Better ultrasound technology in diagnosis … is it time for change?

For many years a relatively small group of specialists have argued that “enhanced” types of transrectal ultrasound technology (most specifically inclusive of color Döppler ultrasound) have a greater ability to identify possible signs of prostate cancer than traditional “gray-scale” ultrasound.

A new review by Trabulsi et al., just published on line in Urology, seems to endorse this viewpoint in one of the major urology journals. (We think for the first time.)

We have not seen the full article yet, but according to the abstract:

  • Enhanced ultrasound modalities (EUMs) “have demonstrated improved prostate cancer detection” compared to gray-scale ultrasound modalities.
  • These EUMs include color and power Döppler, contrast-enhancement, harmonic and flash replenishment imaging, and elastography.
  • EUMs are particularly helpful when used to target for biopsy areas of the prostate that exhibit increased or abnormal vascularity or firmness.

The authors also imply (in their abstract) that EUMs may be able to improve the accuracy of TRUS-guided prostate biopsy using “standard” numbers of biopsy cores (i.e., 10 or 12 cores) as compared to the potential need for use of “saturation” biopsies (with 20 or more cores), which are known to be associated with higher risk for side effects and complications.

Of course the costs associated with acquisition and use of these enhanced forms of ultrasound technology raise the costs associated with a prostate biopsy, which is a whole other issue.

4 Responses

  1. Is there any thought or evidence that EUMs (or MRI) could replace the biopsy as the first-line diagnostic tool in those cases where the digital exam is negative but the man has a 4+ PSA and family history? The idea of multiple biopsies in a watchful waiting protocol seems risky for subsequent metastases.

  2. Dear Clark:

    A lot of researchers and commercial companies are trying to improve imaging techniques enough to make a biopsy unnecessary. However, as of today that certainly isn’t a reality.

    An accurate diagnosis needs to be able to make an accurate estimation of the Gleason score, since this is a critical component of the patient’s risk and need for treatment. At present there is no evidence that I am aware of that would allow any imaging technique to accurately predict Gleason score. To get a Gleason score you need a tissue sample. To get a tissue sample you need a biopsy.

    The other part of your question is, however, different. What you are really asking in that case is, “How often do I need to have a biopsy on an active risk monitoring program?” My entirely personal view is that having a biopsy on an annual basis is not a great idea. Perhaps you could talk to your doctor(s) about the feasibility of a color Doppler untrasound every year with a biopsy only if there was a significant change in the appearance of the ultrasound image, or a significant change in the PSA level, or every third year if there was no apparent change.

    There are no data to substantiate such a recommendation, but there are increasing amounts of data suggesting that frequent repeat biopsies are not associated with a clinically significantly increased likelihood of diagnosis, and each biopsy does come with risks (although those risks do not, as far as I am aware, include any increase in risk for metastatic disease).

  3. Mike,
    Do you know the cost of each of these to the patient?

  4. Sorry, no. I haven’t a clue.

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