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Persistently raised PSA following a negative prostate biopsy with low-risk mpMRI — MSRA MCQ

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HardPI-RADSPersistently raised PSA following a negative prostate biopsy with low-risk mpMRIMSRA

A 62-year-old man is reviewed in urology after a previous benign systematic transrectal prostate biopsy performed 18 months ago for a raised PSA. Histology showed high-grade prostatic intraepithelial neoplasia but no malignancy. He remains fit for radical treatment if clinically significant prostate cancer is diagnosed. His PSA was 5.6 micrograms/L 6 months ago and is now 6.8 micrograms/L. MRI-derived prostate volume is 52 mL, giving a PSA density of 0.13 ng/mL/mL. Digital rectal examination is benign. He has no urinary infection, recent instrumentation, ejaculation within 48 hours or vigorous cycling. Multiparametric MRI is reported as Likert 2, with PI-RADS v2.1 category 2 appearances and no focal target. What is the most appropriate next diagnostic management step?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: E — Arrange specialist review to offer a repeat prostate biopsy because clinical suspicion remains high

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

The correct answer is A. Although the MRI is low risk (Likert 2/PI-RADS 2) and PSA density is below 0.15 ng/mL/mL, he has a PSA rise of 1.2 micrograms/L over 6 months, equivalent to a PSA velocity of 2.4 ng/mL/year. This exceeds NICE's example threshold of 0.75 ng/mL/year for strong clinical suspicion following a negative biopsy. In addition, high-grade prostatic intraepithelial neoplasia on the previous biopsy is a recognised factor associated with a slightly higher residual risk of prostate cancer. A repeat biopsy should therefore be offered after specialist review and discussion. B would be appropriate only where suspicion is low after a negative biopsy and low-risk MRI; this man's PSA kinetics are not reassuring. C unnecessarily delays biopsy because the repeat PSA interval has already demonstrated a concerning velocity. D may be considered in selected surveillance pathways, but NICE directs biopsy when suspicion is high after a low-risk MRI and negative biopsy rather than waiting routinely for interval MRI. E is incorrect because NICE does not recommend PCA3 or Prostate Health Index testing after a negative or inconclusive prostate biopsy.

Reference: NICE NG131: Prostate cancer: diagnosis and management — Recommendations 1.2.9 and 1.2.12 (2019; amended 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations