What are the typical signs and symptoms of sarcoma?

Signs and Symptoms of Sarcoma

The most common presentation of sarcoma is a painless, enlarging mass, though pain—particularly night pain in bone lesions—is a critical red flag that should never be dismissed. 1, 2

Primary Clinical Presentations

Soft Tissue Sarcomas

Key warning signs include:

• Painless enlarging mass is the classic presentation, typically increasing in size over weeks to months 3, 2, 4
• Size >5 cm significantly increases malignancy risk and warrants urgent specialist referral 3
• Deep location beneath the fascia, particularly in the thigh or retroperitoneum, is highly concerning 3
• Pain may be present but is not predictive of malignancy; its absence does not exclude sarcoma 3, 4

Critical anatomic locations:

• Extremities (most common site), with thigh being particularly frequent 2, 5
• Retroperitoneum and intra-abdominal locations often present late as large masses due to vague symptoms until organ compression occurs 5
• Trunk wall lesions present earlier due to visible deformity or palpable mass 5

Bone Sarcomas

Characteristic presentations:

• Pain is the most frequent early symptom, often intermittent initially and frequently confused with growing pains or attributed to musculoskeletal injury 1
• Night pain is a specific red flag for primary malignant bone tumors requiring immediate investigation 1, 3
• Swelling typically appears later when tumor extends through cortex and distends periosteum 1
• Pathological fracture at presentation, particularly common in spindle cell sarcomas of bone 1
• Functional impairment develops as disease progresses 1

Common sites:

• Metaphysis of distal femur or proximal tibia (osteosarcoma) 1
• Extremity tumors, ribs, and vertebral column (Ewing sarcoma) 1
• Diametaphyseal region of long bones and flat bones like pelvis, rib, scapula (chondrosarcoma) 1

Age-Related Diagnostic Considerations

The differential diagnosis is heavily age-dependent: 1

• <5 years: Destructive bone lesions more likely metastatic neuroblastoma or Langerhans cell histiocytosis 1
• 5-40 years: Higher likelihood of primary bone sarcoma 1
• >40 years: Bone metastases and myeloma become most common diagnoses 1
• 30-60 years: Peak age for chondrosarcoma 1
• 10-14 years: First peak for osteosarcoma, with second peak >65 years (often secondary to Paget disease) 1

Specific Sarcoma Subtypes

Osteosarcoma

• Pain and swelling are most frequent early symptoms 1
• Symptoms often intermittent initially, leading to delayed workup 1
• Most common sites: distal femur, proximal tibia 1

Chondrosarcoma

• Typically affects adults 30-60 years 1
• Can arise in pre-existing benign lesions (enchondroma, osteochondroma) 1
• High-grade variants frequently arise in axial skeleton and long bones 1

Ewing Sarcoma

• Affects children and young adults 1
• Can arise in bone (70%) or soft tissue (30% in adults) 1
• Extremity tumors, ribs, and vertebral column frequently affected 1

Spindle Cell Sarcomas of Bone

• Present with pain and high incidence of fracture at presentation 1
• Similar age group to chondrosarcoma but skeletal distribution like osteosarcoma 1

Critical Red Flags Requiring Urgent Investigation

The National Health Service identifies these as mandatory urgent assessment criteria: 3

• Increasing size (single most important warning sign) 3
• Size >5 cm 3
• Deep location 3
• Pain, especially night pain 3

Common Diagnostic Pitfalls

Avoid these critical errors:

• Recent trauma does not exclude malignancy and must not prevent appropriate diagnostic procedures 1, 3
• Painless masses can be deceptive, leading to delayed diagnosis despite being the most common presentation 3
• Soft tissue sarcomas can mimic hematoma or deep vein thrombosis, causing dangerous delays in diagnosis 6
• Assuming lipomas are always benign can miss atypical lipomatous tumors requiring different management 3
• Normal X-rays do not exclude sarcoma; persistent pain or mass requires MRI or specialist referral 3

Physical Examination Findings

Specific attention should focus on: 1

• Size and consistency of swelling 1
• Location and mobility 1
• Relation of swelling to involved bone 1
• Presence of regional/local lymph nodes 1

Systemic Symptoms

Most patients lack systemic symptoms: 6

• Fever, weight loss, or malaise are uncommon 6
• Abdominal/pelvic sarcomas often clinically silent until late, causing only vague symptoms until organ invasion or compression 5

When to Suspect Sarcoma

Maintain high clinical suspicion for: 7

• Persistent, localized knee pain that is non-mechanical or occurs at night, even without palpable swelling 7
• Any unexplained lump that is enlarging, warranting urgent ultrasound within 2 weeks 3
• Masses beneath deep fascia, particularly in thigh or retroperitoneum 3