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Suspected clinically localised prostate cancer — MSRA MCQ

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HardPI-RADSSuspected clinically localised prostate cancerMSRA

A 64-year-old man is being investigated for a persistently raised PSA. He is fit for radical treatment should clinically significant prostate cancer be diagnosed. His PSA was 6.4 micrograms/L at referral. Multiparametric MRI showed a 40 mL prostate with an overall Likert score of 2; the radiology report also describes the finding as PI-RADS v2.1 category 2. Digital rectal examination is benign and there is no family history of prostate cancer. He has not had a prostate biopsy. Four months after the MRI, his PSA is 6.5 micrograms/L. He is asymptomatic and has had no urinary infection, catheterisation or recent ejaculation. What is the most appropriate next step in the diagnostic pathway?

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Correct answer: C — Offer a systematic prostate biopsy after discussion of its benefits and harms

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

The correct answer is B. Although the MRI is low risk (Likert 2, also reported as PI-RADS 2), this does not justify discharge in isolation. His PSA density is 6.5/40 = 0.1625 ng/mL/mL, exceeding the NICE threshold of 0.15 ng/mL/mL for strong suspicion of prostate cancer. He has also already had the recommended repeat PSA interval of 3 to 6 months after a low-risk MRI. NICE advises offering biopsy in this setting; where biopsy is undertaken after a Likert 1 or 2 MRI, this should be systematic rather than MRI-targeted. A is attractive because the MRI score, benign examination and low PSA velocity are reassuring, but discharge is appropriate only when overall suspicion is low; the raised PSA density prevents this. C incorrectly treats the low-risk MRI finding as a target requiring targeted biopsy; NICE specifies systematic biopsy if biopsy is chosen after Likert 1 or 2 imaging. D delays tissue diagnosis despite the PSA-density trigger. E would be appropriate immediately after low-risk MRI before the scheduled repeat PSA, but that repeat measurement has already occurred and PSA density independently indicates strong suspicion.

Reference: NICE NG131: Prostate cancer: diagnosis and management, Recommendations (Published 2019; last updated 15 December 2021; last reviewed 13 August 2025) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE NG131: Prostate cancer: diagnosis and management, Overview (Last reviewed 13 August 2025) — https://www.nice.org.uk/guidance/ng131