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Suspected clinically localised prostate cancer — MSRA MCQ

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HardMRISuspected clinically localised prostate cancerMSRA

A 65-year-old Black Caribbean man is assessed in a urology diagnostic clinic after a suspected cancer pathway referral from his GP. He has 8 months of nocturia and urinary hesitancy. There is no dysuria, fever, recent urinary infection, catheterisation, ejaculation or vigorous cycling before testing. His PSA is 9.2 ng/mL on repeat testing. Digital rectal examination finds a smooth, moderately enlarged prostate without nodularity. He has no bone pain, weight loss or neurological symptoms, is fit for radical treatment, and has no contraindication to MRI. Multiparametric prostate MRI reports a Likert score of 2, with a prostate volume of 42 mL. There has been no previous prostate biopsy. What is the most appropriate next diagnostic step?

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Correct answer: E — Offer a systematic prostate biopsy

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

The appropriate next step is a systematic prostate biopsy. Although a Likert score of 2 is a low-suspicion MRI result and can support omission of biopsy in selected patients, this man has persistent clinical concern: his PSA density is 9.2/42 = 0.22 ng/mL/mL, exceeding the NICE example threshold of 0.15 ng/mL/mL for strong suspicion. His Black Caribbean background further increases baseline risk. NICE advises offering biopsy after a Likert 1 or 2 MRI when suspicion remains strong; if biopsy is undertaken after a low-suspicion MRI, it should be systematic rather than MRI-targeted. B is inappropriate because MRI-influenced biopsy is recommended for Likert scores of 3 or more, where there is an imaging target. C would be reasonable after shared decision-making only if suspicion were low, for example with low PSA density and no major risk factors. D is not appropriate before histological confirmation in a man with no evidence of metastatic disease. E delays diagnosis without addressing the current high-risk clinical features; NICE uses PSA follow-up after low-suspicion MRI only when the residual suspicion is low.

Reference: NICE NG131: Prostate cancer: diagnosis and management — MRI and biopsy (2019) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations