World Journal of Urology

, Volume 36, Issue 7, pp 1059–1065 | Cite as

Quantitation of hypoechoic lesions for the prediction and Gleason grading of prostate cancer: a prospective study

  • Kwang Suk Lee
  • Kyo Chul Koo
  • Byung Ha Chung
Original Article



Hypoechoic lesions are not included as indicators for prostate biopsy. To discriminate the features of hypoechoic lesions, we investigated the ultrasonographic characteristics of hypoechoic lesions using numerical analysis in image. In addition, we evaluated previously suggested subjective parameters on hypoechoic lesion.


We performed one-core targeted biopsy (TBx) for each hypoechoic lesion in up to two lesions in each patient before the 12-core systemic biopsy was obtained between July 2015 and May 2016. Image analysis data were analyzed using grayscale values and Hounsfield units (HU) to measure heterogeneity. Subjective evaluation of hypoechoic lesions including hypoechoicity, irregularity, vascularity, and microcalcification was also validated.


Of 157 patients (median age = 67.1 years, median prostate-specific antigen = 6.21 ng/mL) included in the study, 77 (49.0%) were diagnosed with prostate cancer (PCa), and 39 (17.0%) diagnoses were confirmed by the results of targeted cores. The existence of hypoechoic lesions was not a final predictor for PCa detection. In multivariate analysis using a combination of clinical and quantitative image analyses, the grayscale value was identified as a significant predictive factor for the presence of PCa and high-grade disease (Gleason score ≥ 7) on target lesions. The combination of clinical and image variables had the highest area under the curve (0.890) for detecting PCa in TBx.


The proposed method for the quantitation of hypoechoic lesions using grayscale images and HU is simple. Combined with the current clinical approaches, quantitative scoring of lesions can be useful for detecting PCa and making more precise diagnoses.


Biopsy Prostate-specific antigen Prostate cancer Ultrasound 



This research was supported in the collection and analysis phases by the Korean Society for Urologic Ultrasonography Grant (Grant Number 2016-00).

Authors’ contribution

KS Lee: project development and manuscript writing; KC Koo: manuscript writing/editing; and BH Chung: project development and manuscript writing

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

The study was approved by our institutional review board. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required. This article does not contain any studies with animals performed by any of the authors.

Supplementary material

345_2018_2224_MOESM1_ESM.docx (167 kb)
Supplementary material 1 (DOCX 166 kb)


  1. 1.
    Birs A, Joyce PH, Pavlovic ZJ, Lim A (2016) Diagnosis and monitoring of prostatic lesions: a comparison of three modalities: multiparametric MRI, fusion MRI/transrectal ultrasound(TRUS), and traditional TRUS. Cureus 8:e702. PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Lee DH, Nam JK, Park SW et al (2016) Visually estimated MRI targeted prostate biopsy could improve the detection of significant prostate cancer in patients with a PSA level < 10 ng/mL. Yonsei Med J 57:565–571. CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Carroll PR, Parsons JK, Andriole G et al (2016) NCCN guidelines insights: prostate cancer early detection, version 2.2016. J Natl Compr Cancer Netw 14:509–519CrossRefGoogle Scholar
  4. 4.
    Dahnert WF, Hamper UM, Eggleston JC, Walsh PC, Sanders RC (1986) Prostatic evaluation by transrectal sonography with histopathologic correlation: the echopenic appearance of early carcinoma. Radiology 158:97–102. CrossRefPubMedGoogle Scholar
  5. 5.
    Salo JO, Rannikko S, Makinen J, Lehtonen T (1987) Echogenic structure of prostatic cancer imaged on radical prostatectomy specimens. Prostate 10:1–9CrossRefPubMedGoogle Scholar
  6. 6.
    Heijmink SW, van Moerkerk H, Kiemeney LA, Witjes JA, Frauscher F, Barentsz JO (2006) A comparison of the diagnostic performance of systematic versus ultrasound-guided biopsies of prostate cancer. Eur Radiol 16:927–938. CrossRefPubMedGoogle Scholar
  7. 7.
    Stokes M, Anderson M, Chandrasekar S, Motta R (2017) A standard default color space for the Internet – sRGB. Accessed 22 Aug 2017
  8. 8.
    Hodge KK, McNeal JE, Terris MK, Stamey TA (1989) Random systematic versus directed ultrasound guided transrectal core biopsies of the prostate. J Urol 142:71–74 (discussion 74–75) CrossRefPubMedGoogle Scholar
  9. 9.
    Gosselaar C, Roobol MJ, Roemeling S, Wolters T, van Leenders GJ, Schroder FH (2008) The value of an additional hypoechoic lesion-directed biopsy core for detecting prostate cancer. BJU Int 101:685–690. CrossRefPubMedGoogle Scholar
  10. 10.
    Strohmeyer D, Rossing C, Strauss F, Bauerfeind A, Kaufmann O, Loening S (2000) Tumor angiogenesis is associated with progression after radical prostatectomy in pT2/pT3 prostate cancer. Prostate 42:26–33CrossRefPubMedGoogle Scholar
  11. 11.
    Muldoon L, Resnick MI (1989) Results of ultrasonography of the prostate. Urol Clin North Am 16:693–702PubMedGoogle Scholar
  12. 12.
    Vallancien G, Prapotnich D, Veillon B, Brisset JM, Andre-Bougaran J (1991) Systematic prostatic biopsies in 100 men with no suspicion of cancer on digital rectal examination. J Urol 146:1308–1312CrossRefPubMedGoogle Scholar
  13. 13.
    Hammerer P, Huland H (1994) Systematic sextant biopsies in 651 patients referred for prostate evaluation. J Urol 151:99–102CrossRefPubMedGoogle Scholar
  14. 14.
    Lee DH, Lee SH, Rha KH et al (2013) The establishment of K-CaP (the multicenter Korean prostate cancer database). Korean J Urol 54:229–233. CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Li XG, Zhang DX, Cui XG et al (2012) Evaluating the oncologic outcomes in 152 patients undergoing extraperitoneal laparoscopic radical prostatectomy. Chin Med J (Engl) 125:1529–1535Google Scholar
  16. 16.
    Egawa S, Suyama K, Arai Y et al (2001) Treatment outcome by risk group after radical prostatectomy in Japanese men. Int J Urol 8:295–300CrossRefPubMedGoogle Scholar
  17. 17.
    Van Houten M, Gooren LJ (2000) Differences in reproductive endocrinology between Asian men and Caucasian men—a literature review. Asian J Androl 2:13–20PubMedGoogle Scholar
  18. 18.
    Lee DH, Koo KC, Lee SH et al (2013) Low-risk prostate cancer patients without visible tumor (T1c) on multiparametric MRI could qualify for active surveillance candidate even if they did not meet inclusion criteria of active surveillance protocol. Jpn J Clin Oncol 43:553–558. CrossRefPubMedGoogle Scholar
  19. 19.
    Nakano Junqueira VC, Zogbi O, Cologna A et al (2012) Is a visible (hypoechoic) lesion at biopsy an independent predictor of prostate cancer outcome? Ultrasound Med Biol 38:1689–1694. CrossRefPubMedGoogle Scholar
  20. 20.
    Shakir NA, Siddiqui MM, George AK et al (2016) Should hypoechoic lesions on transrectal ultrasound be sampled during magnetic resonance imaging–targeted prostate biopsy? Urology 105:113–117. CrossRefPubMedGoogle Scholar
  21. 21.
    Neumaier CE, Martinoli C, Derchi LE, Silvestri E, Rosenberg I (1995) Normal prostate gland: examination with color Doppler US. Radiology 196:453–457. CrossRefPubMedGoogle Scholar
  22. 22.
    Erbersdobler A, Fritz H, Schnoger S et al (2002) Tumour grade, proliferation, apoptosis, microvessel density, p53, and bcl-2 in prostate cancers: differences between tumours located in the transition zone and in the peripheral zone. Eur Urol 41:40–46CrossRefPubMedGoogle Scholar
  23. 23.
    Browne JE, Watson AJ, Hoskins PR, Elliott AT (2004) Validation of a sensitivity performance index test protocol and evaluation of colour Doppler sensitivity for a range of ultrasound scanners. Ultrasound Med Biol 30:1475–1483. CrossRefPubMedGoogle Scholar
  24. 24.
    Kravchick S, Cytron S, Peled R, Altshuler A, Ben-Dor D (2003) Using gray-scale and two different techniques of color Doppler sonography to detect prostate cancer. Urology 61:977–981CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Kwang Suk Lee
    • 1
  • Kyo Chul Koo
    • 1
  • Byung Ha Chung
    • 1
  1. 1.Department of UrologyYonsei University College of MedicineSeoulKorea

Personalised recommendations