Myths and Misconceptions
Evidence-based clarification of common myths in orthopaedic oncology, highlighting diagnostic pitfalls, biopsy planning, and surgical decision-making principles.
1. “If it looks benign on X-ray, it must be benign.”
False. Low-grade malignancies (e.g. well-differentiated chondrosarcoma) can appear deceptively benign.
Reality: Imaging must always be correlated with clinical and histologic findings.
2. “Slow-growing masses are harmless.”
False. Many low-grade sarcomas (e.g. parosteal osteosarcoma, liposarcoma) enlarge gradually.
Reality: Painless, slowly enlarging lesions are classically malignant until proven otherwise.
3. “MRI is sufficient for diagnosis—biopsy is unnecessary.”
False. MRI defines local anatomy, not histology.
Reality: Tissue diagnosis via a planned biopsy is mandatory, performed by the surgeon who will do the definitive resection.
4. “Excisional biopsy is safest.”
False. Unplanned excisions lead to contamination of compartments and higher recurrence.
Reality: Core needle biopsy under image guidance is the gold standard.
5. “Wider excision always means better outcome.”
False. Unnecessarily wide resections compromise function.
Reality: Goal is an R0 resection (negative margins); the required width depends on tumour grade and site.
6. “Benign tumours never metastasise.”
False. Giant Cell Tumour of bone can metastasise to the lungs despite benign histology.
Reality: Some benign lesions show “benign metastasis.”
7. “Chemo and radiotherapy are only for advanced disease.”
False. In osteosarcoma and Ewing sarcoma, neoadjuvant chemotherapy is standard of care.
Reality: Treatment protocols are histology-specific, not stage-specific.
8. “Pathological fractures require amputation.”
False. Modern limb-sparing techniques permit safe oncologic reconstruction.
Reality: Amputation is reserved for cases with unresectable or contaminated disease.
9. “Childhood bone tumours are almost always benign.”
False. Osteosarcoma and Ewing sarcoma peak in adolescence.
Reality: Age does not rule out malignancy—clinical and radiologic context are key.
10. “Drains can be placed freely after tumour excision.”
False. Dren placement along unintended planes spreads tumour cells.
Reality: If required, drain must lie in line with the incision.
11. “Amputation equals failure.”
False. In select cases (infection, recurrence, neurovascular invasion), amputation is the best oncologic and functional option.
12. “Biopsy can wait after fracture fixation.”
False. Fixation before diagnosis risks spreading tumour cells.
Reality: Always biopsy before any internal fixation—temporary external fixation if stabilization is needed.
13. “Benign biopsy result rules out malignancy.”
False. Sampling error or tumour heterogeneity may cause false negatives.
Reality: Always re-correlate biopsy with clinical and imaging findings.
14. “Tumour cannot develop around metal implants.”
False. Rare but real—post-implant sarcomas can occur after chronic irritation or radiation.
15. “Contrast MRI is unnecessary in tumour imaging.”
False. Contrast enhances delineation of viable tumour and necrosis.
Reality: Contrast MRI is standard for preoperative planning.
Clinical Pearl
Every orthopaedic tumour should be evaluated with a multidisciplinary perspective—radiology, pathology, and surgical oncology must always align before definitive treatment.
References (Short List)
Fletcher CDM, Bridge JA, Hogendoorn PCW, Mertens F. WHO Classification of Soft Tissue and Bone Tumours. 5th ed. IARC, 2020.
Enneking WF, Dunham WK. Resection and reconstruction for musculoskeletal sarcoma. J Bone Joint Surg Am. 1978;60:1–14.
Grimer RJ, Judson I, Peake D, Seddon B. Guidelines for the management of soft tissue sarcomas. Sarcoma. 2010;2010:506182.
Simon MA, Springfield DS. Surgery for Bone and Soft Tissue Tumors. Lippincott Williams & Wilkins, 1998.
Casali PG, Abecassis N, Bauer S, et al. ESMO–EURACAN–GENTURIS Guidelines for soft tissue and bone sarcomas. Ann Oncol. 2022;33(12):1348–1365.
