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Suspected clinically localised prostate cancer after previous negative biopsy — MSRA MCQ

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ModeratePI-RADSSuspected clinically localised prostate cancer after previous negative biopsyMSRA

A 63-year-old man is reviewed in urology because of a persistently raised PSA. He remains fit for radical treatment should clinically significant prostate cancer be diagnosed. A systematic transrectal biopsy 2 years ago was benign. His PSA has risen from 6.1 micrograms/L to 7.5 micrograms/L over 10 months. MRI-derived prostate volume is 44 mL, giving a PSA density of 0.17 ng/mL/mL. Digital rectal examination is benign. Multiparametric MRI shows a 10 mm focal lesion in the right peripheral zone. It is mildly hypointense on the ADC map and mildly hyperintense on high-b-value diffusion-weighted imaging (DWI score 3). There is no focal early enhancement on dynamic contrast-enhanced imaging and no extracapsular extension. The radiologist assigns an overall Likert score of 3. Which PI-RADS v2.1 interpretation and next diagnostic management step is most appropriate?

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Correct answer: B — PI-RADS 3; discuss at the urological cancer MDT with a view to repeat MRI-influenced prostate biopsy

In the peripheral zone, DWI is the dominant PI-RADS sequence. A DWI score of 3 is equivocal; it is upgraded to PI-RADS 4 only when there is corresponding focal early enhancement on DCE imaging. As DCE is negative here, the lesion remains PI-RADS 3. ([pubmed.ncbi.nlm.nih.gov](https://pubmed.ncbi.nlm.nih.gov/37045981/?utm_source=openai)) The decisive management feature is the previous negative biopsy combined with a current Likert score of 3. NICE advises MDT discussion of people with a negative first biopsy and MRI Likert score of 3 or more, with a view to repeating prostate biopsy. MRI-influenced biopsy is appropriate because there is now an MRI-defined peripheral-zone target. The raised PSA density further supports ongoing concern, but the NICE MDT recommendation is triggered by the prior negative biopsy and Likert 3 MRI. ([nice.org.uk](https://www.nice.org.uk/guidance/ng131/chapter/recommendations?utm_source=openai)) A is the low-suspicion MRI follow-up pathway and does not apply to a Likert 3 lesion. B inappropriately discharges a man with persistent suspicion after a prior biopsy. C omits the required MDT review and fails to use the MRI target. D delays tissue diagnosis despite an equivocal but persistent MRI abnormality and rising PSA density.

Reference: NICE NG131: Prostate cancer: diagnosis and management — MRI and biopsy; If the MRI or biopsy is negative (2019; current NICE page checked August 2026) — 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/