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Suspected clinically localised prostate cancer with negative mpMRI and strong family history — MSRA MCQ

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ModeratePI-RADSSuspected clinically localised prostate cancer with negative mpMRI and strong family historyMSRA

A 56-year-old man is reviewed on the suspected prostate cancer pathway. He would be fit for radical treatment if clinically significant prostate cancer were diagnosed. His PSA was 5.0 micrograms/L at referral and is 5.1 micrograms/L 4 months later. MRI-derived prostate volume is 46 mL, giving a PSA density of 0.11 ng/mL/mL. Digital rectal examination is benign. There is no urinary infection, recent instrumentation, ejaculation within 48 hours or vigorous cycling. Multiparametric MRI shows no focal suspicious lesion and is reported as overall Likert 2, with PI-RADS v2.1 category 2 appearances. His father was diagnosed with prostate cancer aged 61 years and his brother was diagnosed aged 55 years. What is the most appropriate next diagnostic management step?

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Correct answer: C — Offer systematic prostate biopsy after discussion of risks and benefits

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

This man has a low-risk MRI (Likert 2; PI-RADS 2) and reassuring PSA density and PSA velocity. However, he has a strong family history, with two first-degree relatives affected, including one diagnosed before age 60. NICE advises that, after a Likert 1 or 2 MRI and repeat PSA testing, prostate biopsy should be offered if clinical suspicion remains strong; strong family history is specifically given as an example. In the absence of an MRI target, this should be a systematic rather than MRI-targeted biopsy. A would be appropriate only where suspicion is low after a negative MRI. B is incomplete because the repeat PSA has already been performed and the family history maintains strong suspicion despite stable PSA kinetics. C may be considered in selected follow-up pathways but does not replace biopsy when NICE criteria for persistent strong suspicion are met. D is attractive because MRI-informed targeting is used for visible lesions, but there is no focal lesion to target in this case.

Reference: NICE NG131: Prostate cancer: diagnosis and management, recommendations 1.2.4 and 1.2.11 (2019; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations