The Good, the Bad, and the Ugly:

How to begin the work-up of a bone tumor.

Part II:  The rest of the work - up prior to biopsy

Latent lesions are just that - they are probably sitting there doing nothing.  If any concern exists, a basic work - up including a CBC with differential and a bone scan is done.  For a latent lesion which is causing the patient no trouble, no further work-up is needed at the time of presentation. In any case the lesion should be observed with radiographs at intervals, say 3 - 6 months, to check for any change or growth.  After one to two years of observation without any change, the lesion may be safely ignored.

Active lesions demand attention.  They need a focused work-up, and likely a biopsy and treatment as well.  In addition to the two new radiographs you just got, I recommend an MRI of the lesion and the surrounding anatomic structures, a whole body technecium bone scan, and basic labs including a CBC with differential and an erythrocyte sedimentation rate. Further work up may be required based on the nature of the lesion, the age and health history of the patient, and other factors, but the basic work-up remains the same. 

Aggressive lesions demand immediate attention, but the biosy must be performed as the last step.   Most aggressive lesions are due to malignant primary or metastatic tumor, although a few may be benign.  They require a complete and prompt work -up which will also serve as a staging work - up for cancer.  In addition to the focused work - up above (Xrays, bone scan, MRI), a CT scan of the chest is required, as well as a complete panel of labs.  I often begin with a CBC with differential, ESR, elecrolytes, LFT's, Ca++ and Alkaline Phosphatase, and LDH.  Other more specialized labs are likely to be required. For probable metastatic lesions where the primary is unknown, a CT scan of the abdomen and pelvis is obtained in addition to the CT of the chest. Remember, the biopsy is the last step.

Most tumor specialists recommend that the biopsy be performed by the person or team who will be performing the definitive surgery.  Consider carefully before you dive into these murky waters.  The complete treatment of an aggressive bone tumor requires an experienced team, including a bone pathologist, musculoskeletal radiologist, medical oncologist, radiation oncologist, orthopedic oncologist, plastic surgeon, clinical psychologist, as well as all the ancillary services they rely on. Patients with these lesions are better off getting their care at a tumor center right from the beginning.

The orthopedic surgeon considering the work - up and care of a patient with a potential bone tumor should rely on his or her judgement in deciding which patients need referral to a tumor specialist.  Some cases clearly need a referral, but others may be borderline. One possible approach is to mail the films and other results to an orthopedic oncologist for review. That way all bases are covered, and both the physician and the patient will feel more confident.  Images sent by e-mail are rarely adequate for these purposes, unless they are of extraordinary quality. 

The bonetumor.org team includes experienced surgeons, radiologists, and pathologists who are willing to provide consultations to requesting physicians. A patient may ask their doctor to obtain such a consultation. Certain restrictions do apply. See sending cases to the bonetumor.org team. 

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