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Raised PSA after negative MRI and prostate biopsy — MSRA MCQ

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HardPSARaised PSA after negative MRI and prostate biopsyMSRA

A 66-year-old man is reviewed following investigation of a raised PSA. His digital rectal examination is benign. Multiparametric MRI showed a Likert score of 2 and prostate volume of 52 mL. Systematic prostate biopsy showed no malignancy, high-grade prostatic intraepithelial neoplasia or atypical small acinar proliferation. His PSA was 6.2 micrograms/L at the time of biopsy and is 6.4 micrograms/L when repeated 4 months later using the same assay. He has no urinary infection, recent instrumentation, ejaculation or vigorous cycling before either test. There is no family history of prostate cancer. He is fit for radical treatment should this become necessary. What is the most appropriate next management plan?

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Correct answer: B — Discharge to primary care with PSA testing every 2 years, with re-referral if PSA density exceeds 0.15 nanogram/mL/mL or PSA velocity exceeds 0.75 nanogram/mL/year

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

This man has completed the recommended reassessment interval after a negative biopsy: PSA has been repeated after 4 months. His risk remains low: MRI was Likert 2, DRE is benign, biopsy was negative without HGPIN or ASAP, PSA density is 6.4/52 = 0.123 nanogram/mL/mL, and PSA velocity is 0.2/0.33 = approximately 0.6 nanogram/mL/year. Both are below NICE examples of strong suspicion thresholds (PSA density above 0.15 or PSA velocity above 0.75). He therefore should be discharged with PSA surveillance every 2 years and an explicit re-referral threshold. A is the follow-up schedule for a person with low-suspicion MRI who has not had a biopsy; following a negative biopsy, NICE recommends less frequent, 2-yearly surveillance. C is inappropriate because PSA alone should not trigger repeat biopsy. D would be appropriate if there were persistent strong suspicion, such as PSA density above 0.15, PSA velocity above 0.75, strong family history, or concerning clinical findings. E is unsafe because a negative MRI and biopsy reduce, but do not eliminate, the future risk of prostate cancer.

Reference: NICE NG131: Prostate cancer: diagnosis and management, recommendations 1.2.9-1.2.12 (Updated November 2023) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations