Pediatric shoulder girdle tumors: Long-term oncologic and early functional outcomes

Abstract

Background:

The shoulder girdle is a common location for both benign and malignant bone tumors in children, with the proximal humerus being the most frequently affected site. However, comprehensive outcome data for surgically treated pediatric shoulder girdle tumors are limited. This study aimed to evaluate the pathological diagnoses, anatomical locations, surgical treatments, and midterm functional outcomes of shoulder girdle tumors managed surgically in childhood and adolescence.

Methods:

A retrospective analysis was conducted on 69 pediatric patients (mean age: 11.9 years) who underwent surgical treatment for shoulder girdle tumors between 2012 and 2019, a window selected to ensure a minimum oncologic follow-up of ≥5 years at the time of analysis. Data on demographics, tumor type and location, surgical method, complications, recurrence, and functional outcomes using the Musculoskeletal Tumor Society score and Toronto Extremity Salvage Score were analyzed.

Results:

The most common benign tumor was a simple bone cyst (43.5%), followed by osteochondroma (20.3%) and aneurysmal bone cyst (8.7%). Osteosarcoma (5.8%) was the most frequent malignant tumor. The proximal humerus was affected in 92% of cases. Limb-sparing surgery was preferred in malignant tumors when feasible. The mean Musculoskeletal Tumor Society score and Toronto Extremity Salvage Score in patients with malignant tumors were 64 ± 19 and 66 ± 21, respectively. Recurrence was observed in 1 patient with a simple bone cyst and 1 with Ewing sarcoma. Functional outcomes were satisfactory, particularly in patients with benign tumors.

Conclusion:

Most pediatric shoulder girdle tumors are benign and can be effectively managed with appropriate surgical interventions. Favorable functional outcomes are achievable even in malignant cases when limb-sparing strategies are employed. Long-term follow-up is essential to monitor for recurrence and complications.

1. Introduction

The shoulder girdle consists of the scapula, clavicle, the proximal third of the humerus, and the surrounding soft tissues. Shoulder pain is a common condition encountered in orthopedic clinics. Particularly in children, shoulder pain is less likely to result from rotator cuff or long head of biceps pathologies, which are more common in adults. Instead, bone tumors and tumor like lesions should be considered as potential causes when evaluating shoulder pain in childhood and adolescence.^[1] The upper extremity is a region where primary bone and soft tissue tumors are commonly observed.^[2] and tumors around the shoulder are most commonly located in the proximal humerus, followed by the scapula and clavicle.^[3]

Primary bone tumors are more commonly seen in childhood and adolescence compared to adulthood.^[4] Malignant tumors constitute approximately 5% of childhood tumors.^[5] Among these malignancies, osteosarcoma is the most commonly observed.^[6] The most common bone tumor located in the proximal humerus during childhood is simple bone cyst (SBC).^[7] Chondroblastomas are rare benign tumors originating from cartilage, accounting for approximately 2% of all primary bone tumors. Furthermore, around 20% of them are observed in the proximal humerus.^[8]

Treatment options for tumors around the shoulder may include excisional biopsy, curettage with grafting, internal fixation following curettage with grafting, or finally wide resection with application of tumor prosthesis. When deciding on a treatment plan, a therapeutic algorithm should be established in accordance with the fundamental principles of bone tumor management, in accordance with the location of the lesion, pathological diagnosis, and expected lifespan. In some cases, adjuvant methods like high-speed burring and the use of phenol alongside curettage can be an integral part of accurate and effective treatment.^[9,10]

The aim of this study is to evaluate the pathological diagnoses, locations, treatment methods, and midterm outcomes of malignant and benign bone tumors around the shoulder that were surgically treated during childhood and adolescence using a tertiary oncology reference hospitals database.

2. Materials and methods

This single-center, retrospective observational cohort study was conducted with pediatric patients who underwent surgical treatment for shoulder girdle bone tumors at an orthopedics and traumatology clinic of an oncology hospital between 2012 and 2019. This period was a priori chosen to guarantee ≥60 months of oncologic follow-up for all included patients at analysis. A retrospective review of 313 patients was performed using the hospital database and patient follow-up records. The study protocol was approved by the local Ethics Committee (Date: 05/09/2024, No. 2024-09/119). The study was conducted in accordance with the principles of the Declaration of Helsinki and written informed consent was obtained from all subjects. Our institution is a tertiary referral center for musculoskeletal tumors, which primarily handles oncological cases. The study included patients under the age of 18 who were operated on, due to malignant or benign shoulder girdle bone tumors. The inclusion and exclusion criteria for the study are shown in Figure 1.

Figure 1.

Cohort selection for pediatric shoulder girdle bone tumors (2012–2019).

2.1. Diagnostic workup and histopathology

Preoperative evaluation integrated clinical assessment and imaging (radiographs ± magnetic resonance imaging/computed tomography as indicated). All surgically excised specimens were processed using standard musculoskeletal pathology protocols and reviewed by fellowship trained pathologists. Primary diagnoses were established on hematoxylin–eosin (H&E) sections; immunohistochemistry (e.g., SATB2 for osteogenic differentiation; CD99/FLI1/NKX2.2 for Ewing sarcoma; S100 for chondroid lesions) and molecular assays were applied when clinically indicated and available in the medical record. Final diagnoses were rendered in a multidisciplinary tumor board context, integrating clinicoradiologic and pathologic data.

Patients were assessed based on their age, gender, diagnosis, follow-up duration, lesion location, surgical technique, and the occurrence of recurrence. Complications, such as infection, wound site issues, physeal injury, nonunion, malunion, fracture, and implant failure, were also noted. Additionally, postoperative outcomes were evaluated at the 1-year visit using the Musculoskeletal Tumor Society (MSTS) score and the Toronto Extremity Salvage Score (TESS). MSTS was completed by the treating surgeon; TESS was self-administered when age and literacy permitted, or completed with parent/guardian assistance under clinic staff supervision.

The MSTS-1993 is a clinician-reported instrument assessing 6 domains – pain, function, emotional acceptance, hand positioning, dexterity, and lifting ability – each rated 0 to 5 and summed to a total of 0 to 30.^[11] The emotional acceptance domain offers a limited proxy of psychosocial adaptation to the operated limb; it does not constitute a comprehensive mental health assessment.

The TESS is developed to assess individuals’ physical and functional status in daily life at a specific point in time after surgery.^[12] It is 1 of the most widely accepted scoring systems in orthopedic oncology patients.^[13] The TESS questionnaire covers various activities, including physical movement, mobility, personal care, and completing everyday tasks. If a question is not applicable to the participant, they can select the option “This task is not applicable for me.” The total score can range from 0 to 155.

Preoperative coexisting conditions (including ASA physical status) were abstracted from anesthesia and clinic records. Treatment-related adverse events were identified from operative notes and follow-up encounters and classified as surgical (e.g., wound complications, fracture, implant issues) or systemic (therapy related). Events were recorded across the entire follow-up period.

Statistical analyses were performed using the Statistical Package for the Social Science (IBM SPSS Statistics ver. 27.0, SPSS Inc., Chicago) software package. Frequency tables and descriptive statistics were used to interpret the findings. Outcomes are summarized as counts and percentages by histology (Table 1). Associations among variables were explored using Spearman’s rank correlations (ρ) with 2-tailed P values (α = 0.05).

Table 1.

Functional outcomes by histology (MSTS and TESS; 1-yr postoperative).

Histology	n	MSTS, M ± SD (min–max)	TESS, M ± SD (min–max)
Simple bone cyst	30	29.20 ± 0.41 (29–30)	143.30 ± 0.65 (143–145)
Osteochondroma	14	29.36 ± 0.50 (29–30)	143.79 ± 0.97 (143–145)
Enchondroma	2	29.00 ± 0.00 (29–29)	143.00 ± 0.00 (143–143)
Chondroblastoma	3	28.67 ± 0.58 (28–29)	143.67 ± 0.58 (143–144)
Aneurysmal bone cyst	6	29.00 ± 0.00 (29–29)	143.00 ± 0.00 (143–143)
Osteosarcoma	4	14.50 ± 9.81 (8–29)	113.50 ± 21.08 (96–143)
Giant cell tumor	2	26.00 ± 0.00 (26–26)	143.00 ± 0.00 (143–143)
Ewing sarcoma	3	17.67 ± 9.81 (12–29)	119.67 ± 20.21 (108–143)
Cavernous hemangioma	1	29.00 (single case)	143.00 (single case)
Myositis ossificans	1	29.00 (single case)	143.00 (single case)
Rhabdomyosarcoma	2	13.5 ± 2.12 (12–15)	110.5 ± 3.53 (108–113)
Synovial chondromatosis	1	30.00 (single case)	143.00 (single case)

Values are means ± standard deviations with ranges in parentheses, unless N = 1 (single case). MSTS (0–30). TESS values are shown on the scale used in the dataset (0–155) % values could be calculated by multiplying by 100 and dividing by 30 for MSTS; by dividing by 1.5 for TESS.

MSTS = Musculoskeletal Tumour Society, TESS = Toronto Extremity Salvage Score.

3. Results

Mean age of the patients included in the study were 11.9 years (2–18) and 44 (63.8%) of the patients were male. In 39 patients (56.5%) the right shoulder was affected while the mean follow-up period was 99.2 months (69–127).

Preoperative coexisting conditions. Baseline comorbidity burden was low. ASA class at index surgery was ASA I in the majority, ASA II in 2 patients, and ASA III in 1 patient; 1 patient had a prior malignancy documented preoperatively.

This study, the most common benign tumor was a SBC (43.5%), while the most common malignant tumor was osteosarcoma (5.8%). The most frequent location was the proximal humerus (93.8%). The locations and frequencies of the pathological diagnoses are presented in Table 2.

Table 2.

Pathological diagnoses of patients, frequency and distribution of tumor locations.

	Frequency	%	Proximal humerus	Scapula	Clavicle
Simple bone cyst	30	43.5	30
Osteochondroma	14	20.3	11	3
Enchondroma	2	2.9	1	1
Chondroblastoma	3	4.3	3
Anuerysmal bone cyst	6	8.7	4		2
Osteosarcoma	4	5.8	4
Giant cell tumor	2	2.9	2
Ewing’s sarcoma	3	4.3	2	1
Cavernous hemangioma	1	1.4	1
Myositis ossificans	1	1.4	1
Rhabdomyosarcoma	2	2.9	1	1
Synovial chondromatosis	1	1.4	1
Total	69	100.0	61	6	2

The MSTS and TESS scores evaluated in the postoperative period are presented in Table 3.

Table 3.

Scores evaluated in the postoperative period.

N = 69	Minimum	Maximum	Mean	Standard deviation
MSTS	8.00	30.00	27.29	5.45
TESS	96	145	139.65	7.52

MSTS (0–30). TESS values are shown on the scale used in the dataset (0–155) % values could be calculated by multiplying by 100 and dividing by 30 for MSTS; by dividing by 1.5 for TESS.

MSTS = Musculoskeletal Tumour Society, TESS = Toronto Extremity Salvage Score.

The diagnoses of the patients and the treatments performed based on their diagnoses are presented in Table 4.

Table 4.

Treatment methods according to diagnoses.

	C + G	C + G + IF	Excision	Extensive resection	Extensive resection + arthroplasty	Amputation
Simple bone cyst	22	8	–	–	–
Osteochondroma			14
Enchondrome	2
Chondroblastoma	2				1
Anuerysmal bone cyst	4	2
Osteosarcoma					3	1
Giant cell tumor	1	1
Ewing’s sarcoma				1	2
Cavernous hemangioma	1
Myositis ossificans			1
Rhabdomyosarcoma				2
Synovial chondromatosis			1
Total (n)	69

C + G = curettage and grafting.

C + G + IF = curettage, grafting, and internal fixation.

In our study, 30 patients (43.5%) underwent surgery due to SBCs. As a treatment option, curettage + grafting was performed, and in some patients, curettage + grafting + titanium elastic nailing was applied (Table 4).

Ewing’s sarcoma was observed in the proximal humerus of 2 patients and in the scapula of 1 patient.

In a patient who underwent extensive resection of the scapula due to Ewing’s sarcoma, the scapula was reconstructed with cement following extensive resection, followed by partial shoulder arthroplasty for the proximal humerus (Fig. 2).

Figure 2.

Ewing sarcoma of the scapula in a 17-yr-old patient: preoperative imaging and postoperative reconstruction. (A) Preoperative shoulder radiographs (anteroposterior views) demonstrating a scapular lesion. (B) Preoperative T2-weighted MR images of the scapula (sagittal and axial planes) showing a heterogeneous mass with soft tissue extension. (C) Postoperative anteroposterior radiograph following limb-sparing resection and reconstruction (partial shoulder arthroplasty) and immunohistochemical image of the tumor. AP = anteroposterior, MRI = magnetic resonance imaging, T2-WI = T2-weighted imaging.

All patients diagnosed with osteosarcoma underwent wide resection and tumor arthroplasty. However, recurrence was observed in 1 patient during the third year of follow-up, and shoulder disarticulation was performed (Fig. 3).

Figure 3.

Osteosarcoma of the proximal humerus in a 17-yr-old patient: preoperative imaging and postoperative reconstruction. (A) Preoperative shoulder radiographs (anteroposterior and lateral views) showing an aggressive lesion of the proximal humerus with mixed lytic–sclerotic appearance and cortical disruption. (B) Preoperative MR images (axial and coronal, fluid-sensitive sequences) demonstrating a heterogeneous marrow replacing mass with extraosseous soft tissue extension. (C) Immediate postoperative anteroposterior radiographs following limb-sparing wide resection and reconstruction with a proximal humeral tumor endoprosthesis (hemiarthroplasty), with soft tissue repair. (D) Immunohistochemical image of the tumor. AP = anteroposterior, MRI = magnetic resonance imaging.

Documented postoperative complications consisted of postoperative fractures in 2 patients. In our cohort, no recurrences and 1 metastasis were observed, and all patients were alive at last evaluation.

The preoperative, perioperative, and postoperative images of a patient who underwent excision and internal fixation for osteochondroma in the proximal humerus are shown in Figure 4.

Figure 4.

Osteochondroma of the proximal humerus in an 11-yr-old patient: imaging, intraoperative views, and postoperative fixation. (A) Preoperative shoulder radiographs (anteroposterior and lateral views) showing a pedunculated, exophytic lesion of the proximal humerus. (B) Preoperative MR images (coronal and axial, T2 sequences). (C) Immediate postoperative radiographs demonstrating prophylactic plate fixation following extraperiosteal excision. (D) Pre-incision clinical photograph illustrating the palpable prominence. (E) Intraoperative exposure of the osteochondroma prior to resection. (F) Intraoperative view of the resection bed after excision with soft tissue repair. (G) Gross specimen following excision, showing the pedunculated osteochondroma with cartilage cap (scalpel for scale). (H) Immunohistochemical image of the tumor. AP = anteroposterior, MRI = magnetic resonance imaging.

The Spearman correlation matrix (Table 5) shows that MSTS and TESS were strongly and positively associated (ρ = 0.82, P < .01). Malignancy status correlated negatively with both MSTS (ρ = −0.57, P < .01) and TESS (ρ = −0.60, P < .01). Smaller associations were observed for age with MSTS (ρ = 0.24, P = .043).

Table 5.

Spearman rank correlations among key variables (n = 69).

#	Variable	1	2	3	4	5	6	7	8
1	Pathologic†	1.00	−0.51**	0.01	0.00	0.37**	0.54**	−0.44**	−0.36**
2	Sex‡		1.00	−0.08	−0.20	0.03	−0.25*	0.30*	0.22
3	Age (yr)			1.00	0.01	−0.01	−0.02	0.24*	0.23
4	Follow-up duration (mo)				1.00	0.02	−0.06	−0.13	−0.11
5	Anatomic location†					1.00	0.35**	−0.29*	−0.33**
6	Malignancy (0 = benign, 1 = malignant)						1.00	−0.57**	−0.60**
7	MSTS (0–30)							1.00	0.82**
8	TESS (0–100, upper-extremity)								1.00

Entries are Spearman’s ρ (2-tailed).

^†Ordinal/categorical variables coded numerically in the dataset.

^‡Sex coded per dataset. Malignancy coded 0 = benign, 1 = malignant.

^*P < .05.

^**P < .01.

Since our study was designed retrospectively, the ability to systematically evaluate or document deviations from the initial treatment plan was limited. However, a review of patient records revealed that in some cases, modifications were made to the planned treatment during the clinical course. For example, in some patients initially scheduled for curettage and grafting due to a diagnosis of SBC, internal fixation was added intraoperatively due to fracture risk or lesion size. Similarly, in 1 case of osteosarcoma, shoulder disarticulation was performed following local recurrence in the third year after an initially planned limb-sparing surgery. These instances indicate that the treatment plan was dynamically updated based on the biological behavior of the tumor.

In our study, during postoperative follow-ups, recurrence was observed in 1 patient with a SBC and in 1 patient with Ewing’s sarcoma who underwent wide resection. Additionally, in a patient who underwent wide resection and tumor arthroplasty for osteosarcoma, early postoperative infection was noted, followed by radiological signs of prosthetic loosening during the third-year follow-up.

4. Discussion

This study demonstrated the distribution, treatment methods, and midterm outcomes of shoulder girdle tumors operated on during childhood at a tertiary oncology hospital. The most significant finding of the study was that most lesions observed around the shoulder in childhood were benign, and the functional evaluations of the operated patients in the postoperative period yielded satisfactory results.

The proximal humerus is a common site for bone tumors and metastases.^[14] However, this situation is more valid for adults and elderly patients. In our study, the most common lesion seen around the shoulder in patients under 18 years of age was SBC (43.5%). This result was consistent with the Leeds Regional Bone Tumour Registry. In their study, Barlow and Newman showed that the most common lesion they saw in the shoulder girdle in children was SBC.^[15] Cleeman et al in their studies evaluating adult and child patients, they showed that the most common lesion they saw around the shoulder was enchondroma.^[1] We think that the reason for this difference is that only patients under the age of 18 were included in our study.

Diagnosing pediatric shoulder girdle lesions requires explicit attention to common mimics. In our cohort, major differentials included aneurysmal bone cyst (ABC) versus telangiectatic osteosarcoma (TOS), SBC versus ABC, chondroblastoma versus clear-cell chondrosarcoma, osteochondroma versus surface osteosarcomas, and Ewing sarcoma versus lymphoma/osteomyelitis.^[16] Distinction rests on clinicoradiologic context and histology (e.g., malignant osteoid in TOS vs cystic spaces without cytologic atypia in primary ABC). Where available, immunohistochemistry/molecular assays supported diagnoses – CD99 with NKX2.2 (and, when indicated, EWSR1-family rearrangement) for Ewing sarcoma; H3.3 K36M for chondroblastoma; USP6 rearrangement for primary ABC; and SATB2 as an osteogenic marker interpreted with morphologic correlation.^[17,18]

Treatments such as curettage + grafting and intralesional steroid injections can be applied in the treatment of SBCs.^[19,20] However, Hashemi – Nejad and Cole mentioned in their study that adequate treatment cannot be provided with intralesional steroid application in SBC.^[21] In our study, we observed recurrence in only 1 patient among SBC patients treated with curettage + grafting.

Osteochondromas are benign bone tumors originating from cartilage tissue. They can occur in any bone as a result of endochondral ossification. However, they are most commonly observed in the metaphysis of long bones, particularly around the knee and the proximal humerus.^[22] In the present study, osteochondromas were the second most commonly observed lesions around the shoulder. In a case report published by Reize and Buess, they discussed the arthroscopic treatment of a subscapularis tear caused by an osteochondroma located on the lesser tubercle.^[23] In our series, 1 case involved a significantly large osteochondroma located in the proximal humerus (Fig. 3). In this case, the mass had grown large enough to affect the subscapularis tendon. Additionally, in our series, 11 patients (79%) with osteochondromas had lesions located in the proximal humerus, while 3 patients (21%) had lesions in the scapula. Excision was performed as the treatment in all cases, and no recurrences were observed after treatment.

ABC is a local, aggressive bone tumor that occurs more frequently in the first 2 decades. ABC usually affects bones such as femur, tibia and humerus.^[24] Rajiv et al observed ABC around the shoulder in 8 children under the age of 18 in their study and showed that the involvement of 4 patients was in the proximal humerus.^[25] In the current study, 6 patients had ABC, 4 of which were located in the proximal humerus and 2 in the scapula.

Primary malignant bone tumors are more common in children and adolescents compared to the adult population, accounting for approximately 6% of all cancers in children. They are strongly associated with high mortality and morbidity rates.^[26] Osteosarcoma and Ewing sarcoma are the most common malignant bone tumors in childhood.^[27] In our study, we observed osteosarcoma in 4 patients and Ewing sarcoma in 3 patients. In all osteosarcoma patients, the primary site of involvement was the proximal humerus. No synchronous primary neoplasms were identified, and no distant metastases occurred during follow-up. Nevertheless, soft tissue extension is a frequent feature of malignant osseous tumors in this region (e.g., Ewing sarcoma, osteosarcoma) and has critical implications for surgical planning. In our cohort, where recorded, extraosseous components were addressed with limb-sparing resections aimed at wide margins, with attention to neurovascular clearance on preoperative magnetic resonance imaging. This approach, alongside contemporary adjuvant protocols when indicated, likely contributed to the absence of metastatic progression in our series.

Ewing sarcoma is a common primary bone tumor of the distal femur and pelvis.^[28] Hargiss et al evaluated 9 patients with Ewing Sarcoma in the scapula in their study and the mean MSTS was 79 ± 14% (23.7 points).^[29] In our study, MSTS was 58.89 ± 32.72% (17.67 ± 9.81)in 2 patients with Ewing sarcoma localized in the proximal humerus and 1 patient with Ewing sarcoma localized in the scapula.

Several entities in our cohort have hallmark molecular alterations that aid diagnosis and, in some cases, reflect heritable risk: osteochondroma may occur as part of hereditary multiple osteochondromas with germline EXT1/EXT2 variants; chondroblastoma is characterized by the H3K36M mutant histone with supportive IHC; enchondromas in Ollier/Maffucci typically harbor mosaic IDH1/IDH2 mutations; primary ABC shows USP6 rearrangements distinguishing it from secondary ABC change; and Ewing sarcoma is defined by EWSR1–ETS fusions (classically EWSR1::FLI1).^[30–34] Osteosarcoma exhibits complex genomics and is enriched in cancer-predisposition syndromes (e.g., TP53/Li-Fraumeni, RB1/hereditary retinoblastoma).^[35] Nonsurgical management follows pediatric oncology standards: osteosarcoma receives limb-sparing surgery plus multi-agent chemotherapy (commonly MAP), Ewing sarcoma receives multidrug chemotherapy (e.g., VDC/IE) with surgery and/or radiation for local control, and rhabdomyosarcoma uses VAC-based regimens. For selected benign/aggressive benign lesions, image-guided sclerotherapy is effective in ABC, and SBCs are treated with steroid injection/decompression or internal fixation according to fracture risk and location.^[36–38] Our management aligned with these principles when indicated.

In recent years, significant advancements have been made in reconstructive surgery following the resection of musculoskeletal tumors. Thanks to methods such as limb-sparing surgical approaches, biological reconstruction techniques and tumor prostheses, satisfactory results are achieved in terms of both oncological control and functional results.^[39–41] A recent case series published by Hargiss et al has also shown that limb-sparing surgery is a safe and effective treatment option, especially in rare lesions such as Ewing sarcoma located in the scapula.^[29] Supported by long-term follow-up data and functional assessments, this study provides a significant contribution to the current knowledge regarding the surgical management of pediatric shoulder girdle tumors.

New chemotherapy protocols and advanced imaging techniques have made it possible to treat tumors that were previously inoperable, enabling both the improvement of the disease and the preservation of limb function.^[42]

The occurrence of bone metastases in childhood is rare. Neuroblastoma is the most common tumor in childhood characterized by bone metastases.^[43] In a study by Jensen et al, which evaluated patients aged 0 to 19 years, 127 children with metastatic rhabdomyosarcoma were analyzed, and bone metastases were found in 34 patients (27%).^[44] In the current study, we also observed metastatic rhabdomyosarcoma in 2 patients.

As a single-center retrospective cohort without a comparator group, causal inference is limited and findings should be interpreted descriptively. First, beyond the MSTS Emotional Acceptance domain, we did not administer a dedicated pediatric psychological PROM, so psychological status was not comprehensively measured. Second, caregiver-assisted completion of TESS in younger children may introduce proxy-report bias; future prospective studies should include age-appropriate pediatric psychological PROMs (e.g., PROMIS Pediatric or PedsQL psychosocial domains). Another limitation is the lack of preoperative scoring. However, a strength of this study is its high patient count and long-term prognostic follow-up, especially when compared to the literature. Consequently, 1-year postoperative results should be interpreted as cross-sectional functional status rather than change from baseline; we could not estimate Δ scores, effect sizes, or MCID-based responder rates. In addition, caregiver-assisted TESS in younger children may introduce proxy-report bias, and response-shift may affect patient-reported perceptions over time. We acknowledge that the failure to systematically document deviations from the initial treatment plan is a significant limitation. However, careful review of patient records has identified and exemplified such changes whenever possible. We could not calculate Cronbach’s alpha for MSTS/TESS in this cohort because item-level data were not retained; future prospective work will capture domain/item responses to permit within-cohort reliability analyses.

Primary and metastatic bone tumors can be seen in the shoulder girdle during childhood. Bone tumors around the shoulder in childhood are typically benign, and excellent functional outcomes can be achieved when treated. However, it should be noted that malignant bone tumors can also occur in this age group, and careful attention is required.

Author contributions

Data curation: Batuhan Ayhan, Resul Bircan.

Formal analysis: Asim Ahmadov, Resul Bircan.

Investigation: Batuhan Ayhan, İbrahim Kaya.

Methodology: Özlem Orhan.

Resources: Batuhan Ayhan.

Supervision: Coşkun Ulucaköy.

Writing – original draft: Semih Yaş.

Writing – review & editing: Semih Yaş, Asim Ahmadov, İsmail Burak Atalay.