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Suspected clinically localised prostate cancer — MSRA MCQ

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HardPI-RADSSuspected clinically localised prostate cancerMSRA

A 69-year-old man is referred with persistently raised PSA. He is fit for radical treatment should clinically significant prostate cancer be diagnosed. He has no urinary infection, recent instrumentation, ejaculation or vigorous cycling. Digital rectal examination is normal. PSA was 7.8 micrograms/L 5 months ago and is now 9.6 micrograms/L. Multiparametric MRI shows a 36 mL prostate and a 9 mm anterior transition-zone lesion, reported as overall Likert 3 and PI-RADS v2.1 category 3. What is the most appropriate next step in the diagnostic pathway?

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

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

The correct answer is E. NICE recommends offering an MRI-influenced prostate biopsy when the MRI Likert score is 3 or more. This patient has an equivocal MRI lesion (Likert 3/PI-RADS 3), but his other risk features reinforce rather than reduce the need for biopsy: PSA density is 9.6/36 = 0.27 ng/mL/mL, exceeding 0.15 ng/mL/mL, and PSA velocity is approximately 4.3 ng/mL/year, exceeding 0.75 ng/mL/year. He is also fit for radical treatment, so establishing whether clinically significant cancer is present is clinically meaningful. A is inappropriate because the NICE repeat-PSA pathway applies to biopsy-naive people with Likert 1 or 2 MRI findings, not Likert 3. B is similarly inappropriate: primary-care surveillance after low-suspicion MRI depends on Likert 1 or 2 findings and reassuring PSA density/velocity. C is incomplete because the known MRI lesion should inform biopsy targeting. D may be considered in selected local protocols or after an inconclusive assessment, but it should not replace biopsy in this biopsy-naive patient with Likert 3 disease and strongly suspicious PSA parameters.

Reference: NICE NG131: Prostate cancer: diagnosis and management — Recommendations (2019; current guidance checked August 2026) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations