NICE guidance suggests the following:
1.13 Bone cancer and sarcoma
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.
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
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.
References UK guidelines for the management of bone sarcomas. NICE referral guidelines for suspected cancer 2005
Soft tissue lumps are common: malignant ones are rare, but detecting them early is important. Delay in diagnosis is a significant problem in the treatment of sarcomas, as is unplanned excision. An unplanned excision occurs when a soft tissue lump is removed by a surgeon (or General Practitioner) without any thought about whether the lump might be malignant. (these are called “whoops” operations by sarcoma teams). Both of these problems can be minimised by using the referral guidelines.
A soft tissue lump exhibiting any of the following four following criteria should be considered malignant until proven otherwise:
- increasing in size
- size >5cm
- deep to the deep fascia
Patients with lumps such as these are best referred to a specialist centre for further investigation, which would start with imaging (eg USS or MRI).
UK soft tissue sarcoma guidance can be found here.
The North of England Bone and Soft Tissue Tumour Service has a fax for urgent referrals: 0191 223 1328.