This document describes transrectal ultrasound (TRUS)-guided prostate biopsy techniques. It begins with background on the anatomy of the prostate and ultrasonographic imaging. TRUS-guided biopsy is considered the mainstay for prostate cancer detection and involves using a biopsy gun to obtain core samples under ultrasound guidance. Various biopsy schemes are described, including the original sextant technique and more extensive schemes involving additional cores. Factors such as patient preparation, anesthesia, and antibiotic prophylaxis for biopsies are also outlined. The document provides an overview of TRUS-guided prostate biopsy procedures and technical considerations.

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TRUS
GUIDED
PROSTATE
BIOPSY
BY: PARTH NATHWANI
GUIDE: DR.NITIN JOSHI

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INTRODUCTION
• There is a significant decline in prostate
cancer related mortality due to early prostate
cancer detection programs.
• Role of PSA screening efforts, introduction
& refinement of systematic transrectal
ultrasonography (TRUS)– guided prostate
biopsy techniques, and increased public
awareness about prostate cancer.

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• TRUS of the prostate- first described by
Watanabe et al(1968).
• TRUS-guided systematic sextant biopsy
protocol- introduced by Hodge et al(1989).
• TRUS: mainstay of many image-guided
prostate interventions, including prostate
biopsy, brachytherapy, cryotherapy, & high-
intensity focused ultrasonography (HIFU),
evaluation of appropriate patients for treatment
of BPH.

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ULTRASONOGRAPHIC
ANATOMY OF PROSTATE
• The prostate lies
between bladder
neck and urogenital
diaphragm, just
anterior to rectum,
an ideal position to
be imaged by
TRUS.

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• On the basis of pathologic zonal architecture,
prostate is divided into:
 Anterior fibromuscular stroma (AFS) that is
devoid of glandular tissue,
 transition zone (TZ),
 central zone (CZ),
 periurethral zone, and
 peripheral zone (PZ).
• But these regions are not visible
sonographically as distinct entities.

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TRANSVERSE SAGITTAL

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• Normal CZ and PZ(posterior): majority of
adenocarcinomas; homogeneous echogenic
appearance.
• TZ(anterior) is more heterogeneous.
• Calcification along the surgical capsule known
as corpora amylacea highlight the plane between
PZ & TZ
• Small , multiple , diffuse calcifications are
normal

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• The prostatic urethra traverses the length of the gland
in the midline and thus must be imaged in the sagittal
plane to be simultaneously viewed along the entirety
of its course .
• The distended urethral lumen has a hypoechoic
appearance whereas periurethral calcifications may
produce a thin echogenic outline.
• The smooth muscle of the internal sphincter extends
from the bladder neck, encircling the urethra to the
level of the verumontanum.

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• These muscle fibers may be visualized
sonographically as a hypoechoic ring around the
upper prostatic urethra, giving it a funneled
appearance proximally as it arises from the bladder
neck.
• On reaching the verumontanum the urethra angles
anteriorly and runs through the remainder of the
gland to exit at the apex of the prostate.
• This angle gives the prostatic urethra an anteriorly
concave appearance when viewed along its entire
course in the sagittal plane.

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• The paired seminal vesicles (SVs) are
positioned posteriorly at the base of the
prostate.
• They have a smooth, saccular appearance and
should be symmetrical.
• The normal SV measures 4.5 to 5.5 cm in
length and 2 cm in width.

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A, In the transverse plane with the hypoechoic urethra centrally located
(star) and dotted line representing transverse measurement.
B, Midline sagittal view with the hypoechoic urethra running the length of
the gland, D1 represents longitudinal and D2 anteroposterior measurement.

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Seminal vesicles and vasa
deferentia in the transverse plane

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GRAY-SCALE TRUS
• Most common imaging modality for prostate.
• Most commonly used for:
prostate cancer detection
evaluation of other conditions such as
infertility
directing the biopsy of prostate cancer.
Staging of carcinoma prostate (limited role).

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• Endorectal probes available in both side- and end-
fire models; transmits frequencies of 6 to 10
MHz.
• Newer biplane probes provide simultaneous
sagittal and transverse imaging modes.
• Probes provide a scanning angle approaching 180
degrees to allow simultaneous visualization of the
entire gland in both the transverse and sagittal
planes.
• Increasing frequency yields increased resolution

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• As the frequency of the probe is increased, the
portion of the image that is in focus (focal range) is
closer to the transducer.
• The commonly used 7-MHz transducer produces a
high resolution image with a focal range from 1 to 4
cm from the transducer (best for PZ where most
cancers arise).
• Lower-frequency transducers (e.g., older 4-MHz
transducers) have a focal range from 2 to 8 cm but at
lower resolution they improve anterior deliniation of
large gland & provides poor internal architecture
visualization

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TECHNIQUE
• Medium-gray image of normal PZ serves as
the "reference point" for judging lesions as
hypoechoic (darker than the normal PZ),
isoechoic (similar to the normal PZ),
hyperechoic (lighter than the normal PZ), or
anechoic (completely black).
• Patients are scanned in left lateral ducubitus
position
• TRUS should be performed in both transverse
and sagittal planes.

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VOLUME CALCULATION
• π/6 × transverse diameter × AP diameter ×
longitudinal diameter
• Mature average prostate-20-25 g and remains
constant until age 50.
• For more accurate determination of prostate
volume (Brachytherapy), Planimetry is
required.
• PSA density = serum PSA/gland volume
• Elevated PSAD have sensitivity & specificity
of 75% & 44%, but it is operator dependent.

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PROSTATE CANCER IMAGING
ON TRUS
• All hypoechoic lesions within the PZ: consider
biopsy.
• A hypoechoic lesion is malignant in 17-57% of cases,
but they are not pathognomonic for cancer.
• Lack of a distinct hypoechoic focus doesn't preclude
biopsy, as 39% of Ca prostate cases are isoechoic, &
1% hyperechoic on conventional gray scale TRUS.

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• Granulomatous prostatitis, prostatic infarct &
lymphoma- all may produce hypoechoic
lesions.
• Extracapsular extension of prostate cancer,
although not well visualized if present as a
microfocus, is suggested by a focal loss of the
typically bright white periprostatic fat.

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Classic hypoechoic peripheral zone (PZ) lesion
(dotted line) in the right midgland that transrectal
ultrasonography–guided biopsy proved to be a
Gleason 3 + 3 = 6 adenocarcinoma.

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CYSTIC LESION OF
PROSTATE
• Simple cysts have the same sonographic appearance
as in any other part of the body: they are thin walled,
are anechoic, and show acoustic enhancement
posterior to the cyst.
• Congenital prostatic cystic lesions may arise from
either müllerian (müllerian duct cysts and prostatic
utricles) or wolffian (ejaculatory duct and seminal
vesicle cysts) structures.
• They appear in the midline as anechoic lesion

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• Ejaculatory duct cysts are typically small, lie
off of the midline, and may accompany
ejaculatory duct obstruction/obliteration with
azoospermia.
• Seminal vesicle cysts can be caused by
congenital or acquired obstruction of the
ejaculatory duct and are associated with cystic
renal disease; up to two thirds of men with
seminal vesicle cysts may also have renal
agenesis

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Prostatic cyst

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INDICATIONS FOR PROSTATE
BIOPSY
TRUS without Biopsy
• Treatment planning volume measurements: brachytherapy,
cryotherapy, BPH therapy (e.g.TUMT, RFA)
• Volume measurement during hormonal downsizing for EBRT
or brachytherapy
• Placement of fiducial markers for EBRT
• Evaluation of azoospermia: ejaculatory duct cysts, seminal
vesicle cysts, etc.
• Therapeutic aspiration or unroofing of prostatic cysts; drainage
of prostatic abscess

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TRUS-Directed Biopsy
• Diagnosis of suspected symptomatic prostate cancer (i.e., bone
metastasis, cord compression)
• Screening for prostate cancer in asymptomatic patient > age 50 with
> a 10-year life expectancy (if strong family history or if African-
American, consider screening at age 45)
 Prostate nodule or significant prostate asymmetry regardless of PSA
level
 PSA > 4.0 ng/dL regardless of age
 In men < age 60 to 65 years, consider biopsy if PSA > 2.5 ng/dL
 If PSA > 0.6 ng/dL at age 40
 Increased PSA velocity (>0.75 ng/dL/year)
 Free PSA in considering initial biopsy with PSA < 10 ng/mL: >25%
no biopsy; >10% and <15%, consider biopsy; <10%, biopsy

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• Prior to intervention in symptomatic BPH (e.g., surgical
therapy or initiation of 5α-reductase inhibitors)
• Prior to cystoprostatectomy or orthotopic urinary diversion
• To diagnose failed radiation therapy before use of second-line
therapy
• Follow-up biopsy (3-6 months) after diagnosis of high-grade
PIN or Atypical small acinar proliferation.

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• Data from the Prostate Cancer Prevention Trial
have shown that no safe PSA threshold can
rule out prostate cancer in any age range.
• For a serum PSA value between 4.0 and 10.0
ng/mL, using a % free PSA threshold of <25%
allowed detection of 95% of cancers while
eliminating 20% unnecessary biopsies.

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• Volume-based PSA parameters evaluated to
reduce confounding from BPH.
• These include:
PSA density (PSAD; PSA divided by prostate
volume),
complexed PSA density (complexed PSA
divided by prostate volume), and
PSA transition zone density (PSA divided by
transition zone volume).

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• PSA levels between 4 and 10 ng/mL and a
normal DRE:
PSAD ≥ 0.15- prostate biopsy recommended.
PSA transition zone volume was the parameter
with highest overall sensitivity & specificity.

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PSA Dynamics/PSA Velocity(PSAV):
• Rate of change in PSA.
• With PSA levels between 4-10 ng/mL, PSAV ≥ 0.75
ng/mL/year: a specific marker for the presence of
prostate cancer.
• In PSA <4, PSAV > 0.5ng/mL/yr is significant.
• PSAV may play a role in the prediction of life-
threatening prostate cancer .
• A PSAV > 0.35 ng/mL/year 10-15 years prior to
diagnosis- fivefold increased risk of life-threatening
prostate cancer more than a decade later.

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CONTRAINDICATIONS TO
PROSTATE BIOPSY
• Significant coagulopathy
• Painful anorectal conditions
• Severe immunosuppression, and
• Acute prostatitis.

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PATIENT
PREPARATION
• Written, informed consent.
• All anticoagulant therapy (warfarin,
clopidogrel, aspirin/NSAIDs, herbal
supplements) should be stopped 7-10 days
before prostate biopsy.
• For coagulopathic pts., INR should be
below 1.5.
• A small amount of urine can facilitate the
examination .

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ANTIBIOTIC PROPHYLAXIS
• Oral FQ one dose 30-60 min.before biopsy -
continue for 3 days.
• Single dose oral FQ=3day regimen.
• High risk pts.(endocarditis, prosthetic joints,
pacemakers, automated implanted cardiac
defibrillators)- i.v. Ampicillin/Vancomycin +
Gentamicin preop f/b 3days oral FQ.

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Cleansing enema:
• decreases the amount of faeces in the rectum,
thereby producing a superior acoustic window
for prostate imaging.
• may reduce bacterial seeding of the prostate.

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Analgesia
• Topical lidocaine jelly.
• Infiltration anesthesia around nerve
bundles.
• Direct infiltration(Intraprostatic
injection).
• Skin & subcut.infiltration for
transperineal biopsy.

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POSITION
• Left lateral decubitus position with knees and hips
flexed 90 degrees.
• Lithotomy position preferred for transperineal
biopsies, brachytherapy treatment planning, or
placement of fiducial gold markers for external-beam
therapy.
• Lithotomy position is preferred when color Doppler
imaging is used to identify areas of hyperemia for
targeted biopsy of the prostate(distribution of color
Doppler flow within the prostate is dependent on
patient position)

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TRUS PROSTATE BIOPSY
TECHNIQUES
• Assess prostate volume.
• Prostate imaging in transverse &
sagittal planes(from base to apex).
• Note location and characteristics of any
lesions (i.e., hypoechoic, hyperechoic,
calcifications, contour abnormalities,
cystic structures).

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• A spring-driven, 18-gauge, needle core biopsy
device or biopsy gun, passed through the
needle guide attached to the ultrasound probe.
• Biopsy gun advances the needle 0.5 cm and
samples subsequent 1.5 cm of tissue with the
tip extending 0.5 cm beyond the area sampled.

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BIOPSY GUN

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18-gauge prostate needle biopsy core specimen

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SEXTANT BIOPSY:
• one core, bilaterally,
each from base, mid,
and apex.
• samples both PZ &
TZ.
• Vast majority of
AdenoCa-
posterolateral PZ.
TRUS BIOPSY SCHEMES

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EXTENDED CORE BIOPSY
SCHEMES
• Improved cancer detection rates by
incorporating additional laterally
directed cores into the standard
systematic sextant technique.
• At present, 6 cores are considered
inadequate for routine prostate
biopsy for cancer detection.

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• TZ and SVs are not routinely sampled(low yields for
cancer detection at initial biopsy).
• TZ and anteriorly directed biopsies may
occasionally prove necessary to diagnose prostate
cancer in patients with persistently elevated PSA
levels and prior negative biopsies.
• A role for TZ biopsies in men with gland size > 50
mL, with an additional yield of 15% cancer detection.

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• Seminal vesicle biopsy is not
routinely performed unless there is a
palpable abnormality, when PSA
value > 30, or if brachytherapy is
being considered.

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Various reported systematic biopsy schemes.
A, Sextant biopsy scheme originally proposed by Hodge and
associates (Hodge et al, 1989b)
B, The 10-core biopsy of Presti and coworkers (2000).
C, The 12-core, or double sextant, biopsy.
D, The 13-core “5-region biopsy” of Eskew and colleagues

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Rp & lp-right &left periphery,
rpm &lpm – rt & lt paramedian

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Cross-sectional view of commonly
biopsied zones.

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A 36 core biopsy scheme

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• Proper sampling and labelling
• Sample should be sent in 10% formalin filled
bottles
• Preferably each individual sample should be
sent in different bottle, some prefer to send right
& left only separately
• Some pathologists believe strongly that each
site should be specifically identified because
certain locations predisposed to cancer may
look-alike(cooper’s gland at apex , seminal
vesicle at base)

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REPEAT PROSTATE BIOPSY
• Use of a 2nd prostate biopsy in all cases
of a negative finding on initial biopsy is
justified.
• But 3rd and 4th repeat biopsies should
only be obtained in selected patients
with high suspicion of cancer and/or
poor prognostic factors on the 1st or 2nd
biopsy.

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• Overall cancer detection rates for repeat prostate
needle biopsy with various biopsy templates ranges
from 10% - 38%.
• Indications for a repeat prostate biopsy include the
following:
1) A highly suspicious DRE (digital rectal examination)
2) A persistently rising serum PSA (> 0.4 – 0.75
ng/ml/yr.)
3) A low free PSA (certainly < 10%, maybe < 22% -
25%)
4) Presence of PIN or atypia on prior biopsy

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RISKS & COMPLICATIONS OF
PROSTATE BIOPSY
Immediate:
• Hematuria
• Vasovagal episode
• Rectal bleeding
• Urinary retention
Delayed:
• Persistent hematuria
• Vague pelvic discomfort
• Dysuria
• Hematochezia
• Hematospermia
• Postbiopsy infections(low grade febrile illness, UTI,acute prostatitis,
epididymitis, fatal septicemia)

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INTERPRETATION
• Benign prostatic hyperplasia
• Acute inflammation
• Chronic granulomatous inflammation
• Atrophy
• High grade prostatic intraepithelial neoplasm
(PIN)
• Suspicious (lesion too small or insufficient
criteria present)
• Adenocarcinoma.

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ADVANCED USG TECHNIQUES
FOR PROSTATE IMAGING
COLOR & POWER DOPPLER TRUS:
• Color Doppler imaging is based on the
frequency shift in the reflected sound waves
from the frequency of insonation
• Thus it depicts the velocity of blood flow in a
directionally dependent manner.

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• Color assignment is based on the direction of
blood flow related to the orientation of the
transducer receiving the signal; flow toward
the transducer- red and flow away in shades of
blue; color is not specific for arterial or venous
flow.

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Transrectal ultrasonography.
• Top image, solid white arrow
depicts hypoechoic lesion
within the peripheral zone
concerning for prostate cancer.
• Lower image depicts
hypervascular area seen with
color Doppler imaging, yellow
and red area corresponds to the
hypoechoic area seen on the
grayscale ultrasonography
above.

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POWER DOPPLER IMAGING (enhanced color
Doppler, color amplitude imaging [CAI], or
color angiography) uses amplitude shift to
detect flow in a velocity and directionally
independent manner.
• Advantages: ability to detect slower flow and
to have less reliance on the Doppler angle,
making it more suitable for detection of
prostate cancer neovascularity.

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A. Color Doppler transrectal ultrasonography (TRUS) and
B. Power Doppler TRUS identify a Gleason 4 + 4 = 8
adenocarcinoma in the left midgland

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• Patients with detectable color Doppler flow
within their dominant tumor at the time of
TRUS-guided biopsy are at a 10-fold increased
risk for PSA recurrence after radical retropubic
prostatectomy.
• The presence of increased flow was also
accociated with high gleason grade, increased
incidence of SV invasion & lower incidence of
biochemical disease free survival rate.

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CONTRAST ENHANCED TRUS(CE-
TRUS)
• Intravenous microbubble ultrasound contrast agents, infused
systemically during gray-scale and TRUS Doppler imaging
amplify flow signals within the microvasculature of prostate
tumors, allowing selective visualization of malignant foci.
• These agents increase the echogenicity of the intravascular
space on grey-scale imaging and provide a dramatic visible
increase in the Doppler signal.
• These are constructed with air or higher-molecular-weight gas
agents encapsulated (albumin or polymer hard shell, lipid- or
surfactant-coated) for longevity.

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• CE-TRUS + 3D IMAGE
RECONSTRUCTION of enhanced power
doppler.
• GREY-SCALE HARMONIC imaging: better
spatial & temporal resolution.
• FLASH REPLENISHMENT IMAGING:
improved visualisation of vessels.

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Unenhanced color (A) transrectal ultrasonography (TRUS) and power Doppler (B)
TRUS fail to detect evidence of an underlying malignancy. After infusion of a
microbubble contrast agent, color (C) TRUS and power Doppler (D) TRUS
demonstrate an area of increased flow in the left midgland that proved to be a Gleason
3 + 4 = 7 adenocarcinoma on targeted biopsy

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OTHER TECHNIQUES
ARTIFICIAL NEURAL NETWORKS
ELASTOGRAPHY:
• New sonography technique.
• employs real-time sonographic imaging of
the prostate at baseline and under varying
degrees of compression.
• Through computerized calculations,
differences in displacement between
ultrasonic images from baseline and during
compression may be visualized, and regions
with decreased tissue elasticity may be
tagged as suggestive of malignancy.

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Elastography demonstrates an area of decreased compliance in the right base
consistent with an underlying malignancy (blue near arrow). Note color scale
in upper right corner indicating relative tissue “firmness.” Targeted biopsy of
this region revealed a Gleason 4 + 4 = 8 adenocarcinoma

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ENDORECTAL MRI & MR SPECTROSCOPIC
IMAGING(MRSI):
• MRSI identifies biochemical changes within
the tissue that may predate the appearance of
histological changes.
• MRSI suggestive of malignancy may not have
biopsy detectable PCa at the time of MRSI but
may develop histological cancer at a later date.

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TAKE HOME MESSAGE
• TRUS ALONE CANNOT DIAGNOSE
PROSTATE CANCER WITHOUT A
TISSUE BIOPSY
• MAINSTAY OF IMAGING FOR
PROSTATE BIOPSY,BRACHYTHERAPY,
CRYOTHERAPY & HIFU
• HYPOECHOIC FOCI SEEN ON GRAY
SCALE TRUS SHOULD BE
CONSIDERED S/O ADENOCARCINOMA
& INCLUDED IN BIOPSY SPECIMEN

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• 39% OF PROSTATE CANCER ARE NOT VISIBLE
ON ROUTINE GRAY SCALE USG
• SEXTANT BIOPSY IS INADEQUATE, PREFER
10 TO 14 CORE BIOPSY.
• CONTRAST ENHANCED TRUS & BIOPSY ,
COLOUR & POWER DOPPLER IMAGING
MODES MAY IMPROVE CANCER DETECTION
IN FUTURE
• TRUS GRAY SCALE CORE NEEDLE BIOPSY IS
THE GOLD STANDARD FOR DIAGNOSIS OF
PROSATE CANCER AT PRESENT

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ThankYou!!