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Metastatic prostate cancer — MSRA MCQ

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HardProstate CancerMetastatic prostate cancerMSRA

A 76-year-old man presents with 3 months of progressive lumbar pain, reduced appetite and unintentional weight loss. He has no fever, dysuria, recent urinary instrumentation or symptoms of acute urinary retention. Examination finds a hard, irregular prostate on digital rectal examination. PSA is 168 micrograms/L and alkaline phosphatase is 612 IU/L. An urgent isotope bone scan shows multiple lesions consistent with skeletal metastases in the pelvis, lumbar spine and ribs. He has no limb weakness, sensory level, sphincter disturbance or other features of metastatic spinal cord compression. Which is the most appropriate diagnostic strategy now?

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Correct answer: E — Do not offer biopsy for histological confirmation and refer to the urological cancer MDT

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

This man has a very high PSA, a malignant-feeling prostate on DRE and radiological evidence of widespread sclerotic skeletal metastases. Together, these make the clinical suspicion of metastatic prostate cancer sufficiently high that NICE advises against prostate biopsy solely to obtain histological confirmation, unless this is required within a clinical trial. He should instead be referred promptly to the urological cancer MDT for management planning. His absence of neurological deficit, sensory level or bladder/bowel disturbance means that the immediate priority is not the emergency pathway for metastatic spinal cord compression. A and C would be appropriate routes to tissue diagnosis in suspected clinically localised disease, but unnecessary biopsy exposes him to harm without changing the diagnostic certainty sufficiently in this presentation. D may be considered when the primary malignancy is uncertain or imaging is atypical, but is not required here. E is inappropriate because there are no infective features, and neither infection nor benign enlargement plausibly accounts for the combined PSA, DRE and metastatic imaging findings.

Reference: NICE NG131: Prostate cancer: diagnosis and management — Recommendations, section 1.2.8 (Last updated 15 December 2021; reviewed 13 August 2025) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations