skip to main content

Suspected clinically localised prostate cancer — MSRA MCQ

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

HardPI-RADSSuspected clinically localised prostate cancerMSRA

A 68-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 7.8 micrograms/L and MRI-derived prostate volume is 41 mL (PSA density 0.19 ng/mL/mL). Digital rectal examination is benign. He has not previously had a prostate biopsy. Multiparametric MRI shows a 12 mm transition-zone nodule with an incomplete capsule, consistent with an atypical benign prostatic hyperplasia nodule (T2-weighted score 2). It is markedly hypointense on ADC and markedly hyperintense on high-b-value diffusion-weighted imaging (DWI score 4). There is no focal early enhancement or extracapsular extension. The local radiologist's overall clinical assessment is MRI Likert 2. Which reporting interpretation and immediate diagnostic management is most appropriate?

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

Reveal the answer and explanation

Correct answer: A — Classify the lesion as PI-RADS 3 and offer systematic prostate biopsy because the Likert 2 MRI is accompanied by high clinical suspicion

This is a PI-RADS v2.1 transition-zone ‘2 + 1’ lesion. An incompletely encapsulated atypical BPH nodule has a T2-weighted score of 2, but marked restricted diffusion (DWI score 4 or 5) upgrades the overall PI-RADS category to 3; it does not become PI-RADS 4 solely because diffusion restriction is marked. Dynamic contrast enhancement does not alter this transition-zone scoring pathway. Management in UK practice is determined by the local MRI Likert assessment and clinical risk, rather than mechanically substituting PI-RADS for Likert. Although the reported Likert score is 2, his PSA density is 0.19 ng/mL/mL, exceeding NICE's example threshold of 0.15 for strong suspicion. In a biopsy-naive person with Likert 1 or 2 MRI and strong suspicion, NICE recommends offering prostate biopsy. As the MRI is low-risk by the local Likert report, the appropriate biopsy approach is systematic rather than MRI-targeted biopsy. A and B wrongly underweight the raised PSA density. C incorrectly assumes PI-RADS 3 independently mandates targeted biopsy despite a Likert 2 report. E incorrectly upgrades a PI-RADS v2.1 atypical BPH nodule beyond category 3.

Reference: NICE NG131: Prostate cancer: diagnosis and management — MRI and biopsy recommendations (Updated March 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/