A positive real-time elastography is an independent marker for detection of high-risk prostate cancers in the primary biopsy setting Yngve Nygård*, Svein A. Haukaas* ‡ , Ole J. Halvorsen †‡ , Karsten Gravdal † , Jannicke Frugård*, Lars A. Akslen †‡ and Christian Beisland* ‡ Departments of *Urology and † Pathology, Haukeland University Hospital, and ‡ Department of Clinical Medicine, University of Bergen, Bergen, Norway Objective • To evaluate the performance of real-time elastography (RTE) in an initial biopsy setting. Patients and Methods • In the period from February 2011 to June 2012, 127 consecutive patients were included in the study. • We used a Hitachi Preirus with Hi-RTE module, a prostate end-fire transrectal probe was used for RTE and for targeted biopsies, and a simultaneous biplane probe was used for the standard systematic biopsies. • The peripheral zone of the prostate was divided into six regions, and each biopsy obtained was referred to a specific region. • All patients were first examined with RTE and, if cancer was suspected, targeted biopsies were taken. A standard systematic 10-core biopsy was then taken in all patients. Results • In all, 64 (50%) patients were diagnosed with prostate cancer in the initial biopsy setting. Three patients were diagnosed solely on RTE-targeted biopsies, 31 were found only in systematic biopsies, and 30 were correctly diagnosed with both methods. • In the RTE-positive group there was a significantly higher frequency of positive cores, a lower prostate volume, a higher Gleason score, and a higher fraction of cancer tissue in each core. • In a multiple regression model RTE was an independent marker for high-risk cancer. • The sensitivity of 42% for all prostate cancers increased to 60% for high-grade prostate cancers. • Similarly, the negative predictive value increased from 79% to 97%. An additional eight patients were diagnosed with prostate cancer during the study period. Conclusions • A positive RTE is an independent marker for detection of high-risk prostate cancer, and a negative RTE argues against such. • RTE with targeted biopsies cannot replace systematic biopsies, but provides valuable additional information about the tumours. Keywords real-time elastography, prostate cancer, prostate biopsy, high-risk cancers, diagnosis, treatment Introduction Prostate cancer is the most common cancer in men, accounting for 4299 new cases in Norway in 2009. The incidence was 110 per 100 000 (world standard), and is increasing. The principal tools for detection of prostate cancer are serum PSA level and DRE. PSA and DRE have low specificity, and they do not differentiate between aggressive and indolent disease. Currently the diagnostic standard of care is to perform B-mode TRUS-guided systematic biopsy of the prostate [1,2]. According to European Association of Urology guidelines there is a need for at least two series of biopsies with at least 10 cores in the first series and 12 cores in the repeat biopsy series to exclude prostate cancer the cause of an elevated PSA level [3]. Even after two series of biopsies there will still be men with undetected but significant prostate cancer in the group. On the other hand, due to the low specificity of PSA testing, many men will have to undergo unnecessary prostate biopsies. There is a definite need for improvement in the diagnostic tools in prostate cancer and several new methods are emerging. Real-time elastography (RTE) is an ultrasound (US) method that can be helpful in detecting prostate cancer [4,5]. The advantage of RTE is the possibility for the operator to place the biopsy needle into a BJU Int 2014; 113: E90–E97 © 2013 The Authors BJU International © 2013 BJU International | doi:10.1111/bju.12401 wileyonlinelibrary.com Published by John Wiley & Sons Ltd. www.bjui.org