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Challenges in liver stiffness measurement: cardiovascular complications as diagnostic pitfalls in sinusoidal obstruction syndrome

Bone Marrow Transplantation volume 60, pages 924–926 (2025)Cite this article

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Sinusoidal obstruction syndrome (SOS) is a potentially severe complication of allogeneic hematopoietic cell transplantation (HCT). Clinical diagnostic criteria for SOS are non-specific and closely linked to portal hypertension (PH) [1]. Recently, liver stiffness measurement (LSM) has demonstrated high sensitivity and specificity for identifying SOS, particularly in cases with significantly elevated stiffness values compared to baseline [2,3,4]. This has led to the incorporation of ultrasound liver elastography techniques into the latest European Society for Blood and Marrow Transplantation (EBMT) diagnostic criteria for probable SOS [5]. Herein, through a review of two cases, we aim to highlight how elevated LSM can lead to an initial misdiagnosis of SOS, emphasizing the importance of a comprehensive diagnostic approach that combines clinical evaluation and multimodal imaging.

At our center, LSM is routinely performed using transient elastography (TE). All patients undergoing HCT receive a baseline assessment prior to conditioning, and repeated measurements are performed when SOS is clinically suspected. As per institutional guidelines, graft versus-host disease (GvHD) prophylaxis is based on the use of post-transplant cyclophosphamide (PTCy) at 50 mg/Kg on days +3 and +4, and rapamycin plus mycofenolate starting from day +5. Prophylaxis for SOS and fungal infections is based on ursodeoxycholic acid and azoles, respectively.

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Available from the corresponding author upon reasonable request.

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Funding

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be interpreted as a potential conflict of interest. The authors declare that no source of funding was used for the present research.

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Authors and Affiliations

  1. Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy

    Lorenzo Lazzari, Antonella Capasso, Matteo Cristante, Maddalena Ponti, Maria Teresa Lupo-Stanghellini, Fabio Ciceri, Annalisa Ruggeri & Andrea Assanelli

  2. Vita-Salute San Raffaele University, Milan, Italy

    Fabio Ciceri

Authors
  1. Lorenzo Lazzari
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  2. Antonella Capasso
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  3. Matteo Cristante
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  4. Maddalena Ponti
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  5. Maria Teresa Lupo-Stanghellini
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  6. Fabio Ciceri
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  7. Annalisa Ruggeri
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  8. Andrea Assanelli
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Contributions

LL, AC, MC, and MP were responsible for data collection and manuscript preparation. LL, MTLS, FC, AR, and AA contributed to the study design. All authors were involved in patient clinical care, and all reviewed and approved the final version of the manuscript.

Corresponding author

Correspondence to Annalisa Ruggeri.

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Competing interests

The authors declare no competing interests.

Ethics

Ethics approval and consent to participate: All patients were treated according to current institutional programs after providing written informed consent for transplantation procedures and use of medical records within framework of the non-interventional ALMON study, which was approved by the San Raffaele Institutional Ethical Committee (approval date: 2007-10-19). In addition, all patients provided consent for the acquisition of clinical data within the international EBMT registry. The study involved the use of anonymized data, and all patient information was handled according to institutional ethical guidelines and privacy regulations. The study was conducted in compliance with the ethical principles outlined in the Declaration of Helsinki.

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Lazzari, L., Capasso, A., Cristante, M. et al. Challenges in liver stiffness measurement: cardiovascular complications as diagnostic pitfalls in sinusoidal obstruction syndrome. Bone Marrow Transplant 60, 924–926 (2025). https://doi.org/10.1038/s41409-025-02603-4

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