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Suspected clinically localised prostate cancer — MSRA MCQ

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HardPI-RADSSuspected clinically localised prostate cancerMSRA

A 60-year-old man is investigated on the suspected prostate cancer pathway. He is fit for radical treatment if clinically significant prostate cancer is diagnosed. His PSA is 5.4 micrograms/L, prostate volume is 60 mL (PSA density 0.09 ng/mL/mL), DRE is benign and he has no family history of prostate cancer. Multiparametric MRI identifies an 11 mm focal peripheral-zone lesion. It is mildly hypointense on the ADC map and mildly hyperintense on high-b-value diffusion-weighted imaging (DWI score 3). Dynamic contrast-enhanced imaging shows focal early enhancement corresponding to this lesion. There is no extracapsular extension. Which reporting interpretation and immediate diagnostic management is most appropriate?

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Correct answer: E — Assign PI-RADS category 4 and offer MRI-influenced prostate biopsy

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

This is a peripheral-zone lesion, where DWI is the dominant PI-RADS sequence. The lesion has equivocal diffusion restriction (DWI score 3), but the focal early enhancement corresponds to the MRI abnormality. Under PI-RADS v2.1, a peripheral-zone lesion with DWI score 3 and positive dynamic contrast enhancement is upgraded to overall PI-RADS category 4. The low PSA density is relevant to overall risk discussion, but it does not override the MRI-directed diagnostic pathway here. NICE recommends MRI-influenced prostate biopsy for a Likert score of 3 or more; an MRI lesion assessed as PI-RADS 4 represents a sufficiently suspicious finding to proceed to biopsy in a man suitable for radical treatment. A is wrong because the lesion is focal and has DWI score 3, not low-suspicion PI-RADS 2 appearances. B incorrectly ignores the DCE-driven upgrade. C recognises that biopsy is indicated for an equivocal-or-higher MRI lesion, but misclassifies the lesion. D correctly assigns PI-RADS 4 but wrongly substitutes PSA surveillance for biopsy; surveillance based on PSA density is principally relevant after low-risk MRI findings rather than a suspicious MRI target.

Reference: NICE NG131: Prostate cancer: diagnosis and management — MRI and biopsy recommendations (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations Low cancer yield in PI-RADS 3 upgraded to 4 by dynamic contrast-enhanced MRI: is it time to reconsider scoring categorization? (2023) — https://pubmed.ncbi.nlm.nih.gov/37045981/