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Home » EU Health, Health, Prostate Cancer

The role of micro-ultrasound imaging in PCa screening and management

Submitted by on 14 Jul 2017 – 10:00

ExactVu™ micro-ultrasound offers a 300% improvement in resolution over conventional ultrasound, and is proving highly sensitive to prostate cancer, providing a powerful new tool to improve patient care

Prostate cancer is the most common cancer in the western world, and the inefficacy of current screening practices are leading health care systems to explore new technologies. Current screening using systematic biopsy guided by conventional ultrasound is cost effective and has a well established patient flow centered around the urologist, who is best positioned to manage and treat the patient.

Unfortunately, conventional ultrasound lacks the resolution required to target biopsies effectively and thus fails to find cancer in an estimated 30-40% of men with the disease. (1–3) Failing to identify cancer on first biopsy results in repeated procedures which are costly and increase risk to the patient. Further, the delay in detection causes patients with aggressive disease to be identified later, resulting in lower rates of curative treatment, reduced quality of life, and higher healthcare costs.
Multi-parametric MRI

Using multi-parametric MRI as a screening tool has become a topic of debate within the urology community. Some large academic centers have achieved good results performing MRI-based targeted biopsies, recently demonstrating a 12% (4) missed cancer rate, and in certain cases an ability to postpone biopsy in men who have no targets identified by MRI. Similar results (5) merited changes to the EAU recommendations (6), which now suggest that MRI be used on men with prior negative biopsy and persistent clinical indications.
Unfortunately, these lower false negative rates have been inconsistent, especially at lower volume centers, and there is significant variability even between expert readers. (7,8) Further, within this highly complex procedure, there are significant economic concerns due to the high cost of MRI, expert radiologist review, and specialized MRI/US fusion system required, especially compared to traditional in-office ultrasound costs. If this technology is to expand from the niche identified in the EAU recommendation, costs must drop significantly and a unified education and quality plan will be required to ensure consistency between readers. Even then, this technology has been shown to be less sensitive to low-grade cancer. While this is often discussed as a positive for MRI, it may require tighter screening intervals since it is unable to separate men with benign prostates from those with low-grade cancer who require more frequent follow-up.

High Resolution Micro-Ultrasound

Exact Imaging has developed a high-resolution ( The ExactVu™ system recently received regulatory approval for sale in both Europe and North America, and is now available commercially. Like MRI’s PI-RADS, a standardized risk identification and reporting protocol is available for micro-ultrasound as well. PRI-MUS™, or “Prostate Risk Identification using Micro Ultrasound”, has undergone retrospective and forthcoming prospective validation studies to demonstrate its performance. (10) Also like MRI, initial results suggest that micro-ultrasound with PRI-MUS may be useful in safely avoiding biopsy in some men with low risk factors and no targets identified on imaging. (11)

Micro-Ultrasound Imaging for Active Surveillance

Prostate cancer is the most common cancer among men in the western world, however it is only the 3rd leading cause of cancer-specific mortality in Europe. (12,13) This is because many prostate cancers progress too slowly to be a danger. Men with suspected low-grade disease are offered Active Surveillance where they are re-biopsied, often annually, and progress to treatment only when their biopsy results show the cancer has spread or become more aggressive.

One of the promises of imaging-based technologies is to allow comparison of images between follow-up intervals, with biopsy only required if the imaging results show a change. For this to be safe and effective a high sensitivity is required, ensuring that the rate of missed cancer is very low. Preliminary results show this may be possible with micro-ultrasound. A similar technique could be considered for low-risk screening patients, where imaging is used first and the patient only biopsied if a change is seen compared to the baseline scan, or high risk features are seen.

Recommendation

The high false negative rate of prostate biopsy is a significant burden on European health care systems and patients. Recent advances in MRI and micro-ultrasound present an opportunity to find cancer sooner, and be more confident in classifying low- and high-grade disease. Unlike MRI, micro-ultrasound is a direct upgrade for the current standard of care, with far lower procedural costs, time, and unique imaging expertise required. Adoption of the micro-ultrasound technology has the significant potential to improve patient outcomes while simultaneously reducing health care costs.

References:

1. Jain S, Loblaw A, Vesprini D, et al. Gleason Upgrading with Time in a Large Prostate Cancer Active Surveillance Cohort. J Urol. 2015;194(1):79-84. doi:10.1016/j.juro.2015.01.102.
2. Otaibi M Al, Ross P, Jeyaganth S, et al. Role of Repeated Biopsy of the Prostate in Predicting Disease Progression in Patients With Prostate Cancer on Active Surveillance. 2008;(May):286-292. doi:10.1002/cncr.23575.
3. Berglund RK, Masterson TA, Vora KC, Eggener SE, Eastham JA, Guillonneau BD. Repeat Biopsy in Patients Eligible for Active Surveillance. 2008;180(November):1964-1968. doi:10.1016/j.juro.2008.07.051.
4. Rosenkrantz AB, Verma S, Choyke P, et al. Prostate MRI and MRI-Targeted Biopsy in Patients with Prior Negative Biopsy.; 2016.
5. Fütterer JJ, Briganti A, De Visschere P, et al. Can Clinically Significant Prostate Cancer Be Detected with Multiparametric Magnetic Resonance Imaging? A Systematic Review of the Literature. Eur Urol. 2015;68(6):1045-1053. doi:10.1016/j.eururo.2015.01.013.
6. Mottet N, Bellmunt J, Representative EBP, et al. Guidelines on Prostate Cancer. 2016.
7. Vargas HA, Akin O, Afaq A, et al. Magnetic Resonance Imaging for Predicting Prostate Biopsy Findings in Patients Considered for Active Surveillance of Clinically Low Risk Prostate Cancer. J Urol. 2012;188(5):1732-1738. doi:10.1016/j.juro.2012.07.024.
8. Branger N, Maubon T, Traumann M, et al. Is negative multiparametric magnetic resonance imaging really able to exclude significant prostate cancer? The real-life experience. BJU Int. 2016. doi:10.1111/bju.13657.
9. Pavlovich CP, Cornish TC, Mullins JK, et al. High-resolution transrectal ultrasound: Pilot study of a novel technique for imaging clinically localized prostate cancer. Urol Oncol. April 2013. doi:10.1016/j.urolonc.2013.01.006.
10. Ghai S, Eure G, Fradet V, et al. Assessing Cancer Risk on Novel 29 MHz Micro-Ultrasound Images of the Prostate: Creation of the Micro-Ultrasound Protocol for Prostate Risk Identification. J Urol. 2016;196(2):562-569. doi:10.1016/j.juro.2015.12.093.
11. Wodlinger B, Ghai S, Eure G, et al. Micro-ultrasound of the prostate, PRI-MUSTM protocol guidance along with clinical variables: Combined approach for reducing unnecessary biopsies. In: ESUI. Milan, Italy; 2016.
12. Ferlay J, Parkin DM, Steliarova-Foucher E. Estimates of cancer incidence and mortality in Europe in 2008. Eur J Cancer. 2010;46(4):765-781. doi:10.1016/j.ejca.2009.12.014.
13. Bray F, Ren JS, Masuyer E, Ferlay J. Global estimates of cancer prevalence for 27 sites in the adult population in 2008. Int J Cancer. 2013;132(5):1133-1145. doi:10.1002/ijc.27711.