# History and examination History and examination It is important to take a thorough history , including a pain history . Non-mechanical and/or night pain, particularly in the young adolescent, is a concerning symptom and a primary bone tumour should be suspected. Relief with non-steroidal anti-inflammatory drugs may suggest an osteoid osteoma. Patients with a history of malignancy who present with back pain should be considered to have metastatic bone dis ease until proven otherwise. Plain radiographs of the spine and routine blood tests are the minimum that is required. An MRI of the spine is a more sensitive test for the detection of a malig nant tumour and may demonstrate soft-tissue extension into the spinal canal. Multiple my eloma ( Figure 42.3 ) is the most common primary malignancy of bone in adults and should be considered in all patients over 65 years of age with back pain. Back pain associated with an ESR >100 /uni00A0 mm/h indicates m ultiple myeloma until proven otherwise. Monoclonal gam mopathy or elevated urinary and serum Bence Jones proteins are diagnostic. All patients with suspected cancer in the spine should be examined for signs of spinal cord compression, a potential surgical emergency . Great care should be taken when managing a patient with an apparently ‘solitary’ bone metastasis. This could be a pri mary bone tumour, and further investigation including biopsy is required. Soft-tissue tumours are common and the vast majority are benign. Ho wever, a soft-tissue mass meeting any of the fol lowing criteria may be malignant and the pa tient should be referred to a specialist centre: /uni25CF painful; /uni25CF increasing in size; /uni25CF more than 5 /uni00A0 cm in diameter. In addition, tumours that have recurred after previous excision and tumours located deep to the fascia are more likely to be malignant. It is important to note that tumours that appear mostly superficial but involve the deep fascia are classified as deep tumour s. Henry Bence Jones , 1813–1873, physician, St George’s Hospital, London, UK. The investigation of a patient with a suspected primary bone - or soft-tissue tumour should include the following. /uni25CF Local investigations: /uni25CF ultrasound scan (for soft-tissue tumours); /uni25CF plain radiographs of the whole a ff ected bone or soft- tissue lesion ( Figure 42.1 ); /uni25CF MRI of the whole a ff ected bone or soft-tissue mass; /uni25CF computed tomography (CT) scan may be helpful in ad - dition to an MRI scan. /uni25CF Distant: /uni25CF blood tests, including full blood count, ESR, urea and electrolytes, bone profile and protein electrophoresis; /uni25CF plain radiographs or CT scan of the chest (more sen - sitive); /uni25CF whole-body isotope bone scan (for suspected primary or metastatic bone tumours); /uni25CF ultrasound or CT scan of the abdomen (if renal metas - tasis is a possibility). Plain radiographs are usually the most useful imaging investigations in determining the diagnosis of a primary bone tumour, but further appropriate scans are usually required for confirmation and staging . Imaging should always include the whole of the a ff ected bone to look for satellite lesions and skip metastases. Satellite lesions occur within, whereas skip lesions - occur beyond, the reactive zone of the tumour, which is the layer of compressed tissues, inflammatory cells and tumour infiltration that surrounds the tumour. - Both primary bone and soft-tissue sarcomas metastasise to the lungs, and a CT scan of the chest is an essential part of staging. Patients who present with a lytic bone lesion could have a primary renal carcinoma and an ultrasound or CT scan of the abdomen is advised. Surgery to a renal metastasis can lead to - significant b lood loss. Summary box 42.9 Staging - /uni25CF /uni25CF /uni25CF /uni25CF - Plain radiography is most informative for bone tumours Always image the whole bone in the case of skip lesions CT of the lung detects lung metastases Lytic lesions require imaging of the abdomen to check for a primary renal carcinoma History and examination It is important to take a thorough history , including a pain history . Non-mechanical and/or night pain, particularly in the young adolescent, is a concerning symptom and a primary bone tumour should be suspected. Relief with non-steroidal anti-inflammatory drugs may suggest an osteoid osteoma. Patients with a history of malignancy who present with back pain should be considered to have metastatic bone dis ease until proven otherwise. Plain radiographs of the spine and routine blood tests are the minimum that is required. An MRI of the spine is a more sensitive test for the detection of a malig nant tumour and may demonstrate soft-tissue extension into the spinal canal. Multiple my eloma ( Figure 42.3 ) is the most common primary malignancy of bone in adults and should be considered in all patients over 65 years of age with back pain. Back pain associated with an ESR >100 /uni00A0 mm/h indicates m ultiple myeloma until proven otherwise. Monoclonal gam mopathy or elevated urinary and serum Bence Jones proteins are diagnostic. All patients with suspected cancer in the spine should be examined for signs of spinal cord compression, a potential surgical emergency . Great care should be taken when managing a patient with an apparently ‘solitary’ bone metastasis. This could be a pri mary bone tumour, and further investigation including biopsy is required. Soft-tissue tumours are common and the vast majority are benign. Ho wever, a soft-tissue mass meeting any of the fol lowing criteria may be malignant and the pa tient should be referred to a specialist centre: /uni25CF painful; /uni25CF increasing in size; /uni25CF more than 5 /uni00A0 cm in diameter. In addition, tumours that have recurred after previous excision and tumours located deep to the fascia are more likely to be malignant. It is important to note that tumours that appear mostly superficial but involve the deep fascia are classified as deep tumour s. Henry Bence Jones , 1813–1873, physician, St George’s Hospital, London, UK. The investigation of a patient with a suspected primary bone - or soft-tissue tumour should include the following. /uni25CF Local investigations: /uni25CF ultrasound scan (for soft-tissue tumours); /uni25CF plain radiographs of the whole a ff ected bone or soft- tissue lesion ( Figure 42.1 ); /uni25CF MRI of the whole a ff ected bone or soft-tissue mass; /uni25CF computed tomography (CT) scan may be helpful in ad - dition to an MRI scan. /uni25CF Distant: /uni25CF blood tests, including full blood count, ESR, urea and electrolytes, bone profile and protein electrophoresis; /uni25CF plain radiographs or CT scan of the chest (more sen - sitive); /uni25CF whole-body isotope bone scan (for suspected primary or metastatic bone tumours); /uni25CF ultrasound or CT scan of the abdomen (if renal metas - tasis is a possibility). Plain radiographs are usually the most useful imaging investigations in determining the diagnosis of a primary bone tumour, but further appropriate scans are usually required for confirmation and staging . Imaging should always include the whole of the a ff ected bone to look for satellite lesions and skip metastases. Satellite lesions occur within, whereas skip lesions - occur beyond, the reactive zone of the tumour, which is the layer of compressed tissues, inflammatory cells and tumour infiltration that surrounds the tumour. - Both primary bone and soft-tissue sarcomas metastasise to the lungs, and a CT scan of the chest is an essential part of staging. Patients who present with a lytic bone lesion could have a primary renal carcinoma and an ultrasound or CT scan of the abdomen is advised. Surgery to a renal metastasis can lead to - significant b lood loss. Summary box 42.9 Staging - /uni25CF /uni25CF /uni25CF /uni25CF - Plain radiography is most informative for bone tumours Always image the whole bone in the case of skip lesions CT of the lung detects lung metastases Lytic lesions require imaging of the abdomen to check for a primary renal carcinoma History and examination It is important to take a thorough history , including a pain history . Non-mechanical and/or night pain, particularly in the young adolescent, is a concerning symptom and a primary bone tumour should be suspected. Relief with non-steroidal anti-inflammatory drugs may suggest an osteoid osteoma. Patients with a history of malignancy who present with back pain should be considered to have metastatic bone dis ease until proven otherwise. Plain radiographs of the spine and routine blood tests are the minimum that is required. An MRI of the spine is a more sensitive test for the detection of a malig nant tumour and may demonstrate soft-tissue extension into the spinal canal. Multiple my eloma ( Figure 42.3 ) is the most common primary malignancy of bone in adults and should be considered in all patients over 65 years of age with back pain. Back pain associated with an ESR >100 /uni00A0 mm/h indicates m ultiple myeloma until proven otherwise. Monoclonal gam mopathy or elevated urinary and serum Bence Jones proteins are diagnostic. All patients with suspected cancer in the spine should be examined for signs of spinal cord compression, a potential surgical emergency . Great care should be taken when managing a patient with an apparently ‘solitary’ bone metastasis. This could be a pri mary bone tumour, and further investigation including biopsy is required. Soft-tissue tumours are common and the vast majority are benign. Ho wever, a soft-tissue mass meeting any of the fol lowing criteria may be malignant and the pa tient should be referred to a specialist centre: /uni25CF painful; /uni25CF increasing in size; /uni25CF more than 5 /uni00A0 cm in diameter. In addition, tumours that have recurred after previous excision and tumours located deep to the fascia are more likely to be malignant. It is important to note that tumours that appear mostly superficial but involve the deep fascia are classified as deep tumour s. Henry Bence Jones , 1813–1873, physician, St George’s Hospital, London, UK. The investigation of a patient with a suspected primary bone - or soft-tissue tumour should include the following. /uni25CF Local investigations: /uni25CF ultrasound scan (for soft-tissue tumours); /uni25CF plain radiographs of the whole a ff ected bone or soft- tissue lesion ( Figure 42.1 ); /uni25CF MRI of the whole a ff ected bone or soft-tissue mass; /uni25CF computed tomography (CT) scan may be helpful in ad - dition to an MRI scan. /uni25CF Distant: /uni25CF blood tests, including full blood count, ESR, urea and electrolytes, bone profile and protein electrophoresis; /uni25CF plain radiographs or CT scan of the chest (more sen - sitive); /uni25CF whole-body isotope bone scan (for suspected primary or metastatic bone tumours); /uni25CF ultrasound or CT scan of the abdomen (if renal metas - tasis is a possibility). Plain radiographs are usually the most useful imaging investigations in determining the diagnosis of a primary bone tumour, but further appropriate scans are usually required for confirmation and staging . Imaging should always include the whole of the a ff ected bone to look for satellite lesions and skip metastases. Satellite lesions occur within, whereas skip lesions - occur beyond, the reactive zone of the tumour, which is the layer of compressed tissues, inflammatory cells and tumour infiltration that surrounds the tumour. - Both primary bone and soft-tissue sarcomas metastasise to the lungs, and a CT scan of the chest is an essential part of staging. Patients who present with a lytic bone lesion could have a primary renal carcinoma and an ultrasound or CT scan of the abdomen is advised. Surgery to a renal metastasis can lead to - significant b lood loss. Summary box 42.9 Staging - /uni25CF /uni25CF /uni25CF /uni25CF - Plain radiography is most informative for bone tumours Always image the whole bone in the case of skip lesions CT of the lung detects lung metastases Lytic lesions require imaging of the abdomen to check for a primary renal carcinoma