What are the signs and symptoms of bone cancer?

Signs and Symptoms of Bone Cancer

The cardinal symptom of bone cancer is pain that occurs at rest or during the night—this "red flag" requires immediate investigation and distinguishes malignant bone disease from mechanical musculoskeletal injuries. 1

Primary Presenting Symptoms

Pain Characteristics

• Pain is the most common presenting symptom and may vary in intensity, but night pain specifically is a critical warning sign that demands urgent workup 1, 2
• Pain typically occurs at rest or during nighttime hours, which differentiates it from benign mechanical injuries or overuse syndromes 1, 3
• The average duration of symptoms before patients seek medical attention is approximately 3 months, though many present even later 1
• A recent history of trauma does NOT exclude bone cancer and must never prevent appropriate diagnostic evaluation 1

Mass or Swelling

• A palpable mass or localized swelling may be present, particularly in superficial bone locations 1, 2
• Physical examination should assess the size, consistency, and mobility of any mass, its relationship to underlying bone, and evaluate regional lymph nodes 1

Functional Impairment

• Decreased joint range of motion adjacent to the tumor site may occur 2
• Loss of mobility and functional decline are common, particularly when skeletal complications develop 4

Skeletal-Related Events (Advanced Disease)

When bone cancer progresses, patients may develop serious complications known as skeletal-related events (SREs):

• Pathological fractures (fractures occurring through weakened bone with minimal or no trauma) 4
• Severe bone pain requiring radiotherapy for control 4
• Spinal cord compression causing neurologic symptoms 4
• Hypercalcemia (elevated blood calcium levels) 4
• These complications are associated with significant morbidity, reduced quality of life, loss of mobility, and decreased survival 4

Tumor-Specific Presentations

Osteosarcoma

• Most frequently affects the metaphysis (growth plate region) of long bones, particularly around the knee joint (distal femur and proximal tibia) 1, 3
• Predominantly occurs in children and adolescents, with peak incidence at ages 10-14 years 3, 5
• Lung metastases are common at presentation or during disease course 3

Ewing Sarcoma

• Accounts for 50% of cases in extremity bones, with the tibia being a frequent site 1
• Most common in teenagers and young adults 5
• Can occur in long bones or the pelvis 5

Chondrosarcoma

• Typically occurs in adults over 40 years of age 3, 5
• Can arise as a primary tumor or from malignant transformation of benign bone lesions 5

Multiple Myeloma

• Bone pain, most commonly in the back due to vertebral involvement, is a presenting feature in 75% of patients 4
• Extensive lytic (bone-destroying) lesions are characteristic 4
• Diffuse osteoporosis may also be present 4

Other Rare Tumors

• Adamantinoma is highly specific for the tibial shaft (medial or distal portions) 1
• Giant Cell Tumor usually occurs at the epiphyses (ends) of long bones adjacent to joints in patients aged 20-40 years 1

Age-Based Diagnostic Considerations

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 sarcomas (osteosarcoma, Ewing sarcoma) are more likely in this age group 1

Over 40 Years

• Metastatic carcinoma or multiple myeloma becomes the most common diagnosis and should be investigated first before considering primary bone cancer 1, 6
• Common primary sources of bone metastases include breast, prostate, lung, kidney, and thyroid cancers 6
• Bone metastases are actually much more common than primary bone cancers in adults 7

Critical Clinical Assessment Elements

History

• Duration, intensity, and diurnal variation of pain (specifically inquire about night pain) 1
• Prior benign or malignant tumors and family history of cancer 1
• Previous radiotherapy exposure 1
• Any history of recent trauma (which does not exclude malignancy) 1

Physical Examination

• Size, consistency, and mobility of any palpable mass 1
• Location in relation to bone structures 1
• Regional and local lymph node examination 1
• Assessment of joint range of motion 2

Common Pitfalls to Avoid

• Do not dismiss bone pain in patients with recent trauma history—malignancy can coexist with or present after minor injury 1
• Do not assume pain is musculoskeletal in origin without considering red flags, particularly night pain and pain at rest 1, 3
• Do not delay imaging in patients with persistent bone pain, especially if accompanied by night symptoms 1
• Do not attribute symptoms solely to age-related changes in older adults without proper investigation, as metastatic disease is common in this population 1, 6

Immediate Action Required

• Urgent X-ray of the affected site in two planes should be obtained as the first investigation when bone cancer is suspected 1
• Urgent referral to a bone sarcoma center is indicated if X-ray shows bone destruction, new bone formation, periosteal swelling, or soft tissue swelling 1
• Patients under 40 years with suspected primary bone malignancy should be referred urgently to a specialized bone sarcoma center 1