Benign tumours

  • Osteoma - a benign overgrowth, most often of the skull - seen in Gardner syndrome 
  • Osteochondroma - most common - ‘cartilage-capped’ bony projections
  • Giant cell tumour - tumours most often at the epiphyses of long bones. Double bubble sign on XR. 

Malignant tumours

  • Ewing’s sarcoma 
    • Most commonly occur in childhood or early adulthood
    • Usually present with severe pain +/- swelling in pelvis, chest wall or long bones
  • Chondrosarcoma
    • Malignant cartilage in axial skeleton 
  • Osteosarcoma
    • The most common primary bone malignancy, presenting with unexplained bone pain or swelling +/- night time pain in children and young adults. 

Bone and soft tissue Sarcoma

Osteosarcoma

  • An aggressive, malignant bone tumour, most common in children and young adults (age 10-20 years)
  • Red flag symptoms for osteosarcoma - unexplained bone pain or swelling 
    • Pain is commonly worse at night
    • Most commonly sites: end of long bones - particularly proximal femur, tibia and proximal humerus, or in the mandible 
    • May present as low trauma fracture
  • Investigation: X-ray is 1st line
    • Sunburst appearance
    • Codman triangle - the malignant osteoid causes elevation of the cortex of the affected bone 

Soft tissue sarcoma

  • A malignant tumour of soft tissue (muscles, ligaments, tendons, fat etc.) 
  • Red flag symptoms for soft tissue sarcoma - unexplained lump that is increasing in size 
    • Most commonly found in arms, legs, chest and abdomen
  • Investigations: US is 1st line 
     

Recognition and Referral

Red flag symptoms - NICE guidance on recognition and urgent imaging:

Adults

  • Unexplained lump increasing in size - concerning for soft tissue sarcoma
    • Urgent ultrasound within 2 weeks

Children and young people

  • Unexplained lump increasing in size - concerning for soft tissue sarcoma
    • Very urgent ultrasound (within 48 hours)
  • Unexplained bone pain OR bone swelling - concerning for bone sarcoma
    • Very urgent x-ray (within 48 hours)

NICE guidance on referral following imaging:

Adults

  • If X-ray is concerning for bone sarcoma OR if US suggests soft tissue sarcoma (or is uncertain and concern persists)
    • Refer via 2 week wait pathway

Children and young people

  • If X-ray is concerning for bone sarcoma OR if US suggests soft tissue sarcoma (or is uncertain and concern persists)
    • Refer via very urgent referral pathway - for specialist assessment within 48 hours 
       

References and Further Reading

NICE CKS. Bone and soft tissue sarcoma - recognition and referral [August 2020]. Available at URL: https://cks.nice.org.uk/topics/bone-soft-tissue-sarcoma-recognition-referral/