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Suspected clinically significant prostate cancer after negative biopsy — MSRA MCQ

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HardPSASuspected clinically significant prostate cancer after negative biopsyMSRA

A 65-year-old man is reviewed in urology following investigation for a raised PSA. Eight months ago, his PSA was 7.2 micrograms/L and multiparametric MRI showed a 14 mm anterior lesion with a Likert score of 4. An MRI-influenced transperineal biopsy showed benign prostatic tissue only. His PSA is now 5.8 micrograms/L using the same assay. Repeat multiparametric MRI shows a persistent lesion, now reported as Likert score 3; prostate volume is 58 mL. Digital rectal examination is benign. He has no urinary infection, recent instrumentation, ejaculation or vigorous cycling before testing. He is fit for radical treatment should clinically significant prostate cancer be identified. What is the most appropriate next management plan?

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Correct answer: B — Discuss the case in the urological cancer MDT with a view to repeating prostate biopsy

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

This man has a negative first biopsy but a persistent MRI abnormality with a Likert score of 3. NICE recommends that people with a negative first prostate biopsy and MRI Likert score of 3 or more are discussed in an MDT with a view to repeating biopsy. This applies despite a benign DRE, falling PSA and low PSA density (5.8/58 = 0.10 ng/mL/mL), because these features do not negate the significance of an equivocal-to-suspicious MRI after a potentially false-negative biopsy. B is inappropriate because discharge surveillance is the low-suspicion pathway for MRI Likert 1 or 2, not persistent Likert 3 disease after a negative biopsy. C misapplies the PSA-density threshold used in follow-up of low-risk MRI findings; it is not a requirement before reconsidering biopsy in this setting. D is premature because NICE specifically advises MDT review for this difficult post-negative-biopsy scenario; the MDT can determine whether and how repeat sampling should target the persistent lesion. E is inappropriate because mapping transperineal template biopsy is not routinely recommended as part of initial assessment outside a clinical trial.

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