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

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ModeratePSASuspected clinically localised prostate cancer following low-risk mpMRIMSRA

A 62-year-old man is reviewed in urology after referral for nocturia, hesitancy and reduced urinary flow. His digital rectal examination is benign. At referral, his PSA was 4.2 micrograms/L. Multiparametric MRI showed a Likert score of 2 and a prostate volume of 40 mL. After discussion of the risks and benefits, he initially chose not to have a biopsy. Four months later, his PSA is 4.5 micrograms/L using the same assay. He has no urinary infection, recent urinary retention, catheterisation or urinary instrumentation. He avoided ejaculation and vigorous cycling for 48 hours before both PSA tests. There is no family history of prostate cancer. He is fit for radical treatment should clinically significant prostate cancer be identified. What is the most appropriate next management plan?

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

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Correct answer: E — Offer a systematic prostate biopsy after discussion of its risks and benefits

Explanation lettering: D = shown as A · A = shown as D

The appropriate next step is to offer systematic prostate biopsy. His MRI is low risk (Likert 2) and his PSA density is low: 4.5/40 = 0.113 ng/mL/mL, below 0.15. However, the repeat PSA has been performed after 4 months and has risen from 4.2 to 4.5 micrograms/L. This equates to a PSA velocity of 0.9 ng/mL/year, exceeding the NICE example threshold of 0.75 ng/mL/year for strong suspicion of prostate cancer after a raised PSA and Likert 1 or 2 MRI. He is fit for radical treatment, so further diagnostic investigation is appropriate. If biopsy is chosen following a low-risk MRI, NICE recommends a systematic biopsy. A would be appropriate only where the level of suspicion remains low after repeat PSA assessment. B is not the recommended response to concerning PSA kinetics following a negative MRI; biopsy is indicated. C delays action despite an already appropriately timed repeat PSA demonstrating concerning velocity. D is inappropriate because he has not had a previous negative biopsy; MDT consideration of repeat biopsy is specifically relevant to people with a negative biopsy and MRI Likert score of 3 or more.

Reference: NICE NG131: Prostate cancer: diagnosis and management — Recommendations (2019) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations NICE NG131: Prostate cancer: diagnosis and management — Recommendations (2019) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations NICE NG131: Prostate cancer: diagnosis and management — Recommendations (2019) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations