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Suspected clinically localised prostate cancer — MSRA MCQ

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HardPI-RADSSuspected clinically localised prostate cancerMSRA

A 61-year-old man is assessed on the suspected prostate cancer pathway. He would be fit for radical treatment if clinically significant prostate cancer were diagnosed. His PSA has remained between 5.8 and 6.2 micrograms/L over 5 months. He has no urinary infection, recent instrumentation, ejaculation within 48 hours or vigorous cycling. Digital rectal examination is benign and there is no family history of prostate cancer. Multiparametric MRI shows a 68 mL prostate and an 8 mm peripheral-zone lesion reported as overall Likert 3, corresponding to PI-RADS v2.1 category 3. His PSA density is 0.09 ng/mL/mL. He has not previously had a prostate biopsy. What is the most appropriate next step in the diagnostic pathway?

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Correct answer: D — Arrange an MRI-influenced prostate biopsy

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

The correct answer is E. In NICE guidance, an overall MRI Likert score of 3 or more warrants an MRI-influenced prostate biopsy in a person being investigated for suspected localised prostate cancer and eligible for radical treatment. A PI-RADS 3/Likert 3 result is equivocal, rather than reassuring; the low PSA density does not move this patient into the negative-MRI surveillance pathway. A is inappropriate because discharge with PSA follow-up is the low-suspicion option after an MRI Likert score of 1 or 2, not a score of 3. B is plausible because PSA density is low and PSA kinetics are reassuring, but NICE uses PSA density and velocity thresholds to guide management after low-risk MRI (Likert 1–2); they do not replace biopsy for a Likert 3 lesion. C is incomplete because the MRI abnormality should inform biopsy targeting. D risks delaying diagnosis of clinically significant cancer in a biopsy-naive man with an equivocal MRI lesion. MRI-influenced biopsy permits targeted sampling of the lesion, with the biopsy approach determined by the specialist service.

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, recommendations (2019; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations