Role of Contrast-Enhanced Ultrasonography in Hepatocellular Carcinoma by Using LI-RADS and Ancillary Features: A Single Tertiary Centre Experience

Clinical utility of ancillary features (AFs) in contrast-enhanced ultrasound (CEUS) Liver Imaging Reporting and Data System (LI-RADS®) is yet to be established. In this study, we assessed the diagnostic yield of CEUS LI-RADS and AFs in hepatocellular carcinoma (HCC). We retrospectively included patients with risk factors for HCC and newly diagnosed focal liver lesions (FLL). All lesions have been categorized according to the CEUS LI-RADS v2017 by an experienced sonographer blinded to clinical data and to the final diagnosis. From a total of 143 patients with 191 FLL, AFs favoring HCC were observed in 19.8% cases as hypoechoic rim and in 16.7% cases as nodule-in nodule architecture. From the total of 141 HCC cases, 83.6% were correctly classified: 57.4%- LR-5 and 26.2%- LR-4. In 9.21% cases, CEUS indicated LR-M; 2.12% cases- LR-3. The LR-5 category was 96.2% predictive (PPV) of HCC. LR-5 had 60.4% sensitivity and 93.6% specificity. PPV for primitive malignancy (LR-4 + LR-5) was 95.7%, with 88% sensitivity, 89.3% specificity and 88.4% accuracy for HCC. LR-4 category had 94.8% PPV and 26.2% sensitivity. CEUS LR4 + LR5 had 81,8% sensitivity for HCCs over 2 cm and 78.57% sensitivity for smaller HCCs. CEUS LR-5 remains an excellent diagnostic tool for HCC, despite the size of the lesion. The use of AFs might improve the overarching goal of LR-5 + LR-4 diagnosis of high specificity for HCC and exclusion of non-HCC malignancy.

Enhancing Drilling Response and Improving ROP on PDC Bits by Utilizing 1-in. Diameter Cutters

This paper details the improvements to drilling performance and torsional response of fixed cutter bits when changing from a conventional 19-mm cutter diameter configuration to 25-mm cutter diameters for similar blade counts in two different hole sizes. Key performance metrics include rate of penetration (ROP), rerun-ability, torsional response, and ability to maintain tool-face control during directional drilling. A high-performance drilling application was selected with several existing offset wells using a 12¼-in., five-bladed, 19-mm (519) drill bit design, and a concept bit developed using 25-mm diameter cutters while maintaining comparable ancillary features. This was tested in the same field on both vertical and S-shape sections using the same bent-housing motor assembly and drilling performance compared to the existing offsets. A 17½-in. hole size application that experiences high drillstring vibration was also selected, and a 25-mm cutter diameter drill bit was designed with comparable ancillary features to replace a six-bladed, 19-mm (619) drill bit. This was tested in the same field with the drilling performance, and vibration propensity was assessed. Initial testing in the 12¼-in. section showed extremely promising initial results, breaking the field ROP record in a well-established field of more than 3,000 wells. The rerun of the same bit without repair placed fourth in the field in terms of ROP records. Additional testing in the vertical and s-shape sections showed the new 25-mm cutter diameter design consistently exceeding the ROP performance of the 519 drill bit design while achieving directional targets without any reported drilling concerns. Subsequent trials with other operators saw similar performance improvement with multiple instances of breaking field ROP records. The first trial of the new 17½-in. hole size design with 25-mm diameter cutters had 34% average higher ROP than the offset average ROP, achieving the field ROP record. An overall 70% improvement during trials was seen in ROP versus the existing 619 drill bit design. The daily drilling reports and client feedback reported a significantly reduced level of drillstring vibration versus offset wells. This paper demonstrates the potential for a paradigm shift in drilling response and overall ROP by using 25-mm diameter cutters on fixed cutter bits. When correctly modeled, designed, and selected for specific applications, they benefit operators by reducing the time it takes to drill the section, improving repairability, reducing the time that an openhole is left exposed, and reducing drilling costs.

CT/MRI LI-RADS v2018 vs. CEUS LI-RADS v2017—Can Things Be Put Together?

Different LI-RADS core documents were released for CEUS and for CT/MRI. Both documents rely on major and ancillary diagnostic criteria. The present paper offers an exhaustive comparison of the two documents focusing on the similarities, but especially on the differences, complementarity, and added value of imaging techniques in classifying liver nodules in cirrhotic livers. The major diagnostic criteria are defined, and the sensitivity and specificity of each major diagnostic criteria are presented according to the literature. The existing differences between techniques in assessing the major diagnostic features can be then exploited in order to ensure a better classification and a better clinical management of liver nodules in cirrhotic livers. Ancillary features depend on the imaging technique used, and their presence can upgrade or downgrade the LI-RADS score of an observation, but only as far as LI-RADS 4. MRI is the imaging technique that provides the greatest number of ancillary features, whereas CEUS has fewer ancillary features than other imaging techniques. In the final part of the manuscript, some recommendations are made by the authors in order to guidephysicians as to when adding another imaging technique can be helpful in managing liver nodules in cirrhotic livers.

Diagnosis and Treatment of the Central Disorders of Hypersomnolence

The central disorders of hypersomnolence (CDH) are lifelong conditions that cause an irrepressible need for sleep during waking hours. Some of these disorders are due to medications or other conditions, but narcolepsy type 1 (NT1), narcolepsy type 2 (NT2), and idiopathic hypersomnia (IH) occur as primary conditions. In each disorder excessive daytime sleepiness (EDS) may be accompanied by ancillary features such as sleep paralysis, hypnagogic/hypnopompic hallucinations, sleep drunkenness, or, in the case of NT1, cataplexy. Polysomnography and a multiple sleep latency test are used for diagnosis. Diagnostic lumbar puncture may be performed to differentiate NT1 from NT2. Although the mainstay of treatment for CDH is currently pharmacotherapy, management may also involve behavioral approaches such as sleep and nap scheduling, dietary modifications, and cognitive-behavioral therapy. Pharmacologic treatment can include traditional medications such as modafinil, methylphenidate, or sodium oxybate. Novel therapeutic agents such as pitolisant, clarithromycin, flumazenil, and melatonin may be useful in relieving EDS and associated symptoms.

Gadoxetic acid-enhanced MRI of hepatocellular carcinoma: Diagnostic performance of category-adjusted LR-5 using modified criteria

The Liver Imaging Reporting and Data System (LI-RADS) is widely adopted for the noninvasive diagnosis of hepatocellular carcinoma (HCC). Herein, possible strategies to improve the diagnostic performance of LR-5 without reducing specificity for HCC were investigated. This retrospective study included 792 patients who underwent gadoxetate disodium-enhanced magnetic resonance imaging. Hepatic observations were categorized according to LI-RADS v2018 and categories were readjusted by upgrading LR4 to LR5 using ancillary features, arterial phase hyperenhancement (APHE) interpreted with subtraction images, indication of no washout when APHE was absent, extension of washout to the transitional phase, and subthreshold growth as a major feature. Based on LI-RADS v2018, LR-5 showed a sensitivity of 71.9% and a specificity of 97.9% for the diagnosis of HCC. Category-readjusted LR-5 after upgrading LR-4 to LR-5 using ancillary features favoring HCC in particular, subthreshold growth as a major feature, extending washout to transitional phase and APHE interpreted using subtraction images showed significantly increased sensitivity (P<0.001) without decreased specificity (Ps>0.05). The sensitivity of LR-5 can be improved without loss of specificity via category readjustment using AFs favoring HCC in particular, subthreshold growth as a major feature, extending washout to transitional phase and APHE interpreted with subtraction images.