NICE guidance suggests the following:
1.13 Bone cancer and sarcoma General recommendations 1.13.1 A patient who presents with symptoms suggesting bone cancer or sarcoma should be referred to a team specialising in the management of bone cancer and sarcoma, or to a recognised bone cancer centre, depending on local arrangements. 1.13.2 If a primary healthcare professional has concerns about the interpretation of a patient’s symptoms and/or signs, a discussion with the local specialist should be considered. 1.13.3 Patients with increasing, unexplained or persistent bone pain or tenderness, particularly pain at rest (and especially if not in the joint), or an unexplained limp should be investigated by the primary healthcare professional urgently. The nature of the investigations will vary according to the patient’s age and clinical features. • In older people metastases, myeloma or lymphoma, as well as sarcoma, should be considered. Specific recommendations Bone tumours 1.13.4 A patient with a suspected spontaneous fracture should be referred for an immediate X-ray. 1.13.5 If an X-ray indicates that bone cancer is a possibility, an urgent referral should be made. 1.13.6 If the X-ray is normal but symptoms persist, the patient should be followed up and/or a repeat X-ray or bone function tests or a referral requested.
The UK guidance on the management of bone sarcomas states the following:
The most common symptom of a primary bone tumour is pain which may be nonmechanical or night pain. The presence of bone pain at night should always be considered to be a “red flag” symptom leading to further investigation. The presence of bone swelling or a soft-tissue mass may occur later. The average duration of symptoms is 3 months although a history of 6 months or longer is not uncommon [13–15]. The presence of pain or a palpable mass arising from any bone should cause concern and lead to further investigation of which a plain X-ray is the first investigation of choice. The presence of any of the following on the X-ray is suggestive, but not diagnostic of a bone tumour and should also lead to further investigation:
- bone destruction,
- new bone formation,
- periosteal swelling,
- soft tissue swelling.
The North of England Bone and Soft Tissue Tumour Service has a fax for urgent referrals: 0191 223 1328. A referral form for professionals can be found here.