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Suspected clinically localised prostate cancer with low-risk MRI but high PSA density — MSRA MCQ

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HardUrologySuspected clinically localised prostate cancer with low-risk MRI but high PSA densityMSRA

A 68-year-old man is referred on a suspected prostate cancer pathway after PSA testing for nocturia and hesitancy. He is fit, with an estimated life expectancy of more than 10 years. Digital rectal examination is benign. His PSA is 7.2 micrograms/L and multiparametric MRI reports a Likert score of 2; prostate volume is 35 mL. He has no family history of prostate cancer and has not previously had a prostate biopsy. What is the most appropriate next step?

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Correct answer: D — Offer a systematic prostate biopsy after discussion of risks and benefits

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

The PSA density is 7.2/35 = 0.21 nanogram/mL/mL, which exceeds the NICE example threshold of 0.15 nanogram/mL/mL indicating strong suspicion of clinically significant prostate cancer. Although a Likert 1 or 2 MRI may allow biopsy to be omitted, this is appropriate only when the overall level of suspicion is low. In a fit person with substantial life expectancy and raised PSA density, NICE recommends offering prostate biopsy. Where biopsy is undertaken after a low-risk MRI, this should be a systematic biopsy. B and C would be appropriate approaches for a person with Likert 1 or 2 MRI findings and low overall suspicion, for example PSA density below 0.15 nanogram/mL/mL without concerning PSA kinetics or family history. D is appropriate for MRI Likert scores of 3 or more, where MRI identifies a lesion requiring targeted sampling. E is inappropriate because NICE advises against mapping transperineal template biopsy as part of initial assessment outside a clinical trial.

Reference: NICE NG131: Prostate cancer: diagnosis and management — MRI and biopsy (2019; current recommendations page checked 15 August 2026) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations