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Suspected clinically localised prostate cancer with persistent suspicious MRI after negative biopsy — MSRA MCQ

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HardPI-RADSSuspected clinically localised prostate cancer with persistent suspicious MRI after negative biopsyMSRA

A 63-year-old man is reviewed in urology following investigation of a persistently raised PSA. He is fit for radical treatment if clinically significant prostate cancer is diagnosed. His PSA is 8.4 micrograms/L and MRI-derived prostate volume is 46 mL. DRE is normal and there is no urinary infection, recent instrumentation or family history of prostate cancer. His initial multiparametric MRI showed a 13 mm anterior transition-zone lesion reported as Likert 4, corresponding to PI-RADS v2.1 category 4. MRI-influenced transperineal targeted and systematic biopsies showed benign prostatic tissue. PSA repeated 5 months later is 9.1 micrograms/L, and repeat MRI continues to show the same Likert 4/PI-RADS 4 lesion. What is the most appropriate next step?

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Correct answer: B — Discuss the case at the multidisciplinary team meeting with a view to repeat MRI-influenced prostate biopsy

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

The correct answer is D. He has persistent clinical suspicion after a negative biopsy: the lesion remains Likert 4/PI-RADS 4 and his PSA density is approximately 0.20 ng/mL/mL (9.1/46), above the 0.15 ng/mL/mL threshold used by NICE as an example of strong suspicion. NICE advises that people with a negative biopsy and MRI Likert score of 3 or more should have the possibility of significant disease discussed in an MDT, with a view to repeating prostate biopsy. A negative MRI-influenced biopsy reduces risk but does not exclude sampling error, particularly for a persistent suspicious anterior lesion. A is inappropriate because the PSA-density/velocity-led primary-care surveillance pathway applies to MRI Likert 1 or 2, not a persistent Likert 4 lesion. B delays action despite sustained radiological suspicion and increasing PSA. C is plausible because repeat biopsy is likely, but bypasses the recommended MDT assessment and does not ensure repeat sampling is MRI-influenced. E incorrectly treats a negative biopsy as definitive; NICE specifically recognises residual risk after a negative biopsy when MRI remains suspicious.

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