Color Doppler ultrasound and prostate cancer biopsy


Here in the USA there has been a nucleus of physicians who have argued for years that the use of color Doppler ultrasound enhances the ability to identify and biopsy prostate cancer. New data from Germany are relevant to this conversation.

Mitterberger et al. have just reported comparative (albeit retrospectively analyzed) data on the effectiveness of biopsies guided by transrectal, contrast-enhanced, color Doppler ultrasound (CECD-US) as compared to a systematic biopsy in 1,776 men between 2002 and 2006.

All men who were biopsied had a PSA level ≥ 1.25 ng/ml. Each patient first received just five CECD-US targeted biopsies in hypervascular areas in the peripheral zone of the prostate while receiving a special contrast agent. Subsequently, a second physician took a series of 10 systematically planned biopsy cores (presumably also under ultrasound guidance, although the paper’s abstract does not actually state this).

The results of this retrospective analysis show that:

  • Prostate cancer was detected in 559/1,776 patients (31 percent) in total.
  • The 5-core CECD-US-guided biopsy identified prostate cancer in 476/1,776 patients (27 percent).
  • The 10-core systematic biopsy identified prostate cancer in 410/1,776 patients (23 percent).
  • The prostate cancer detection rate using CECD-US targeted biopsy was 10.8 percent (i.e., 961/8,880 cores were positive for cancer).
  • The prostate cancer detection rate using systematic biopsy was 5.1 percent (i.e., 910/17,760 cores).
  • A positive biopsy for prostate cancer using CECD-US-guided biopsy that was negative using systematic biopsy occurred in 149/559 patients (27 percent).
  • A positive biopsy for prostate cancer using systematic biopsy that was negative using CECD-US-guided biopsy occurred in 83/559 patients (15 percent).

What can we make of these data?

Well the authors, to their credit, conclude only that, “This study represents the largest clinical trial to date, demonstrating a [statistically] significant benefit of CECD-US targeted biopsy relative to [systematic biopsy].”

In the favor of CECD-US-guided biopsy, it has to be said that this clearly identified a high number of tumors that were not samples by systematic biopsy — but what we don’t know is what proportion of those 149 tumors might have been identifed with a standard TRUS-guided biopsy using a “black and white” ultrasound system.

The immediate problem would seem to be that color Doppler ultrasound missed 15 percent of the cancers found on a systematic biopsy. That looks like a disturbingly high failure rate for a technology that some people have argued is far better than standard transrectal ultrasound-guided biopsy using standard (“black and white”) ultrasound technology.

Of course what is really needed here is a strict, prospective study of the use of transrectal color Doppler ultrasound-guided biopsy plus (say) an 8-core or 10-core systematic biopsy vs. the same technique using standard TRUS. It will almost certainly never happen. In the meantime, what seems to be the case is that any biopsy today should comprise two elements — a series of systematic biopsies designed to sample specific areas of the prostate (specifically including the apical area) combined with additional biopsy cores from areas that look suspicious under ultrasound guidance. Whether color Doppler ultrasound really enhances the ability to better identify areas that actually turn out to be positive for prostate cancer compared to standard TRUS guidance would appear to still be an arguable point.

5 Responses

  1. I think this article does not describe the Doppler appearances in cancerous as compared with non-cancerous prostates, but the benefit of vascular detection is indubitable. Perhaps there are particular conditions that are limiting the Doppler detection accuracy of the prostatic cancer, to be further specified. In our experience, the cancerous areas of the prostate has more vasculature as compared with the non-cancerous areas, and that was proved by using spiral CT and MRI on the same patient. Even in early stages of disease, with no evident tumor mass present on the imaging exams, we suspected cancer when the pericapsular vessels were enlarged (CT, MRI) or with high flow velocities (Doppler). As differential diagnosis, acute prostatitis has more homogeneous increased vasculature and the clinical diagnosis is conclusive, while chronic prostatitis is sometimes similar to prostate cancer on the clinical exam but has no vascular changes.

  2. Where is color Doppler ultrasound for prostate tests available?

  3. An informative article about this subject (entitled “New prostate biopsy strategy of 3-dimensional cancer mapping for active surveillance and focal therapy”) appears in the March 2012 issue of Prostate Cancer Communication Choices. The author of the article is Osamu Ukimura, MD, PhD.

    I have been receiving a copy of this publication for the past 12 years, following the death of my dad from prostate cancer. So far, I’ve had no luck locating a physician’s office or hospital in the New York City area that has the color Doppler ultrasound.

    I’m not a clinician, so you’ll have to draw your own conclusions as to the usefulness of the “emerging image-targeted biopsy (using Doppler ultrasound, elastosonography, enhanced ultrasound, or magnetic resonance imaging,” over the “image-blinded” biopsy.

  4. Unfortunately, doppler TRUS of the prostate has been marketed by some physicians as granting them power to diagnose cancer when others can’t. As we come to appreciate the gross over-diagnosis and over-treatment of prostate cancer, perhaps these “seers” will provide data that their diagnostic acumen actually saves lives compared to standard 12-core systemic or no biopsy at all!

  5. My husband had a color Doppler done after having had three annual biopsies with 2-3 cores positive, Gleason 3 + 3, but < 5% cancerous in each of those cores. The doctor who did the color Doppler saw nothing indicative of cancer and suggested having future biopsies only if the PSA spiked. (It's always been less than 1.0.) This doctor was clearly not trying to diagnose prostate cancer. It's been 3 years since the color Doppler and no spike in PSA yet, and no more biopsies … just lots of veggies. In this case, the color Doppler helped support our thinking that my husband's prostate cancer is the indolent kind; that's something most doctors and urologists would rarely admit a few years ago. Maybe more would now, in 2014.

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