Bone Cancer Presentation and Diagnosis

Primary Presenting Symptoms

Pain is the cardinal symptom and may vary in intensity, but night pain is a critical "red flag" requiring immediate investigation 1, 2
Pain often occurs at rest or during the night, distinguishing it from mechanical musculoskeletal injuries 3, 4
The average duration of symptoms before presentation is 3 months, though many patients present later 1
A history of recent injury does NOT exclude bone cancer and must not prevent appropriate diagnostic workup 1, 5

Osteosarcoma most frequently affects the metaphysis of long bones, particularly around the knee (distal femur and proximal tibia) 8, 9
Ewing Sarcoma accounts for 50% of cases in extremity bones, with the tibia being a common site 6, 7
Adamantinoma is highly specific for the tibial shaft (medial or distal portions) 1
Giant Cell Tumor of Bone usually occurs at the epiphyses of long bones next to joints in patients aged 20-40 years 1, 2

Duration, intensity, and diurnal variation of pain (specifically ask about night pain) should be obtained in the patient's history 1, 2
Prior benign or malignant tumors, family history of cancer, and previous radiotherapy exposure should be investigated 1, 2
Physical examination should focus on size, consistency, and mobility of any mass, location in relation to bone, and regional and local lymph node examination 1, 2

Under 5 years: Destructive bone lesions more likely represent metastatic neuroblastoma or Langerhans cell histiocytosis 6, 7
Ages 5-40 years: Primary bone sarcoma is more likely 5, 6
Over 40 years: Metastatic carcinoma or myeloma becomes the most common diagnosis and should be investigated first 1, 2, 5

Urgent X-ray of the affected site in two planes as the first investigation 1, 2
Urgent referral to a bone sarcoma center if X-ray shows bone destruction, new bone formation, periosteal swelling, or soft tissue swelling 1, 2
Patients under 40 years with suspected primary bone malignancy should be referred urgently to a bone sarcoma center 1