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Persistent PSA elevation following negative prostate biopsy — MSRA MCQ

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HardPI-RADSPersistent PSA elevation following negative prostate biopsyMSRA

A 66-year-old man is reviewed in urology for persistent PSA elevation. He remains suitable for radical treatment if clinically significant prostate cancer is diagnosed. A systematic prostate biopsy 18 months ago was benign. His PSA is now 6.6 micrograms/L, MRI-derived prostate volume is 55 mL (PSA density 0.12 ng/mL/mL), and digital rectal examination is benign. Multiparametric MRI shows an 11 mm transition-zone nodule with an incomplete capsule, consistent with a T2-weighted score of 2. It is markedly hypointense on ADC and markedly hyperintense on high-b-value diffusion-weighted imaging, consistent with a DWI score of 4. There is no extracapsular extension or focal early enhancement. The radiologist gives an overall Likert score of 3. Which reporting interpretation and immediate diagnostic management is most appropriate?

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Correct answer: C — PI-RADS 3; discuss possible significant disease at MDT with a view to repeating prostate biopsy.

This is a PI-RADS v2.1 transition-zone “2 + 1” lesion. An incompletely encapsulated transition-zone nodule is an atypical BPH nodule with a T2-weighted score of 2. Marked diffusion restriction in an 11 mm lesion gives DWI score 4; in this specific PI-RADS v2.1 pathway, the lesion is upgraded from PI-RADS 2 to PI-RADS 3, not PI-RADS 4. The separate UK management decision follows the overall Likert score and biopsy history. NICE advises MDT discussion of the possibility of significant disease, with a view to repeat biopsy, when a person has had a negative biopsy but has MRI Likert 3 or above. Therefore, directly booking repeat biopsy without MDT review is premature in this setting. A is inappropriate because this is not a low-risk MRI result. B incorrectly combines a low-risk PI-RADS interpretation with immediate biopsy; his PSA density is below the NICE example threshold for strong suspicion after low-risk MRI. C identifies the PI-RADS category correctly but omits the required MDT step after a negative biopsy. D overcalls the PI-RADS category and also bypasses MDT review.

Reference: NICE NG131: Prostate cancer: diagnosis and management — Recommendations 1.2.10 and 1.2.11 (2019; page checked August 2026) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations Prospective PI-RADS v2.1 Atypical Benign Prostatic Hyperplasia Nodules With Marked Restricted Diffusion: Detection of Clinically Significant Prostate Cancer on Multiparametric MRI (2020) — https://pubmed.ncbi.nlm.nih.gov/32876473/ Characterization of high-grade prostate cancer at multiparametric MRI: assessment of PI-RADS version 2.1 and version 2 descriptors across 21 readers with varying experience (2023) — https://pubmed.ncbi.nlm.nih.gov/36939970/