Multiparametric Ultrasound of the Prostate: Adding Contrast Enhanced Ultrasound to Real-Time Elastography to Detect Histopathologically Confirmed Cancer

Purpose: We prospectively assessed whether a combined approach of real-time elastography and contrast enhanced ultrasound would improve prostate cancer visualization. Material and Methods: Between June 2011 and January 2012, 100 patients with biopsy proven prostate cancer underwent preoperative transrectal multiparametric ultrasound combining real- time elastography and contrast enhanced ultrasound. After initial elastographic screening for suspicious lesions, defined as blue areas with decreased tissue strain, each lesion was allocated to the corresponding prostate sector. The target lesion was defined as the largest cancer suspicious area. Perfusion was monitored after intravenous injection of contrast agent. Target lesions were examined for hypoperfusion, normoperfusion or hyperperfusion. Imaging results were correlated with final pathological evaluation on whole mount slides after radical prostatectomy. Results: Of 100 patients 86 were eligible for final analysis. Real-time elastography detected prostate cancer with 49% sensitivity and 73.6% specificity. Histopathology confirmed malignancy in 56 of the 86 target lesions (65.1%). Of these 56 lesions 52 (92.9%) showed suspicious perfusion, including hypoperfusion in 48.2% and hyperperfusion in 48.2%, while only 4 (7.1%) showed normal perfusion patterns (p = 0.001). The multiparametric approach decreased the false-positive value of real-time elastography alone from 34.9% to 10.3% and improved the positive predictive value of cancer detection from 65.1% to 89.7%. Conclusions: Perfusion patterns of prostate cancer suspicious elastographic lesions are heterogeneous. However, the combined approach of real-time elastography and contrast enhanced ultrasound in this pilot study significantly decreased false-positive results and improved the positive predictive value of correctly identifying histopathological cancer.