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Persistent suspicion of clinically significant prostate cancer after a negative biopsy — MSRA MCQ

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HardPI-RADSPersistent suspicion of clinically significant prostate cancer after a negative biopsyMSRA

A 68-year-old man is reviewed after investigation of a persistently raised PSA. He is fit and would be eligible for radical treatment if clinically significant prostate cancer were found. Multiparametric MRI demonstrated a PI-RADS v2.1 category 3 lesion, which the reporting radiologist also graded as Likert 3. MRI-targeted and systematic transperineal biopsies subsequently showed benign prostatic tissue, without high-grade prostatic intraepithelial neoplasia or atypical small acinar proliferation. At review 6 months later, his PSA is 7.3 micrograms/L, compared with 7.2 micrograms/L at biopsy. MRI-measured prostate volume was 72 mL. Digital rectal examination is normal, and there is no family history of prostate cancer. The hospital letter proposes ongoing PSA monitoring in primary care because his PSA density and velocity are reassuring. Which is the most appropriate next step?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Refer back for urological MDT review, with repeat biopsy considered after reassessment

Explanation lettering: B = shown as A · D = shown as B · E = shown as C · A = shown as D · C = shown as E

His PSA density is approximately 0.10 nanograms/mL/mL, and the small PSA change over 6 months represents a low velocity. Alongside the normal DRE and benign targeted and systematic biopsies, these findings reduce—but do not eliminate—the likelihood of clinically significant cancer. The decisive discriminator is the explicit Likert 3 classification. NICE recommends that a negative biopsy accompanied by an MRI Likert score of 3 or higher is discussed at a urological cancer MDT, with a view to repeating the biopsy. Reassuring PSA kinetics do not transfer this patient into the primary-care surveillance pathway intended for negative biopsy with Likert 1 or 2 imaging or an MRI contraindication. B and C are therefore inappropriate despite the low PSA density and velocity. D is plausible because interval MRI may be chosen by specialists, but it predetermines management before the required multidisciplinary reassessment of the imaging, biopsy adequacy and residual risk. E recognises the possibility of a false-negative biopsy but omits the recommended sequence: repeat biopsy should be considered following MDT discussion rather than arranged automatically. The GP should challenge the proposed discharge plan and request specialist MDT review.

Reference: Prostate cancer: diagnosis and management — Recommendations (Published 9 May 2019; last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations Prostate cancer: diagnosis and management — Recommendations (Published 9 May 2019; last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations Prostate cancer: diagnosis and management — Rationale and impact (Published 9 May 2019; last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/rationale-and-impact