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Suspected localised prostate cancer with low-risk MRI and persistent high clinical suspicion after previous ne

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HardPI-RADSSuspected localised prostate cancer with low-risk MRI and persistent high clinical suspicion after previous negative biopsyMSRA

A 66-year-old man is reviewed following investigation of a persistently raised PSA. He would be fit for radical treatment if clinically significant prostate cancer were diagnosed. A systematic transrectal biopsy 3 years ago was benign. Four months ago, multiparametric MRI showed a 38 mL prostate with no focal suspicious lesion; the report gave an overall Likert score of 2 and PI-RADS v2.1 category 2 appearances. Digital rectal examination remains benign and there is no urinary infection, recent instrumentation, ejaculation within 48 hours or vigorous cycling. His PSA was 6.2 micrograms/L at the time of MRI and is now 6.9 micrograms/L. There is no known family history of prostate cancer. What is the most appropriate next step in the diagnostic pathway?

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Correct answer: D — Offer repeat systematic prostate biopsy after discussing risks and benefits

The appropriate next step is to offer repeat prostate biopsy after shared decision-making. Although the MRI is low risk (Likert 2/PI-RADS 2), the current PSA density is 6.9/38 = 0.18 ng/mL/mL, exceeding NICE’s example threshold of 0.15 ng/mL/mL for strong suspicion of prostate cancer. PSA has also increased by 0.7 micrograms/L over 4 months, equivalent to approximately 2.1 ng/mL/year, above the example PSA-velocity threshold of 0.75 ng/mL/year. These risk features outweigh reassurance from a low-risk MRI and a previous negative biopsy. A low-risk MRI can support discharge only where suspicion is low. Repeating PSA without biopsy would be appropriate if PSA density, velocity and other risk factors were reassuring. Repeating MRI does not replace biopsy where strong clinical suspicion persists. MDT discussion with a view to repeat biopsy is specifically recommended after a negative biopsy when MRI Likert score is 3 or more; this patient has Likert 2. As the MRI does not identify a target, a systematic biopsy is the appropriate biopsy strategy. ([nice.org.uk](https://www.nice.org.uk/guidance/ng131/chapter/recommendations?utm_source=openai))

Reference: NICE NG131: Prostate cancer: diagnosis and management — Assessment and diagnosis, MRI and biopsy (2019; amended 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE NG131: Prostate cancer: diagnosis and management — MRI and biopsy (2019; amended 2021) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations