Synopsis
Recognise a possible primary malignant bone tumour before fracture or unplanned surgery, complete compartment-aware imaging, obtain a sarcoma-centre-planned biopsy and coordinate histology-specific chemotherapy, wide resection, radiotherapy, reconstruction and survivorship care.
- Primary malignant bone tumours are rare; osteosarcoma peaks in adolescents, Ewing sarcoma in children and young adults, and conventional chondrosarcoma in later adulthood.
- Persistent night or rest pain, focal swelling and an unexplained pathological fracture are key warning features; a remembered sports injury does not exclude sarcoma.
- First-line imaging is a high-quality plain radiograph in two planes including the whole involved bone and adjacent joints.
- MRI of the entire involved bone and compartment is the preferred local-staging test and must be completed before biopsy where practical.
- CT chest is the standard first staging test for pulmonary metastases; bone scintigraphy or PET-based imaging assesses additional skeletal disease according to histology and protocol.
- The diagnostic reference standard is image-guided core biopsy planned by the bone-sarcoma MDT so its tract can be removed with the definitive specimen.
- Never perform unplanned curettage, excision or routine internal fixation of a suspicious lesion; contamination can convert a limb-sparing resection into a larger operation or amputation.
- Osteosarcoma treatment usually combines multiagent chemotherapy with wide surgical resection; response is assessed by necrosis in the resection specimen.
- Ewing sarcoma requires systemic multiagent chemotherapy plus surgery and or radiotherapy for local control; treatment of all metastatic sites is considered in curative protocols.
- Conventional chondrosarcoma is managed mainly by complete wide resection because ordinary chemotherapy and radiotherapy have limited activity; mesenchymal and dedifferentiated subtypes differ.
- A pathological fracture is immobilised and discussed with the sarcoma surgeon before any fixation; the definitive construct must be part of the oncological resection plan.
- Limb salvage is preferred when a wide margin and useful function are achievable, but amputation may provide the safest margin or best function in selected cases.
- Follow-up concentrates on lung relapse, local recurrence, reconstruction performance and lifelong cardiotoxic, renal, auditory, fertility and second-cancer effects.
Key red flags
Persistent focal bone pain, especially pain at night or at rest, warrants imaging when it is progressive, localised or unexplained by a resolving injury.
A firm enlarging swelling fixed to bone, reduced adjacent-joint movement or focal warmth requires urgent radiography and specialist review.
A fracture after trivial force through a lytic, mixed or sclerotic lesion is pathological until proved otherwise and must not undergo routine fixation before tumour planning.
A child or young adult with metaphyseal pain and swelling around the knee or shoulder may have osteosarcoma even when symptoms began after sport.
Fever, weight loss and diaphyseal pain can mimic infection but may indicate Ewing sarcoma; neither antibiotics nor drainage should precede adequate imaging and tissue when stable.
Back pain with weakness, sensory change, gait loss or bladder or bowel dysfunction requires emergency spinal imaging and specialist decompression assessment.
A destructive bone lesion in a patient older than 40 is more likely metastasis or myeloma than primary sarcoma, but tissue strategy still matters when the diagnosis is uncertain.
Sudden inability to bear weight through a destructive lesion is an oncological emergency requiring immobilisation and sarcoma-centre planning before fixation.
Investigation priorities
Characterise matrix, margins, periosteal reaction, cortical integrity and fracture in two planes including both adjacent joints.
Map full intramedullary length, skip lesions, soft-tissue extension, joint involvement and relationship to nerves and vessels before biopsy.
Management branches
Persistent focal bone symptoms or radiography shows an aggressive or unexplained lesion.
- Obtain two-plane radiographs of the whole bone, examine swelling, joint and neurovascular function and provide safe analgesia and weight-bearing advice.
- Contact the regional bone-sarcoma service and complete tumour-protocol MRI before biopsy, with CT chest and whole-body staging arranged through the specialist team.
- Use MDT-planned image-guided core biopsy with a resectable tract, then integrate expert pathology, molecular results and stage before any definitive operation.