Laboratory Workup for Suspected Bone Cancer
For any patient with suspected bone cancer, obtain a complete blood count (CBC), comprehensive metabolic panel with calcium, lactate dehydrogenase (LDH), and alkaline phosphatase (ALP) before definitive treatment, as these serve both diagnostic and prognostic purposes. 1, 2
Essential Laboratory Tests
Prognostic Markers (Required)
- Alkaline phosphatase (ALP): Elevated levels correlate with adverse outcomes in osteosarcoma and predict skeletal metastases 1, 2, 3
- Lactate dehydrogenase (LDH): Elevated levels indicate higher disease burden, poorer outcomes, and are predictive of skeletal metastases in osteosarcoma 1, 2, 3
Comprehensive Baseline Panel (Required)
- Complete blood count (CBC) with differential: Assess baseline hematologic status before chemotherapy 1, 2
- Comprehensive metabolic panel with calcium: Monitor for hypercalcemia and establish baseline renal/hepatic function, as chemotherapy causes renal dysfunction 1, 2
- Coagulation profile: Evaluate bleeding risk before biopsy and surgery 2
- Blood group typing: Required for potential transfusions during surgery 2
- Serum electrolytes (including magnesium and phosphate): Baseline monitoring for chemotherapy toxicity 2
Optional Studies
- Molecular studies: Consider to delineate potential therapeutic options 1
- Serum protein electrophoresis: In patients ≥40 years to evaluate for multiple myeloma as alternative diagnosis 1
Critical Timing and Sequencing
All laboratory studies and staging investigations must be completed BEFORE biopsy to avoid contamination of tissue planes and ensure accurate baseline assessment. 1, 2
The NCCN guidelines emphasize that in patients <40 years with an aggressive, symptomatic bone lesion, immediate referral to an orthopedic oncologist should occur before further workup, as there is significant risk of malignant primary bone tumor 1. In patients ≥40 years, the workup should also include evaluation for bone metastases from other primary cancers 1.
Age-Specific Considerations
Patients <40 Years
Patients ≥40 Years
- Add prostate-specific antigen (men), mammogram (women) to evaluate for metastatic disease 1
- Consider serum protein electrophoresis for myeloma 1
Common Pitfalls to Avoid
Do not delay referral to a cancer center or bone sarcoma reference center while waiting for laboratory results. Any patient with radiographic suspicion of bone malignancy requires quick multidisciplinary evaluation 2, 4. The most significant error is performing biopsy before completing staging workup, which can contaminate tissue planes and compromise limb-salvage surgery 1.
Laboratory values should be repeated periodically during treatment and throughout surveillance, as they help monitor treatment response and detect recurrence 1.