What is the most likely diagnostic study for a patient with severe midback pain and a history of prostate cancer?

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Dainyal Siddiqui, MD

Internal Medicine

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Manuel Jimenez, MD

Cardiology

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Franz Pierre-Louis, MD

Infectious Disease

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Last updated: May 23, 2025 • View editorial policy

From the Guidelines

The most likely study to establish the diagnosis in this case is an X-ray of the thoracic spine (option E). This patient presents with severe midback pain that worsened acutely with movement, is not relieved by lying down, and is associated with point tenderness over the thoracic spine. Given his history of prostate cancer treated 10 years ago with no recent follow-up, these symptoms strongly suggest metastatic disease to the spine, particularly since prostate cancer commonly metastasizes to bone 1. A thoracic spine X-ray would be the initial imaging study to identify vertebral metastases, compression fractures, or other bony abnormalities that could explain his severe pain. While serum PSA measurement would be useful to monitor for prostate cancer recurrence, it wouldn't directly visualize the suspected spinal pathology causing his acute symptoms. The other options (DEXA scan, prostate biopsy, and lumbar puncture) are less appropriate for diagnosing suspected spinal metastases in this clinical scenario. Some key points to consider include:

  • The patient's symptoms of severe midback pain that worsened with movement and are not relieved by lying down are highly suggestive of a spinal issue, such as a metastatic lesion or compression fracture.
  • The patient's history of prostate cancer, which has a high propensity to metastasize to bone, further supports the likelihood of spinal metastases.
  • An X-ray of the thoracic spine is a rapid and readily available imaging modality that can quickly identify or rule out bony abnormalities in the spine, making it the most appropriate initial study in this scenario 1.

From the Research

Diagnostic Approach

To establish a diagnosis for the 69-year-old man with a history of prostate cancer and current midback pain, the following studies can be considered:

  • The patient's history of prostate cancer and current symptoms suggest the possibility of metastasis, which can cause back pain.
  • Imaging studies can help identify the cause of the back pain and determine if it is related to the prostate cancer.

Imaging Options

The following imaging options can be considered:

  • X-ray of the thoracic spine: This can help identify any fractures or lesions in the spine that may be causing the back pain 2, 3.
  • DEXA scan: This can help assess bone density and identify any osteoporotic fractures that may be causing the back pain.
  • Fine-needle aspiration biopsy of the prostate: This is not directly relevant to the current symptoms of back pain.
  • Lumbar puncture for examination of cerebrospinal fluid: This is not directly relevant to the current symptoms of back pain.
  • Measurement of serum prostate specific antigen concentration: This can help monitor the patient's prostate cancer, but it is not directly relevant to the current symptoms of back pain.

Most Likely Diagnostic Study

Based on the patient's symptoms and history, the most likely diagnostic study to establish the diagnosis is:

  • X-ray of the thoracic spine: This can help identify any fractures or lesions in the spine that may be causing the back pain, and it is a common initial imaging study for back pain 3, 4.

References

1
Guideline

acr appropriateness criteria<sup>®</sup> post-treatment follow-up prostate cancer.

Journal of the American College of Radiology, 2018

3
Research

Imaging of prostate carcinoma.

Cancer control : journal of the Moffitt Cancer Center, 2013

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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