The Journal of Bone and Joint Surgery 82:667 (2000)
© 2000 The Journal of Bone and Joint Surgery, Inc.
Initial Symptoms and Clinical Features in Osteosarcoma and Ewing Sarcoma*
Björn Widhe, M.B. and
Torulf Widhe, M.D.
Investigation performed at Huddinge University Hospital,
Huddinge, Sweden
*No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the subject
of this article. Funds were received in total or partial support
of the research or clinical study presented in this article. The
funding source was The King Oscar II and Queen Sofia Golden Wedding
Anniversary Foundation, Stockholm, Sweden.
Department of Orthopedics, Huddinge University Hospital, S-141
86 Huddinge, Sweden. E-mail address: h95bwi{at}student.ki.se (Björn
Widhe). E-mail address: torulf.widhe@karo.ki.se (Torulf Widhe).
Background: The time between the initial
symptoms of osteosarcoma and Ewing sarcoma and the correct diagnosis
and treatment is long. Over the last two decades, the prognosis
for patients with these diseases has dramatically improved due to
a new chemotherapy regimen. As a consequence, a limb-sparing operation
has become an alternative to amputation. The aim of this study was
to establish the initial symptoms and physical signs of osteosarcoma
and Ewing sarcoma from the records of the first medical visit and
to identify early characteristics of the diseases to shorten the
delay to diagnosis.
Methods: A group of patients with osteosarcoma
or Ewing sarcoma was identified from the Swedish Cancer Register
of patients thirty years old and younger. Records from the first
medical visit due to symptoms related to the bone tumor were obtained
for 102 patients with osteosarcoma and forty-seven patients with
Ewing sarcoma.
Results: Pain related to strain was reported
by eighty-seven (85 percent) of the patients with osteosarcoma and thirty
(64 percent) of those with Ewing sarcoma, but only twenty-one (21
percent) of the patients with osteosarcoma and nine (19 percent)
of those with Ewing sarcoma reported pain at night. Forty-eight
(47 percent) of the patients with osteosarcoma and twelve (26 percent)
of those with Ewing sarcoma related the onset of symptoms to minor trauma
occurring around the same time. A palpable mass was noted in forty
(39 percent) of the patients with osteosarcoma and sixteen (34 percent) of
those with Ewing sarcoma at the first visit, and in most cases the
tumor diagnosis was suspected. There was a broad spectrum of misdiagnoses;
the most common was tendinitis, which was the initial diagnosis
in thirty-two (31 percent) of the patients with osteosarcoma and
ten (21 percent) of those with Ewing sarcoma. The doctor's delay
(the period from the first medical visit due to the symptoms to
the correct diagnosis) was longer for Ewing sarcoma than for osteosarcoma
(nineteen weeks and nine weeks, respectively; p < 0.0001).
Conclusions: An initial symptom of both osteosarcoma
and Ewing sarcoma was pain, which was intermittent and often related
to strain but not frequently felt at night. A history of trauma
was common, but the clinical course often diverged from what was
expected from trauma. The clinical course of osteosarcoma and particularly
of Ewing sarcoma was not steadily progressive but intermittent, which
often misled the doctor into believing that the condition was temporary.
The most important clinical feature was a palpable mass, which was noted
in more than one-third of the patients at the first visit. This
finding emphasizes that a thorough physical examination is absolutely
necessary.
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