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Suspected clinically localised prostate cancer — MSRA MCQ

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HardPI-RADSSuspected clinically localised prostate cancerMSRA

A 66-year-old man is reviewed in urology after persistent PSA elevation. He has no urinary infection, recent instrumentation, ejaculation or vigorous cycling. PSA measurements 6 weeks apart are 6.2 micrograms/L and 6.3 micrograms/L. DRE is benign. He is fit for radical treatment should clinically significant prostate cancer be diagnosed. Multiparametric MRI shows a 78 mL prostate and a 14 mm posterolateral peripheral-zone lesion. The report gives an overall Likert score of 4, corresponding to PI-RADS v2.1 category 4. His PSA density is 0.08 ng/mL/mL. What is the most appropriate next step in the diagnostic pathway?

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Correct answer: A — Offer an MRI-influenced prostate biopsy

The correct next step is an MRI-influenced prostate biopsy. He is fit for radical treatment and has a suspicious MRI lesion: a Likert score of 4 (also reported as PI-RADS 4) meets NICE criteria for MRI-influenced biopsy, as NICE recommends this for Likert scores of 3 or more. His low PSA density is clinically relevant but does not override the MRI finding. NICE uses PSA density greater than 0.15 ng/mL/mL and PSA velocity greater than 0.75 ng/mL/year to identify strong suspicion in people with a low-risk MRI (Likert 1 or 2), including decisions about surveillance versus biopsy. Those thresholds should not be extrapolated to avoid biopsy in a man with a Likert 4 lesion. Repeating PSA before biopsy or discharging for PSA surveillance would be appropriate considerations after a low-risk MRI where overall suspicion is low, not here. A systematic biopsy alone fails to use the MRI lesion to direct sampling; NICE specifies MRI-influenced biopsy. Repeating MRI without tissue diagnosis would unnecessarily delay investigation of a lesion with substantial suspicion of clinically significant cancer.

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