From the Guidelines
The patient's presentation of a 5 cm mass on the right upper back with a family history of tumors warrants an urgent referral to a bone sarcoma centre, rather than just prescribing naproxen and ordering an ultrasound. The patient's lack of pain or discomfort does not exclude the possibility of a primary malignant bone tumour (PMBT), as some patients may present with a lump or swelling without pain 1. Given the patient's age and family history, a thorough investigation is necessary to rule out PMBT.
The initial assessment should include a full history and clinical examination, considering the size, consistency, mobility, and location of the mass, as well as regional and local lymph nodes, adjacent joints, and neurovascular examination 1. An urgent x-ray of the affected site is required, and if the x-ray shows any signs of bone destruction, new bone formation, periosteal swelling, or soft tissue swelling, further investigation with an MRI scan or referral to a bone sarcoma centre is necessary 1.
Although the patient is over 40 years old, and metastatic carcinoma in bone is likely, it is still essential to exclude PMBT 1. The patient should be referred to a bone sarcoma centre on an urgent cancer pathway, and all histological diagnoses of PMBT should be reviewed by a specialist pathologist within a bone sarcoma multidisciplinary team 1.
In terms of pain management, naproxen 500 mg twice daily may be prescribed for back pain, but the patient should be advised about potential gastrointestinal side effects and instructed to take it with food. However, this should not delay the urgent referral to a bone sarcoma centre. The patient should be scheduled for follow-up after the initial evaluation to discuss results and develop a management plan based on the findings.
Key points to consider in the management of this patient include:
- Urgent referral to a bone sarcoma centre
- Thorough investigation, including imaging studies and biopsy if necessary
- Consideration of the patient's family history of tumors
- Pain management with naproxen, if necessary, while awaiting further evaluation
- Close follow-up to discuss results and develop a management plan.
From the Research
Patient Assessment and Diagnosis
- The patient presents with a mass on the right upper back, approximately 5 cm in diameter, with no reported pain or discomfort.
- A family history of tumors is noted, specifically the patient's grandmother's diagnosis.
- The patient requests naproxen for back pain, and an ultrasound of the right upper back is ordered for further evaluation.
Treatment and Management
- Naproxen 500 mg twice a day is prescribed for the patient's back pain, which is consistent with the recommendation for first-line medications for chronic low back pain 2.
- The use of ultrasound for diagnostic evaluation is supported by studies, which highlight its advantage in visualizing and assessing soft tissues 3, 4.
- However, the diagnostic value of ultrasound in this specific case may be limited, and further research is needed to validate its use 3, 4.
Diagnostic Imaging
- Ultrasound is chosen as the initial diagnostic imaging modality, which may be suitable for evaluating soft tissue structures and guiding further management.
- Other imaging modalities, such as CT or MRI, may be considered if the ultrasound findings are inconclusive or if further evaluation is needed, as seen in studies comparing ultrasound and CT in the diagnostic evaluation of right upper quadrant pain 5.
- The choice of imaging modality depends on the specific clinical scenario and the suspected underlying cause of the patient's symptoms.