skip to main content

Suspected localised prostate cancer — MSRA MCQ

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

ModeratePI-RADSSuspected localised prostate cancerMSRA

A 61-year-old man is investigated on the suspected prostate cancer pathway. He would be suitable for radical treatment if clinically significant prostate cancer were diagnosed. His PSA is 5.4 micrograms/L, MRI-derived prostate volume is 64 mL (PSA density 0.08 ng/mL/mL), digital rectal examination is benign, and he has no family history of prostate cancer. He has not previously had a prostate biopsy. Multiparametric MRI shows a 10 mm focus within a circumscribed, completely encapsulated transition-zone benign prostatic hyperplasia nodule. The focus is markedly hypointense on the ADC map and markedly hyperintense on high-b-value diffusion-weighted imaging. There is no focal early enhancement and no extracapsular extension. Which interpretation and next diagnostic management step is most appropriate?

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

Reveal the answer and explanation

Correct answer: B — Classify the lesion as PI-RADS category 2 and repeat PSA in 3 to 6 months, with discharge to primary care if suspicion remains low.

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

The key discriminator is that this is a focus within a completely encapsulated transition-zone BPH nodule. Such a “nodule-in-nodule” appearance can show marked diffusion restriction from benign stromal tissue and should remain PI-RADS category 2. The PI-RADS v2.1 upgrade from category 2 to 3 applies to atypical transition-zone nodules with an incomplete or absent capsule and marked diffusion restriction, not to a typical fully encapsulated BPH nodule. This man has a low-risk MRI appearance, low PSA density (0.08 ng/mL/mL), benign DRE and no stated high-risk family history. NICE recommends repeat PSA after 3 to 6 months for people with a raised PSA and a low-risk MRI who have not had previous biopsy. Biopsy is then considered if suspicion is strong, for example PSA density above 0.15 ng/mL/mL, rapid PSA velocity or strong family history; otherwise he can be discharged to primary care with planned PSA follow-up. A incorrectly applies the atypical-nodule upgrade rule. B treats marked diffusion restriction alone as sufficient for PI-RADS 4 despite the typical encapsulated BPH morphology. C may be chosen after shared decision-making in selected low-risk cases, but is not the default pathway here. E omits the recommended repeat PSA before discharge.

Reference: NICE NG131: Prostate cancer: diagnosis and management — MRI and biopsy recommendations (2019 recommendations; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations PI-RADS version 2.1 for the evaluation of transition zone lesions: a practical guide for radiologists (2022) — https://pubmed.ncbi.nlm.nih.gov/34919421/?dopt=Abstract