GPAtlas🧭 When to suspect
Sarcomas are rare cancers of mesenchymal tissue, divided into soft-tissue (muscle, fat, fibrous tissue, vessels, nerves) and bone sarcomas. They are easily missed: almost every lump and almost all bone pain seen in primary care is benign, yet the cost of overlooking a sarcoma is high, and diagnostic delay is the norm – roughly 1 in 3 patients waits over six months from first consultation to diagnosis, by which time many tumours are already large. The whole skill is a low threshold to image and to refer on uncertainty.
The decision in primary care is essentially binary: arrange the right first-line scan – ultrasound for a soft-tissue lump, X-ray for bone – and refer on a suggestive or uncertain result, faster in children and young people than in adults.
Note the age pattern. Bone sarcomas (osteosarcoma, Ewing sarcoma) cluster in children, adolescents and young adults, classically around the knee and the long bones, whereas soft-tissue sarcomas become commoner with increasing age. Risk is raised by previous radiotherapy, genetic syndromes (Li-Fraumeni, neurofibromatosis type 1, hereditary retinoblastoma), Paget's disease of bone, and chronic lymphoedema (angiosarcoma).
| Presentation | Children & young people (under 25) | Adults (25 and over) |
|---|---|---|
| Unexplained soft-tissue lump increasing in size | Very urgent direct-access ultrasound – within 48 hours | Urgent direct-access ultrasound – within 2 weeks |
| Unexplained bone swelling or pain | Very urgent direct-access X-ray – within 48 hours | Urgent direct-access X-ray – within 2 weeks |
| Scan suggestive of sarcoma, or uncertain with persisting concern | Very urgent referral – appointment within 48 hours | Suspected cancer pathway referral (2-week wait) |
NICE NG12 triggers urgent imaging simply for an unexplained lump that is increasing in size – it sets no size cut-off. In practice, the widely-used features that should raise concern for a soft-tissue sarcoma are a lump that is > 5 cm (about the size of a golf ball), deep to the fascia, rapidly enlarging, painful, or one that has recurred after a previous excision. The more features present, the higher the risk – but a single one is enough to act on. Young people aged 16–24 may be managed by either the children's or the adult pathway depending on local arrangements.
Source: NICE NG12
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