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

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HardPI-RADSSuspected clinically localised prostate cancer with low-risk MRI but elevated PSA densityMSRA

A 62-year-old man is referred with a persistently raised PSA. He is fit for radical treatment if clinically significant prostate cancer is diagnosed. He has no urinary infection, recent urinary instrumentation, ejaculation within 48 hours, or vigorous cycling. Digital rectal examination is benign and there is no family history of prostate cancer. His PSA is 8.6 micrograms/L. Multiparametric MRI shows a 50 mL prostate with no suspicious focal lesion; the overall Likert score is 2 and the report describes PI-RADS v2.1 category 2 appearances. He has not previously had a prostate biopsy. What is the most appropriate next step in the diagnostic pathway?

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

Reveal the answer and explanation

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

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

The correct answer is B. His MRI is low risk (Likert 2/PI-RADS 2), which would usually permit consideration of biopsy avoidance. However, PSA density is 8.6/50 = 0.172 ng/mL/mL. This exceeds the NICE example threshold of 0.15 ng/mL/mL for strong suspicion of prostate cancer in a person with raised PSA and a Likert 1 or 2 MRI. He is fit for potentially curative treatment, so the residual risk is clinically actionable and a biopsy should be offered after shared decision-making. A and E would be appropriate only where suspicion is low after a low-risk MRI; this patient’s PSA density is above the re-referral/biopsy threshold. C is inappropriate because NICE recommends MRI-influenced biopsy for a Likert score of 3 or more; there is no MRI target here. D delays diagnosis without addressing the current high PSA-density risk and is not the recommended next diagnostic step. In this setting, if biopsy proceeds despite low-risk MRI, it should be systematic rather than targeted.

Reference: NICE NG131: Prostate cancer: diagnosis and management — Recommendations, MRI and biopsy (2019 recommendations; page checked 2026) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations NICE NG131: Prostate cancer: diagnosis and management — Recommendation 1.2.11 (2019 recommendations; page checked 2026) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations