What are the clinical symptoms of bone cancer?

Symptoms of Bone Cancer

The most common symptoms of bone cancer are pain and/or a lump or swelling, with bone pain at night being a critical "red flag" that requires immediate investigation. 1

Primary Symptoms

Pain Characteristics

• Pain is the first symptom in all patients 2
• Pain may vary in intensity but has distinctive features:
  • Night pain is a "red flag" requiring urgent investigation 1
  • Pain worse on weight bearing (53% of patients) 2
  • Persistent, non-mechanical pain lasting more than a few weeks 3, 4
  • Pain that may be progressive over time 5

Swelling and Mass

• A lump or swelling develops as the second most common symptom 1
• Swelling typically appears later (average 7 weeks after pain onset) 2
• Only becomes evident when the tumor has progressed through the cortex and distended the periosteum 3, 4
• May demonstrate soft tissue mass on examination 1

Secondary Presentations

Pathological Fracture

• Some patients present with fracture as the initial manifestation 1
• High incidence of fracture at presentation in certain tumor types 1
• Only 7% of patients present with pathological fracture in osteosarcoma around the knee 2

Functional Impairment

• Limp (67% of patients, sometimes without associated pain on weight bearing) 2
• Decreased joint range of motion 6
• Functional impairment when tumor extends through cortex 4

Neurological Symptoms

• Patients with spinal tumors may present with:
  • Spinal cord compression 1
  • Other neurological symptoms 1

Less Common Symptoms

Constitutional Symptoms

• Systemic symptoms are unusual but may indicate metastatic disease 1
• In Ewing sarcoma specifically, constitutional symptoms occasionally occur:
  • Fever 7
  • Weight loss 7
  • Fatigue 7

Laboratory Abnormalities

• Elevated serum LDH (in Ewing sarcoma) 7
• Leukocytosis (in Ewing sarcoma) 7

Critical Clinical Pitfalls

Delayed Diagnosis

• Average duration of symptoms before presentation is 3 months, but many patients present later 1
• Mean total delay from symptom onset to definitive diagnosis can be 17 weeks (range 4-55 weeks) 2
• A history of recent injury does NOT exclude bone cancer and must not prevent appropriate diagnostic procedures 1, 3, 1, 8, 3

Misleading Presentations

• Symptoms often mimic common musculoskeletal injuries, leading to low physician suspicion 9
• Nonspecific symptoms contribute to diagnostic challenges 9
• A "normal" X-ray does NOT exclude bone cancer - persistent pain or mass requires urgent MRI or referral 1

Age-Related Considerations

The most likely diagnosis varies by age:

• Before 5 years: destructive bone lesions are most commonly metastatic neuroblastoma or Langerhans cell histiocytosis 4, 5
• Above 5 years: primary bone sarcoma becomes more likely 3, 4, 3, 5
• After 40 years: bone metastases and myeloma are most common 3, 4, 8, 4, 3, 5

When to Refer Urgently

Patients under 40 years with suspected bone cancer should be referred urgently to a bone sarcoma centre 1. Red flags requiring immediate investigation include:

• Bone pain at night 1
• Persistent pain lasting more than a few weeks 3, 4, 5
• Noticeable swelling or mass 1, 2
• Limp, especially without clear traumatic cause 2