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Localised prostate adenocarcinoma on active surveillance — MSRA MCQ

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HardProstate CancerLocalised prostate adenocarcinoma on active surveillanceMSRA

A 63-year-old man is followed under a shared-care active surveillance protocol for CPG2 localised prostate adenocarcinoma. Initial systematic biopsy, performed before MRI, found Gleason score 3+4=7 (grade group 2) cancer in 1 of 12 cores. PSA was 7.2 micrograms/L and clinical stage was cT1c. He is fit for radical treatment and initially chose active surveillance after MDT discussion. At 12 months, PSA remains 7.4 micrograms/L and DRE is unchanged. His first multiparametric MRI shows a 14 mm right anterior lesion with Likert score 4. This lesion is anatomically discordant with the small left posterior focus identified on the original biopsy. He has no urinary infection, recent instrumentation or symptoms suggesting metastatic disease. What is the most appropriate next management step?

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Correct answer: D — Arrange a new MRI-influenced prostate biopsy

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

The correct answer is E. He is on active surveillance, which remains a curative-intent strategy for suitable people with CPG2 localised disease. He had not previously undergone MRI, so MRI is indicated as part of surveillance. Crucially, the Likert 4 anterior lesion is discordant with the original limited systematic biopsy finding. NICE recommends a new MRI-influenced biopsy when MRI findings do not agree with biopsy findings, because the anterior lesion may represent previously unsampled higher-volume or higher-grade clinically significant cancer. A is inappropriate because stable PSA does not override a concerning discordant MRI finding; PSA kinetics are one surveillance component, not a reason to disregard radiological reclassification. B is plausible because repeat sampling is needed, but systematic biopsy alone may again miss or inadequately characterise the MRI-visible anterior lesion; sampling should be MRI-influenced. C is premature: radical treatment should not be selected solely from a new MRI abnormality without confirming the pathological risk category, unless there is another compelling reason. D is inappropriate because watchful waiting is non-curative and is generally for people in whom radical treatment is unsuitable or unwanted; this patient remains fit and within a curative pathway.

Reference: NICE NG131: Prostate cancer: diagnosis and management — Recommendations (Last updated 15 December 2021; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations