Pathobiology and Precision Management of Benign and Malignant Bone Tumors: A Narrative Review

Bone tumors range from incidental benign lesions and locally aggressive intermediate tumors to primary sarcomas, and metastatic carcinoma is the most common malignant lesion of adult bone.This narrative review focuses on primary bone tumors, examining their classification, molecular pathobiology, diagnosis, staging, and treatment, and it addresses metastatic bone disease briefly from an orthopedic-oncology perspective.We synthesized literature identified through PubMed, Scopus, Web of Science, and the Cochrane Library, supplemented by targeted verification and updating of cited sources during revision in 2026.Classifications, clinical practice guidelines, clinical trials, cohort studies, and reviews informed the synthesis.Management depends on histological subtype, anatomical site, disease extent, symptoms, and the feasibility of preserving function.Suspected primary bone sarcomas should be imaged locally, staged with chest computed tomography, and referred to a sarcoma center before biopsy.Observation or intralesional treatment is appropriate for many benign lesions, whereas selected locally aggressive tumors require more extensive intervention.Osteosarcoma and Ewing sarcoma generally require systemic chemotherapy and local treatment.Surgery remains central to conventional chondrosarcoma management, and systemic treatment options differ across its subtypes.Molecular findings support, but do not replace, integrated radiological and histopathological diagnosis.Checkpoint inhibitors have shown limited activity in unselected bone sarcomas, and multikinase inhibitors have modest activity in relapsed osteosarcoma.Patient-specific implants, radiomics, liquid biopsy, and cellular therapies are promising, but each requires prospective evidence of improved patient outcomes before broad adoption.Accurate biopsy planning, specialist pathology review, and coordinated sarcoma care remain essential.