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Metastatic prostate cancer — MSRA MCQ

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HardPI-RADSMetastatic prostate cancerMSRA

A 74-year-old man is assessed on the suspected prostate cancer pathway after progressive back pain, weight loss and worsening lower urinary tract symptoms. His PSA is 148 micrograms/L. Digital rectal examination identifies a hard, irregular prostate with loss of the median sulcus. Multiparametric MRI demonstrates a large peripheral-zone lesion with extracapsular extension and seminal-vesicle invasion, reported as Likert 5 and PI-RADS v2.1 category 5. CT shows multiple sclerotic lesions in the pelvis and lumbar spine, and an isotope bone scan confirms widespread osseous metastases. He is clinically stable and has no features of metastatic spinal cord compression. What is the most appropriate next diagnostic management step?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Refer to the cancer multidisciplinary team without prostate biopsy for management based on the clinical and radiological diagnosis

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

This man has an overwhelmingly high clinical suspicion of metastatic prostate cancer: a markedly elevated PSA, malignant DRE, PI-RADS 5/Likert 5 lesion with local extension, and radiologically confirmed sclerotic bone metastases. NICE advises that when clinical suspicion is high because of a high PSA and evidence of bone metastases, prostate biopsy should not be offered for histological confirmation unless this is required within a clinical trial. He should therefore proceed urgently to the urological cancer MDT for treatment planning without delaying management for biopsy. A would usually be appropriate for a person with Likert 3 or more disease being investigated for potentially localised cancer, but the metastatic-disease exception applies here. B is superficially attractive because histology usually confirms cancer, but the concordant prostate findings and typical osseous metastatic pattern satisfy the NICE exception. D is inappropriate because surveillance would delay management of established metastatic disease. E is inappropriate: mapping template biopsy is not recommended as part of initial assessment outside a clinical trial and would not alter the immediate need for MDT-directed management.

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