 Introduction/Background Prostate cancer ranks second only after lung cancer as a leading cause of cancer-related deaths in American patients. In 2020, an estimated 191,930 American patients were diagnosed with prostate cancer, and 33,330 died of the disease [1]. In addition to the personal toll of these deaths, there is a substantial amount of direct economic costs related to prostate cancer in the Unites States at an estimated $10 billion per year [2]. The primary goal during pretreatment evaluation of prostate cancer is disease detection, localization, and characterization, that is, establishing disease extent, both local and distant, and aggressiveness, because these drive patient outcomes in terms of recurrence and survival. Reprint requests to: publications@acr.org Special Imaging Considerations A few emerging imaging techniques have not yet made their way into mainstream clinical practice, showing the potential to improve detection of the primary tumor, nodal, and distant metastatic disease in addition to achieving better risk stratification. Studies on advanced ultrasound (US) techniques have focused on assessment of the primary prostate tumor [31-36]. For example, a recent meta-analysis showed that shear wave elastography had a pooled sensitivity and specificity of 83% and 85%, respectively [31]. In addition, targeted biopsy using real-time elastography was able to improve the Gleason score assignment when added to systematic biopsy than systematic biopsy alone (68.3% versus 56.7%) [32]. High-resolution micro-US has also shown potential to improve detection of clinically significant prostate cancer [33]. Furthermore, when a multiparametric approach was used for US using B-mode, shear wave elastography and contrast-enhanced US, it was able to improve the sensitivity in detecting index lesions compared with B-mode alone (74% versus 55%) [34].
Pretreatment Detection Surveillance and Staging of Prostate Cancer.  Introduction/Background Prostate cancer ranks second only after lung cancer as a leading cause of cancer-related deaths in American patients. In 2020, an estimated 191,930 American patients were diagnosed with prostate cancer, and 33,330 died of the disease [1]. In addition to the personal toll of these deaths, there is a substantial amount of direct economic costs related to prostate cancer in the Unites States at an estimated $10 billion per year [2]. The primary goal during pretreatment evaluation of prostate cancer is disease detection, localization, and characterization, that is, establishing disease extent, both local and distant, and aggressiveness, because these drive patient outcomes in terms of recurrence and survival. Reprint requests to: publications@acr.org Special Imaging Considerations A few emerging imaging techniques have not yet made their way into mainstream clinical practice, showing the potential to improve detection of the primary tumor, nodal, and distant metastatic disease in addition to achieving better risk stratification. Studies on advanced ultrasound (US) techniques have focused on assessment of the primary prostate tumor [31-36]. For example, a recent meta-analysis showed that shear wave elastography had a pooled sensitivity and specificity of 83% and 85%, respectively [31]. In addition, targeted biopsy using real-time elastography was able to improve the Gleason score assignment when added to systematic biopsy than systematic biopsy alone (68.3% versus 56.7%) [32]. High-resolution micro-US has also shown potential to improve detection of clinically significant prostate cancer [33]. Furthermore, when a multiparametric approach was used for US using B-mode, shear wave elastography and contrast-enhanced US, it was able to improve the sensitivity in detecting index lesions compared with B-mode alone (74% versus 55%) [34].