Prognostic factors in Ewing's tumor of bone: analysis of 975 patients from the European Intergroup Cooperative Ewing's Sarcoma Study Group

Loss of Stag2 cooperates with EWS-FLI1 to transform murine Mesenchymal stem cells

BACKGROUND

Ewing sarcoma is a malignancy of primitive cells, possibly of mesenchymal origin. It is probable that genetic perturbations other than EWS-FLI1 cooperate with it to produce the tumor. Sequencing studies identified STAG2 mutations in approximately 15% of cases in humans. In the present study, we hypothesize that loss of Stag2 cooperates with EWS-FLI1 in generating sarcomas derived from murine mesenchymal stem cells (MSCs).

METHODS

Mice bearing an inducible EWS-FLI1 transgene were crossed to p53^-/- mice in pure C57/Bl6 background. MSCs were derived from the bone marrow of the mice. EWS-FLI1 induction and Stag2 knockdown were achieved in vitro by adenovirus-Cre and shRNA-bearing pGIPZ lentiviral infection, respectively. The cells were then treated with ionizing radiation to 10 Gy. Anchorage independent growth in vitro was assessed by soft agar assays. Cellular migration and invasion were evaluated by transwell assays. Cells were injected with Matrigel intramuscularly into C57/Bl6 mice to test for tumor formation.

RESULTS

Primary murine MSCs with the genotype EWS-FLI1 p53^-/- were resistant to transformation and did not form tumors in syngeneic mice without irradiation. Stag2 inhibition increased the efficiency and speed of sarcoma formation significantly in irradiated EWS-FLI1 p53^-/- MSCs. The efficiency of tumor formation was 91% for cells in mice injected with Stag2-repressed cells and 22% for mice receiving cells without Stag2 inhibition (p < .001). Stag2 knockdown reduced survival of mice in Kaplan-Meier analysis (p < .001). It also increased MSC migration and invasion in vitro but did not affect proliferation rate or aneuploidy.

CONCLUSION

Loss of Stag2 has a synergistic effect with EWS-FLI1 in the production of sarcomas from murine MSCs, but the mechanism may not relate to increased proliferation or chromosomal instability. Primary murine MSCs are resistant to transformation, and the combination of p53 null mutation, EWS-FLI1, and Stag2 inhibition does not confer immediate conversion of MSCs to sarcomas. Irradiation is necessary in this model, suggesting that perturbations of other genes beside Stag2 and p53 are likely to be essential in the development of EWS-FLI1-driven sarcomas from MSCs.

Treatment of pelvic Ewing's sarcoma: Pros and cons of chemotherapy plus definitive radiotherapy versus surgery

OBJECTIVE

The aim of this study was to compare the results of chemotherapy or combined chemotherapy-radiation therapy with surgical intervention following neodjuvant therapy in pelvic Ewing's sarcoma patients.

METHODS

The study population consisted of 39 patients with pelvic Ewing's sarcoma treated in our clinic between 1994 and 2014. Of these patients, 28 patients (11 boys and 17 girls; mean age: 19.57±6.8 years) were treated with chemotherapy and radiation therapy and the remaining 11 patients (9 boys and 2 girls; mean age: 18.64±8.1 years) patients underwent surgical intervention after neoadjuvant chemotherapy or chemotherapy plus radiation therapy. Internal hemipelvectomy was performed in 10 patients, and external hemipelvectomy was performed in one patient. Survival rates were compared between the surgical and non-surgical treatment groups. Predictive factors, such as treatment protocol (surgery, neoadjuvant chemotherapy, definitive radiotherapy), mass localisation, mass size, presence of metastasis at the time of diagnosis, and presence of late metastases were compared between the groups. The effects of each variable on survival were also examined.

RESULTS

The overall 3- and 5-year survival rates of the 28 non-surgical patients were 41.4% and 26.1%, respectively, while those of the surgical patients were 53% and 35.4%, respectively (p=0.777). Large mass size, presence of metastasis at the time of diagnosis, and presence of late metastases were significantly associated with lower survival rates.

CONCLUSION

The survival rates of the patients who underwent surgery were higher than those of non-surgical patients, although the difference was not statistically significant. Definitive radiation and chemotherapy would be preferable in selected cases, such as patients with sacral localisation, without surgical intervention.

LEVEL OF EVIDENCE

Level III, Therapeutic Study.

Impact of chemotherapy cycles and intervals on outcomes of nonspinal Ewing sarcoma in adults: a real-world experience

BACKGROUND

Adult Ewing sarcoma (ES) is a rare disease, the optimal treatment model is unknown. This study aimed to retrospectively analyze treatment-related prognostic factors of nonspinal ES in Chinese adults.

METHODS

Eighty-one patients treated between January 2005 and December 2017 were included in the present study. Thirty-three (40.7%) presented with metastatic disease at diagnosis. Eight patients were submitted to primary surgery followed by chemotherapy, while 73 patients received chemotherapy before and after surgery and/or local radiotherapy. The chemotherapy regimen included 8-17 cycles of vincristine, doxorubicin, and cyclophosphamide (VDC) alternating with ifosfamide and etoposide (IE) every 3 weeks. Clinical outcomes and safety were analyzed.

RESULTS

VDC/IE chemotherapy was well tolerated in adult patients with ES. Multivariate Cox regression analyses revealed that chemotherapy of at least 12 cycles was a favorable independent prognostic factor of event-free survival (hazard ratio, 0.558; 95% confidence interval, 0.323-0.965; P = 0.037) and overall survival (hazard ratio, 0.424; 95% confidence interval, 0.240-0.748; P = 0.003). Similarly, a low frequency of chemotherapy delays was an independent prognostic factor of improved OS (hazard ratio, 0.438; 95% confidence interval, 0.217-0.887; P = 0.022).

CONCLUSION

Our study suggests that adults with ES should be treated with an aggressive multidisciplinary approach, intensive chemotherapy with adequate cycles and appropriate intervals can be recommended in this group.

Primitive neuroectodermal tumors of the abdominal wall and vulva in children: Report of two cases and review of the literature

BACKGROUND

Primitive neuroectodermal tumors are rare, highly malignant small round cell tumors belonging to the Ewing sarcoma family. The purpose of this article is to present clinical manifestation, histology, treatment, and prognosis of two primitive neuroectodermal tumors (PNETs) in extremely rare anatomic locations, the abdominal wall and vulva.

CASE SUMMARY

Case 1 was a 66-month-old girl with lesions on the abdominal wall; tumor size was about 3.4 cm × 6.1 cm × 2 cm. The patient underwent radical resection of the tumor. After the operation, an alternating vincristine, doxorubicin, and cyclophosphamide/ifosfamide and etoposide (IE) regimen was given for eight cycles, and the patient survived for 66 mo without progression. Case 2 was a 40-month-old girl, with a vulvar lesion; tumor size was about 3.3 cm × 5 cm × 2.5 cm. The tumor was partially resected by surgery. The family left treatment after two cycles of vincristine, pirarubicin, and cyclophosphamide/IE chemotherapy, and the patient died at home six months after surgery.

CONCLUSION

PNET is a rare, fast-growing, highly malignant tumor that requires histologic and molecular analyses for exact diagnosis, and multimodal treatment is required to achieve a good prognosis.

Individual risk evaluation for local recurrence and distant metastasis in Ewing sarcoma: A multistate model: A multistate model for Ewing sarcoma

BACKGROUND

We investigated the effects of surgical margins, histological response, and radiotherapy on local recurrence (LR), distant metastasis (DM), and survival in Ewing sarcoma.

PROCEDURE

Disease evolution was retrospectively studied in 982 patients with Ewing sarcoma undergoing surgery after chemotherapy using a multistate model with initial state surgery, intermediate states LR, pulmonary metastasis (DMpulm), other DM ± LR (DMother), and final state death. Effect of risk factors was estimated using Cox proportional hazard models.

RESULTS

The median follow-up was 7.6 years (95% CI, 7.2-8.0). Risk factors for LR are pelvic location, HR 2.04 (1.10-3.80), marginal/intralesional resection, HR 2.28 (1.25-4.16), and radiotherapy, HR 0.52 (0.28-0.95); for DMpulm the risk factors are <90% necrosis, HR 2.13 (1.13-4.00), and previous pulmonary metastasis, HR 4.90 (2.28-8.52); for DMother are 90% to 99% necrosis, HR 1.56 (1.09-2.23), <90% necrosis, HR 2.66 (1.87-3.79), previous bone/other metastasis, HR 3.08 (2.03-4.70); and risk factors for death without LR/DM are pulmonary metastasis, HR 8.08 (4.01-16.29), bone/other metastasis, HR 10.23 (4.90-21.36), and <90% necrosis, HR 6.35 (3.18-12.69). Early LR (0-24 months) negatively influences survival, HR 3.79 (1.34-10.76). Once DMpulm/DMother arise only previous bone/other metastasis remain prognostic for death, HR 1.74 (1.10-2.75).

CONCLUSION

Disease extent and histological response are risk factors for progression to DM or death. Tumor site and surgical margins are risk factors for LR. If disease progression occurs, previous risk factors lose their relevance. In case of isolated LR, time to recurrence is important for decision-making. Radiotherapy seems protective for LR especially in pelvic/axial. Low percentages of LR in extremity tumors and associated toxicity question the need for radiotherapy in extremity Ewing sarcoma.

Risk Factors for Metastasis at Initial Diagnosis With Ewing Sarcoma

Purpose: We aimed to identify potential risk factors predictive of metastasis at initial diagnosis in Ewing sarcoma patients.

Patients and methods: We enrolled selected patients diagnosed with Ewing sarcoma between 2004 and 2015 in the Surveillance, Epidemiology, and End Results (SEER) Program database. Demographic and clinical features of patients were analyzed to demonstrate the potential risk factors of distant metastasis at presentation. We utilized descriptive statistics, univariate methods, and a series of regression models to analyze the significance of risk factors. Moreover, we conducted survival analysis in patients with different metastatic sites through Kaplan–Meier analysis.

Results: We identified 1,066 cases of Ewing sarcoma and 332 (31.1%) of the patients had metastasis at initial diagnosis. In the univariate logistic regression analysis, patients had higher probability of metastasis at initial diagnosis if they aged between 18 and 59 years old (OR = 1.43; 95% CI, 1.09 to 1.86), had a tumor located in the axial or cranial bones (OR = 1.38; 95% CI, 1.05 to 1.81), or had a tumor over 8 cm (OR = 2.55; 95% CI, 1.66 to 3.89). These three factors were still significant when analyzed in a multivariate logistic regression model or another multivariate logistic regression model controlling for age, location, and tumor size, which had univariate p < 0.1. Besides, we found that patients with lung metastasis alone had a better prognosis than patients with bone metastasis alone or with two or more metastatic sites (p < 0.01).

Conclusion: Ewing sarcoma patients with an age between 18 and 59 years old, a tumor in the axial or cranial bones, and a tumor size over 8 cm had an increased likelihood to have metastatic diseases at initial diagnosis.

Feasibility of Treating Adults with Ewing or Ewing-Like Sarcoma with Interval-Compressed Vincristine, Doxorubicin, and Cyclophosphamide Alternating with Ifosfamide and Etoposide

BACKGROUND

Vincristine, doxorubicin, and cyclophosphamide (VDC) alternating with ifosfamide and etoposide (IE) administered every 2 weeks demonstrated a superior event-free survival compared with 3-week dosing in a landmark pediatric trial and is now standard of care for younger patients. Only 12% of patients enrolled in that trial were over 18 years of age; thus, the feasibility of interval-compressed VDC/IE in adults remains poorly described. We conducted a retrospective analysis of our institutional experience using this regimen.

MATERIALS AND METHODS

Pharmacy administration records at Oregon Health and Science University were reviewed to identify patients with Ewing and Ewing-like sarcoma aged 18 years and older who received VDC/IE every 2 weeks.

RESULTS

We identified 24 patients. Median age was 28 years (range 18-60 years). At diagnosis, 67% had localized disease. The most common primary sites were extremity (38%) and pelvis (17%); another 25% had extraosseous disease. The median interval between cycles was 15.0 days, with no difference between patients aged <30 years versus ≥30 years. The median number of admissions for toxicity per patient was two, primarily for febrile neutropenia. Early treatment discontinuation occurred in 17%. Dose reductions were minimal, with mean cumulative doses achieved comparable to original planned dose and no difference between patients aged <30 years versus ≥30 years.

CONCLUSION

For adults with Ewing and Ewing-like sarcoma, administration of interval-compressed chemotherapy is feasible, without significant dose reductions required. Our results are comparable to prior studies involving a primarily pediatric population.

IMPLICATIONS FOR PRACTICE

For Ewing sarcoma, interval-compressed vincristine, doxorubicin, and cyclophosphamide alternating with ifosfamide and etoposide administered every 2 weeks rather than every 3 weeks has been shown to improve event-free survival in pediatric patients. However, in adults, oncologists may be hesitant to pursue interval-compressed therapy because of concerns for feasibility. In the adult population in this study, a median interval between cycles of 15.0 days (mean 17.0 days) was achieved, comparable to the interval achieved in AEWS0031 (median 15.0, mean 17.3 days). Given that this was achieved without unexpected toxicity or substantial dose reductions and that clinical outcomes were favorable compared with adult historical controls, these results support the use of this regimen in adults.

Ewing sarcoma/primitive neuro-ectodermal tumor of the urogenital system in children: a retrospective observational case series

INTRODUCTION

Pediatric Ewing sarcoma (ES)/primitive neuro-ectodermal tumor (PNET) occurring in the genitourinary system has been rarely reported. And the result of long-term follow-up is still a matter of debate.

OBJECTIVE

The aim of the study was to identify the characteristics, therapeutic strategies, and long-term outcomes of pediatric ES/PNET in the genitourinary system.

PATIENTS AND METHODS

All children with genitourinary system PNET from a single center were retrospectively reviewed. The American Joint Committee on Cancer (AJCC) staging system was used to evaluate tumor grade.

RESULTS

Four patients were included. Three were boys, and 1 was a girl. The locations of the lesions were the penis in 1 patient, ureter in 1 patient, and kidney in 2 patients. Two patients were of AJCC stage IVB, and the other 2 patients were of stage IIA. In the follow-up ranging from 2.5 to 8.0 years, 3 patients had survival, and 1 patient died. The patient with penis PNET survived during the 8 years of follow-up. One patient with renal PNET had tumor thromboses in the renal vein, inferior vena cava, and right atrium, which was the first definite report in children (case 3).

DISCUSSION

Primitive neuro-ectodermal tumor as a highly malignant subgroup of blue round cell tumor is extremely rare in the genitourinary system, especially in children. The current case series represents the first report of penis PNET in children with the longest (8 years) follow-up and first definite report of pediatric renal PNET with vena cava and atrium tumor thrombus. In contrast to the previous literature, the patient with ureteral PNET in this study was much younger, who was the youngest child to be reported in the literature thus far. Although the key prognostic factor of the outcomes is detectable metastases at diagnosis, the patient with penis PNET and bone and lung metastasis in this series still survived. It was hypothesized from the data of present cases that young age was a protective factor, which was consistent with the previous literature. Aggressive therapy is not trivial for patients with multiple recurrences who can also be a long-term survivor. The survival outcomes of these high-stage patients were favorable with combination treatment. As the patient with penis PNET in this series had bone metastasis at his 7.5 years after definite diagnosis, five years of follow-up was not enough. The follow-up period should be extended, even to a lifetime follow-up.

CONCLUSIONS

Children with PNET have a better prognosis than adults. Aggressive combination treatment should be performed to improve prognosis and the survival rate. It is better to monitor the changes of the disease by extending the follow-up period.

Clinicopathologic Features of the Non-CNS Primary Ewing Sarcoma Family of Tumors in the Head and Neck Region

Ewing sarcoma family of tumor (ESFT) is a group of malignant neoplasms that affect children and young adults. Primary ESFT does not commonly arise from the head and neck region. This study aimed to elucidate the clinicopathologic characteristics of ESFT of the head and neck region except for central nervous system primitive neuroectodermal tumors. Among the 207 cases of ESFT of the bone and soft tissue, diagnosed at Asan Medical Center during a 20-year period, 25 (12.1%) involved the head and neck region. Of those, 21 were available for histologic, immunohistochemical, and molecular studies. EWSR1 rearrangement was detected in 19 cases by reverse transcriptase-polymerase chain reaction and/or fluorescence in situ hybridization. Primary sites included the cranial area (6 cases, 31.6%), sinonasal tract (6 cases, 31.6%), paraspinal space (4 cases, 21.0%), and other spaces (3 cases, 15.8%). The 5-year overall survival and disease-free survival rates for all cases were 69.7% and 33.6%, respectively. A large tumor size (>5 cm) correlated significantly with overall survival (P=0.009), but not with disease-free survival (P=0.210). Microscopically, 8 cases (42.1%) showed nested growth pattern. Clear and/or eosinophilic cytoplasm was observed in 68.4% cases. Immunopositivity for CD99, Friend leukaemia integration-1 (FLI-1), CD57, and caveloin-1 were detected in 100%, 88.9%, 83.3%, and 50% cases, respectively. ESFT in the head and neck region had a favorable prognosis and frequent atypical and epithelioid features. An awareness of these histologic and immunophenotypic characteristics will improve the diagnostic accuracy for head and neck round cell malignancies.

Gene expression and immunohistochemical analyses identify SOX2 as major risk factor for overall survival and relapse in Ewing sarcoma patients

BACKGROUND

Up to 30-40% of Ewing sarcoma (EwS) patients with non-metastatic disease develop local or metastatic relapse within a time span of 2-10 years. This is in part caused by the absence of prognostic biomarkers that can identify high-risk patients and thus assign them to risk-adapted monitoring and treatment regimens. Since cancer stemness has been associated with tumour relapse and poor patient outcomes, we investigated in the current study the prognostic potential SOX2 (sex determining region Y box 2) - a major transcription factor involved in development and stemness - which was previously described to contribute to the undifferentiated phenotype of EwS.

METHODS

Two independent patient cohorts, one consisting of 189 retrospectively collected EwS tumours with corresponding mRNA expression data (test-cohort) and the other consisting of 141 prospectively collected formalin-fixed and paraffin-embedded resected tumours (validation and cohort), were employed to analyse SOX2 expression levels through DNA microarrays or immunohistochemistry, respectively, and to compare them with clinical parameters and patient outcomes. Two methods were employed to test the validity of the results at both the mRNA and protein levels.

FINDINGS

Both cohorts showed that only a subset of EwS patients (16-20%) expressed high SOX2 mRNA or protein levels, which significantly correlated with poor overall survival. Multivariate analyses of our validation-cohort revealed that high SOX2 expression represents a major risk-factor for poor survival (HR = 3·19; 95%CI 1·74-5·84; p < 0·01) that is independent from metastasis and other known clinical risk-factors at the time of diagnosis. Univariate analyses demonstrated that SOX2-high expression was correlated with tumour relapse (p = 0·002). The median first relapse was at 14·7 months (range: 3·5-180·7).

INTERPRETATION

High SOX2 expression constitutes an independent prognostic biomarker for EwS patients with poor outcomes. This may help to identify patients with localised disease who are at high risk for tumour relapse within the first two years after diagnosis.

FUNDING

The laboratory of T. G. P. Grünewald is supported by grants from the 'Verein zur Förderung von Wissenschaft und Forschung an der Medizinischen Fakultät der LMU München (WiFoMed)', by LMU Munich's Institutional Strategy LMUexcellent within the framework of the German Excellence Initiative, the 'Mehr LEBEN für krebskranke Kinder - Bettina-Bräu-Stiftung', the Walter Schulz Foundation, the Wilhelm Sander-Foundation (2016.167.1), the Friedrich-Baur foundation, the Matthias-Lackas foundation, the Barbara & Hubertus Trettner foundation, the Dr. Leopold & Carmen Ellinger foundation, the Gert & Susanna Mayer foundation, the Deutsche Forschungsgemeinschaft (DFG 391665916), and by the German Cancer Aid (DKH-111886 and DKH-70112257). J. Li was supported by a scholarship of the China Scholarship Council (CSC), J. Musa was supported by a scholarship of the Kind-Philipp foundation, and T. L. B. Hölting by a scholarship of the German Cancer Aid. M. F. Orth and M. M. L. Knott were supported by scholarships of the German National Academic Foundation. G. Sannino was supported by a scholarship from the Fritz-Thyssen Foundation (FTF-40.15.0.030MN). The work of U. Dirksen is supported by grants from the German Cancer Aid (DKH-108128, DKH-70112018, and DKH-70113419), the ERA-Net-TRANSCAN consortium (project number 01KT1310), and Euro Ewing Consortium (EEC, project number EU-FP7 602,856), both funded under the European Commission Seventh Framework Program FP7-HEALTH (http://cordis.europa.eu/), the Barbara & Hubertus Trettner foundation, and the Gert & Susanna Mayer foundation. G. Hardiman was supported by grants from the National Science Foundation (SC EPSCoR) and National Institutes of Health (U01-DA045300). The laboratory of J. Alonso was supported by Instituto de Salud Carlos III (PI12/00816; PI16CIII/00026); Asociación Pablo Ugarte (TPY-M 1149/13; TRPV 205/18), ASION (TVP 141/17), Fundación Sonrisa de Alex & Todos somos Iván (TVP 1324/15).

Surgical treatment for pelvic Ewing sarcoma: What is a safe and functional acetabular reconstruction when combined with modern multidisciplinary treatments?

PURPOSE

The purpose of this study was to clarify which local treatment is oncologically and functionally effective in pelvic Ewing sarcoma (ES).

METHODS

A consecutive series of patients who underwent pelvic resections and acetabular reconstructions after chemotherapy between 1986 and 2016 at a supra-regional center were evaluated.

RESULTS

The cohort consisted of 35 patients. The 5-year overall survival (OS) and local recurrence-free survival (LRFS) was 61% and 72%, respectively. Preoperative radiotherapy (RT) and surgery provided an excellent/good histological response in 92% and achieved significantly better OS (5 years, 64%) and LRFS (5 years, 100%) than surgery alone or surgery with postoperative RT. The Musculoskeletal Tumor Society functional scores were significantly better in patients with hip transposition than those with structural reconstructions (74% vs 57%; P = .031) using custom-made prostheses, irradiated autografts, and ice-cream cone prostheses. These scores were significantly lower if patients had deep infection (P = .035), which was the most common complication (28%) in structural reconstructions but did not occur in hip transposition even when performed after preoperative RT.

CONCLUSION

Acetabular reconstruction with hip transposition resulted in no deep infection and superior function in patients with pelvic ES even when combined with preoperative RT, which improved tumor necrosis and rate of local control and survival.

Treatment and outcome of patients with thoracic tumors of the Ewing sarcoma family: A report from the Cooperative Weichteilsarkom Studiengruppe CWS-81, -86, -91, -96, and -2002P trials

BACKGROUND

Ewing tumors are the most frequent malignant tumors of the chest wall in children and young adults. Surgical management of these tumors can be challenging. Optimal local control remains controversial. The aim of this study was to analyze treatment, outcome, and surgical procedures in patients with thoracic tumors of the Ewing sarcoma family (TES) treated within four Cooperative Soft-Tissue Sarcoma (CWS) trials and one registry.

PATIENTS AND METHODS

Sixty-two patients from 0 to 21 years treated between 1981 and 2014 were selected for this analysis. A retrospective chart analysis was carried out. Institutional review board approval was obtained for all trials.

RESULTS

The median age of the patients was 7 years. The 5-year overall (OS) and event-free survival (EFS) rates were 58.7% (52.7-64.7) and 52.8% (46.8-58.8). Patients with intrathoracic tumor localization (n = 24) had a worse outcome (EFS: 37.5%; 27.5-37.5) compared with those with chest wall tumors (n = 38; EFS: 62.3%; 54.3-70.3, P = 0.008). Patients ≤10 years (n = 38) had a better survival compared with those > 10 years (EFS: 65.7%; 57.7-73.7 vs 31.3%; 21.3-41.3, P = 0.01). Tumor size ≤5 cm (n = 15) was associated with significantly better survival compared with a size > 5 cm (n = 47, EFS: 93.3%; 87.3-99.3 vs 40%; 33-47, P = 0.002). Primary resections were carried out in 36 patients, of which 75% were incomplete resulting in inferior EFS (P = 0.006). Complete secondary resections were performed in 22 of 40.

CONCLUSIONS

Positive predictive factors for outcome are age ≤10 years, size ≤5 cm, and localization at the chest wall. Diverse IRS groups require individual treatment.

Easy-to-use clinical tool for survival estimation in Ewing sarcoma at diagnosis and after surgery

Accurate survival estimations in Ewing sarcoma are necessary to develop risk- and response adaptive treatment strategies allowing for early decision-making. We aim to develop an easy-to-use survival estimation tool from diagnosis and surgery. A retrospective study of 1314 Ewing sarcoma patients was performed. Associations between prognostic variables at diagnosis/surgery and overall survival (OS), were investigated using Kaplan-Meier and multivariate Cox models. Predictive accuracy was evaluated by cross-validation and Harrell C-statistics. Median follow-up was 7.9 years (95%CI 7.6–8.3). Independent prognostic factors at diagnosis were age, volume, primary tumor localization and disease extent. 5 risk categories (A-E) were identified with 5-year OS of 88% (86–94), 69% (64–74), 57% (50–64), 51% (42–60) and 28% (22–34) respectively. Harrell C-statistic was 0.70. Independent prognostic factors from surgery were age, volume, disease extent and histological response. In categories A-B, 5y OS increased to 92% (87–97) and 79% (71–87) respectively for 100% necrosis and decreased to 76% (67–85) and 62% (55–69) respectively for <100% necrosis. In categories C-E, 5y OS increased to 65% (55–75), 65% (52–78) and 52% (38–66) respectively for ≥90% necrosis and decreased to 38% (22–54), 11% (0–26) and 7% (0–19) respectively for <90% necrosis. We present an easy-to-use survival estimation tool from diagnosis in Ewing sarcoma based on age, volume, primary tumor localization and disease extent. Histological response is a strong additional prognostic factor for OS.

Local recurrence of Ewing sarcoma: Is wide excision an acceptable treatment?

BACKGROUND AND OBJECTIVES

Local recurrence in Ewing sarcoma (ES) is associated with poor prognosis. The purpose of the study is to determine what factors affect overall survival after local recurrence and whether wide excision constitutes appropriate treatment.

METHODS

From 1992 to 2017, 26 patients were treated for local recurrence of ES. Sixteen patients presented with local recurrence only while 10 had metastasis. The median follow-up was 23 months (range, 3-255 months). Overall survival was assessed with Kaplan-Meier analysis.

RESULTS

At the last follow-up, seven of 26 (27%) patients were alive. Overall survival after local recurrence was 28% at 5 years. Later onset of local recurrence (P = .041), surgical treatment (P < .001), and complete eradication of all recurrent disease (P < .001) predicted better survival. Metastasis was associated with worse survival (P = .014). All three patients who survived more than 10 years were treated with wide local excision. A second local recurrence developed in seven patients (28%) but did not predict worse overall survival.

CONCLUSIONS

Overall survival after local recurrence is better for patients with nonmetastatic disease treated surgically. Wide excision can be compatible with long survival. We do not advocate amputation on a routine basis for local recurrence. Complete eradication of all diseases is associated with better survival.

[Round-cell sarcomas]

Round-cell sarcomas represent highly malignant tumors that occur predominantly in children, adolescents, and young adults. Round-cell sarcomas are caused by recurrent translocations that involve certain transcription factors. Ewing's sarcoma, Ewing-like sarcomas (e.g. CIC-DUX positive or BCOR positive sarcomas), desmoplastic small round-cell tumors (DSRCTs), and alveolar rhabdomyosarcomas (ARMs) are typical examples of this particular group of sarcomas. These entities differ in their tumor genetics, which is correlated with immunohistochemical expression profiles and with clinical phenotypes. Classification should be based on molecular findings. Immunohistochemistry may serve as a surrogate marker.

Exploiting Signaling Pathways and Immune Targets Beyond the Standard of Care for Ewing Sarcoma

Ewing sarcoma (ES) family of tumors includes bone and soft tissue tumors that are often characterized by a specific translocation between chromosome 11 and 22, resulting in the EWS-FLI1 fusion gene. With the advent of multi-modality treatment including cytotoxic chemotherapy, surgery, and radiation therapy, the prognosis for patients with ES has substantially improved. However, a therapeutic plateau is now reached for both localized and metastatic disease over the last two decades. Burdened by the toxicity limits associated with the current frontline systemic therapy, there is an urgent need for novel targeted therapeutic strategies. In this review, we discuss the current treatment paradigm of ES, and explore preclinical evidence and emerging treatments directed at tumor signaling pathways and immune targets.

Ewing sarcoma of the rib presenting with hemothorax

Ewing sarcoma is a malignant primitive neuroectodermal tumor, primarily affecting the long bones in young children and adolescents. It is a rare disease but is the most common malignancy of the chest wall, accounting for 6%–16% of chest wall cancers. We report a case of Ewing sarcoma of the rib presenting with massive hemothorax in a teenage boy, with rapid disease progression.

Bone marrow biopsy in the initial staging of Ewing sarcoma: Experience from a single institution

BACKGROUND

Ewing sarcoma (ES) is the second most common bone tumor in adolescents and children. Staging workup for ES includes imaging and bone marrow biopsy (BMB). The effective role of BMB is now under discussion.

PROCEDURE

A monoinstitutional retrospective analysis reviewed clinical charts, imaging, and histology of patients with diagnosis of ES treated at the Rizzoli Institute between 1998 and 2017.

RESULTS

The cohort included 504 cases of ES of bone; 137 (27%) had metastases at diagnosis, while the remaining 367 had localized disease. Twelve patients had a positive BMB (2.4%). Eleven had distant metastases detected at initial workup staging with imaging assessment: six patients presented with bone metastases, five with both bone and lung metastases. Only one patient with ES of the foot (second metatarsus) was found to have bone marrow involvement with negative imaging evaluation (0.3%).

CONCLUSIONS

On the basis of our data, we suggest reconsidering the effective role of BMB in initial staging workup for patients with ES with no signs of metastases by modern imaging techniques. In metastatic disease, the assessment of the bone marrow status may remain useful to identify a group of patients at very high risk who could benefit from different treatment strategies.

Bone marrow examination in patients with Ewing sarcoma/peripheral primitive neuroectodermal tumor without metastasis based on 18F-fluorodeoxyglucose positron emission tomography/computed tomography

Ewing sarcoma/peripheral primitive neuroectodermal tumor (ES/PNET) is an aggressive bone tumor. Bone marrow aspiration and biopsy (BMAB) has been recognized as the gold standard for assessing bone marrow status. While the latest guideline suggests the need to omit bone marrow aspiration in patients with no findings on ¹⁸F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET) based on one retrospective report, there is no study using ¹⁸F-FDG PET/computed tomography (CT). We retrospectively reviewed 26 consecutive, previously untreated, ES/PNET patients. We compare the results of bone marrow aspiration and biopsy (BMAB) and those of ¹⁸F-FDG PET/CT in ES/PNET patients. All of the 21 patients without metastases on ¹⁸F-FDG PET/CT had negative BMAB. The sensitivity of bone marrow involvement in bone metastases positive patients on ¹⁸F-FDG PET/CT was 75% (3/4), and the specificity was 100% (22/22). In addition to the metastatic findings on ¹⁸F-FDG PET/CT, tumor diameter, lactate dehydrogenase level at diagnosis, and the presence or absence of bone metastasis were factors related to bone marrow involvement. It may be a reasonable option to omit BMAB in ES/PNET patients with no distant metastasis based on ¹⁸F-FDG PET/CT findings.

PTPRD copy number variants and Ewing's sarcoma: Strengthening the association and therapeutic implications

Ewing sarcoma (ES), a common pediatric primary bone neoplasm, has a well-defined genomic landscape with various predisposing genomic elements including TP53, PMS2 and RET. Additionally, germline and somatic variants in protein tyrosine phosphatase delta (PTPRD), a tumor suppressor gene, have been identified in a limited number of ES patients. Here we present an ES patient, remarkable in terms of his young age and extent at presentation, found to have a PTPRD CNV. We explore the pathogenicity of this CNV, describe the patient's clinical course and touch upon the potential therapeutic implications in this subset of patients.

Outcomes in different age groups with primary Ewing sarcoma of the spine: a systematic review of the literature

OBJECTIVE

Ewing sarcoma (ES) is among the most prevalent of bone sarcomas in young people. Less often, it presents as a primary lesion of the spine (5%-15% of patients with ES).

METHODS

A systematic literature search was performed, querying several scientific databases per PRISMA guidelines. Inclusion criteria specified all studies of patients with surgically treated ES located in the spine. Patient age was categorized into three groups: 0-13 years (age group 1), 14-20 years (age group 2), and > 21 (age group 3).

RESULTS

Eighteen studies were included, yielding 28 patients with ES of the spine. Sixty-seven percent of patients experienced a favorable outcome, with laminectomies representing the most common (46%) of surgical interventions. One-, 2-, and 5-year survival rates were 82% (n = 23), 75% (n = 21), and 57% (n = 16), respectively. Patients in age group 2 experienced the greatest mortality rate (75%) compared to age group 1 (9%) and age group 3 (22%). The calculated relative risk score indicated patients in age group 2 were 7.5 times more likely to die than other age groups combined (p = 0.02).

CONCLUSIONS

Primary ES of the spine is a rare, debilitating disease in which the role of surgery and its impact on one's quality of life and independence status has not been well described. This study found the majority of patients experienced a favorable outcome with respect to independence status following surgery and adjunctive treatment. An increased risk of recurrence and death was also present among the adolescent age group (14-20 years).

Ewing Sarcoma in Nepal Treated With Combined Chemotherapy and Definitive Radiotherapy

PURPOSE

To our knowledge, we conducted the first prospective oncologic clinical trial in Nepal aimed at providing state-of-the-art chemotherapy to patients with Ewing sarcoma. The efficacy of external-beam radiotherapy (RT) as the sole local treatment modality was explored and deemed justified as a result of the lack of available advanced tumor-orthopedic services in Nepal.

PATIENTS AND METHODS

Twenty patients, 11 female and 9 male patients between the ages of 6 and 37 years, with newly diagnosed Ewing sarcoma were enrolled. Neoadjuvant combination chemotherapy, comprising well-established drug combinations, was administered in five courses before external-beam RT, during which one course of etoposide and ifosfamide was given. After RT, six additional chemotherapy courses were scheduled.

RESULTS

RT was tolerated well, providing rapid symptom relief and local tumor control, with no pathologic fractures observed among the 15 patients who received such treatment. Eleven patients completed the entire treatment protocol; seven patients were under continued follow-up, with no evidence of disease in six patients at a median follow-up time of 2.3 years (range, 1.3 to 3.1 years) and one patient alive but with a regional recurrence. Four patients experienced metastatic relapse and died as a result of their disease. Three treatment-related deaths linked to toxicity from chemotherapy occurred. Four of the six patients who refused to complete the treatment protocol and were lost to follow-up experienced progressive disease and were assumed dead.

CONCLUSION

This study was feasible with RT as the sole local treatment modality in combination with chemotherapy. As a result of the high number of patients lost to follow-up, no firm conclusions can be drawn, but the majority of the patients who completed treatment obtained durable long-term remissions.

Important Recently Characterized Non-Ewing Small Round Cell Tumors

Round cell sarcomas morphologically similar to Ewing sarcoma, but lacking the classic immunohistochemical features, EWSR-ETS family fusions, and other signs of differentiation, are classified as Ewing-like sarcomas. Recent molecular advances led to the discovery and characterization of two recurrent oncogenic fusion rearrangements, CIC-DUX4 and BCOR-CCNB3, in a significant subset of Ewing-like sarcomas. Uncovered alternate fusion partners broadened the proposed classification of these tumors to CIC-rearranged sarcomas and BCOR-rearranged sarcomas. This article summarizes the clinicopathologic and molecular features of these entities, with particular attention paid to those features that overlap with and distinguish these sarcomas from other round cell sarcomas.

Treatment and outcome of patients with thoracic tumors of the Ewing sarcoma family: A report from the Cooperative Weichteilsarkom Studiengruppe CWS-81, -86, -91, -96, and -2002P trials

BACKGROUND

Ewing tumors are the most frequent malignant tumors of the chest wall in children and young adults. Surgical management of these tumors can be challenging. Optimal local control remains controversial. The aim of this study was to analyze treatment, outcome, and surgical procedures in patients with thoracic tumors of the Ewing sarcoma family (TES) treated within four Cooperative Soft-Tissue Sarcoma (CWS) trials and one registry.

PATIENTS AND METHODS

Sixty-two patients from 0 to 21 years treated between 1981 and 2014 were selected for this analysis. A retrospective chart analysis was carried out. Institutional review board approval was obtained for all trials.

RESULTS

The median age of the patients was 7 years. The 5-year overall (OS) and event-free survival (EFS) rates were 58.7% (52.7-64.7) and 52.8% (46.8-58.8). Patients with intrathoracic tumor localization (n = 24) had a worse outcome (EFS: 37.5%; 27.5-37.5) compared with those with chest wall tumors (n = 38; EFS: 62.3%; 54.3-70.3, P = 0.008). Patients ≤10 years (n = 38) had a better survival compared with those > 10 years (EFS: 65.7%; 57.7-73.7 vs 31.3%; 21.3-41.3, P = 0.01). Tumor size ≤5 cm (n = 15) was associated with significantly better survival compared with a size > 5 cm (n = 47, EFS: 93.3%; 87.3-99.3 vs 40%; 33-47, P = 0.002). Primary resections were carried out in 36 patients, of which 75% were incomplete resulting in inferior EFS (P = 0.006). Complete secondary resections were performed in 22 of 40.

CONCLUSIONS

Positive predictive factors for outcome are age ≤10 years, size ≤5 cm, and localization at the chest wall. Diverse IRS groups require individual treatment.

Prognostic factors and survival in Ewing's sarcoma treated by limb salvage surgery

PURPOSE

Survival in Ewing's sarcoma (ES) has increased with the use of chemotherapy. Surgical techniques such as limb salvage (LS) have been developed. Survival and adverse events have been widely studied in general series of ES, but there are few specific series of ES cases treated by LS, despite this being the most commonly used (surgical) approach. The aim of this study was to determine survival and prognostic factors in ES patients undergoing LS.

PATIENTS AND METHODS

We analysed all ES patients treated between January 1984 and May 2008 and selected all those treated by systemic multimodal therapy and LS. We assessed the influence of patient characteristics, tumour parameters and therapeutic results in event-free survival (EFS).

RESULTS

Ninety patients were included. Fifty of them were treated by systemic multimodal therapy and locally by LS. ean age was 20 years. Overall survival (OS) was 68.8% and EFS was 60.6% at years. In the univariate analysis, pelvic location, age and response to chemotherapy were associated with poor prognosis. After multivariate analysis, poor response to treatment, pelvis location and age between 12 and 17 years were found to be independent prognostic factors. Dissemination at diagnosis was not a prognostic factor.

CONCLUSIONS

OS and EFS in ES treated by LS were similar to findings in previous ES studies. factors are no different, except for the presence of metastasis at diagnosis.

The relation of radiological tumor volume response to histological response and outcome in patients with localized Ewing Sarcoma

Background

Magnetic resonance imaging (MRI) is the modality of choice for local staging and response evaluation of Ewing sarcoma (EwS). Aim of this study was to determine the relevance of tumor volume response (TVR) in relation to histological response (HisRes) and survival, in order to evaluate if early modification of chemotherapy might be indicated in patients with inadequate TVR.

Methods

Three dimensional (3D)‐tumor volume data at diagnosis, during early induction phase (1‐3 courses of chemotherapy; n = 195) and/or late induction phase (4‐6 courses; n = 175) from 241 localized patients were retrospectively analyzed. A distinction was made between adequate response (reduction ≥67%) and inadequate response (reduction <67% or progression). Correlations between TVR, HisRes, event free survival (EFS), and overall survival (OS) were analyzed using chi‐square tests, log‐rank tests, and the Cox‐regression model.

Results

Early adequate TVR, noted in 41% of patients, did not correlate with EFS (P = 0.92) or OS (P = 0.38). During late induction phase 62% of patients showed an adequate TVR. EFS for patients with late adequate TVR was better (78%) than for those with inadequate late TVR (61%) (P = 0.01); OS was 80% and 69% (P = 0.26), respectively. No correlation was found between TVR and HisRes. Multivariate analysis showed that poor HisRes, pelvic location and late inadequate TVR were associated with poor outcome.

Conclusions

Early inadequate TVR does not predict adverse outcome; therefore, changing the treatment to second line chemotherapy is not indicated in case of inadequate early TVR. Late adequate TVR and good HisRes correlate with better EFS; patients with late inadequate TVR might benefit from augmented therapy.

Surgical Resection of Primary Ewing's Sarcoma of Bone Improves Overall Survival in Patients Presenting with Metastasis

Background

Metastatic Ewing’s sarcoma (ES) of bone has a poor prognosis. Because there have been few previous studies on the prognostic factors and clinical outcome in patients with ES who have metastases at presentation, the aim of this study was to use the Surveillance, Epidemiology, and End Results (SEER) database to compare the clinical outcome following single and combined radiation treatment and surgery.

Material/Methods

The SEER database was used to identify patients with ES who presented with bone involvement and metastasis between 1973 to 2015. Prognostic analysis was performed using the Kaplan-Meier method and the Cox proportional hazards regression model.

Results

There were 643 patients identified from the SEER database. The 5-year overall survival (OS) and cancer-specific survival (CSS) rates were 33.1% and 34.3%, respectively and the median OS and CSS were 29.0±1.9 and 29.0±2.1 months, respectively. Multivariate analysis identified age <20 years and surgical resection of the primary tumor to be significantly associated with improved OS. Radiation therapy was not an independent predictor of OS or CSS. Radiation therapy alone resulted in a significantly reduced the OS and CSS compared with surgical resection alone. Combined surgery and radiation therapy of the primary tumor did not significantly improve the OS or CSS of patients with ES and metastatic disease when compared with surgery alone.

Conclusions

Age <20 years and surgical resection of the primary tumor were significantly associated with improved OS in patients with primary ES of bone who presented with metastasis.

A nomogram to predict prognosis in Ewing sarcoma of bone

Objective

This study was designed to develop a nomogram for assessing the survival of patients with Ewing sarcoma (ES).

Methods

Data from patients diagnosed with ES between 2004 and 2013 were collected from the Surveillance, Epidemiology, and End Results (SEER) database. Based on patient registration, the primary cohort was divided into a training set (n = 479, data from 17 cancer registries) and a validation set (n = 137, data from 1 cancer registry). Then, the prognostic effects of variables were analyzed using Kaplan–Meier method and Cox proportional hazard model. Moreover, nomograms were established for estimating 3- and 5-year overall survival (OS) and cancer-special survival (CSS) based on Cox regression model. Last, nomogram was validated by training set and validation set.

Results

According to the multivariate analysis of training set, nomogram which combined age, race, stage, tumor site, tumor size and chemotherapy was identified. The internal bootstrap resampling approach suggested the nomogram had sufficient discriminatory power with the C-index of OS: 0.754 (95% CI, 0.705–0.802) and CSS: 0.759 (95% CI, 0.700–0.800). The calibration plots also demonstrated good consistence between the prediction and the observation.

Conclusion

Our nomogram is a reliable and powerful tool for distinguishing and predicting the survival of ES patients, thus helping to better select medical examinations and optimize treatment options in collaboration with medical oncologists and surgeons.

Treatment Outcomes of Pediatric Patients With Ewing Sarcoma in a War-Torn Nation: A Single-Institute Experience From Iraq

PURPOSE

Ewing sarcoma (ES) is a relatively rare, highly malignant tumor of the musculoskeletal system. It is the second most common malignant bone tumor in children and adolescents in the age group of 5 to 20 years. The aim of this study was to identify the treatment outcomes of pediatric patients with ES in Sulaimani governorate, Iraq.

PATIENTS AND METHODS

This was a retrospective study that reviewed the medical records of pediatric patients with ES who were managed between 2009 and 2015, with follow-up until late 2017. Patient- and tumor-related factors were correlated with clinical outcomes.

RESULTS

A total of 31 pediatric patients with ES were included in this study. All the patients received chemotherapy and radiotherapy, whereas only 14 patients underwent surgical resection and just eight had free surgical margins. The median age at diagnosis was 13 years, 58% were male, and 42% were female. The presenting symptoms at diagnosis were mostly pain (67.7%) and palpable mass (25.8%). The primary tumor was located in the extremities (51.6%), the thoracic cage (19.4%), the pelvis (16.1%), and the lumbar vertebrae (12.9%). Approximately two thirds of the patients (61.3%) had localized disease at the time of presentation. The 5-year overall survival was 19%, and the 5-year recurrence-free survival was 34%.

CONCLUSION

Clinical outcomes of ES in pediatric patients in our war-torn nation, Iraq, are still markedly inferior to the published outcomes from stable, developed nations. Additional large and multicenter national studies are required. Diagnostic and therapeutic measures need improvement, and multidisciplinary and comprehensive cancer-integrated approaches are vital for better outcomes.

Treatment and survival of osteosarcoma and Ewing sarcoma of the skull: a SEER database analysis

Background

Common primary bone tumors include osteosarcomas (OSC) and Ewing sarcomas (EWS). The skull is a rare site, and literature about their treatment and survival is scarce. Using the Surveillance, Epidemiology, and End Results (SEER) database, this study aims to assess the treatment and survival of skull OSC and skull EWS, as well as predictors for survival.

Methods

Skull OSC and EWS cases were obtained from the SEER database. Patient and tumor characteristics, treatment modalities, and survival were extracted. Overall survival (OS) was assessed using multivariable Cox proportional hazard regression stratified by tumor histology. Kaplan-Meier curves were constructed for OS comparing OSC and EWS, as well as histological subtypes in OSC.

Results

A total of 321 skull OSC and 80 skull EWS patients were registered from 1973 to 2013. EWS was more common in younger patients (p < 0.001). Resection was the predominant treatment strategy (80.1%), frequently in combination with adjuvant radiotherapy (30.4%). The 5-year survival rate varied significantly between OSC and EWS (51.0% versus 68.5%, p = 0.02). Kaplan-Meier curves show that EWS had a significantly better survival compared to OSC. Comparing histological subtypes of skull OSC, chondroblastic OSC had the best OS, Paget OSC the worst. Older age, tumor advancement, no surgical treatment, and the use of radiotherapy were identified as independent predictors of decreased OS in skull OSC.

Conclusion

Overall prognosis is better for EWS compared to OSC. Chondroblastic OSC have the best overall survival, while OSC associated with Paget’s disease of the bone has the poorest overall survival.

Pediatric Ewing sarcoma of the head and neck: A retrospective survival analysis

OBJECTIVE

To determine the demographics, treatment modalities, and overall survival of pediatric Ewing sarcoma of the head and neck.

METHODS

The National Cancer Institute's Surveillance, Epidemiology, and End Results database was used to identify cases of pediatric Ewing sarcoma of the head and neck between 1973 and 2015. Additional variables collected included age, gender, ethnicity, tumor grade, staging, treatment modality, and follow-up time. Kaplan-Meier survival curves were generated and overall survival was calculated.

RESULTS

One hundred and twenty-seven cases of pediatric Ewing sarcoma were identified. The majority of patients were male (52.8%), white (88.2%), and non-Hispanic (75.6%), and the mean age at diagnosis was 10.5 years. The most common tumor sites were bones and joints of the skull and face (45.5%), followed by soft tissue of the head, face, and neck (25.2%), followed by the mandible (13.4%). Most patients (69.2%) had some type of surgery, 70.0% received radiation, and 92.1% received chemotherapy as part of their treatment. Overall 1-, 5-, and 10-year survival was 91.1%, 72.9%, and 68.2%, respectively. There was no significant difference in survival based on patient gender, age, tumor location, radiation, or chemotherapy treatment.

CONCLUSION

This study demonstrates that pediatric patients with Ewing sarcoma of the head and neck most commonly have stage II disease, no distant metastasis, and are treated with chemotherapy, with or without radiation. One, five, and ten-year survival are 91.1%, 72.9%, and 68.2%, respectively, and age, gender, and radiation do not seem to affect prognosis.

Precision medicine approaches for the management of Ewing sarcoma: current perspectives

Advancements in molecular and genetic techniques have significantly furthered our biological understanding of Ewing sarcoma (ES). ES is typified by a driving TET-ETS fusion with an otherwise relatively quiet genome. Detection of one of several characteristic fusions, most commonly EWSR1-FLI1, is the gold standard for diagnosis. We discuss the current role of precision medicine in the diagnosis, treatment, and monitoring of ES. Continued efforts toward molecularly guided approaches are actively being pursued in ES to better refine prognosis, identify germline markers of disease susceptibility, influence therapeutic selection, effectively monitor disease activity in real time, and identify genetic and immunotherapeutic targets for therapeutic development.

Primary Intra-abdominal Ewing's Sarcoma in Adults: A Multimodality Imaging Spectrum

Ewing sarcoma (ES) and peripheral primitive neuroectodermal tumor are part of a spectrum of neoplastic diseases known as the ES family of tumors, which also includes extraosseous ES, peripheral primitive neuroectodermal tumor, malignant small-cell tumor of the thoracopulmonary region (Askin's tumor), and atypical ES. Although imaging features of these tumors have been previously described, extensive discussion about intra-abdominal manifestations is scarce in the literature. We present an imaging spectrum of these tumors in the abdomen and pelvis with particular attention to multimodality approach for staging and restaging.

Risk stratification by somatic mutation burden in Ewing sarcoma

BACKGROUND

Up to one-third of patients with localized Ewing sarcoma (ES) develop recurrent disease, but current biomarkers do not accurately identify this high-risk group. Therefore, the objective of this study was to determine the utility of mutational burden in predicting outcomes in patients with localized ES.

METHODS

Clinical and genomic data from 99 patients with ES, of whom 63 had localized disease at diagnosis, were obtained from the cBioPortal for Cancer Genomics. Genomic data included the type and number of somatic mutations using cBioPortal mutation calling. Primary endpoints were overall survival (OS) and the time to progression (TTP).

RESULTS

Patients had a median number of 11 somatic mutations. Patients were stratified according to whether they had a lower or higher mutational burden if they had ≤11 or >11 mutations, respectively. Higher mutational burden was significantly associated with inferior OS and TTP, a finding that was confirmed by univariate and multivariable analyses. In patients who had localized disease at diagnosis, higher mutational burden was the only variable significantly associated with inferior OS and TTP. The presence of a mutation in either stromal antigen 2 (STAG2) or tumor protein 53 (TP53), both of which were correlated previously with shorter OS in patients with ES, were significantly associated with higher mutational burden. Upon stratifying patients who had localized disease based on a standard panel of cancer genes, higher risk stratification was correlated significantly with inferior TTP and trended toward significance with inferior OS.

CONCLUSIONS

Patients who have localized ES and a higher mutational burden have inferior OS and TTP compared with those who have lower mutation burden. The current findings suggest that the somatic mutation burden can be used to better risk stratify these patients and to guide clinical decision making.

Primary Ewing's Sarcoma of Zygoma

Ewing's sarcoma is a small round cell tumor, malignant in nature, typically affecting long bones and pelvis. It is most commonly presented in the pediatric age group. The occurrence of Ewing's sarcoma in the head-and-neck region is rare and is reported to be around 2%–3%, of which chances of having primary lesion are rarer. Among facial bones, mandible is the most commonly affected bone. Primary involvement of zygoma is extremely rare. Here, we present a case of primary Ewing's sarcoma of the left zygoma in a 17-year-old girl. The diagnosis was made after surgical resection, histopathology with immunohistochemistry confirmation, and cytogenetic study.

Ewing sarcoma of the mobile spine; predictive factors for survival, neurological function and local control. A Scandinavian sarcoma group study with a mean follow-up of 12 years

Object: Many patients with Ewing sarcoma (ES) of the mobile spine present with neurologic symptoms leading to emergency decompressive surgery. Only rarely is optimal treatment involving neo-adjuvant chemotherapy followed by en bloc excision possible. The purpose of this study was to study treatment, neurologic and oncologic outcome in patients with ES of the mobile spine.

Methods: Twenty-four patients diagnosed between 1986 and 2012 were identified through the Scandinavian Sarcoma Group registry. Charts were reviewed in order to assess details in patient characteristics, neurologic status, treatment and outcome. Prognostic factors were analyzed with respect to local control, disease-free survival and overall survival.

Results: Neurologic symptoms were frequently observed at presentation, being present in 19/23 patients with documented neurologic status. Most (13/19) patients had a complete neurologic recovery regardless of whether or not emergency decompressive surgery was performed. The majority (18/24) of patients were treated with definitive radiotherapy. However, only 9/17 received the recommended dose of  ≥  50.4 Gy. The disease-free and overall survival rates at 10 years were 48% and 57%, respectively. The local recurrence rates were 19% and 27% at 5 and 10 years, respectively. Only year of diagnosis, categorized into periods with significant changes in chemotherapy protocols, was a significant factor for local recurrence, but there was a trend (p = 0.06) for an increased risk of a local recurrence if emergency decompressive surgery was performed.

Conclusion: Patients with ES of the mobile have a relatively favorable prognosis. Nonetheless, local recurrence rate is high for this group of patients for which local treatment mainly relies on definitive radiotherapy.

Emergency decompressive surgery may increase the risk for local recurrence.

The efficacy and safety of apatinib in Ewing's sarcoma: a retrospective analysis in one institution

BACKGROUND

Ewing's sarcoma (ES) is a highly aggressive and metastatic neoplasm occurring mainly in children and young adults. The standard treatment of localized ES requires a combination of surgery, chemotherapy, and radiotherapy. Although the 5-year survival rate for local ES has improved, the survival rate and prognosis are still very poor for metastatic or recurrent ES patients. The aim of this study was to investigate the efficacy and safety of apatinib, a specific vascular endothelial growth factor receptor 2 inhibitor, in ES patients.

METHODS

This retrospective analysis involved eleven patients with ES not amenable to curative treatment. All patients suffered poor responses to two cycles of chemotherapy (vincristine, doxorubicin, and cyclophosphamide). Apatinib 500 mg (or 250 mg) was given daily. Tumor responses were assessed according to the Response Evaluation Criteria in Solid Tumors 1.1. Survival analysis was performed by the Kaplan-Meier test. The safety profile was also recorded.

RESULTS

The mean age of the patients was 18 (range, 10-31) years. The 12-month overall survival and progression-free survival rates were 90% and 72%, respectively. Four patients achieved partial response, and four patients achieved stable disease, with objective response rate of 40%. The median follow-up in our study was 16 months (range, 3-26 months). The most common adverse events included hand-foot skin reaction (n=5; 45%), oral ulcers (n=4; 36%), and gastrointestinal discomfort (n=4; 36%).

CONCLUSION

Apatinib may provide as second- or first-line treatment options for ES patients, particularly in chemoresistant cases. Further studies with more cases and longer follow-up will be necessary to determine the clinical efficacy and safety of apatinib in ES patients.

Comparison of clinical features and outcomes in patients with extraskeletal vs skeletal Ewing sarcoma: an SEER database analysis of 3,178 cases

Background

The clinicopathological characteristics, outcomes and prognostic factors of primary extraskeletal Ewing sarcoma (EES) remained insufficiently explored. We aimed to examine these aspects and compared the same with skeletal Ewing sarcoma (SES).

Patients and methods

We identified Ewing sarcoma, peripheral primitive neuroectodermal tumors or Askin tumor patients who were registered in the Surveillance, Epidemiology, and End Results database from 1973 to 2014. Clinicopathological features were assessed by using Fisher’s exact tests. Cancer-specific survival (CSS) and overall survival (OS) were estimated by using the Kaplan–Meier method and the Cox proportional hazards model. Prognostic factors were identified by multivariate Cox regression analysis.

Results

The age of patients with EES was diagnosed to be higher and they were more likely to be female (46.1% vs 36.2%; P<0.001), have tumor <10 cm (49.8% vs 35.4%; P<0.001), have regional node involvement (5.4% vs 1.0%; P<0.001) and receive surgery (69.1% vs 53.8%; P<0.001) compared to patients with skeletal tumors. Metastatic status did not differ by origin. Kaplan–Meier analysis showed that the origin had significant difference in CSS and OS among patients aged 0–19 years and with metastatic stage at presentation, but not in patients aged 20–39, ≥40 years and with no-metastatic stage. A Cox multivariable model controlling for differences between groups confirmed inferior survival for patients with EES. Age, tumor size, tumor stage and surgery were the most important factors significantly influencing both CSS and OS in the EES and SES patients. Race, year of diagnosis and tumor site were associated with CSS and OS among patients with SES, but failed in EES.

Conclusion

The clinicopathological characteristics, outcomes and prognostic factors differed among patients with EES compared to patients with SES. Extraskeletal origin was an unfavorable prognostic factor.

Cutaneous Ewing Sarcoma and Ewing Sarcoma of the Bone: Distinct Diseases

Ewing sarcoma is an aggressive mesenchymal malignancy. It is the second most common bone tumor among children and adolescents and less commonly presents as a soft tissue or primary skin lesion. Cutaneous Ewing sarcoma has only been reported in case reports and case series. In this article, we describe a 12-year-old Hispanic female cured of localized, cutaneous Ewing sarcoma (pT1aN0M0) at the 40-month follow-up following surgical resection and adjuvant chemotherapy according to the COG AEWS1031 protocol for Ewing sarcoma of the bone. To our knowledge, this is the first article to provide a potential biological explanation for the differences in the prognosis of Ewing sarcoma of the bone, soft tissue, and skin.

Risk factors for detectable metastatic disease at presentation in Ewing sarcoma - An analysis of the SEER registry

BACKGROUND

Ewing family of tumors (EFT) represents the second-most common primary bone malignancy in children and adolescents. Approximately 25% of patients have radiographically detectable metastatic disease at presentation and experience poorer five-year survival, yet risk factors for metastatic disease at presentation are poorly characterized. We sought to study patient characteristics associated with metastatic disease upon presentation for patients with EFT.

METHODS

We identified EFT cases in the Surveillance, Epidemiology, and End Results Program (SEER) registry from 2004 to 2012. Using univariate analyses and multivariable logistic regression, we explored the relationship between demographic and clinical factors and the presence of detectable metastatic disease at presentation.

RESULTS

Among 870 EFT cases, 35% (n = 304) presented with detectable metastatic disease. These patients were commonly older (>24 years: 28% vs 19%, p = 0.002) and had a primary tumor site in the axial skeleton (56% vs 44%, p < 0.001). After adjusting for all covariates, compared to patients <11 years, those >24 years old faced a two-fold increase in the odds of metastatic disease (OR = 1.99, 95% CI: 1.17-3.38). Axial (OR = 2.31, 95% CI: 1.58-3.37) and "other" (OR = 2.35, 95% CI: 1.15-4.81) tumor locations had more than twice the likelihood of presenting with metastatic disease, compared to extremity tumor sites. Increasing tumor size conferred up to a three-fold increase in odds of metastatic disease (pTrend <0.001).

CONCLUSIONS

Advanced age, axial tumor location, and increasing tumor size are associated with increased odds of detectable metastatic disease upon presentation with EFT. Although these characteristics are not modifiable, they provide objective factors that may inform patient counseling of metastatic risk.

Analysis of bone and soft-tissue sarcomas registered during the year 2012 at Tata Memorial Hospital, Mumbai, with clinical outcomes

Introduction

Primary bone and soft tissue sarcomas are rare, but diagnostically and therapeutically challenging group of tumors, requiring multidisciplinary management. There are limited documented studies from multidisciplinary teams , in the form of comprehensive analysis of these tumors, from our country. This study is an analysis of cases of osteosarcomas, Ewing sarcomas (ESs), chondrosarcomas (CSs), and soft-tissue sarcomas (STSs), registered at our institution during 2012.

Methods

Clinical details, including outcomes of cases of bone and STSs, during the year 2012, were retrieved from the medical records of our institution and were further analyzed.

Results

Ninety-five high-grade, extremity-based, treatment-naïve cases of osteosarcomas were treated with a novel, dose-dense, nonhigh-dose methotrexate-based OGS-12 protocol. Good histopathologic response (necrosis ≥90%) was achieved in 59% nonmetastatic and 56% metastatic patients. At a median follow-up of 48 months, the estimated 5-year event-free survival and overall survival (OS) were 67% and 78%, respectively. In the metastatic cohort at a median follow-up of 51 months, the 5-year estimated progression-free survival was 24% and OS was 26%. Among 87 (73.2%) nonmetastatic and 32 (26.8%) metastatic, analyzable cases of ES, at a median follow-up of 40 months, the disease-free survival (DFS) and OS in the nonmetastatic group were 62% and 83%; in the metastatic group, they were 37.5% and 65.6%, respectively. Among 40 cases of CSs (33 nonmetastatic and 7 metastatic), 21 had limb salvage surgery while 5 had amputation. Microscopically, 90.4% were Grade II CSs. Five-year OS and DFS were 84.6% and 71%, respectively. Among 189 high-grade, extremity-based STSs (89% nonmetastatic), synovial sarcoma was the most common subtype (31%). Eighty-five percent had limb preservation surgery; a majority were offered adjuvant radiation with or without chemotherapy. At a median follow-up of 51 (1-63) months, 3-year local control, DFS, and OS were 81%, 48%, and 64%, respectively.

Conclusions

The novel OGS 12 and Ewing Family of Tumors 2001 protocols have shown comparable outcomes to international standards in cases of osteosarcoma and ES, respectively, and merit wider applications, especially in low- and middle-income countries (LMICs). Outcomes in STS and CSs were also comparable and underscore the importance of a multidisciplinary approach for the management of sarcomas in LMICS.

Effectiveness of 18F-FDG PET/CT in the diagnosis, staging and recurrence monitoring of Ewing sarcoma family of tumors: A meta-analysis of 23 studies

BACKGROUND

To investigate the value of positron emission tomography (PET) and PET/computed tomography (CT) using fluorine-18-fluorodeoxyglucose (F-FDG) in the diagnosis, staging, restaging and recurrence monitoring of Ewing sarcoma family of tumors (ESFTs), a meta-analysis was performed through systematically searching PubMed, Embase, and Cochrane Central library to retrieve articles.

METHODS

After screening and diluting out the articles that met inclusion criteria to be used for statistical analysis the pooled evaluation indexes including sensitivity, specificity, and diagnostic odd ratio (DOR) as well as the summary receiver operating characteristic curve (SROC) were calculated involving diagnostic data (true positive, false positive, false negative, and true negative) extracted from original studies.

RESULTS

Screening determined that out of 2007, 23 studies involving a total of 524 patients were deemed viable for inclusion in the meta-analysis. The results of the analysis showed that the sensitivity and specificity were at 86% and 80%, respectively. Additionally, a satisfactory accuracy of F-FDG PET and PET/CT was observed in detecting ESFT recurrence, lung metastasis, and osseous metastasis.

CONCLUSION

This meta-analysis suggests that F-FDG PET and PET/CT with an extremely high accuracy could be considered a valuable method for detecting distant metastasis and post-operational recurrence of ESFT, which might have a profound impact on the development of treatment protocols for ESFT.

Spinal Ewing Sarcoma Metastatic to Bilateral Orbits

A 39-year-old woman with primary spinal Ewing sarcoma and known lung metastases presented with painless bilateral decreased visual acuity over a 1-month period. Examination revealed bilateral disc edema. MRI of the brain/orbits showed metastatic lesions to the dura and bilateral orbits. Venous sinus thrombosis extending to the jugular vein was also noted. To the authors' knowledge, this is the first case of bilateral orbital metastasis and papilledema secondary to Ewing sarcoma and related hypercoagulability.

An Uncommon Presentation of a Primary Bone Tumor: Anti-AMPA (Anti-α-Amino-3-Hydroxy-5-Methyl-4-Isoxazolepropionic acid) Receptor Limbic/Paraneoplastic Encephalitis as a Presenting Feature of Ewing Sarcoma

Anti-AMPA (anti-α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) receptor limbic encephalitis is a rare autoimmune syndrome. It can be associated with an underlying malignancy, such as lung, breast, or thymus. We are reporting a case of a 19-year-old patient who presented with a 2-week history of confusion and short-term memory loss. A magnetic resonance imaging of brain showed increased T2 hyperintensity within the hippocampi bilaterally. Cerebrospinal fluid analysis was positive for anti-AMPA receptor antibodies. A computed tomography revealed multiple pulmonary metastases as well as an expansile lucent and sclerotic lesion in the ilium, which was subsequently biopsied. Histopathology confirmed a diagnosis of Ewing sarcoma (ES). Fluorescence in situ hybridization testing of the specimen identified EWSR1 (22q12.2) signal rearrangements in 80% of cells scored. To date, this is the first case report describing anti-AMPA receptor limbic/paraneoplastic encephalitis as a presenting feature of ES. Although it is rare, the possibility of ES may be considered in young patients presenting with anti-AMPA receptor limbic encephalitis.

Introducing fluorescence guided surgery into orthopedic oncology: A systematic review of candidate protein targets for Ewing sarcoma

Ewing sarcoma (ES), an aggressive bone and soft‐tissue tumor, is treated with chemotherapy, radiotherapy, and surgery. Intra‐operative distinction between healthy and tumorous tissue is of paramount importance but challenging, especially after chemotherapy and at complex anatomical locations. Near infrared (NIR) fluorescence‐guided surgery (FGS) is able to facilitate the determination of tumor boundaries intra‐operatively, improving complete resection and therefore survival. This review evaluates potential ES‐specific proteins from the literature as targets for NIR FGS.

Establishment of a Nomogram-Based Model for Predicting the Prognostic Value of Inflammatory Biomarkers and Preoperative D-Dimer Level in Spinal Ewing's Sarcoma Family Tumors: A Retrospective Study of 83 Patients

BACKGROUND

Ewing's sarcoma family tumors (ESFTs) are the second most common malignancy in children and adolescents. The purpose of the present retrospective study was to evaluate the prognostic role of inflammatory biomarkers and preoperative D-dimer levels in patients with spinal ESFTs.

METHODS

The neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, lymphocyte/monocyte ratio, albumin/globulin ratio, C-reactive protein/albumin ratio (CAR), preoperative D-dimer level, and clinical parameters were evaluated and analyzed. Univariate and multivariate analyses for disease-free survival (DFS) and overall survival (OS) were performed using the log-rank test and Cox regression analysis, respectively. The DFS and OS rates were calculated using the Kaplan-Meier method. Nomograms were established to predict DFS and OS quantitatively.

RESULTS

The optimal cutoff values for D-dimer, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, lymphocyte/monocyte ratio, CAR, and albumin/globulin ratio were 0.3, 3.2, 168, 2.2, 1.5, and 1.4, respectively. The patients were stratified into 2 groups according to the cutoff values. Multivariate analysis revealed that age, resection mode, and D-dimer level were favorable prognostic factors for DFS and OS (P < 0.05). Metastasis and CAR <1.5 were significantly associated with OS (P < 0.05). Nomograms with all significant factors were established to predict DFS and OS.

CONCLUSIONS

Our results have indicated that the preoperative D-dimer level is an effective prognostic factor with discriminatory ability for DFS and OS, superior to other indicators. Also, CAR was favorable prognostic factor for OS. Nomograms of DFS and OS can be recommended as practical models to evaluate the prognosis for patients with spinal ESFTs.