Diagnostic strategy for bone and soft-tissue tumors.

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Abstract
A patient with a bone tumor usually complains of pain and has a change in locomotive or prehensile function, regardless of the presence or absence of a palpable mass. In contrast, a patient with a soft-tissue tumor usually has a palpable mass that produces little or no pain and causes little alteration in function. Both types of symptoms ultimately cause the patient to consult the physician, who, in turn, almost invariably obtains a conventional radiograph of the region in question. This radiograph, when correlated with even sparse clinical information, leads to a differential diagnosis that is remarkably specific for the patient with the bone tumor but is of little diagnostic import for the patient with the soft-tissue tumor. At this point, at least in the hands of a knowledgeable orthopaedic oncologist, the diagnostic and staging process begins. In the diagnosis of bone tumors, the patient's medical history usually contributes only limited information. The age of the patient is probably the most important piece of clinical information used in the clinicoradiographic interpretation of bone tumors. Most bone tumors develop in an age-range of about two decades. For example, in a patient with a destructive lesion of bone who is more than forty years old, the lesion is likely to indicate metastasis to bone, even if information about a known primary focus is lacking. On the other hand, histiocytosis should be considered as a diagnostic possibility in a patient less than ten years old who has a destructive lesion in a bone. Some tumors have a sex predilection (for example, giant-cell tumors are more frequent in female patients and osteosarcomas occur more often in male patients), but the bias is not sufficiently striking to be helpful in the diagnosis. The race of a patient is of limited relevance, except perhaps in the case of Ewing sarcoma, which is rare in black individuals. The character and intensity of the pain and the presence of altered function are usually of little diagnostic importance. However, unremitting pain or pain that is more severe at rest or at night than during the day is often considered a symptom of malignant disease. A history of activity that could have caused a stress fracture, or of a traumatic event that could have resulted in myositis ossificans, can be of diagnostic value. Information that the patient has been exposed to chemical or physical agents that are known to be carcinogenic may also be useful for the diagnosis. Findings on physical examination are also non-specific and are rarely diagnostic. The presence of a soft-tissue mass should make the physician suspect an aggressive bone lesion with an extraosseous extension. Furthermore, a large bone tumor may be accompanied by a locally elevated temperature and, occasionally, by dilation of superficial veins. The presence of cafe-au-lait spots or hemangiomas can sometimes be helpful in the diagnosis. Neurological dysfunction is not common, but it may result when the tumor is in an anatomical region in which nerves cannot move freely, such as the sciatic notch or the sacrum. Edema of an extremity may occur unilaterally when a bone tumor has undergone extensive spread to soft tissue. Except for tests of the presence of immunoglobulins in patients who have multiple myeloma, or of prostate-specific antigen in those who have metastatic prostate cancer, serological, biochemical, and immunological tests of peripheral blood have limited value in the diagnosis and staging of bone and soft-tissue tumors.