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Suspected metastatic prostate cancer — MSRA MCQ

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ModerateProstate CancerSuspected metastatic prostate cancerMSRA

A 76-year-old man is assessed in a rapid-access urology clinic for 3 months of worsening lumbar and bilateral hip pain. He has no leg weakness, sensory disturbance, bladder dysfunction or bowel symptoms. Digital rectal examination identifies a hard, irregular prostate. PSA is 186 micrograms/L and alkaline phosphatase is raised. An isotope bone scan shows multiple lesions typical of skeletal metastases in the spine, pelvis and proximal femora. What is the most appropriate next diagnostic management step?

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Correct answer: B — Proceed to uro-oncology MDT management without prostate biopsy for histological confirmation

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

This presentation gives a very high clinical probability of metastatic prostate cancer: there is a markedly elevated PSA, a malignant-feeling prostate on DRE and bone-scan appearances typical of skeletal metastases. NICE advises that, when clinical suspicion is high because of a high PSA and evidence of bone metastases, prostate biopsy for histological confirmation should not be offered unless it is required for a clinical trial. He should therefore proceed promptly to uro-oncology MDT assessment and management planning. A and B would usually be reasonable diagnostic approaches for suspected localised prostate cancer, but biopsy is unnecessary here and could delay management without changing the working diagnosis. D is inappropriate because the PSA result, examination and imaging are already concordant; repeating PSA would not add useful diagnostic certainty. E may have a role in selected specialist staging pathways, but it does not create a need for biopsy in this guideline-defined situation; further imaging should be determined by the MDT rather than used to delay treatment planning. His absence of neurological or sphincter symptoms means this stem does not indicate metastatic spinal cord compression, although he requires clear safety-netting for those symptoms.

Reference: NICE NG131: Prostate cancer: diagnosis and management, recommendations (2019; amended 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations