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A 72-year-old man has three months of gradually worsening back pain in his thoracic and lumbar spine. He has hypertension and atrial fibrillation. He is taking bisoprolol and apixaban. He has no other past medical history. He is an ex-smoker with a 30-pack-year smoking history. He drinks 20 units of alcohol per week. The pain is now keeping him awake at night and he has weakness in his legs. He has lost 4 kg in weight and has also been constipated for the last month. He has had nocturia and urinary urgency for the last 2 years. These have not changed. He is tender over T4/5 and L3/4 verterbrae. He has weakness of ankle dorsiflexion and knee flexion and extension in both legs. He has an enlarged, irregular, firm prostate on rectal examinationinvestigations show: serum calcium - 3 mmol/L (2.2-2.6) prostate specific antigen (PSA) 150 μg/L (<4)tumour mass in the upper thoracic spinal canal and in the prevertebra

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