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Suspected clinically localised prostate cancer after a previous negative biopsy — MSRA MCQ

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HardPI-RADSSuspected clinically localised prostate cancer after a previous negative biopsyMSRA

A 67-year-old man is reviewed on the suspected prostate cancer pathway. He would be fit for radical treatment if clinically significant prostate cancer were diagnosed. A 12-core systematic transrectal biopsy undertaken 18 months ago, before MRI, showed benign prostatic tissue. His PSA was 6.0 micrograms/L 10 months ago and is now 7.2 micrograms/L. Digital rectal examination is benign. There is no urinary infection, recent instrumentation, ejaculation within 48 hours or vigorous cycling. Multiparametric MRI now shows a 60 mL prostate and an 11 mm anterior transition-zone lesion reported as Likert 3, corresponding to PI-RADS v2.1 category 3. His PSA density is 0.12 ng/mL/mL. What is the most appropriate next diagnostic management step?

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Correct answer: C — Discuss the case in the multidisciplinary team with a view to repeating an MRI-influenced prostate biopsy

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

This man has a previous negative biopsy but now has a suspicious MRI finding: Likert 3 (PI-RADS 3) meets NICE's threshold for an MRI-influenced biopsy. NICE specifically advises that, after a negative biopsy, people with an MRI Likert score of 3 or more should be discussed at MDT with a view to repeating biopsy. The low PSA density does not override this recommendation; PSA-density thresholds are principally used to guide decisions after a low-suspicion MRI (Likert 1–2). His PSA rise further supports ongoing concern, despite a benign DRE. A is inappropriate because discharge with PSA surveillance is the low-suspicion pathway for Likert 1–2 MRI findings, not a persistent equivocal/suspicious lesion after a negative biopsy. B similarly delays indicated specialist reassessment. C is attractive because repeat sampling is required, but a non-targeted repeat TRUS biopsy risks again missing the anterior MRI-visible lesion and bypasses the recommended MDT decision. E is inappropriate because MRI suspicion alone does not establish histological diagnosis or justify radical treatment.

Reference: NICE NG131: Prostate cancer: diagnosis and management — Recommendations, MRI and biopsy (2019; current online guidance checked 15 August 2026) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations