Incidence of occult cancer in children presenting with musculoskeletal symptoms: A 10-year survey in a pediatric rheumatology unit

Objectives: To assess the frequency and types of cancer found in children p resenting to our Unit with musculoskeletal symptoms over a 10-year period. Methods: The medical records of patients with musculoskeletal symptoms and a final diagnosis of cancer were reviewed. In each case age, gender, presen ting symptoms, laboratory data, diagnostic procedures, provisional and fina l diagnoses, and time between clinical onset and correct diagnosis were rev iewed. Results: An underlying neoplasia was found in 10 of 1,254 patients (<1%) co mplaining of musculoskeletal symptoms. The types of malignancies found incl uded acute lymphocytic leukemia (ALL) (6 cases), lymphoma (2 cases), neurob lastoma (1 case), and Ewing's sarcoma (1 case). The mean time between disea se onset and final diagnosis was 3.2 months. The most common presenting fea ture was monoarthritis, involving the larger joints such as the elbows, kne es or ankles. Juvenile idiopathic arthritis (JIA) was the most frequent pro visional diagnosis. In the preliminary hematologic evaluation, eight patien ts had an increased erythrocyte sedimentation rate (ESR) or C-reactive prot ein (CRP) value. White blood cell (WBC) count was normal in almost all chil dren, with a normal differential count, lactic dehydrogenase (LDH) was rais ed in all children. Bone marrow aspirates and lymph node or bone biopsies w ere necessary to reach the final diagnosis. Conclusions:A malignancy should always be excluded in children with musculo skeletal symptoms, especially when the clinical pattern is not characterist ic of a specific rheumatic disease. Routine laboratory tests may be mislead ing. The simultaneous presence of high LDH or cu-hydroxybutyric dehydrogena se (alpha-HBDH) levels and raised ESR or CRP, even with normal blood cell c ounts, should lead to additional investigations. Relevance: All patients presenting with arthritis or other musculoskeletal symptoms should have a thorough clinical examination. Disproportionate pain levels and an atypical pattern of "arthritis," especially in the presence of systemic manifestations, suggest a possible underlying malignancy. Copyr ight (C) 2000 by W.B. Saunders Company.