Autologous stem cell transplantation for high-risk Ewing's sarcoma and other pediatric solid tumors

The prognosis for many pediatric and young adult patients with solid tumors that have metastasized at the time of diagnosis or have relapsed after therapy remains very poor. The steep dose-response curve of many of these tumors to alkylating agents makes myeloablative chemotherapy followed by autologous stem cell transplantation (ASCT) an attractive potential therapy. The role of ASCT for these high-risk patients is yet to be conclusively determined. We have transplanted 36 patients on two consecutive protocols with a variety of histological diagnoses. Overall survival (OS) was 63% (95% CI: 47-79%) at 1 year and 33% (95% CI: 16-50%) at 3 years. Patients with a diagnosis of Ewing's sarcoma (ES) or desmoplastic small round cell tumor (DSRCT) had significantly better survival than those with other diagnoses with estimated 3-year OS of 54% (95% CI: 29-79%) for this group of patients (P = 0.03). There were two transplant-related deaths both attributable to hepatic veno-occlusive disease. Median follow-up among survivors is 3.5 years (range: 0.6-7.9 years). These data justify continued investigation of ASCT as a consolidation therapy in patients with metastatic or relapsed ES and DSRCT.

Ewing sarcoma/PNET: 27 years of experience in Slovenia

The study includes 91 patients treated for Ewing sarcoma between 1972 and 2002. Forty were younger and 51 were older than 16. The overall 5-year survival was 36%: 53.5% in the younger and 22.5% in the older age group. Among patients with localized disease, 5-year survival was 58% in younger and 25.5% in the older. Survival was similar whether patients received three treatment modalities or chemotherapy combined with either surgery or radiotherapy. Recurrence was noted in 47 out of 75 patients with localized disease, most commonly as local recurrence or lung metastases. Among 18 evaluated patients, 14 had minor physical defects and 4 had severe late treatment effects (sterility in 3 and secondary osteogenic sarcoma in 1).

Incidence of multiple primary malignancies among patients with bone cancers in Sweden

PURPOSE

The present study aimed at quantifying risks for second malignancies in patients with bone cancers, and risks for second bone cancers after other primary tumors.

METHODS

Adjusted standardized incidence ratios (SIRs) were used as a measure of risk.

RESULTS

Among 2,546 primary bone cancer patients, a total of 171-second malignancies occurred. Besides second bone cancers, other cancer sites with an increased SIR were the soft tissues and endocrine glands. The overall risk of second malignancies following Ewing's sarcoma was 5.63, followed by chordoma (1.99), osteosarcoma (1.54), and chondrosarcoma (1.51). Patients diagnosed before age 20 years showed an increased SIR of 3.11. The increased occurrence of second bone cancers was noted after the cancer sites of upper aerodigestive tract, kidney and nervous system.

CONCLUSIONS

The incidence of second primary malignancies in bone cancer patients was moderately increased. Among histological types, Ewing's sarcoma showed the highest risk of developing second cancers. Young age was also associated with an increased risk. Besides therapeutic effects, the observed excesses of a second bone or soft tissue tumor may be related to Li-Fraumeni syndrome. Increases at other sites may be related to unknown factors or spurious findings.

An unusual cause of constipation presenting to the emergency department

A case report of a 16-year-old girl who presented to the emergency department with constipation and recurrent urinary tract infections is examined. She gave a history of persistent coccygeal pain stemming from a fall on a trampoline 1 year ago. On examination, she was found to have an abdominal mass arising from the pelvis and paraesthesia of S1-S5 dermatomes in the right leg. An abdominal radiograph showed bony erosion of the sacrum. Magnetic resonance scanning revealed a mass arising from the sacrum and subsequent biopsy diagnosed the tumour as Ewing's sarcoma.

Comparative analysis between osteosarcoma and Ewing's sarcoma: evaluation of the time from onset of signs and symptoms until diagnosis

OBJECTIVE

The purposes of this study were to describe the early signs and symptoms of osteosarcoma and Ewing's sarcoma, identify symptoms that could be used to help differentiate the two types of tumors, and determine the time elapsed between the onset of signs and symptoms and the definitive diagnosis in our service, providing information and imputus for earlier diagnosis of these tumors.

METHODS

A retrospective analysis of the medical dossiers of 365 patients under 30 years of age diagnosed with osteosarcoma or Ewing's sarcoma was performed, and the aspects of the clinical diagnosis were statistically analyzed and compared.

RESULTS

The time between the onset of signs and the symptoms was 5.25 months for osteosarcoma and 8.1 months for Ewing's sarcoma, and the most frequent (89.5%) early symptom of osteosarcoma and Ewing's sarcoma was local pain. Symptoms that might aid diagnosis included early local volume increase and the presence of fever.

CONCLUSION

The time until diagnosis of both neoplasias was higher than that reported for North America and Europe. Education of the lay public and medical professionals regarding suspicious early signs and symptoms might shorten the delay of diagnosis.

Extraskeletal Ewing’s Sarcoma Presenting With Multifocal Intrathoracic Mass Lesions Associated With Mediastinal Shift

Extraskeletal Ewing's sarcoma is an uncommon disease that predominantly involves the soft tissues of the trunk or the extremities. This article presents a patient with multifocal intrathoracic mass lesions involving the mediastinum and the lingula associated with mediastinal shift, eventually diagnosed as extraskeletal Ewing's sarcoma.

Acquired von Willebrand syndrome in a patient with Ewing sarcoma

Acquired von Willebrand syndrome is a rare bleeding disorder with clinical and laboratory features closely resembling to hereditary von Willebrand disease. The syndrome may accompany various conditions, including malignant disorders, most often with Wilms tumor and adrenal cell carcinoma. In this report, the authors present a patient with AvWS in association with Ewing sarcoma for the first time in the literature. The abnormal bleeding tendency was successfully treated with fresh frozen plasma and did not recur after the first two courses of chemotherapy with clinical improvement.

[Surgical management of paediatric malignant bone tumours]

The malignant bone tumours in children are rare, concerning 5% of the all paediatric tumours. Among all paediatric bone tumours, 15% of them are malignant. The main bone tumours in children are the osteosarcoma and the Ewing sarcoma. The diagnosis and treatment need a multidisciplinary medical team. It is essential in front of potential clinical or radiological signs, to perform quickly the specific medical exams and biopsy. The treatment needs a paediatric medical and surgical staff.

Primary Ewing sarcoma of the petrous temporal bone: An exceptional cause of facial palsy and deafness in a nursling

BACKGROUND

Primary Ewing sarcoma affecting the skull base in general and the petrous bone in particular is extremely rare with only 4 reports of Ewing sarcoma arising in the petrous temporal bone in the international medical literature.

METHODS

The authors report for the first time a case of a primary Ewing sarcoma of the petrous temporal bone in a 5-month-old nursling, which became apparent with a complete peripheral facial palsy and ipsilateral surdity.

RESULTS

The neoformation was treated by systemic chemotherapy and radiation of the tumor region. The diagnostic steps, therapy, and development of the child are described in detail; the literature concerning Ewing sarcoma originating from the skull in general and from the petrous temporal bone in particular is reviewed.

CONCLUSIONS

The highlights of this case are an extremely uncommon location, an unusual age of presentation, as well as a unique set of symptoms.

Prospective multicenter registration of major late sequelae in sarcoma patients using the Late Effects Surveillance System (LESS)

BACKGROUND

Late effects become progressively more important for the evaluation of therapeutic success in paediatric oncology. Thus, in 1998, the Late Effects Surveillance System (LESS) started to register and assess multicentrally, prospectively and longitudinally late effects of treatment for the group of Ewing's, soft tissue- and osteosarcoma patients.

PATIENTS AND METHODS

The yearly results of the follow-up examinations of 785 Ewing's, soft tissue- and osteosarcoma patients, who were treated from 1.1.1998 until 31.12.2001, were prompted and assessed conforming to the guidelines developed by the LESS-study.

RESULTS

136/181 (75 %) of follow-up institutions take part in the LESS-study. Only 8 % of patients eligible for the LESS-study were cared for in non-cooperating facilities. Questionnaire return could be raised to 73-78 % and data completeness could also be significantly improved in the course of the study. Departments of internal medicine had a lower questionnaire return percentage than departments of paediatrics. Data availability for the nephrologic after-care was not satisfactory.

CONCLUSIONS

The LESS project has been well established. Thus, the basis has been set for the development of risk-oriented strategies for intervention and for the further improvement of the follow-up of major late effects in sarcoma patients.

Concomitant Ewing sarcoma and acute lymphoblastic leukemia in a 5-year-old girl

Malignancies from the Ewing family of tumors and acute lymphoblastic leukemia (ALL) are not known to be associated with each other. A 5-year-old girl was incidentally found to suffer from acute lymphoblastic leukemia during bone marrow staging for Ewing sarcoma of the radius. The simultaneous presence of two distinct neoplasms was confirmed by RT-PCR, with EWS/FLI1 type 1 rearrangement in the bone tumor and TEL/AML1 rearrangement in the marrow. She was treated with chemotherapy, radiotherapy, and surgery and was in remission of both diseases 31 months after diagnosis.

Hernias and Ewing's sarcoma family of tumours: a pooled analysis and meta-analysis

BACKGROUND

Ewing's sarcoma family of tumours has been associated with a history of hernia and with a parental occupation of farming. However, the causes of these tumours remain unknown. We therefore aimed to investigate the association between hernia and Ewing's sarcoma family of tumours.

METHODS

We did a pooled analysis of two case-control studies and a meta-analysis of three case-control studies of Ewing's sarcoma family of tumours that had adequate information on history of hernia. The primary endpoint was development of a tumour from the Ewing's sarcoma family. 138 patients with such a tumour and 574 controls were included in the pooled analysis, and 357 patients with these tumours and 745 controls were included in the meta-analysis. Risk was assessed by an odds ratio (OR) and 95% CI by use of multivariate analysis with unconditional logistic regression for the pooled analysis and random effects model for the meta-analysis.

FINDINGS

Pooled analysis showed that children with Ewing's sarcoma family of tumours were more likely to have had an umbilical hernia than were controls (odds ratio [OR] 3.3 [95% CI 1.3-8.0]). Meta-analysis showed that children with Ewing's sarcoma family of tumours were more likely to have had a hernia (3.2 [1.9-5.7]).

INTERPRETATION

Ewing's sarcoma family of tumours and hernias (particularly inguinal hernias) have common embryological pathways of neuroectodermal origin, and environmental factors, such as farming, might link the two entities.

Primary intracranial peripheral primitive neuroectodermal tumor/Ewing's sarcoma presenting with acute intracerebral hemorrhage

OBJECTIVE

To report two cases of intracerebral hemorrhage due to primary intracranial peripheral primitive neuroectodermal tumor (pPNET)/Ewing's sarcoma (ES) and review of related literatures.

MATERIAL

Two cases of 17-year-old patients presented with acute increased intracranial pressure one of which also had left hemiparesis.

METHOD

On neuroimaging studies, the first patient had an intraparenchymal hematoma with a size of 4 cm at the right fronto-parietal junction adjacent to tumor infiltrating the superior sagittal sinus. The second patient had a large left temporal tumor with intraventricular hemorrhage. Both patients underwent craniotomy with complete removal of tumor and hematoma.

RESULTS

Pathological examination in both cases revealed numerous small round tumor cells with stippled chromatin pattern and scanty cytoplasm. Tumor cells strongly expressed CD99. Vimentin immunoreactivity was observed. The final diagnosis of pPNET/ES was rendered. There was no evidence of extracranial disease in both cases. Both patients were doing well without evidence of recurrent disease at 12 and 24-month follow-up respectively.

CONCLUSIONS

Peripheral primitive neuroectodermal tumor (pPNET)/Ewing's sarcoma (ES) is a malignant small round cell tumor, commonly arising in soft tissue of the trunk and lower extremity. Those occurring in the intracranium are rare, and most patients present with progressively increased intracranial pressure and/or cranial nerve deficit. The occurrence of intracerebral hemorrhage due to primary intracranial pPNET/ES is exceedingly rare. The role of adjuvant therapy in this condition is yet to be investigated.

Extraskeletal Ewing sarcoma of the diaphragm presenting with hemothorax

Ewing sarcoma is a relatively uncommon malignant bone neoplasm that usually occurs in children and young adults and involves the major long bones, pelvis, and ribs. Primary diaphragmatic Ewing sarcoma is extremely rare. To the best of our knowledge, only three cases of primary Ewing sarcoma of the diaphragm have been reported. A 12-year-old girl presented spontaneous occurrences of the right hemothorax. After drainage, a roentgenogram film, computed tomography, ultrasonography, and magnetic resonance image showed a giant mass on the right diaphragm. Primary diaphragmatic tumor was resected totally by right posterolateral thoracotomy, and histologically, an extraskeletal Ewing sarcoma was identified. The patient received adjuvant radio-chemotherapy, and there was no evidence of disease 10 months after the operation. Although extremely rare, extraskeletal Ewing sarcoma should be kept in mind in the differential diagnosis of diaphragmatic soft tissue tumors.

Ewing's sarcoma of the humerus mimicking fibrous dysplasia on imaging and biological behavior

We present the case of a 12-year-old girl who presented with a pathological fracture through a benign-appearing osteolytic lesion that was presumed to represent fibrous dysplasia. The fracture healed, and over the next 2.5 years there was further refracturing and healing with progressive osteolysis. A biopsy was performed and revealed Ewing's sarcoma. The disease was locally controlled by neoadjuvant chemotherapy and radiation therapy. The patient is disease free with excellent function 6 years following the discovery of the lesion. We illustrate and discuss the sequence of events.

Video-assisted thoracic surgery for Ewing's sarcoma of the mediastinum in a 3-year-old girl

We report of the experience of video-assisted thoracic surgery (VATS) for a Ewing's sarcoma at the posterior mediastinum in a 3 year old girl. The patient developed common cold like symptoms and developed rapid lower limb paraplegia. A chest computed tomography (CT) showed a solid mass adjacent to the vertebrae. This was diagnosed as a Ewing's sarcoma histopathologically by CT-guided needle biopsy (CT-NB). The mass was pressing on a nerve root in the vicinity of a vertebral foramen. As the tumor reduced after induction chemotherapy, with improvement of paraplegia, the patient underwent thoracoscopic examination followed by complete removal of the tumor by VATS. After surgery, the patient underwent postoperative chemo-radiotherapy. Five years has passed after operation without tumor recurrence. VATS could be an option as combined therapy for Ewing's sarcoma when well controlled and localized under induction therapy.

Infection by Rhodotorula sp. in children receiving treatment for malignant diseases

Rhodotorula sp. are commensal yeasts that may cause opportunistic infections. There have been only a few case reports of Rhodotorula fungemia in children with cancer, and in all of them the patients had a central venous catheter inserted. The authors report three nonfatal cases of fungemia by Rhodotorula in patients with post-chemotherapy neutropenia. Two of three patients required catheter removal, and a response was achieved with systemic antifungal therapy. Aggressive therapy may be required for selected high-risk patients.

Spinal cord Ewing's sarcoma metastasis: presentation of one case

Cervical spinal Ewing's sarcomas are rare and cause problems in diagnosis. We present an unusual case of a primary extraosseous Ewing's sarcoma arising from the spinal cord. An 18-year-old woman with fever, headache and back pain lasting one month was admitted to the hospital. Whole body bone scintigraphy was performed with 1110 MBq technetium-99m methylenediphosphonate. Scintigraphy clearly showed abnormal technetium-99m methylenediphosphonate accumulation in the level of the 5th and 6th cervical vertebrae. Magnetic resonance imaging could also confirm this examination finding. After the scintigraphic study, the patient underwent surgery. Pathological diagnosis of the operation specimen was Ewing's sarcoma.

Spontaneous conception in a young woman who had ovarian cortical tissue cryopreserved before chemotherapy and radiotherapy for a Ewing's sarcoma of the pelvis: Case report

We report the case of a 14 year old girl who presented with a non-metastatic Ewing's sarcoma involving her superior pubic ramus. She received 14 courses of alkylating agent-based chemotherapy and direct radiation to her hemi-pelvis (55 Gy) and is alive and disease-free 8 years later. Multiple biopsies of ovarian cortical tissue were cryopreserved, with her written consent, before treatment began. Ovarian failure was confirmed on completion of treatment with cessation of menses and persistently elevated serum gonadotrophin and low estradiol levels on repeated measurement over 2 years. HRT was initiated. Irregular vaginal bleeding occurred due to radiation vaginitis. Reimplantation of ovarian cortical tissue was considered at 19 years as fertility was desired, but the decision deferred. A spontaneous conception occurred 1 year later and a healthy boy (birthweight 2.9 kg, 3rd-10th centile) was delivered at term by elective Caesarean section. This is the first case of a spontaneous conception occurring in a young woman with documented ovarian failure in whom ovarian cortical tissue had been cryopreserved. Clinicians should be aware of the possibility of spontaneous conception despite confirmed ovarian failure in young women successfully treated for cancer.

Massive pleural effusion in an 18-year-old girl with Ewing sarcoma

Ewing sarcoma is a bone tumour that commonly appears between ages five and 10 in the diaphysis of the long bones and predominantly presents with pain and swelling. The case of an 18-year-old girl who presented with back pain, cough, dyspnea, weakness and fever is described. Chest radiograph showed a homogenous density in the middle and inferior zones of the right hemithorax. Thoracic computed tomography revealed a diffuse pleural effusion and a 6.99 cm x 4.45 cm solid mass composed of lobulated, small cystic lesions and calcifications in the right hemithorax. Biochemical analysis of pleural fluid showed hemorrhagic effusion and exudate. A pleural needle biopsy demonstrated solid uniform tumour cells with narrowed cytoplasm, round nuclei and uncertain nucleoli. All of the tumour cell cytoplasms stained with CD99. The pathological examination supported Ewing sarcoma. Three-phase Tc-99m methylene diphosphonate scintigraphy of the whole body showed pathological tracer uptake in a broad area of the eighth costal bone and in smaller areas of the ninth and 10th costal bones. This case is reported because Ewing sarcoma is a rare cause of pleural effusion in clinical practice among younger adults.