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Elastography of the prostate in the detection

of prostate cancer

Dennis L. Cochlin

Consultant Radiologist, Department of Radiology

University Hospital of Wales
Cardiff, UK

Introduction b­ iopsies for a rising PSA level and a negative There are, however, some limited, but nevertheless
This paper presents initial experience with a new initial set of biopsies require more than 10 very important goals that may be achieved.
Toshiba elastography imaging system used to ­biopsies. 1) Adding elastography-guided biopsies to the
­detect prostate cancer. Since this is a preliminary 2) A proportion of cancers will be missed (false standard biopsy regime may increase positivity
evaluation, the elastography imaging procedure negative tests). The number of false negative rates (reduce false negative results).
was performed in addition to our standard tests is difficult to determine as there is no 2) If a tumour is visualised, diagnosis can be
­procedure of ten systematic biopsies, plus extra gold standard, but based on positivity rates ­supported by targeting the abnormal area with
biopsies of suspicious areas where appropriate. on ­second or third biopsies the rate may be fewer biopsy cores than conventional biopsies.
The elastography images did not influence the ­between 10 and 33 %. 3) The size of the tumour may be more accurately
­biopsy pattern and the elastography findings were 3) Increasing the number of biopsy cores obtained estimated and it might be possible to distinguish
subsequently compared with tumour detection on increases positivity rates but also increases the significant from insignificant tumours.
the biopsy cores (all cores are labelled separately) number of “clinically insignificant” tumours
and with radical prostatectomy specimens where found. These are small, low grade tumours Technique
available. that, evidence suggests, are unlikely to The elastography system features a split screen
The number of patients studied is not yet sufficient progress to clinically significant tumours. with one screen showing a conventional greyscale
to present hard data, but the following initial 4) The size of a detected tumour can be estimated image, while the other one visualizes movement
­impressions of the procedure, illustrative case from biopsy data, i.e. the number of cores using colour Doppler. This is so to speak the basic
­reports and discussion of the possible role of ­involved and the length of tumour in each core. real-time elastography image.
elastography in the detection of prostate cancer The estimate is often inaccurate because the
may provide a starting point for further studies. biopsy core may just detect the edge of a large The greyscale image allows positioning within the
tumour and a tumour may be multi-focal. prostate gland. The gland is then compressed and
Background allowed to relax by applying 3 or 4 simple “flicks”
With patients showing a high serum prostate Because of these disadvantages attempts are of the transducer at about 1–2 second intervals.
­specific antigen (PSA) level and/or an abnormal ­being made to visualise tumours on the ultrasound This produces the data for the more sophisticated
digital rectal examination there is a high probability image so that biopsies can be targeted to the strain imaging.
(40–66 %) of clinically significant prostate cancer. ­tumour. Greyscale ultrasound and colour Doppler
studies, however, are disappointing. More recently, The colour Doppler “elastography” image enables
The standard method to detect prostate cancer in contrast-enhanced ultrasound and elastography gain adjustments which optimise the elastography
these patients is to perform multiple biopsies of imaging are being studied. image. Although the colour Doppler elastography
the prostate obtained in a set pattern throughout image is inherently inferior to the strain images, it
the gland which also allows for histological If prostate cancer could be imaged with a method is a real-time image which means if any suspicious
(Gleason) grading of any cancer detected. that produces a high negative predictive value then areas are detected, the image plane to study these
patients with negative imaging would not need can be accurately determined.
There are, however, certain problems with this ­biopsies. So far, no imaging method has achieved
procedure: this objective and even from an unbiased point of Once the data is stored the strain image can
1) It is invasive and unpleasant. Multiple biopsies view it seems unlikely that elastography imaging be produced. The process takes approximately
– at least 8 or 10 – are necessary. Repeat can close this gap. 10 seconds, and then the image can be viewed.
2 Elastography of the prostate in the detection of prostate cancer

Depending on the number of planes examined, grayscale images and tumours that, as confirmed zone which is much wider in this young man. It
obtaining the data for the images adds 1 to later, were only visible on the grayscale images may be simply because the tissue nearest the
2 minutes to the examination. were detected. transducer moves more on flicking the transducer
6) Initial studies indicate that elastography imaging than the more distal tissues. The more posterior
Although the patient feels the movement of the may well have a place in the detection of part of the gland is shown in medium blue with
transducer during the “flicks” that compress the ­prostate cancer but further research as to its ­irregular, rather random areas of green. Rotating
prostate, this is not painful or uncomfortable. ­precise role is required. the transducer, so that the lateral horns are in the
midline of the image, results in a green band along
Initial impressions Case reports the horns. This is often not as clearly continuous
1) The system is easy to use. Data acquisition Case 1 Normal study as that in the posterior gland (Figs. 1.2, 1.3). The
takes little time. The increased time required A 32-year-old man with haematospermia was base of the gland (Fig. 1.5) shows a similar
for the scan is quite acceptable. The split screen ­referred for transrectal ultrasound imaging of the ­pattern as the mid-gland (Fig. 1.4). At the apex
displays a greyscale image which makes it easy prostate and seminal vesicles. The results showed the green band is discontinuous or often a­ bsent.
to align the elastography scan plane ­accurately no findings. The patient agreed to an elastography
to the plane which needs to be s­ tudied. The study of his prostate. The normal pattern is shown. Case 2
colour Doppler overlay allows an estimate of In the figures the greyscale image and the A 58 year old man with a serum PSA of 30.5.
appropriate gain settings and ­indicates how ­elastography image are displayed alongside each Digital rectal examination showed a firm left
much movement is being p­ roduced while fl­ icking other (a, b). The colour Doppler image used in gland. Greyscale ultrasound (Fig. 2.1) showed a
the transducer. O ­ bviously abnormal a­ reas are ­real-time to aid acquisition of the elastography ­hypoechoic nodule in the left peripheral zone.
­visible in real time on the colour ­Doppler image. ­image is shown in fig. (c). Elastography showed a gap in the normal green
2) The technique is not uncomfortable or painful. The colour scale depicts elasticity. Green is band (Fig. 2.2) and on a slightly different plane
3) Post-processing and measurement of the ­medium elasticity, red is higher elasticity, blue is a dark, stiff area (Fig. 2.3) that matched with the
­images is easy, though best practices are not less elasticity. The darker the blue, the less the hypoechoic nodule. This corresponded to positive
yet clear. The images appear to be reproducible ­elasticity. Tissues that do not react to pressure are biopsies in this area, Gleason grade 7. In cases
over a range of different pressures when flicking black. The colour elastography image is ­overlaid where greyscale match elastography results
the transducer and over a range of gain settings. onto the greyscale image. It is possible to vary ­biopsies of the abnormal area might be all that
This makes the procedure highly reproducible the merged image from 100 % greyscale to 100 % is necessary. Fig. 2.4 shows the corresponding
and relatively operator-independent. elastography. Most of the images shown are 50 % ­velocity gradient image.
4) The method does demonstrate prostate cancer of each.
but initial studies indicate that sensitivity is too Fig. 1.1 a and b show the mid-gland in the Case 3
low to use elastography as the sole examination ­transverse plane. A continuous band of green A 62-year-old man with a serum PSA level of 3.9.
technique. ­(medium elasticity) is seen across the posterior Digital rectal examination showed an enlarged
5) Both tumours which were not visible on the gland. This does not correspond to the peripheral prostate with no palpable nodules. Greyscale

Fig. 1.1 a Fig. 1.1 b Fig. 1.2 a Fig. 1.2 b Fig. 1.3 a Fig. 1.3 b

Fig. 1.1 c Fig. 1.2 c Fig. 1.3 c

Elastography of the prostate in the detection of prostate cancer 3

u­ ltrasound (Figs. 3.1 a, 3.2 a) showed no obvious Two clinical workflows including that together with the time needed to collect the
focal nodules. Elastography showed loss of ­elastography data for the images the total time of the exami­
­elasticity in the left peripheral zone laterally in the The “easy” way to study the prostate with nation increases from about 15 to 30 minutes.
mid-gland (Fig. 3.1 a) but not in the base (Fig.3.2 b). ­elastography imaging is to perform a transrectal During the analysis of the images the transducer
Biopsies revealed a Gleason 6 tumour in the area scan of the prostate using greyscale ultrasound could be removed from the rectum or could
of decreased elastography. Figs. 3.1 c and 3.1 d imaging together with Doppler studies if this is the ­remain in place (insertion of the transducer is
show elasticity measurements of the abnormal standard practice of the department. In addition, ­often the most painful part of the procedure).
area and the corresponding area on the normal elastography images of the prostate are acquired.
side. The different graphs are obvious. After the examination the images are reviewed The possible role of elastography imaging
and measurements are obtained as appropriate. Sensitivity and specificity of elastography imaging
Case 4 The prostate biopsies are obtained at a later date need to be assessed further, both alone and when
A 58-year-old man with a serum PSA level of 9.6. and are planned according to the elastography combined with the current standard technique of
Digital rectal examination was computable with ­results. This has the advantage of allowing ample ultrasound-guided systematic biopsies. Therefore
a T2A tumour on the right. Greyscale ultrasound time to analyse the images. The examination, it is currently not possible to determine the role of
(Fig. 4.1 a) showed a large hypoechoic area on however, becomes a two-stage procedure which elastography. Current experience, however,
the right extending into the transitional zone. might be justified with patients with a rising ­indicates certain possible conclusions.
­Elastography imaging (Fig. 4.1 b) showed a serum PSA level and negative previous biopsies.
­matching area of decreased elasticity, shown as With patients undergoing their first transrectal Firstly, it is important to state what elastography
an area of darker blue. As the tumour was fairly ­ultrasound and biopsy examination such a two- will probably not achieve:
anterior, the green posterior band is unaffected. stage procedure is more difficult to justify. If It seems unlikely that elastography imaging alone
future studies were to show that this two-stage will replace the need for ultrasound-guided
Case 5 approach provides a ­significant advantage, ­systematic biopsies. It is unlikely that the negative
A 65-year-old man with increased serum PSA. either higher positivity rate or the need for less predictive value will prove sufficient to eliminate
Digital rectal examination showed a hard gland ­biopsies, it would be acceptable. the need for biopsies in patients with a normal
compatible with a T2A tumour. Greyscale imaging ­examination.
(Figs. 5.1 a, 5.2 a) showed an inhomogeneous An alternative approach is to analyse the elasto­
gland but no focal nodules. Elastography graphy images immediately while the transducer In cases where a lesion is detected, elastography
(Figs. 5.1 b, 5.2 b) showed decreased elasticity remains in the patient and then to perform the will not eliminate the need for biopsy. It is unlikely
­throughout the gland with loss of most of the ­biopsies with an appropriately modified pattern that specificity will be sufficiently high to make an
­peripheral green band and areas of deep blue in during the same procedure. This allows less time absolute diagnosis. Biopsy will still be needed to
the deeper parts of the gland. Biopsies showed to analyse the images and multiple measurements confirm the diagnosis and for Gleason grading.
extensive tumour with Gleason 9 tumour in all are not possible. It is, however, possible to review
10 cores taken. the images in less than 10 minutes which means

Fig. 1.4 a Fig. 1.4 b Fig. 1.5 a Fig. 1.5 b Fig. 2.1 Fig. 2.2

Fig. 1.4 c Fig. 1.5 c Fig. 2.3 Fig. 2.4

Elastography of the prostate in the detection of prostate cancer 4

Nevertheless, elastography might be used in 3) If elastography imaging is added to grayscale References
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Fig. 3.1 a Fig. 3.1 b Fig. 3.2 a Fig. 3.2 b Fig. 5.1 a Fig. 5.1 b

Fig. 3.1 c Fig. 3.1 d Fig. 4.1 a Fig. 4.1 b Fig. 5.2 a Fig. 5.2 b

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