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Suspected clinically localised prostate cancer — MSRA MCQ

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HardPI-RADSSuspected clinically localised prostate cancerMSRA

A 65-year-old man is investigated on the suspected prostate cancer pathway. He would be suitable for radical treatment if clinically significant prostate cancer were diagnosed. His PSA is 7.1 micrograms/L, MRI-derived prostate volume is 54 mL and DRE is normal. Multiparametric MRI identifies a 15 mm anterior transition-zone lesion, reported as overall Likert 4 and PI-RADS v2.1 category 4. Two years ago, a systematic transrectal biopsy for a raised PSA was benign but was complicated by Escherichia coli sepsis requiring hospital admission; the isolate was fluoroquinolone-resistant. He has no current urinary infection and is not taking anticoagulants. What is the most appropriate next diagnostic step?

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

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

The MRI is suspicious (Likert 4/PI-RADS 4), so MRI-influenced biopsy is indicated; a low PSA density does not provide a basis to defer biopsy when the MRI Likert score is 3 or more. Local-anaesthetic transperineal biopsy is the best route here because it is an NHS-supported diagnostic option and avoids traversing the rectal wall, reducing the risk of biopsy-related infection and sepsis. This is particularly important given his previous fluoroquinolone-resistant E. coli sepsis after transrectal biopsy. A is plausible because antibiotic augmentation may be considered locally after previous resistant infection, but it retains the transrectal route associated with infective complications. C is inappropriate because mapping transperineal template biopsy should not be used as an initial assessment outside a clinical trial. D incorrectly applies the low-suspicion pathway used after Likert 1 or 2 MRI appearances. E similarly misuses PSA density: it is relevant to assessing residual concern after a negative/low-risk MRI, not to overriding a Likert 4 lesion.

Reference: NICE NG131: Prostate cancer: diagnosis and management — Recommendations (2019; current NICE page checked 15 August 2026) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE HTG680: Transperineal biopsy for diagnosing prostate cancer — The diagnostic tests (2023; current NICE page checked 15 August 2026) — https://www.nice.org.uk/guidance/htg680/chapter/2-The-diagnostic-tests NICE NG131: Prostate cancer: diagnosis and management — Recommendations 1.2.11 and 1.2.12 (2019; current NICE page checked 15 August 2026) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations