original article

Transrectal Ultrasonography of Prostate -Correlation with

Histopathology
Manjeet Singh, Feroze Shaheen, Baldev Singh, Rauf Khwaja, Tariq Gojwari, Hamid Hussain
ABSTRACT
One hundred patients with clinical signs/symptoms of prostatic disease were subjected to TRUS and correlated with
histopathological findings. TRUS revealed BPH in 65, chronic prostate in 5, suspicious carcinoma in 23, rest normal.
HPE confirmed BPH in 62, chronic prostatitis in 2 and carcinoma in 11. TRUS sensitivity and specificity for prostatic
carcinoma was 81% and 54% respectively. TRUS + PSA assay were most accurate in detecting and staging
prostatic carcinoma.
JK-Practitioner 2006;13(3);138-139
INTRODUCTION
Transrectal ultrasonography is twice more sensitive than digital rectal
examination for detecting prostatic carcinoma. TRUS provides for direct
visualisation of echopattern site and size of lesion and also helps in proper
interpretation of PSA levels which may be raised in many benign conditions
especially BPH. TRUS along with PSA could become a sensitive and specific tool for
screening prostatic carcinoma.
MATERIAL AND METHODS
One hundred patients referred from Urology department were examined by
transrectal USG using Siemens Adara 7-12 MHz phased array probe over last two
years. Patients were examined with full bladder with properly lubricated transrectal
probe wrapped with a condom in left lateral daeubitus position. The prostate and
adjacent rectal bladder walls were evaluated for any focal lesion, change in
echogenecity. Lesions seen on USG were correlated with HPE, PSAassay and DRE.
RESULTS
Table 1: Sonographic features in TRUS
BPH

Authors affiliations:
Manjeet Singh, Feroze Shaheen,
Tariq Gojwari, Hamid Hussain
Department of Radiodiganosis
Baldev Singh, Rauf Khwaja
Deptt of Urology
Sher-I-Kashmir Institute of Medical
Sciences, Srinagar (INDIA)
Accepted for Publication
November 2005
Correspondence:
Dr. Manjeet Singh, MD
Associate Professor
Department of Radiolidagnosis
Sher-i-Kashmir Institute of Medical
Sciences, Soura, Post Bag : 27,
Srinagar - 190011

Hypoechoic
Hyperechoic
Isoechoic
Ca Prostate
Hypoechoic
Hyperechoic
Isoechoic
Mixed
Chronic prostatitis
Mixed with calcification
Normal
Table 2: TRUS findings with HPE correlation (Fig. 1, 2, 3)

9
6
50
14
7
1
1
7
7

TRUS diagnosis

HPE
Normal BPH Ca prostate
Chr. Pros.
BPH (65)
62
3
Chronic prostitis (5)
3
2
Suspicious carcinoma (23)
4
13
6
Normal prostate(7)
Table 3: Correlation of DRE abnormality, PSA& TRUS findings
DRE
Induration

Serum PSA
1-4 nmol/ml

Nodular prostate

4-10 nmol/ml

Mucosal fixity

> 1nmol/m1

%
94
40
56
100

TRUS findings
Increased echogenicity (5)
with prostitis
Ca prostate
5
Normal
3
Ca prostate
2
Lesion > 1.3 cm

Table 4: Correlation with PSAlevels

DRE + increased PSAlevels
Suspicious carcinoma
= 20
DRE + increased PSA+ TRUS findings
Suspicious carcinoma
= 16
Histopathological proved
= 11 cases
DISCUSSION
With the description of zonal anatomy by McNeal and advent of transrectal
sonography, the various pathological processes became better defined especially for
1

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JK- Practitioner Vol.13, No. 3, July- September 2006

original article
staging method using TRUS and PSA. The
size of the focal lesion was related to serum
PSA levels e.g., two focal lesions > 2.0 cm
had PSA levels in excess of 1nmo1/ml.
Cooner et al found 45 cases out of 144
screened by TRUS with PSA levels > 10
ng/ml having prostatic carcinoma and
concluded that every patient with
significantly raised PSA levels should have
TRUS examination. All the four focal lesions
> 1.5 cm3 volume had raised PSA levels of
>10 nmo1/ml, two having invasion of
prostatic capsule suggesting that size of the
lesion was related to glisson state of the
lesion.. Petter Littrays et al suggested close
relationship of prostatic volume to PSA
5

Fig.1. A Ultrasonography showing normal prostate on TRUS

screening for nonpalpable prostatic carcinoma. Earliest studies in

TRUS showed prostatic carcinoma predominantly is an echogenic
lesion . Benign lesions like BPH were limited to transition zone
and appeared mostly as a diffuse textural changes .
In our series prostate carcinoma appeared mostly as
echogenic focal lesion in the peripheral zone in 23 patients out of
which 13 proved correct on histopathology. Three cases were false
negatively labelled as BPH and proved to be carcinoma.. None of
the normal cases on TRUS had evidence of carcinoma in HPE..
There was a positive correlation between TRUS findings
suggestive of carcinoma, Digital rectal examination and PSA
levels. Thus 7 out of all the focal lesions in TRUS had positive DRE
2,3

4,5

Fig. 2. Ultrasonography showing median lobe

projecting into the bladder
6

Fig.3. Ultrasonography showing large tumour with

features of carcinom

and raised PSAlevels of more than 5 nmol/ml.

JS Wolf demonstrated increased accuracy of combined
6

levels. Wolf et al showed that the volume of hypoechoic lesion as

an independent variable for staging of carcinoma prostate.
Use of combination modality screening such as DRE +
PSA and TRUS + PSA showed increased accuracy compared to
DRE or TRUS as stand alone modality. Twenty of patients in our
series were positive for carcinoma prostate using DRE + PSA
while 16 out of these were positive in TRUS + PSA screening.
Histopathology proved eleven of these patients to have prostatic
carcinoma. Thus TRUS + PSA significantly scores over as a
screening combination. Wolf et al showed that by combining
prospective TRUS evaluation with retrospective PSA analysis,
there was increased accuracy of this combined staging / screening
method compared to TRUS alone.
6

References :
1.
2.

3.

McNeal JE. The zonal anatomy of the

prostate, Prostate 1981;2:35-49.
Wolfgang F. Dahnert et al. Prostatic
evaluation by TRUS with
histopathological correlation. The
echogenic appearance of early
carcinoma. Radiology 1986;158:97102.
Fredlee, Torp-Pederson ST, Siders
DB, Littrup PJ. Transrectal ultrasound
in diagnosis and staging of prostatic

4.

5.

carcinoma. Radiology 1989;170:609615.

Stillman MM, Kulegowska E.
Transrectal ultrasound screening for
prostatic
adenocarcinoma with
hisopathologic correlation. Cancer
March 1993 ;71(6).
Cooner WH. Prostate specific antigen,
digital rectal examination and
transrectal ultrasonic examination of
prostate in prostatic cancer detection.

JK- Practitioner Vol.13, No. 3, July- September 2006

6.

7.

Mongr Urol 1991;12:3.

Wolf IS, Shinohare K, Nareyan D.
Staging of prostate cancer, accuracy of
TRUS enhanced by prostate specific
antigen. British Journal of Urology
1992;70:534- 541.
Littrup P, Kane RA, Williams CR.
Determination of prostate volume
with transrectal US for cancer
screening. Radiology 1991;178:537542.

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