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

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HardPI-RADSSuspected clinically localised prostate cancer after previous negative biopsyMSRA

A 63-year-old man is reviewed in urology for a persistently raised PSA. He remains fit for radical treatment should clinically significant prostate cancer be diagnosed. A systematic transrectal biopsy 3 years ago was benign. His PSA is 6.3 micrograms/L and MRI-derived prostate volume is 70 mL (PSA density 0.09 ng/mL/mL). Digital rectal examination is benign and PSA has been stable for 9 months. Multiparametric MRI shows an 11 mm focal lesion in the left posterolateral peripheral zone. It is focally mildly hypointense on the ADC map and mildly hyperintense on high-b-value diffusion-weighted imaging (DWI score 3). Dynamic contrast-enhanced imaging demonstrates focal early enhancement corresponding to this lesion. There is no extracapsular extension. The local report is calibrated as MRI Likert 4. Which reporting conclusion and next diagnostic step is most appropriate?

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Correct answer: E — PI-RADS v2.1 category 4; discuss at MDT with a view to MRI-influenced repeat prostate biopsy

This is a peripheral-zone lesion, in which DWI is the dominant PI-RADS sequence. DWI score 3 is equivocal, but focal early enhancement at the same site is DCE-positive; under PI-RADS v2.1 this upgrades the overall assessment to PI-RADS 4. The lesion is not PI-RADS 5 because it is smaller than 15 mm and there is no definite extraprostatic extension. The previous benign biopsy changes the UK management sequence. NICE recommends that people with a negative biopsy and MRI Likert score of 3 or more are discussed in the MDT with a view to repeat biopsy. His low PSA density, stable PSA and benign DRE reduce background clinical suspicion but do not negate the MRI Likert 4 finding or the recommendation for MDT review. Therefore, surveillance or discharge is inappropriate. Immediate staging is also premature: staging investigations do not replace histological confirmation in this situation.

Reference: NICE NG131: Prostate cancer: diagnosis and management, recommendations 1.2.3 and 1.2.10 (2019; current online recommendations checked 16 August 2026) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations Investigating the role of DCE-MRI, over T2 and DWI, in accurate PI-RADS v2 assessment of clinically significant peripheral zone prostate lesions (2018) — https://pubmed.ncbi.nlm.nih.gov/30361870/