What are the signs and symptoms of bone cancer?

Signs and Symptoms of Bone Cancer

The cardinal presenting symptom of bone cancer is localized pain that characteristically occurs at rest or during the night—this "night pain" is a critical red flag requiring immediate investigation. 1

Primary Clinical Presentations

Pain Characteristics

• Pain is the most common presenting symptom, with night pain being particularly suspicious for malignancy 1
• Pain intensity may vary, but the key distinguishing feature is that it occurs at rest or during nighttime, unlike mechanical musculoskeletal injuries 1
• The average duration of symptoms before patients seek medical attention is approximately 3 months 1
• Critical pitfall: A history of recent injury does NOT exclude bone cancer and must not delay appropriate diagnostic workup 1

Localized Physical Findings

• Swelling or palpable mass at the affected site is common 2, 1
• The mass should be assessed for size, consistency, mobility, and relationship to underlying bone 1
• Regional and local lymph nodes should be examined 1

Constitutional Symptoms (Particularly Ewing Sarcoma)

• Fever, weight loss, and fatigue may be present, especially with Ewing sarcoma—this distinguishes it from other bone sarcomas 2
• Elevated serum lactate dehydrogenase (LDH) and leukocytosis may be noted on laboratory studies 2

Tumor-Specific Presentations by Location

Long Bone Involvement

• Osteosarcoma most frequently affects the metaphysis of long bones, particularly around the knee (distal femur and proximal tibia) 1, 3
• Ewing sarcoma affects the diaphysis when arising in long bones, with 50% of cases occurring in extremity bones 2, 1
• Adamantinoma is highly specific for the tibial shaft (medial or distal portions) 1

Axial Skeleton Involvement

• Pelvic or axial lesions typically present later in the disease course because pain has a more insidious onset and occurs when the tumor has reached significant size 2
• Ewing sarcoma commonly affects pelvic bones and bones of the chest wall 2

Epiphyseal Involvement

• Giant cell tumor of bone usually occurs at the epiphyses of long bones next to joints in patients aged 20-40 years 1

Radiographic Findings That Suggest Malignancy

Plain radiography in two planes is the first-line investigation 1

Suspicious radiographic features include:

• Poorly marginated lesion on plain radiograph 2
• Bone destruction or mottled appearance 2
• New bone formation 1
• Periosteal reaction (classic "onion skin" appearance in Ewing sarcoma) 2
• Soft tissue swelling 1
• Cortical destruction and loss of medullary bone trabeculations (chondrosarcoma) 2

Age-Based Diagnostic Approach

Under 5 Years

• Destructive bone lesions more likely represent metastatic neuroblastoma or Langerhans cell histiocytosis rather than primary bone cancer 1

Ages 5-40 Years

• Primary bone sarcoma is the most likely diagnosis for aggressive, symptomatic bone lesions 2, 1
• Referral to an orthopedic oncologist should be considered before further workup 2

Over 40 Years

• Metastatic carcinoma or myeloma becomes the most common diagnosis and should be investigated first 2, 1
• Initial workup should include history and physical, bone scan, chest x-ray, CT chest/abdomen/pelvis with contrast, and additional testing such as serum protein electrophoresis, CBC, comprehensive metabolic panel, PSA, or mammogram as indicated 2

Critical Laboratory Abnormalities

Before definitive treatment, obtain:

• Complete blood count (CBC) 2
• Comprehensive metabolic panel with calcium to assess for hypercalcemia 2
• Lactate dehydrogenase (LDH)—elevated levels suggest worse prognosis 2
• Alkaline phosphatase (ALP) 2

When to Refer Urgently

Immediate referral to a bone sarcoma center is required if: 1

• X-ray shows bone destruction, new bone formation, periosteal swelling, or soft tissue swelling
• Patient is under 40 years with suspected primary bone malignancy
• Any patient presents with night pain and suspicious radiographic findings

Common pitfall to avoid: Delaying referral while awaiting additional imaging—patients with radiographic suspicion should be referred immediately to a specialized center for coordinated staging and biopsy 2, 1