skip to main content

Suspected clinically localised prostate cancer following low-risk multiparametric MRI — MSRA MCQ

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

ModerateProstate CancerSuspected clinically localised prostate cancer following low-risk multiparametric MRIMSRA

A 61-year-old man is reviewed in urology after referral for a raised PSA. He is fit for radical treatment if clinically significant prostate cancer is diagnosed. His initial PSA was 4.8 micrograms/L. Multiparametric MRI shows a 30 mL prostate with no suspicious lesion (Likert score 2). He chose not to have an immediate biopsy. Four months later, repeat PSA using the same assay is 5.3 micrograms/L. He has had no urinary tract infection, urinary retention, catheterisation, ejaculation or vigorous cycling before either test. Digital rectal examination is benign. 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: A — Offer a systematic prostate biopsy after discussion of its risks and benefits

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

The appropriate next step is to offer systematic prostate biopsy. Although the MRI is low risk (Likert 2), the repeat PSA is 5.3 micrograms/L and prostate volume is 30 mL, giving a PSA density of approximately 0.18 ng/mL/mL. This exceeds the NICE threshold of 0.15 ng/mL/mL for strong clinical suspicion after a Likert 1 or 2 MRI. He is fit for radical treatment and has no reversible explanation for PSA elevation. A is inappropriate because discharge with PSA surveillance is advised only when suspicion is low; his PSA density is above the re-referral/biopsy threshold. C delays investigation despite an already elevated PSA density. D is incorrect because MRI-influenced biopsy is recommended for MRI lesions scored Likert 3 or above; if biopsy is chosen following a Likert 1 or 2 MRI, it should be systematic. E may seem reasonable because the MRI is reassuring, but NICE recommends biopsy rather than imaging surveillance where there is strong residual suspicion of clinically significant cancer.

Reference: NICE NG131: Prostate cancer: diagnosis and management — Recommendations (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE NG131: Prostate cancer: diagnosis and management — Recommendations (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations