Musculoskeletal

Bone tumours

Bone tumours include benign lesions, rare primary bone sarcomas, myeloma and secondary deposits; the high-yield task is to recognise persistent or unexplained bone pain, swelling, a pathological fracture or an aggressive radiograph, investigate promptly and ensure that suspected primary bone tumour is referred before biopsy to an expert sarcoma centre.

In a nutshell

Bone tumours include benign lesions, rare primary bone sarcomas, myeloma and metastases. Persistent deep or night bone pain, swelling, an unexplained limp, pathological fracture or aggressive X-ray features require prompt investigation. Use plain radiographs first, then specialist MRI and staging; refer suspected primary bone tumour before biopsy to a bone sarcoma MDT. Manage primary sarcoma, metastases, myeloma, fracture risk and MSCC through the relevant specialist pathways.

Classic presentation

A teenager has progressive deep distal-femoral pain and swelling with an aggressive metaphyseal lesion; or an older adult with a known cancer has new focal bone pain and a lytic lesion. The next safe step is specialist referral and planned imaging or biopsy, not local excision.

Key points

Persistent unexplained bone pain or a mass deserves investigation; night or rest pain and a pathological fracture are red flags.
Primary bone sarcoma is rare; metastasis, myeloma, infection and benign lesions remain important differentials, especially in adults.
Plain radiographs in two planes are first-line; aggressive signs include a wide transition zone, cortical destruction, permeative change, aggressive periosteal reaction and soft-tissue extension.
MRI defines local extent and biopsy planning; a normal X-ray does not end assessment if symptoms persist.
Never perform an unplanned biopsy, curettage or excision of a suspicious primary bone tumour; the specialist MDT must plan the tract.
Osteosarcoma usually needs systemic chemotherapy and surgery; Ewing sarcoma needs systemic chemotherapy plus local control; chondrosarcoma is usually surgical, but treatment is histology and grade dependent.
Back pain with neurological symptoms or bladder or bowel dysfunction in someone with cancer is possible MSCC: contact the MSCC coordinator immediately and arrange urgent MRI.

First-line investigation

Prompt plain radiographs of the symptomatic bone, followed by specialist MRI, staging and a planned core biopsy when a primary bone tumour remains possible; add myeloma or metastatic work-up according to age and presentation.

Management

Recognise red flags and urgent complications

Progressive or night bone pain, swelling, an unexplained limp, pathological fracture or an aggressive radiograph needs prompt investigation and specialist referral; in children and young people NICE supports very urgent X-ray and specialist referral.^4,1,5
Weakness, sensory loss, gait disturbance or bladder or bowel dysfunction with current, past or suspected cancer is possible MSCC: contact the MSCC coordinator immediately and arrange urgent MRI.⁸

Image and refer before tissue sampling

Use two-plane radiographs first, then specialist MRI and staging when a primary bone tumour is possible. The bone sarcoma MDT must plan the biopsy route and interpret tissue with imaging; do not perform local biopsy or excision.^1,6,7
In adults with destructive or multifocal lesions, investigate metastasis, myeloma, infection and lymphoma in parallel; follow NG35 for suspected myeloma tests and imaging.^2,1

Use the histology-specific specialist pathway

Primary bone sarcoma treatment is MDT-led: osteosarcoma and many high-grade tumours commonly receive chemotherapy plus surgery, Ewing sarcoma receives systemic chemotherapy plus surgery or radiotherapy for local control, and chondrosarcoma is usually surgical with management adapted to subtype and grade.^1,9
Treat metastases, myeloma, fracture risk and pain through the relevant oncology or haematology pathway, with orthopaedic, radiotherapy, palliative-care and rehabilitation input according to stability, prognosis and goals.^2,10,9

Protect function and monitor for recurrence

Provide a key worker, fertility counselling before gonadotoxic treatment, rehabilitation, psychological and practical support, and surveillance for local recurrence and metastatic disease through the sarcoma MDT.^1,6,9

Exam traps

Do not equate an aggressive periosteal reaction with osteosarcoma; Ewing sarcoma, infection and other lesions can look similar.
Do not biopsy a suspected sarcoma in the community or excise it before specialist planning.
A normal X-ray does not exclude primary bone tumour when pain or swelling persists.
In an older adult, consider metastases and myeloma as well as sarcoma; use serum protein electrophoresis and serum-free light-chain testing when myeloma is suspected.
Do not use a spinal X-ray to rule out MSCC; contact the MSCC coordinator and arrange MRI.
Do not describe all bone metastases as lytic or prescribe one universal bone-protective drug; the pattern and treatment depend on the primary, lesion and patient factors.
Bone sarcoma treatment is not a single operation: histology, stage, resectability, chemotherapy sensitivity, function and patient preference determine the MDT plan.

Illustrations

Aggressive bone-lesion radiographA labelled plain radiograph of an aggressive primary bone lesion showing the zone of transition, cortical destruction, aggressive periosteal reaction and soft-tissue extension, with a warning that imaging suggests urgency but does not replace specialist biopsy.Nephron, Wikimedia Commons · CC-BY-SA-3.0

Ewing sarcoma onion-skin reactionA radiograph of a long-bone diaphysis showing a permeative lesion with laminated onion-skin periosteal reaction, presented as a pattern that requires specialist assessment rather than a standalone diagnosis.Michael Richardson, M.D. on Oct 25th, 2004, Wikimedia Commons · CC-BY-SA-3.0

Lytic and sclerotic bone metastasesRadiographs contrasting lytic and sclerotic metastatic patterns, with a note that pattern alone does not identify the primary and that metastasis, myeloma and primary sarcoma need clinical, imaging and tissue correlation.James Heilman, MD, Wikimedia Commons · CC-BY-SA-3.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.