begins with steroids, most commonly dexamethasone at a starting dose of 0.25 to 0.5 mg/kg IV (maximum dose is usually 10 mg as an initial dose followed by doses of mg every hours thereafter) Multispecialty consultation with neurosurgery, radiation oncology, and pediatric oncology is optimal when choosing among surgical decompression, radiation therapy, and chemotherapy Decisions must consider both the short-term efficacy of the treatment to relieve the compression as well as the long-term consequences TUMORS OF BONE Goal of Treatment Many patients with newly diagnosed bone tumors may be able to be discharged with proper subspecialty follow-up If discharged, consider immobilizing the affected extremity in efforts to prevent the development of a pathologic fracture CLINICAL PEARLS AND PITFALLS A history of trauma does not rule out a malignant etiology of bone pain Radiographic signs of bone malignancy include periosteal elevation, ossification of soft tissue masses in a “sunburst” pattern, and lytic lesions with irregular borders Current Evidence Primary bone tumors are uncommon pediatric malignancies, but bone tumors are the third most frequent malignancy of adolescent and young adults In the United States, it is estimated that 2,400 primary bone tumors are diagnosed annually in children Osteosarcoma and Ewing sarcoma are the most common primary malignant bone tumors Osteosarcoma is characterized by its production of immature bone or osteoid It is the most common malignant bone tumor in children and adolescents, presenting most often in the second and third decades of life Although Ewing sarcoma is second to osteosarcoma in overall frequency, it affects children and adolescents of all ages and is more common than osteosarcoma in children younger than 10 years Leukemia, lymphoma, LCH, and metastases from neuroblastoma, sarcomas, and other childhood tumors can all cause bone pain and abnormalities on radiograph ( Fig 98.3 ) Clinical Considerations Clinical Recognition The differential diagnosis of a bony mass includes both benign and malignant entities Subacute osteomyelitis can present with fever, elevated inflammatory