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The occurrence of acute liver failure (ALF) in pregnant women due to an etiology unrelated to pregnancy (pregALF) that leads to liver transplantation (LT) has rarely been reported. The objective was to report the outcome of pregnant women and fetus and propose a strategy for the timing of delivery and of LT in these patients.Five consecutive pregnant patients with ALF were admitted to our center between 1986 and 2018 and underwent an LT. A systematic review of case reports concerning patients with pregALF who underwent LT was extracted from the literature.Three with gestational ages (GA) at admission of 15, 22, and 31 weeks of gestation (WG) were transplanted after delivery (n = 1) or intrauterine demise (n = 2) and 2 with GA of 16 and 23 WG before delivery. One infant survived in each group. Among the 32 cases published previously, 11 (34%) had been transplanted after delivery (median GA:31 [28-33]); 10 of these 11 infants were alive at birth. The other 21 mothers were transplanted before delivery (GA:21 WG [18-22]). The median GA at delivery was 30 WG [27.75-37]. Twelve of 21 infants were alive at birth. One-year survival among the ALF patients in our series and in the literature was 100%. Overall, the perinatal survival rate was low (64.8%).In pregnant patients presenting with ALF not related to the pregnancy, the LT lifesaving procedure had an excellent outcome. Overall, 65% of the infants were alive at delivery with major mortality in those fetus22 WG despite continued pregnancy.

Evaluation of perfusion CT and dual-energy CT (DECT) quantitative parameters for predicting microvascular invasion (MVI) of hepatocellular carcinoma (HCC) prior to surgery.This prospective single-center study included fifty-six patients (44 men; median age 67; range 31-84) who provided written informed consent. Inclusion criteria were (1) treatment-naïve patients with a diagnosis of HCC, (2) an indication for hepatic resection, and (3) available arterial DECT phase and perfusion CT (GE revolution HD-GSI). Iodine concentrations (IC), arterial density (AD), and 9 quantitative perfusion parameters for HCC were correlated to pathological results. Radiological parameters based principal component analysis (PCA), corroborated by unsupervised heatmap classification, was meant to deliver a model for predicting MVI in HCC. Survival analysis was performed using univariable log-rank test and multivariable Cox model, both censored at time of relapse.58 HCC lesions were analyzed (median size 42.3 mm; range of 20-140). PCA showed that the radiological model was predictive of tumor grade (p = 0.01), intratumoral MVI (p = 0.004), peritumoral MVI (p = 0.04), MTM (macrotrabecular-massive) subtype (p = 0.02), and capsular invasion (p = 0.02) in HCC. Heatmap classification of HCC showed tumor heterogeneity, stratified into three main clusters according to the risk of relapse. Survival analysis confirmed that permeability surface-area product (PS) was the only significant independent parameter, among all quantitative tumoral CT parameters, for predicting a risk of relapse (Cox p value = 0.004).A perfusion CT and DECT-based quantitative imaging profile can provide a diagnosis of histological MVI in HCC. PS is an independent parameter for relapse.ClinicalTrials.gov: NCT03754192.

In this article, we describe the case of a 34-year-old woman presenting a multifocal and metastatic epithelioid hemangioendothelioma (HEHE) of the liver. Under classical chemotherapy using cyclophosphamide, there was a fast tumor progression in liver and extra-hepatic metastatic sites (lungs and mediastinal lymph node). Taking into account the patient’s age and the natural history of the HEHE, our goal was to try to bring her to liver transplantation (LT) and lenvatinib was an acceptable candidate for this reason. Shortly after the initiation of lenvatinib before LT and surgery, we observed the enlargement of large devascularized necrotic areas in most of the liver HEHE masses, suggesting a good response. The patient was finally transplanted 6 months after initiation of lenvatinib treatment. Eight months after LT, progression occurred (ascites, peritoneal recurrence, and mediastinal lymph node). After restarting lenvatinib, ascites disappeared and the lymph node decreased in size, suggesting a good response, more than 1 year after her transplantation. This is the first case report to our knowledge that illustrates the benefit of lenvatinib as a neoadjuvant bridge until LT for a multifocal and metastatic HEHE. In addition, this drug has also shown a benefit in term of disease control after a late recurrence of the tumor. We suggest that lenvatinib should be proposed as a bridge to the LT for nonresectable HEHE. Moreover, this drug was also beneficial in the treatment of late recurrence after LT. The absence of pharmacologic interactions between classical immunosuppressive drugs and lenvatinib may allow its use as an early adjuvant approach when the risk of recurrence is high. The strength of our case consists in the long follow-up and the innovative message allowing changing palliative strategies into curative ones in case of advanced HEHE.

Severe acute liver injury is a grave complication of exertional heatstroke. Liver transplantation (LT) may be a therapeutic option, but the criteria for LT and the optimal timing of LT have not been clearly established. The aim of this study was to define the profile of patients who require transplantation in this context.This was a multicentre, retrospective study of patients admitted with a diagnosis of exertional heatstroke-related severe acute liver injury with a prothrombin time (PT) of less than 50%. A total of 24 male patients were studied.Fifteen of the 24 patients (median nadir PT: 35% [29.5-40.5]) improved under medical therapy alone and survived. Nine of the 24 were listed for emergency LT. At the time of registration, the median PT was 10% (5-12) and all had numerous dysfunctional organs. Five patients (nadir PT: 12% [9-12]) were withdrawn from the list because of an elevation of PT values that mainly occurred between day 2 and day 3. Ultimately, 4 patients underwent transplantation as their PT persisted at10%, 3 days (2.75-3.25) after the onset of exertional heatstroke, and they had more than 3 organ dysfunctions. Of these 4 patients, 3 were still alive 1 year later. Histological analysis of the 4 explanted livers demonstrated massive or sub-massive necrosis, and little potential for effective mitoses, characterised by a "mitonecrotic" appearance.The first-line treatment for exertional heatstroke-related severe acute liver injury is medical therapy. LT is only a rare alternative and such a decision should not be taken too hastily. A persistence of PT10%, without any signs of elevation after a median period of 3 days following the onset of heatstroke, was the trigger that prompted LT, was the trigger adopted in order to decide upon LT.Acute liver injury due to heatstroke can progress to acute liver failure with organ dysfunction despite medical treatment; in such situations, liver transplantation (LT) may offer a therapeutic option. The classic criteria for LT appear to be poorly adapted to heatstroke-related acute liver failure. We confirmed thatmedication is the first-line therapy acute liver injury caused by heatstroke, with LT only rarely necessary. A decision to perform LT should not be made hastily. Fluctuations in prothrombin time and the patient's clinical status should be considered even in the event of severe liver failure.

ObjectivesTo share our experience with digital slide telepathology for intraoperative frozen section consultations (IOCs) and to describe its evolution over time by reporting performance metrics and addressing organizational and economic aspects.MethodsSince 2013, a technician has been alone at the surgical site. At the other site, the pathologist opens the digital slide from a local server via the intranet. Three periods were compared: a 6-month period of conventional IOC (period 1), a 24-month period of telepathology at 6 months after implementation (period 2), and a 12-month period of telepathology at 3.5 years after implementation (period 3).ResultsIn total, 87 conventional IOCs and 464 and 313 IOCs on digital slides were performed respectively during periods 1, 2, and 3; mean turnaround time was 27, 36, and 38 minutes, respectively, and there were a mean number of 1.1, 1.1, and 1.3 slides, respectively, per IOC. Diagnostic accuracy was achieved in 95.4%, 92.7%, and 93.9%, respectively, of IOCs (not significant). The additional cost is in the same range as the cost of urgent transport by courier.ConclusionsDeveloping IOC with digital slides is a challenge but is necessary to optimize medical time in the current context of pathologist shortage and budget restrictions.

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare severe adverse drug-induced reaction with multiorgan involvement. The outcome and prediction of those patients who develop severe acute liver injury (sALI) or acute liver failure (ALF) remain little known.A multicenter retrospective study of patients admitted with a diagnosis of DRESS-related sALI or ALF. Histological review was performed on liver core biopsies from native livers.Sixteen patients (11 women, 5 men; mean age, 39±17.2 years) were classified as having definite (n=13) or probable (n=3) DRESS. At admission, 3 patients had hepatic encephalopathy; median levels of prothrombin time, INR, and total bilirubin were, respectively, 33% (Q1-Q3, 21-41), 2.74 (1.98-4.50), and 94 μmol/L (Q1-Q3, 39.5-243.5). Nine patients received corticosteroid therapy. Overall, 9 patients improved spontaneously and 7 worsened (liver transplantation [LT] (n=5), deceased (n=2)). Transplantation-free and post-LT survival was 56% and 60%, respectively. After LT, DRESS recurrence was observed in 3 of 5 patients. Systemic corticosteroid therapy was not significantly associated with a clinical improvement. In the multivariate analysis, factor V level less than 40% at day 0 and factor V levels of 40% or greater at admission but decreasing at day 2 were associated with worse outcome. Pathological findings (n=7) revealed atypical lymphoid infiltrates, Kupffer cell hyperplasia with erythrophagocytosis, and an inconstant presence of eosinophils.The spontaneous prognosis of patients with sALI/ALF due to DRESS is poor and was not improved by corticosteroid therapy. Histology is helpful to establish diagnosis. Dynamic variables regarding factor V values are predictive of a poor outcome.

Background Idiopathic pulmonary fibrosis (IPF) is a devastating disease characterized by an unpredictable course. Prognostic markers and disease activity markers are needed. The purpose of this single-center retrospective study was to evaluate the prognostic value of lung fluorodeoxyglucose ([18F]-FDG) uptake assessed by standardized uptake value (SUV), metabolic lung volume (MLV) and total lesion glycolysis (TLG) in patients with IPF. Methods We included 27 IPF patients (IPF group) and 15 patients with a gastrointestinal neuroendocrine tumor without thoracic involvement (control group). We quantified lung SUV mean and SUV max, MLV and TLG and assessed clinical data, high-resolution CT (HRCT) fibrosis and ground-glass score; lung function; gender, age, physiology (GAP) stage at inclusion and during follow-up; and survival. Results Lung SUV mean and SUV max were higher in IPF patients than controls (p

Resume Introduction La leishmaniose cutanee est une maladie parasitaire qui se manifeste typiquement sous la forme d’une ulceration crouteuse nommee bouton d’Orient, dont la localisation au niveau des membres inferieurs realise un ulcere de jambe de presentation trompeuse. Observation Un patient de 81 ans, d’origine algerienne, diabetique de type 2, hypertendu et arteriopathe presentait des ulcerations chroniques de la cheville et du pied droits evoquant un pied diabetique infectieux. L’absence d’amelioration sous antibiotiques, soins locaux et repos, ainsi que le caractere non hemodynamique de l’arteriopathie conduisaient a realiser des biopsies cutanees. La Polymerase Chain Reaction realisee sur des biopsies a visee parasitologique permettait de retenir le diagnostic de leishmaniose cutanee a Leishmania major . La cicatrisation complete etait obtenue sous soins locaux seuls, le traitement etiologique ayant ete refuse par le patient. Discussion La leishmaniose cutanee fait partie des etiologies infectieuses rares a evoquer devant un ulcere chronique de jambe. Plusieurs options therapeutiques dont l’abstention peuvent etre proposees.

Resume Introduction Nous rapportons un cas de lesion hepatique hypermetabolique en TEP/TDM a la fluorocholine (18F) de diagnostic difficile, decouverte lors du bilan d’extension d’un carcinome prostatique. Observation Devant une augmentation de la concentration plasmatique totale de PSA, des biopsies prostatiques ont objective un adenocarcinome de score de Gleason a 8 (4 + 4). Il n’y avait pas d’extension extracapsulaire sur l’IRM pelvienne. L’examen TEP/TDM a montre un foyer de fixation prostatique et un foyer de fixation hepatique, au niveau d’un nodule de 25 mm, dans un foie steatosique peu fixant, hypodense en TDM. L’echographie abdominale etait en faveur d’un ilot de foie sain et l’IRM hepatique d’un adenome hepatocellulaire de type inflammatoire. Apres interrogatoire du patient, ce nodule etait connu depuis sept ans, stable en taille, etiquete adenome par l’imagerie, sans diagnostic histologique prouve. Discussion Pour interpreter ce foyer en TEP/TDM, nous n’avons pas retenu les diagnostics de carcinome hepatocellulaire et de metastase de cancer de la prostate compte tenu de la duree d’evolution de la lesion. Nous avons retenu l’hyperplasie nodulaire focale qui est hypermetabolique en fluorocholine, contrairement a l’adenome, dont l’adenome inflammatoire est un sous-type. Chez ce patient, la steatose hepatique semblait hypometabolique et aurait pu etre responsable d’un aspect faussement hypermetabolique de la lesion mais, comme d’autres auteurs, nous n’avons pas reussi a montrer qu’il existait un lien entre densite hepatique et fixation en fluorocholine. Conclusion Il persiste pour cette lesion une discordance entre imagerie anatomique et imagerie metabolique, mais son aspect et l’anamnese plaident pour une etiologie benigne.

Introduction La fibrose pulmonaire idiopathique (FPI) est caracterisee par une degradation progressive de la fonction respiratoire. Les facteurs predictifs de l’evolution de la FPI font defaut. L’objectif de cette etude retrospective monocentrique est d’evaluer l’interet pronostique du Total Lesion Glycolysis (TLG), rapport du volume hypermetabolique et du SUV moyen, mesure sur le TEP/FDG dans la FPI. Methodes Vingt-six patients atteints de FPI et non traites ont ete inclus dans cette etude et ont realise un TEP scanner. Nous avons mesure le TLG dans le poumon total et l’avons compare aux donnees cliniques et paracliniques et enfin a la survie. Resultats Le TLG moyen etait de 1426 ± 1030. Le TLG etait correle avec la severite de l’atteinte pulmonaire mesuree par la CVF, la DLCO et le score GAP. En revanche, il n’existait pas de correlation avec l’atteinte tomodensitometrique appreciee par les scores de fibrose et de verre depoli. Le TLG etait associe a la survie sans progression, hazard ratio (IC 95 % : 1,04–1,19 ; p = 0,002). Dans deux analyses multivariees incluant le TLG avec l’âge, la CVF, la DLCO puis avec le score GAP, le TLG restait associe a la survie sans progression (HR = 1,12 ; IC 95 % : 1,03–1,22 ; p = 0.) et (HR = 1,13 ; IC 95 % : 1,0–1,2 ; p = 0,005), respectivement. Conclusion Ces resultats identifient le TLG comme un facteur pronostique independant de la survie sans progression dans la FPI. Ces resultats devront etre confirmes dans de futures etudes prospectives.

Cutaneous leishmaniasis is a parasitic disease that typically manifests as a typical crusted ulcer called the oriental sore. Its localization on the lower limbs can be mistaken for a leg ulcer.An 81-year-old male, native of Algeria, with type 2 diabetes, arterial hypertension and arteriopathy developed a chronic ulceration of the right ankle and foot compatible with the diagnosis of infectious diabetic foot. Non-improvement with antibiotics, local treatment and rest, and the absence of any hemodynamic arteriopathy led to skin biopsies. Polymerase chain reaction performed on biopsy samples for parasitological investigations yielded the diagnosis of cutaneous leishmaniasis due to Leishmania major. Complete healing was obtained with topical care alone, the patient having declined an etiological treatment.Cutaneous leishmaniasis is one of the rare infectious etiologies of chronic leg ulcers. Several therapeutic options, including abstention, can be proposed.

The 18F-FDG uptake assessed by PET/CT is correlated to prognosis in most tumors. The aim of our study was to compare the 18F-FDG uptake with tumor proliferation (Ki67) and expression of molecules related to cell metabolism [hypoxia (VHL), glucose transport (GLUT1), regulation of cellular pH (CA9)] in well differentiated digestive neuroendocrine tumors (NET). Patients and Methods: This retrospective study included 22 patients. 18F-FDG uptake was assessed by the SUVmax value (Standardized Uptake Values). An immunohistochemical study was performed with Ki67, VHL, GLUT-1 and CA9 antibodies. A score (0-300) was calculated for each antibody. Results: NET were of pancreatic (15), midgut (3), esophageal (1), rectal (1), undetermined origin (2). 7, 9 and 6 tumors were of grade 1, 2 and 3 respectively; the average/median Ki67 was 15.86%/12% [1-60%]. The mean/median SUVmax was 6.26/5.09 [1.47 to 18.70]. Two tumor with SUVmax