Red flags for primary bone sarcoma

Ask the patient to point to the pain and define duration, progression, night waking, rest pain, swelling and functional loss. Clarify whether trauma plausibly explains the trajectory. Osteosarcoma often affects the distal femur, proximal tibia or proximal humerus in adolescents and young adults; Ewing sarcoma may present in diaphysis, pelvis or chest wall with fever; chondrosarcoma more often affects adult pelvis, shoulder girdle or proximal long bone. Constitutional symptoms may be absent.

Inspect and measure any mass, noting skin, veins and relation to a joint. Palpate gently for warmth, firmness and tenderness without stressing a weakened bone. Assess the joint above and below, distal nerves and pulses, lymph nodes and chest symptoms. Record performance status and a baseline functional examination that will inform reconstruction. If a fracture is possible, immobilise before transfers and avoid repeated examination under load.

Obtain full two-plane radiographs that include the lesion and enough bone to understand its compartment. Describe site, matrix, transition, periosteum, cortex and soft tissue. Osteoid may look dense and cloudlike, cartilage mineralises in rings and arcs, and Ewing can be permeative with lamellated periosteal bone, but no single sign replaces integrated diagnosis. A radiograph reported normal should be reviewed or repeated if symptoms remain focal and progressive.

Contact the regional bone-sarcoma service as soon as imaging is suspicious. Do not arrange a convenient local biopsy, curettage or intramedullary device first. The centre coordinates MRI before tissue, usually covering the whole bone, both adjacent joints and the complete soft-tissue component. MRI shows marrow extent, skip lesions, neurovascular proximity and the best viable target. CT adds cortical and matrix detail in pelvis, spine or mineralised tumours.

Staging and biopsy are designed together. CT chest evaluates pulmonary metastases; whole-body bone scintigraphy, PET-CT or whole-body MRI is selected by histology and protocol to identify skeletal spread. Image-guided core biopsy usually provides diagnosis with less morbidity than open sampling. The needle travels through one compartment, avoids neurovascular bundles and joint contamination and ends within a planned resection field. Samples go for histology, molecular testing and microbiology when infection remains plausible.

If a pathological fracture occurs, use a splint or brace, analgesia and safe transfer while the tumour centre determines biopsy and treatment order. A nail passed down the medullary canal can disseminate tumour through the whole bone and convert a limb-sparing resection into a far larger procedure. Closed reduction may also contaminate tissues through haematoma. Selected confirmed sarcoma fractures can still undergo neoadjuvant treatment and limb salvage under specialist control.

Treatment depends on histology. High-grade osteosarcoma receives multi-agent chemotherapy and wide surgical excision; Ewing sarcoma uses systemic chemotherapy with surgery, radiotherapy or both for local control. Conventional chondrosarcoma is primarily treated by adequate surgical resection because standard chemotherapy and radiotherapy have limited effect, while molecular subtypes differ. Reconstruction may use endoprosthesis, allograft, autograft, rotationplasty or amputation according to margin, function and patient priorities.

Care continues for years. Early rehabilitation protects reconstruction while preserving strength and independence. Surveillance examines the primary site and lungs according to histology and time from treatment. Late care addresses prosthetic loosening or infection, fracture, cardiotoxicity, renal or hearing harm, fertility, second malignancy and psychological recovery. New pain or swelling after treatment is imaged promptly rather than waiting for the next routine surveillance visit.