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Suspected clinically localised prostate cancer — MSRA MCQ

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ModeratePI-RADSSuspected clinically localised prostate cancerMSRA

A 69-year-old man is investigated on the suspected prostate cancer pathway. He would be suitable for radical treatment if clinically significant prostate cancer is diagnosed. His PSA is 8.0 micrograms/L, MRI-derived prostate volume is 50 mL and digital rectal examination is benign. Multiparametric MRI demonstrates a 13 mm focal lesion in the right peripheral zone. It is markedly hypointense on the ADC map and markedly hyperintense on high-b-value diffusion-weighted imaging. There is focal capsular breach with extension into the adjacent periprostatic fat. Dynamic contrast-enhanced imaging shows focal early enhancement. Which reporting interpretation and immediate diagnostic management is most appropriate?

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Correct answer: A — PI-RADS v2.1 category 5; arrange MRI-influenced prostate biopsy

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

This is a PI-RADS v2.1 category 5 peripheral-zone lesion. Diffusion-weighted imaging is the dominant sequence in the peripheral zone. Marked diffusion restriction would ordinarily be DWI score 4 when the lesion is under 1.5 cm; however, definite extraprostatic extension or invasive behaviour upgrades the lesion to DWI score 5 irrespective of size. The 13 mm measurement therefore does not limit this lesion to PI-RADS 4. Early focal enhancement supports suspicion but is not the feature responsible for the upgrade. In UK practice, NICE recommends an mpMRI-influenced prostate biopsy for an MRI Likert score of 3 or more in a person being investigated for suspected localised prostate cancer and suitable for radical treatment. A highly suspicious lesion with radiological extraprostatic extension warrants targeted, MRI-informed sampling rather than PSA surveillance. A is attractive because the lesion is smaller than 1.5 cm, but ignores the extraprostatic extension criterion. C wrongly applies the low-suspicion MRI pathway. D understates the imaging category and omits MRI targeting. E is inappropriate because histological confirmation is still required in this otherwise potentially treatable presentation.

Reference: Prostate cancer: diagnosis and management (NG131), recommendations (2019; page checked 2026) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations Prostate MRI based on PI-RADS version 2: how we review and report (2016) — https://pubmed.ncbi.nlm.nih.gov/27067275/