

OBJECTIVES: The purpose of this study was to evaluate the ability of shear wave elastography (SWE) to differentiate seminomas from nonseminomatous germ cell tumors. METHODS: Approval for this retrospective study was obtained from the local Ethics Committee of Istanbul University Cerrahpasa Medical School. Fifteen patients with malignant testicular lesions were examined by grayscale sonography, color or power Doppler sonography, and SWE between February 2011 and October 2015. The size of each lesion, Doppler signal parameters, echogenicity, presence of microlithiasis, unifocality or multifocality, and histopathologic findings were the main factors evaluated. RESULTS: The mean age of the patients was 33 years (range, 25-55 years). There were no differences between seminomas and nonseminomatous germ cell tumors in terms of Doppler signals, echogenicity, microlithiasis, or focality. Only the homogeneous and heterogeneous echogenicity patterns differed significantly. However, a significant difference was evident in SWE-derived quantitative data. CONCLUSIONS: Seminomas and nonseminomatous germ cell tumors do not differ significantly on grayscale or Doppler sonography, except in terms of homogeneity. However, SWE seems to differentiate seminomas from nonseminomatous germ cell tumors.

Shear wave elastography of the placenta in patients with gestational diabetes mellitus.

To evaluate placental elasticty in women with gestational diabetes mellitus (GDM) and non-diabetic controls. Thirty-three pregnant women with GDM according to the current criteria of the American Diabetes Association and 43 healthy pregnant women who were admitted to the antenatal clinic were recruited for this case-control study. Elasticity values of both the peripheral and the central parts of the placentas of the patients in both groups were determined by shear wave elastography (SWE) imaging. Mean elasticity values of both the central and the peripheral part of the placentas were significantly higher in GDM pregnancies (p < 0.001). No difference was observed in the mean elasticity values of the central and the peripheral part of the placentas in two groups (p > 0.05). SWE imaging technology might provide a quantitative assessment of the morphological pathologies of placentas in pregnant women with GDM.

A Rare Complication of the Thyroid Malignancies: Jugular Vein Invasion.

BACKGROUND: Unilateral invasion of the internal jugular vein (IJV) after subtotal thyroidectomy caused by local recurrence of papillary thyroid carcinoma is extremely rare. We report a case of papillary thyroid carcinoma which invades IJV with hypervascular tumor thrombus. CASE REPORT: We report a case of a 52-year-old woman with a history of previous thyroid operation who presented with a 2-month history of a painless, growing, hard, solitary mass on the left side of the neck. Clinical examination revealed also ipsilateral cervical lymphadenopathy. Radiological examination showed a necrotic and cystic mass arising from the operated area extending and invading the left jugular vein wall with hypervascular tumor thrombus. Cytological examination of the mass confirmed a papillary thyroid carcinoma (PTC) and enlarged metastatic lymph nodes. Therefore, total thyroidectomy with left neck dissection and segmental resection of the left internal jugular vein were performed, and the tumor thrombus was cleared successfully. CONCLUSIONS: Invasion of IJV with hypervascular tumor thrombosis is an extremely rare condition in papillary thyroid carcinoma. Thrombosis of IJV is probably underdiagnosed. Early-stage diagnosis is important for long-term survival rates.

Median nerve stiffness measurement by shear wave elastography: a potential sonographic method in the diagnosis of carpal tunnel syndrome.

OBJECTIVES: To measure the median nerve (MN) stiffness by quantitative shear wave elastography (SWE) at the carpal tunnel inlet and to determine whether SWE can be used in the diagnosis of carpal tunnel syndrome (CTS). METHODS: The study included 37 consecutive patients (60 wrists) with a definitive diagnosis of CTS and 18 healthy volunteers (36 wrists). The MN cross-sectional area (CSA) by ultrasound and stiffness by SWE were studied. The difference between CTS patients and controls, and the difference among subgroups based on electrodiagnostic tests were studied by the Student's t test. Interobserver variability and ROC analysis were performed. RESULTS: The MN stiffness was significantly higher in the CTS group (66.7 kPa) when compared to controls (32.0 kPa) (P < 0.001), and higher in the severe or extreme severity group (101.4 kPa) than the mild or moderate severity group (55.1 kPa) (P < 0.001). A 40.4-kPa cut-off value on SWE revealed sensitivity, specificity, PPV, NPV and accuracy of 93.3%, 88.9%, 93.3%, 88.9% and 91.7%, respectively. Interobserver agreement was excellent for SWE measurements. CONCLUSIONS: Median nerve stiffness at the carpal tunnel inlet is significantly higher in patients with carpal tunnel syndrome, for whom shear wave elastography appears to be a highly reproducible diagnostic technique. KEY POINTS: • Clinical examination is important for diagnosis of carpal tunnel syndrome • Shear wave elastography (SWE) offers new clinical opportunities within diagnostic ultrasound • SWE is highly reproducible in evaluation of median nerve stiffness • Median nerve stiffness is significantly increased in carpal tunnel syndrome • Elastography could become useful in diagnosis of carpal tunnel syndrome.

Shear wave elastography in the evaluation of liver fibrosis in children.

BACKGROUND: Shear-wave elastography (SWE) is a novel noninvasive method that involves application of local mechanical compression on soft tissue using focused ultrasonography and acquiring strain images that show tissue response. In this study, our goal was to assess the performance of SWE in the staging of liver fibrosis in children with chronic liver disease. METHODS: The study involved measuring SWE values in the right lobe of the liver in a patient group of 76 children with chronic liver disease and a control group of 50 healthy subjects. In the patient group, the shear elastic modulus values were correlated with biopsy results according to the Brunt scoring system (F0: portal fibrosis, F1: perisinusoidal or portal/periportal fibrosis, F2: both perisinusoidal and portal/periportal fibrosis, F3: bridging fibrosis, and F4: cirrhosis). Performance of SWE in estimating liver fibrosis in children was determined based on a receiver-operating characteristics (ROC) analysis. RESULTS: Mean SWE values of the control group and F0 group were not statistically significantly different (P = 0.106). The mean SWE values of the F1, F2, F3, and F4 groups were higher than that of the control group (all P < 0.001). Based on kiloPascal measurement values, the area under the ROC curve was 95.2% (95% confidence interval [CI] 92.1-99.5), with a sensitivity for diagnosing liver fibrosis of 91.5%, a specificity of 94.0%, a positive predictive value of 93.1%, and a negative predictive value of 92.6%. Based on meter-per-second measurement values, the area under the ROC curve was 96.3% (95% CI 92.7-99.8), with a sensitivity for diagnosing liver fibrosis of 93.2%, a specificity of 94.0%, a positive predictive value of 93.2%, and a negative predictive value of 94.0%. Mean SWE values for patients with nonalcoholic steatohepatitis were higher than those in the remainder of the study group. CONCLUSIONS: Although liver fibrosis can be detected using SWE, differentiation of fibrosis stages could not be achieved. The presence of steatosis significantly increased the mean SWE values on elastography and so care should be taken when assessing children with nonalcoholic steatohepatitis.

Relative proportions of stromal to cellular components of pleomorphic adenomas: determination with shear wave elastography.

OBJECTIVES: The purpose of this study was to evaluate whether the relative proportions of stromal to cellular components of pleomorphic adenomas have an effect on the shear elastic modulus determined by shear wave elastography (SWE). METHODS: This study was approved by the Ethics Committee of our institution and performed between September 2011 and December 2012. Thirty-five patients who underwent surgery for a parotid mass were included in the study. The maximum shear elastic modulus of the mass was measured by SWE. Pleomorphic adenomas were histopathologically subdivided into stroma-poor, intermediate-stroma, and stroma-rich tumors based on the relative proportion of stromal to cellular components. RESULTS: The maximum shear elastic modulus values of the pleomorphic adenomas ranged from 12.6 to 291.9 kPa (mean ± SD, 120.9 ± 92.8 kPa). The Friedman test revealed a statistically significant relationship between the stromal amount and maximum shear elastic modulus (P < .001). Stroma-poor adenomas (mean, 32.3 ± 27.7 kPa; range, 12.6-81.1 kPa) were softer on SWE than stroma-rich adenomas (mean, 174.1 ± 48.4 kPa; range, 92.7-217.2 kPa; P = .009). No such significant difference was detected between stroma-poor and intermediate-stroma tumors (mean, 146.3 ± 106.1 kPa; range, 19.1-291.9 kPa; P = .062) or between intermediate-stroma and stroma-rich tumors (P = .465). CONCLUSIONS: Shear wave elastography depicts pleomorphic adenomas with a variable appearance, which is due to the relative proportions of stromal to cellular contents in the tumors.

Ultrasound-guided injection for MR arthrography of the hip: comparison of two different techniques.

OBJECTIVE: The purpose of this study was to prospectively evaluate the two different ultrasound-guided injection techniques for MR arthrography of the hip. MATERIALS AND METHODS: Fifty-nine consecutive patients (21 men, 38 women) referred for MR arthrographies of the hip were prospectively included in the study. Three patients underwent bilateral MR arthrography. The two injection techniques were quantitatively and qualitatively compared. Quantitative analysis was performed by the comparison of injected contrast material volume into the hip joint. Qualitative analysis was performed with regard to extraarticular leakage of contrast material into the soft tissues. Extraarticular leakage of contrast material was graded as none, minimal, moderate, or severe according to the MR images. Each patient rated discomfort after the procedure using a visual analogue scale (VAS). RESULTS: The injected contrast material volume was less in femoral head puncture technique (mean 8.9 ± 3.4 ml) when compared to femoral neck puncture technique (mean 11.2 ± 2.9 ml) (p < 0.05). The chi-squared test showed significantly more contrast leakage by femoral head puncture technique (p < 0.05). Statistical analysis showed no difference between the head and neck puncture groups in terms of feeling of pain (p = 0.744) or in the body mass index (p = 0.658) of the patients. CONCLUSION: The femoral neck injection technique provides high intraarticular contrast volume and produces less extraarticular contrast leakage than the femoral head injection technique when US guidance is used for MR arthrography of the hip.

Shear wave elastography properties of vastus lateralis and vastus medialis obliquus muscles in normal subjects and female patients with patellofemoral pain syndrome.

OBJECTIVE: The aim of our study was to define and compare the mechanical properties of the vastus lateralis (VL) and vastus medialis obliquus muscles (VMO) by the way of quantitative shear-wave elastography in male and female healthy control (HC) subjects, and in female patients with patellofemoral pain syndrome (PFPS). MATERIALS AND METHODS: Twenty-two healthy volunteers (11 male and 11 female) and 11 female patients with anterior knee pain were included in the study. The SWE examinations for VL and VMO were performed while the subjects were performing open kinetic chain exercises in neutral and 30° hip abduction. The contraction capacity (CC) and contraction ratio (CR) values were determined in resting and contraction phases in both hip positions. RESULTS: The mean elasticity values in the CC for VL and VMO muscles were significantly higher in male HC subjects when compared to female HC subjects (p < 0.05). The CR of the VL muscle in female patients with PFPS was not significantly different than the female HC group. The CR for the VMO muscle was significantly lower in female patients with PFPS when compared to female HC subjects (p < 0.05). CONCLUSIONS: We found a significant VMO weakness, and this method may provide quantitative data that might influence the diagnosis of muscle weakness, in female patients with PFPS.

Cross-sectional area of the labrum: role in the diagnosis of anterior acetabular labral tears.

OBJECTIVE: To investigate the utility of ultrasound cross-sectional area (CSA) measurements for diagnosing acetabular labral (AL) tears. METHODS: The study included qualitative/quantitative ultrasound examinations of 55 hips in 52 patients with a presumed diagnosis of AL tear and 56 hips in 28 healthy volunteers. MR arthrography examinations were available only for the patients and were reviewed for the presence of AL thickening and tear. RESULTS: The CSA of the anterior labrum was significantly larger in patients with an AL tear on MR arthrography than those in healthy volunteers (P < 0.01). The CSA cut-off value in determining labral thickening that maximises accuracy was 34.7 mm(2), and sensitivity, specificity and accuracy were 86.7%, 74.1% and 77.5%. Direct signs of AL tear on ultrasound had sensitivity, specificity and accuracy of 34.9%, 91.7% and 47.3%. The CSA cut-off value that maximises the accuracy of the AL tear was 40.6 mm(2), and sensitivity, specificity and accuracy were 58.1%, 91.2% and 78.4%. CONCLUSIONS: Ultrasound detects the thickened labrum frequently observed in MR arthrography studies, especially in patients with dysplastic hips. Although specificity of the method of detecting AL tears is high, sensitivity is low, with an overlap between subjects with AL tear and controls. KEY POINTS: • Labral degeneration is frequent in dysplastic hips • Thickened labra are frequently observed on MR arthrograms • Labral thickening can be depicted by quantitative ultrasound measurements • The sensitivity is low with overlap between subjects with AL tear and controls.

Comparison of color doppler US and CT portography in evaluating portal hypertension in children.

OBJECTIVES: To compare grayscale and color Doppler ultrasound (CDUS) findings to that of multidetector computed tomography (MDCT) portography in the evaluation of portal hypertension in children. METHODS: Thirty children (mean age, 11.4 years) with definitive clinical and laboratory diagnoses of portal hypertension were included in the study. Liver parenchymal changes, portal vein thrombosis, cavernous transformation, splenomegaly, recanalization of the paraumbilical vein, ascites collateral vessels, and hemodynamic parameters were evaluated prospectively. RESULTS: Liver parenchymal heterogeneity (n = 21) was detected more often by CDUS than MDCT (P = 0.002). CDUS and MDCT established similar results for increased right/left lobe ratio, lobulation of the liver contour, ascites, and splenomegaly. Portal vein thrombosis, cavernous transformation, and recanalization of the paraumbilical vein were comparable between CDUS and MDCT (κ = 1, P < 0.01). Collaterals were detected more by MDCT portography than by CDUS. Esophageal collaterals and azygous vein dilatation were seen only by MDCT portography (P < 0.01, P = 0.024; respectively). CONCLUSIONS: CDUS was superior to MDCT in identifying parenchymal changes and hemodynamic parameters. MDCT was superior in detecting abnormal collateral circulation. The combination of these two modalities provides more comprehensive information than either alone in the diagnosis and follow-up of portal hypertension.

Anatomical variations of the carotid-vertebral arteries: "double-vessel" sign on Doppler ultrasonography.

We describe the "double-vessel" sign and its relevance for the diagnosis of carotid and vertebral arterial anatomical variations in a series of four patients with stroke. In these four patients, two arteries could be seen at the expected location of the common carotid artery (CCA), leading to the diagnosis of anatomical variations including separate origin of internal and external carotid artery from the aortic arch on the left side and from the brachiocephalic trunk and the subclavian artery on the right side, early bifurcation of the CCA on both sides, and an aberrant course of the vertebral artery on the left side. The presence of two arteries at the expected location of the CCA should raise the suspicion of carotid or vertebral arterial variations.

Increased vein wall thickness in Behçet disease.

OBJECTIVE: Lower extremity (LE) deep venous thrombosis (DVT) is the main feature of vascular involvement in Behçet disease (BD). We thought that vein wall thickness (VWT) could be a surrogate marker for venous inflammation and hence predict future vascular involvement. We assessed VWT in proximal LE veins in BD patients without DVT, BD patients with DVT, and healthy controls in a formal, masked protocol. METHODS: We studied 50 (43 male and 7 female) BD patients with LE DVT (group 1), 50 (43 male and 7 female) BD patients without any vascular involvement (group 2), and 50 (43 male and 7 female) age- and sex-matched apparently healthy controls (group 3). Two radiologists blinded to the diagnosis of BD used ultrasound to measure VWT of common femoral vein, femoral vein, and great saphenous vein in both legs. Interobserver reliability was assessed using the intraclass correlation coefficient and Bland-Altman plots. RESULTS: There was good agreement between the two observers. The mean VWT was significantly increased in both BD patients with LE DVT and those without apparent vascular involvement compared with the healthy controls, whereas those with LE DVT had the highest VWT. CONCLUSIONS: VWT of proximal deep and superficial LE veins is increased among the BD patients without any clinical and radiologic vascular involvement. This information, after prospective work, might be useful in management and elucidating disease mechanisms in vascular BD.

EFSUMB Recommendations for Gastrointestinal Ultrasound Part 3: Endorectal, Endoanal and Perineal Ultrasound.

This article represents part 3 of the EFSUMB Recommendations and Guidelines for Gastrointestinal Ultrasound (GIUS). It provides an overview of the examination techniques recommended by experts in the field of endorectal/endoanal ultrasound (ERUS/EAUS), as well as perineal ultrasound (PNUS). The most important indications are rectal tumors and inflammatory diseases like fistula and abscesses in patients with or without inflammatory bowel disease (IBD). PNUS sometimes is more flexible and convenient compared to ERUS. However, the technique of ERUS is quite well established, especially for the staging of rectal cancer. EAUS also gained ground in the evaluation of perianal diseases like fistulas, abscesses and incontinence. For the staging of perirectal tumors, the use of PNUS in addition to conventional ERUS could be recommended. For the staging of anal carcinomas, PNUS can be a good option because of the higher resolution. Both ERUS and PNUS are considered excellent guidance methods for invasive interventions, such as the drainage of fluids or targeted biopsy of tissue lesions. For abscess detection and evaluation, contrast-enhanced ultrasound (CEUS) also helps in therapy planning.

EFSUMB Gastrointestinal Ultrasound (GIUS) Task Force Group: Celiac sprue and other rare gastrointestinal diseases ultrasound features.

Transabdominal gastrointestinal ultrasound (GIUS) is unique in its capacity to examine the bowel non-invasively and in its physiological condition, including extra-intestinal features such as the splanchnic vessels, mesentery, omentum and lymph nodes- even at the bedside. Despite this, and its extensive documentation for its usefulness, it has only been fully implemented in a few European countries and expert centres. Therefore, the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) established a GIUS Task Force Group in 2014 consisting of international experts from 9 European countries with the objectives to standardize and promote the use of GIUS in a clinical setting. This is achieved by publishing clinical guidelines and recommendations on indications and use of GIUS and so far,4 guidelines have been published: first on "examination techniques and normal findings", second on "inflammatory bowel disease", third on "acute appendicitis and diverticulitis" and fourth on "transrectal and perineal ultrasound".This paper describes the ultrasound features of miscellaneous disorders such as celiac disease, cystic fibrosis, omental infarction, Meckel's diverticle, endometriosis, intestinal neoplasia, mucocele, amyloidosis, GVHD, foreign bodies, vasculitis, and pneumatosis cystoides intestinalis. Bowel ultrasound can be indicated in most of these conditions to investigate intestinal symptoms but in other cases the alterations of the bowel can be also an incidental finding that suggest other examinations which finally help to discover an unknown pathological condition.

Lumbosacral osseous tumors in children.

A wide variety of benign and malignant neoplasms in children involve the lumbosacral region. When a solitary lesion of the lower spine occurs, tumors or tumor-like lesions represent an important group of entities for diagnostic consideration. Diagnostic investigation should begin with a patient history, physical examination, laboratory testing, and radiography. Roentgenograms, which demonstrate bone deviations, should be used as an initial examination. The results should direct further imaging studies, such as computed tomography (CT), magnetic resonance imaging (MRI), and bone scintigraphy. CT should be the chosen modality for delineating tumoral osteoid matrix formation. MRI shows soft-tissue masses and medullary infiltration better than any other radiological modality. A multimodal radiological approach is helpful in the overall evaluation and differential diagnosis of vertebral lesions in children. Although imaging features, especially of benign lesions, may yield a high percentage of accurate diagnoses, in cases with radiological findings highly suggestive of malignancy, a specific diagnosis cannot always be made, and histopathological findings are essential to achieve the diagnosis that will guide the therapy.

Portal vein ligation and in situ liver splitting in metastatic liver cancer.

The most serious complication after major liver resection is liver failure. Depending on preoperative liver function, a future liver remnant of 25%-40% is considered sufficient to avoid postoperative liver failure. A new technique known as portal vein ligation combined with in situ splitting has been developed to obtain rapid liver hypertrophy. Herein, we present a case where we performed portal vein ligation combined with in situ splitting. A 37-year-old male patient with a diagnosis of sigmoid adenocarcinoma and liver metastasis underwent anterior resection because of an obstructing sigmoid tumor and received palliative chemotherapy. After chemotherapy, abdominal computed tomography revealed a lesion, 50 mm in diameter, localized between segments 5-8 of the liver on the bifurcation of the anteroposterior segmental branch of the right portal vein. Computed tomography volumetric assessments of the liver were performed in the preoperative period, and it was found that the remnant left liver volume was less than 25%. In the first stage, portal vein ligation and in situ splitting of the liver parenchyma were performed. On the second and sixth postoperative days, computed tomography revealed hypertrophy of the left liver lobe. On the sixth day, a right hepatectomy was performed. Portal vein ligation combined with in situ splitting has been used by surgeons worldwide to obtain rapid and adequate liver hypertrophy. This new approach yields hope for patients with locally advanced liver tumors and may increase the number of curative resections for primary or metastatic liver tumors.