skip to main content

Suspected prostate cancer following low-risk MRI — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

ModeratePSASuspected prostate cancer following low-risk MRIMSRA

A 64-year-old man was referred with nocturia and reduced urinary flow. His initial PSA was 5.8 micrograms/L; digital rectal examination was benign. He had no urinary infection, recent instrumentation, ejaculation or vigorous cycling before testing. Multiparametric MRI showed a Likert score of 2 and a prostate volume of 36 mL. Following discussion, he initially chose not to undergo biopsy. Three months later, PSA is 5.9 micrograms/L using the same assay. He remains fit for radical treatment should clinically significant prostate cancer be diagnosed and wishes to continue investigation. What is the most appropriate next management step?

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

Reveal the answer and explanation

Correct answer: B — Offer a systematic prostate biopsy

The repeat PSA is 5.9 micrograms/L and prostate volume is 36 mL, giving a PSA density of 0.16 ng/mL/mL. This exceeds the NICE example threshold of 0.15 ng/mL/mL for strong suspicion of prostate cancer after a raised PSA with a low-risk MRI (Likert 1 or 2). He is fit for radical treatment and wants further investigation; therefore, biopsy should be offered. Because his MRI is Likert 2, there is no MRI-defined suspicious lesion requiring targeted sampling. NICE advises that if biopsy is undertaken following a Likert 1 or 2 MRI, it should be systematic rather than MRI-influenced. A further PSA at 6 months or discharge with annual surveillance would be appropriate only where suspicion is low, such as PSA density at or below 0.15 ng/mL/mL with no concerning risk factors. Prostate Health Index is not recommended by NICE for this diagnostic pathway. MRI-influenced biopsy is appropriate for MRI Likert scores of 3 or more, not for this low-risk MRI result.

Reference: NICE NG131: Prostate cancer: diagnosis and management — MRI and biopsy; if the MRI or biopsy is negative (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations NICE NG131: Prostate cancer: diagnosis and management — MRI and biopsy (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations