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Prostate Cancer Diagnosis — RACP Adult Medicine MCQ

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ModerateGeneral Internal MedicineProstate Cancer DiagnosisRACP Adult Medicine

A 60-year-old man presents with a 3-month history of progressive difficulty initiating micturition, nocturia ×4, and incomplete emptying. DRE reveals a hard, irregular prostate. PSA is 28 µg/L. MRI pelvis shows a PI-RADS 5 lesion with extracapsular extension. What is the most appropriate next step?

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Correct answer: A — Transperineal prostate biopsy

A PSA of 28 µg/L with a hard irregular prostate and PI-RADS 5 lesion on MRI is highly suspicious for prostate cancer. Histological confirmation via transperineal prostate biopsy (now preferred over transrectal due to lower infection risk – TP-SMART trial) is essential before treatment planning. MRI-targeted biopsy of the PI-RADS 5 lesion plus systematic biopsies should be performed. Staging (bone scan, CT) follows if cancer is confirmed.

Reference: Cancer Council Australia – 2023 – Prostate Cancer Guidelines; PCFA – 2024