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Suspected clinically localised prostate cancer with low-risk MRI — MSRA MCQ

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HardPI-RADSSuspected clinically localised prostate cancer with low-risk MRIMSRA

A 64-year-old man is being investigated on the suspected prostate cancer pathway. He would be fit for radical treatment if clinically significant prostate cancer were diagnosed. His PSA at referral was 6.6 micrograms/L. Multiparametric MRI shows a 41 mL prostate with no focal suspicious lesion; the report gives an overall Likert score of 2 and PI-RADS v2.1 category 2 appearances. Digital rectal examination is benign. He has no family history of prostate cancer and no urinary infection, recent instrumentation, ejaculation or vigorous cycling. Four months after MRI, his PSA is 6.7 micrograms/L. He has not previously had a prostate biopsy. What is the most appropriate next step?

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Correct answer: A — Offer a systematic prostate biopsy following shared decision-making

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

The appropriate next step is to offer systematic prostate biopsy. Although the MRI is low risk (Likert 2; also reported as PI-RADS 2), NICE advises repeating PSA after 3 to 6 months in biopsy-naive men with Likert 1 or 2 MRI, then offering biopsy where suspicion remains strong. This repeat PSA has already been performed. His PSA density is 6.7/41 = 0.163 ng/mL/mL, which exceeds the NICE threshold of 0.15 ng/mL/mL. This constitutes strong suspicion despite a low-risk MRI and benign DRE. The modest PSA change does not provide a PSA-velocity trigger, but that is immaterial because the PSA-density criterion is independently sufficient. As there is no MRI target warranting lesion-directed sampling, a systematic biopsy is the appropriate biopsy approach. B would be appropriate only if overall suspicion were low, including PSA density not exceeding 0.15 ng/mL/mL. C is attractive because combined targeted and systematic sampling is used for MRI-visible suspicious lesions, but this MRI has no lesion requiring targeting. D repeats a step already completed at the recommended interval. E risks delaying diagnosis despite a current biochemical trigger for biopsy.

Reference: NICE NG131: Prostate cancer: diagnosis and management — Recommendations (2019) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE NG131 evidence review E: Managing people at increased risk of prostate cancer (2026) — https://www.nice.org.uk/guidance/ng131/evidence/e-following-up-people-at-increased-risk-of-prostate-cancer-pdf-6779081778