Musculoskeletal Tumors – The Five Presenting Complaints

Most patients with musculoskeletal tumors present with one or more of five signs or symptoms. In some cases (for example the patient complaining of a soft tissue or bony mass), the symptoms are easily referable to the tumor. In other instances, the tumor may be incidental to the real cause of symptoms, or the patient may have pain or a pathologic fracture resulting from the lesion. For all of these circumstances, the clinician should rely on an orderly clinical sequence of eliciting the history, performing a physical examination, and obtaining appropriate investigations to gain a differential diagnosis of the clinical problem.

Tumor Definitions

In discussing the clinical presentation of bone tumors, several terms will be used that require definition. 

• Benign musculoskeletal tumors are bone or soft tissue lesions that have no risk of metastasis. Benign bone lesions may be further characterized as to their effect on the local skeleton. 
  • Benign latent lesions are inactive lesions that show little or no evidence of recent bone destruction or remodeling.  Examples include enchondroma, non-ossifying fibroma, or a healed unicameral bone cyst.
  • Benign active lesions cause local bone destruction or remodeling and may result in symptoms through weakening of the bone or development of a bony mass. Examples include active unicameral bone cysts, fibrous dysplasia, and osteochondromas during active skeletal growth.
  • Benign aggressive lesions cause more significant bone destruction. These lesions are at risk for local relapse after treatment but do not metastasize (or metastasize only rarely). Examples are aneurysmal bone cysts, osteoblastoma, or giant cell tumor (this last aggressive tumor has a small risk of metastases).
• Malignant tumors are lesions that may metastasize and are potentially lethal. They may be primary in bone and derived from mesenchymal cells (osteosarcoma, chondrosarcoma), derived from marrow elements (myeloma, lymphoma), or metastatic to the bone (breast or prostate cancer).

These terms will be used in describing the clinical presentation of bone and soft tissue tumors.

The Presenting Complaints

• Soft tissue mass
• Painless bony mass
• Bone tumor as an incidental finding
• Painful bone lesion
• Pathologic fracture