Diagnostic TRUS Elastography of the Prostate

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1 Diagnostic TRUS Elastography of the Prostate George Zacharopoulos Department of Diagnostic Ultrasound Hygeia Hospital Athens, Greece

2 Prostate HI-RTE Why we need Elastography Better Detection of possible cancerous foci Improved Sampling Methodology Re-establishing a possible US role in local staging

3 Prostate Elastography Current commercially available Elastographic techniques Real time Compression Elastography Shear Wave Elastography

4 Prostate HI-RTE Why HI-RTE Major Advantages Real-time imaging It can be incorporated into existing range of machines at all price levels Most Promising US technique to yield valuable additional diagnostic information Combined to other US techniques (b-mode, color doppler etc) greatly improves detection, sampling and local staging accuracy

5 Prostate TRUS

6 Prostate Color Doppler

7 Prostate HI-RTE

8 Prostate HI-RTE How I Do It Equipment Selection/Probe Software Settings optimization

9 Prostate HI-RTE How I Do It Equipment / Probe TRUS bmode with image optimization (wide FOV, harmonics, Compounding, Speckle Reduction) Color Doppler HI-RTE Optional Contrast Enhanced US capability

10 Prostate HI-RTE Scanning technique How the elastographic images are acquired Waveform selection How the images are displayed

11 Prostate HI-RTE

12 Prostate HI-RTE How the elastographic images are acquired Frame 1 Frame 2

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14 Prostate HI-RTE The significance of ROI size selection

15 Prostate HI-RTE Waveform Selection Ideal waveform from phantom scan Waveforms from routine clinical cases

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17 Prostate HI-RTE Image Interpretation Prostate US Elastography Scoring system Major pitfalls and how to avoid them

18 ELASTOGRAPHY IMAGES SCORING (red: soft, blue: hard) Type I Homogeneous Normal Elasticity Type II Mixed Elasticity appearance Foci of reduced Elasticity <5mm in diameter Type III Areas of reduced Elasticity >5 mm in diameter

19 Prostate HI-RTE Image Interpretation

20 Prostate HI-RTE Image Interpretation

21 Prostate HI-RTE Problems with the use of the free hand method Difficulty in mastering the technique Compression point deviation Use of transrectal probe inability to visually confirm degree and location of compression Insufficient compression may prevent transmission Size of the prostate may influence the RTE examination with suboptimal results

22 Prostate HI-RTE Image Interpretation Insufficient Compression Pitfall

23 Prostate HI-RTE Image Interpretation Insufficient US Window Pitfall

24 Prostate HI-RTE Image Interpretation Suboptimal Elastography of Oversized prostate

25 Prostate HI-RTE Image Interpretation Suboptimal Elastography of Oversized prostate

26 Prostate HI-RTE Clinical cases

27 Inconclusive bmode TRUS Total PSA Elastographic mapping highly indicative of neoplasia Needle biopsy: Cancer

28 Hypoechoic focal lesion in bmode TRUS Total PSA 5.5 Negative color Doppler Images Elastographic mapping highly indicative of neoplasia Needle biopsy: Cancer

29 Two cases positive DRE, normal RTE and Negative Needle Biopsy Hypoechoic lesion in bmode TRUS, Total PSA 5 Near Isoechoic lesion in bmode TRUS, Total PSA 4.9

30 Hypoechoic lesion in bmode TRUS Positive DRE, Total PSA 2.23 Negative Elastographic Imaging Needle Biopsy: Chronic Inflammatory Lesion

31 Hypoechoic lesion in bmode TRUS Total PSA 10.5 Hypervascular Lesion in color Doppler Negative Elastographic Imaging Needle Biopsy: Negative for Neoplasia (Foci of Acute and Chronic Prostatitis)

32 Case of a patient under AntiCoagulative treatment Positive DRE, Total PSA 22 TRUS and RTE positive for neoplasia with Capsule Invasion RTE enabled a selective reduction of needle core sampling Histology: Cancer

33 Conclusions Prostate HI-RTE Can be incorporated into the routine ultrasound examination Improves the differentiation between benign and malignant lesions Increases the accuracy of tissue sampling Yields additional information on the integrity of the prostatic capsule and the surrounding tissue