Primary Ewing's sarcoma of the vertebral column

Sacral tumors: a comprehensive review of imaging, diagnostic challenges, and tumor mimics

The sacrum can harbor a diverse group of both benign and malignant tumors, including metastases. Primary tumors of the sacrum can arise from bone, cartilage, marrow, notochordal remnants, or surrounding nerves and vessels. Among a variety of primary tumors of the spine, chordoma, germ cell tumors and Ewing's sarcoma are recognized for their propensity to occur in the sacrum. Imaging is essential in diagnosis, pretreatment evaluation, and assessment of response to treatment. Radiography, CT and MRI are the primary modalities in assessing morphology and tumor extent whereas PET/CT is crucial in the evaluation of systemic disease in the setting of myeloma, lymphoproliferative disease, and metastasis. A definitive diagnosis is not always achievable by imaging as some tumors lack specific imaging features. However, as we detail in this comprehensive review, many entities have characteristic clinical and epidemiological factors as well as typical imaging findings that can help make either a confident diagnosis or offer a narrow list of differentials. We discuss a wide range of benign and malignant, primary, and secondary tumors that can involve the sacrum, highlighting the pertinent clinical details and typical imaging findings of these entities, enabling the reader to develop and apply a systematic approach to evaluating sacral masses on imaging. We also briefly describe non-neoplastic tumor mimics, which include developmental entities, infections, and insufficiency fractures.

Primary Ewing's Sarcoma affecting the Central Nervous System: A single-center experience and Narrative review

BACKGROUND AND OBJECTIVES

Ewing's sarcoma (EWS) is a malignant round-cell tumor arising from the bone and soft tissue. It is a disease of children and young adults. EWS affecting the central nervous system (cranial and spinal column) is relatively rare with an annual incidence of approximately one case per million in the Western population. Due to their rarity, very few studies are available in the literature. We present our experience of managing 21 such cases, highlighting their clinical, and radiological findings, treatment strategy, and surgical outcomes in patients with primary EWS affecting the central nervous system.

MATERIALS AND METHODS

We retrospectively collected hospital records of patients with primary EWS affecting the CNS (cranial and spinal column), who had been surgically treated in our Neuroscience Center between 2015 and 2023. Patients' demographics, presentation, radiological findings, treatment strategy including surgery and biopsy followed by adjuvant therapy, and outcome at discharge, and the latest follow-up were analyzed from our database.

RESULTS

There were sixteen male and five female patients with a mean age of 18.22 ± 12.73 years (ranging from 6 months to 59 years). The commonest presentation was headache and vomiting in cranial lesions (5/13 patients, 38.46%), and back pain in spinal lesions (4/8 patients, 50%). The site of lesions was cranial in thirteen patients (61.9%) and spinal column in eight patients (38.1%). The commonest site was the frontal region in the cranial group (6 patients, 46.15%) and the lumbar region in the spinal group (4 patients, 50%). All patients underwent surgical intervention [tumor resection (18) and biopsy (3)]. Tumor resection was achieved in 18 patients (85.71%). The extent of resection was gross-total excision in 9 patients (42.86%), near-total excision in 5 patients (23.8%), and tumor decompression in 4 patients (19%). Four patients underwent spinal instrumentation. Fifteen patients (71.42%) received multiagent chemo-radiotherapy according to institute protocol. Five patients (23.8%) with poor KPS expired within 6 months of surgery and could not receive adjuvant therapy. Two patients (9.52%) improved symptomatically, and nine patients (42.86%) remained asymptomatic at a mean follow-up of 25.1 ± 29 months. One patient (4.76%) after receiving 2 cycles of adjuvant therapy had initial improvement but expired later due to disease progression. Four patients after adjuvant chemo-radiotherapy (19%) expired due to systemic spread.

CONCLUSION

Primary EWS affecting the central nervous system is a rare variety. A detailed radiological assessment can aid in adequate planning for safe maximal resection. Timely tissue diagnosis is essential for initiating early treatment. Radical excision followed by adjuvant therapy offers a favorable outcome. Postoperative adjuvant chemo-radiotherapy aids in optimal disease control and surgical outcome. With the current treatment strategy, good surgical outcomes can be achieved. However, metastasis is not uncommon and should be evaluated regularly.

Decoding pediatric spinal tumors: a single-center retrospective case series on etiology, presentation, therapeutic strategies, and outcomes

INTRODUCTION

Spinal tumors (ST) often result in dire prognosis, carrying risks such as permanent paralysis, sensory loss, and sphincter dysfunction. Data on their incidence and etiology in pediatric populations are markedly scant. Our study investigates the etiology, clinical manifestation, treatment, and outcomes of pediatric ST.

METHODS

We conducted a retrospective review of our institutional pediatric oncology and neurosurgery database, examining 14 patients under 18 years admitted with ST due to oncological diseases since 2005. We analyzed the clinical presentations, evaluations, molecular diagnostics and treatments for these patients.

RESULTS

The study spanned 15 years and included 14 pediatric patients, each diagnosed with distinct spinal tumor entity. The mean patient age was approximately 19.6 ± 10.1 months. Severe axial pain along the vertebral column was observed in 13 patients, while acute neurological deterioration manifested in 7 patients. As a first-line intervention, 13 patients underwent decompressive surgery through laminectomy and tumor resection, and only one patient received chemotherapy solely. Before surgery, seven patients were unable to walk; post-surgery, six of them regained their ability to ambulate. The diagnosis encompassed a range of neoplasms: two instances of Ewing sarcoma, 3 instances of teratoma, one case presenting an atypical teratoid Rhabdoid tumor, two instances each of low-grade astrocytoma and neuroblastoma, and single instances of ependymoma, meningioma, rhabdomyosarcoma, and embryonal tumors with multilayered rosettes (ETMRs). Three patients succumbed two years after initiating therapy.

CONCLUSION

Despite their rarity, intraspinal tumors in pediatric patients pose substantial therapeutic challenges. The intertwined complexities of the disease entity and the patient's neurological status demand swift initiation of an individualized therapeutic strategy. This crucial step helps optimize outcomes for this patient cohort, who frequently grapple with debilitating health conditions. Inclusion of these patients within a registry is mandatory to optimize treatment outcomes due to their rarity in pediatric population.

A rare case of Ewing's sarcoma primary of the cervical spine in a 1-year-old child: A case report and literature review

INTRODUCTION AND SIGNIFICANCE

Ewing sarcoma is a rare and malignant bone tumor that can primarily affect the cervical spine. Symptoms may not always be present, but muscle weakness is a critical indicator of disease progression and necessitates urgent surgical intervention to relieve pressure on the spinal cord.

CASE PRESENTATION

We present a case of a child who experienced sudden muscle weakness in the left upper limb. An MRI of the spine revealed a tumor in the cervical spine compressing the spinal cord. Urgent surgical intervention was performed, successfully removing most of the tumor. This was followed by complementary chemotherapy.

CLINICAL DISCUSSION

Tumors located in the cervical spine are challenging to treat due to their location. Urgent surgery may be crucial when muscle weakness is present. This case demonstrates a novel surgical approach through the spinous processes of the vertebrae, avoiding laminectomy and the need for spinal fixation, which can be difficult in children.

CONCLUSION

Our case highlights a rare presentation of Ewing sarcoma in the cervical spine, infrequently reported in medical literature. It also demonstrates the success of a novel surgical approach that avoids spinal fixation in children.

Advances in the multidisciplinary surgical approach to primary spinal sarcomas: insights from a retrospective case series on outcomes and survival

INTRODUCTION

The management of spinal sarcomas is complex, given their widespread involvement and high recurrence rates. Despite consensus on the need for a multidisciplinary approach with surgery at its core, there is a lack of definitive guidelines for clinical decision-making. This study examines a case series of primary spinal sarcomas, focusing on the surgical strategies, clinical results, and survival data to inform and guide therapeutic practices.

METHODS

We conducted a retrospective analysis of patients who underwent surgical resection for primary spinal sarcomas between 2005 and 2022. The study focused on gathering data on patient demographics, surgical details, postoperative complications, overall hospital stay, and mortality within 90 days post-surgery.

RESULTS

The study included 14 patients with a primary diagnosis of spinal sarcoma, with an average age of 48.6 ± 12.6 years. Chondrosarcoma emerged as the most common tumor type, representing 57.1% of cases, followed by Ewing sarcoma at 35.7%, and synovial sarcoma at 7.1%. Patients with chondrosarcoma were treated with en-bloc resection, while the patient with synovial sarcoma underwent intra-lesional excision and those with Ewing sarcoma received decompression and tumor debulking. Postoperative assessments revealed significant improvements in neurological conditions. Notably, functional status as measured by the Karnofski Performance Index (KPI), improved substantially post-surgery (from 61.4 to 80.0%) The mean follow-up was 34.9 ± 9.2 months. During this time period one patient experienced fatal bleeding after en-bloc resection complications involving the vena cava. None of the patient needed further surgery.

CONCLUSIONS

Our 16-year study offers vital insights into managing primary spinal sarcomas, showcasing the effectiveness of surgical intervention, particularly en-bloc resection. Despite their rarity and complexity, our multidisciplinary treatment approach yields improved outcomes and highlights the potential for refined surgical strategies to become standardized care in this challenging domain.

Pediatric Axial Ewing Sarcoma: A Retrospective Population-Based Survival Analysis

INTRODUCTION

Ewing sarcomas of the axial skeleton represent a notable challenge for clinicians because of their aggressive presentation and tendency to obstruct neurovascular structures; however, little data exist regarding axial tumors in children. This study is the first population-based analysis assessing treatment regimens for axial Ewing sarcomas and their effects on cancer-specific survival and overall survival (OS).

METHODS

Data from 2004 to 2019 were collected for all patients aged 1 to 24 years from the Surveillance, Epidemiology, and End Results (SEER) database. Primary groups included pelvic tumors, thoracic tumors, and vertebral tumors. Chi-squared and Kaplan-Meier tests were used to assess associations between demographic variables, clinical and treatment characteristics, and patient survival.

RESULTS

Pelvic tumors were most common, and 49.7% received chemotherapy/radiation. Vertebral tumors were least common, and 56.7% received chemotherapy/surgery/radiation. 53.5% of thoracic tumors received chemotherapy/surgery. Surgery was most common for thoracic tumors (80.2%) and rare for pelvic tumors (38.9%). Radiation therapy was most common for vertebral tumors (83.6%) and least common for thoracic tumors (36.0%). Pelvic tumors exhibited the lowest OS (1-year, 5-year, and 10-year OS: 96%, 70%, and 59%), followed by thoracic tumors (1-year, 5-year, and 10-year OS: 97%, 79%, and 66%) and vertebral tumors (1-year, 5-year, and 10-year OS: 92%, 77%, and 68%).

CONCLUSION

This study underpins the importance of both early detection and chemotherapy-based multimodal therapy in the treatment of axial Ewing sarcoma in a pediatric population. A comparatively large decline in OS was observed between 5 and 10 years for patients with thoracic tumors, and this cohort's 10-year OS has not improved when compared with a similar SEER cohort from 1973 to 2011. Despite a growing body of research supporting definitive radiation therapy, a notable portion of patients with pelvic Ewing sarcoma did not receive radiation, representing an unmet need for this population.

Treatment outcomes in patients with Ewing sarcoma of the spine in a resource-challenged setting: 17-year experience from a single center in India

Ewing sarcoma (ES) of the spine is a rare childhood cancer with sparse literature on treatment outcomes. We aimed to describe survival outcomes and prognostic factors in patients with spinal ES treated at a single institute in a resource-challenged setting. We conducted a retrospective analysis of patients with spinal ES registered at a tertiary care oncology center between 2003-2019. Clinical patient data was retrieved from hospital records. Cox regression analysis was used to identify the association of baseline clinical parameters with event free survival (EFS) and overall survival (OS). A cohort of 85 patients was analyzed including 38 (45%) patients with metastatic disease. The median age was 15 years with 73% being male. Local therapy was administered in 62 (72.9%) patients with surgery alone in 8 (9.4%), radiotherapy alone in 36 (42.4%) and both in 18 (21.2%) patients. A higher proportion of males received local therapy than females (80.3% versus 59.1%; p = 0.049). The median EFS and OS were 20.1 and 28.6 months, respectively. On univariable analysis, age ≤ 15 years, female sex, serum albumin ≤3.5 g/dL and hemoglobin ≤11 g/dL were associated with inferior EFS while younger age, female sex, hypoalbuminemia and metastatic disease were associated with inferior OS. On multivariable analysis, only hypoalbuminemia was predictive for inferior EFS (HR:2.41; p = 0.005) while hypoalbuminemia (HR:2.06;p = 0.033) and female sex (HR:1.83; p = 0.046) were associated with inferior OS. We concluded that hypoalbuminemia confers poor prognosis in ES spine. Survival outcomes are poorer in females treated in our setting, possibly due to prevailing sex-based biases.

Tumors of the Posterior Elements of the Spine in Children-an Overview

In this narrative review, we aim to describe the clinical features, diagnosis, and management of common primary osseous tumors affecting the posterior elements of the spine in children. We searched PubMed, Mendeley, and Google Scholar using the terms primary osseous tumors of the spine in children, tumors of the posterior elements of the spine, and names of individual tumors. The clinical features, investigations, and treatment modalities were analyzed, and a narrative review of the topic was prepared. We have included 54 studies published in the last 20 years. The majority are isolated reports or case series. Tumors of the posterior elements of the spine are rare. They are common in children and the majority of them are benign. Pain and deformity are common presentations. It is better to perform thorough investigations of children complaining of back pain to rule out primary tumors of the posterior elements of the spine.

One-stage combined approach en bloc vertebrectomy for primary Ewing's sarcoma of mobile spine in an adult patient: 3 years following aggressive surgery for a rare entity

Key Clinical Message

Currently, there is no consensus on the optimal management of nonmetastatic Ewing's sarcoma of the mobile spine. However, associated to chemotherapy, aggressive surgery with en bloc wide resection seems to improve local control and survival.

Abstract

Primary Ewing's sarcoma (EWS) of non-sacral spine is extremely rare, especially in middle-age. Therapeutic strategy aims: to large tumor resection, to provide spine stability and to avoid recurrence through chemo and radiotherapy. We report a case of thoracic spine EWS in an adult treated by combined approach en bloc vertebrectomy.

Optimal Delivery of Follow-Up Care Following Treatment for Adults Treated for Ewing Sarcoma

Ewing sarcoma (ES) is a rare, highly malignant sarcoma. It usually presents in the second decade of life; however, patients can be diagnosed as early as newborns and as late as in their seventies. ES is most frequently found in the long bones of the extremities and the pelvis. In older patients, ES can also arise in the soft tissues. Currently, there is no standard schedule for surveillance of adult patients with ES after their initial treatment for localised disease, not only for the early detection of recurrence but also for long-term side effects. Follow-up is based on group recommendations using extrapolated data obtained primarily from studies with paediatric patients. The main objective of this review is to summarise the data available on treatment-associated complications in long-term survivors. Furthermore, we provide a set of recommendations for optimising the follow-up of adults ES survivors, as well as for managing the sequelae that result from intensive multimodal treatment.

Primary Osseous Malignancies of the Spine

Malignant primary vertebral tumours comprise an uncommon group of primary bone malignancies that can pose a diagnostic and therapeutic challenge. The most frequently encountered malignant primary vertebral tumours include chordoma, chondrosarcoma, Ewing sarcoma and osteosarcoma. These tumours often present with nonspecific symptoms, such as back pain, neurologic deficits and spinal instability, which can be confused for the more commonly encountered mechanical back pain and may delay their diagnosis and treatment. Imaging, including radiography, computed tomography (CT) and magnetic resonance imaging (MRI) is crucial for diagnosis, staging, treatment planning and follow-up. Surgical resection remains the mainstay of treatment for malignant primary vertebral tumours, but adjuvant radiotherapy and chemotherapy may be necessary for achieving complete tumour control depending on the type of tumour. In recent years, advances in imaging techniques and surgical approaches, such as en-bloc resection and spinal reconstruction, have improved the outcomes for patients with malignant primary vertebral tumours. However, the management can be complex due to the anatomy involved and the high morbidity and mortality associated with surgery. The different types of malignant primary vertebral lesions will be discussed in this article with an emphasis on the imaging features.

A case report on non-metastatic Ewing sarcoma of the lumbar spine in a young patient

BACKGROUND

Ewing sarcoma (ES), the second most common malignant bone tumor after osteosarcoma in the second decade, occurs in 0.9% of cases as the primary non-sacral form.

CASE

A 20-years-old male presented with acute paraparesis of bilateral lower limb and numbness following initial back pain for the last 6 months. Magnetic resonance imaging (MRI) of the lumbar spine revealed a 4 cm enhancing soft tissue mass at the L4/L5 vertebra extending into the spinal canal with compression of the thecal sac. The computed tomography (CT) of the chest, abdomen, and pelvis revealed aggressive lytic lesions in the L4 spinous process with soft tissue extension into the spinal canal with no other site of distant metastasis. He was treated with IV steroids (Injection dexamethasone 10 mg IV followed by 4 mg tablet dexamethasone q6h; subsequently tapered off). A core needle biopsy showed a small, round blue cell neoplasm, (suggestive of a primitive neuroectodermal) stained positive for CD99 and vimentin stain. The diagnosis of ES lumbar spine was made which was treated with surgical resection with an appropriate margin measuring 8 × 4.5 × 2.5 cm with decompression and L4/5 laminectomies, which had a negative margin in the surgical pathology report. Concomitant local radiotherapy and chemotherapy [cycles of vincristine 2 mg/m² , adriamycin/doxorubicin 75 mg/m² , cyclophosphamide 1200 mg/m² (VDC) with mesna rescue alternating with cycles of ifosfamide 1800 mg/m² and etoposide 100 mg/m² (IE)] was started. The motor strength was regained gradually with preserved spine biomechanics and oncological control with no recurrence in 2-year follow-ups.

CONCLUSIONS

The presentation of lumbar ES can vary from local pain and swelling to acute paraparesis. Timely diagnosis and treatment with multimodal therapy, namely, steroids for acute spinal cord compression and surgery with chemoradiotherapy for ES can improve spinal biomechanics and oncological control.

Sacral Ewing sarcoma with rib, lung, and multifocal skull metastases: A rare case report and review of treatments

Ewing sarcoma (ES) rarely derives from the sacrum or mobile spine. The discovery of primary ES with multimetastatic involvements is exceedingly less frequent in clinical practice. A 23-year-old man with initial primary sacral ES developed metastases of rib, lung, and multifocal skull after receiving surgical intervention and series of adjuvant therapies. We provide this very rare case consisting of its clinical features, imaging findings, treatments, and outcomes. Therapeutic modalities of ES are also reviewed in previous published articles. The prognosis of metastatic ES remains dismal; effective therapeutic modalities for ES require multidisciplinary collaboration, with more high-quality clinical trials to promote the optimal protocols.

Tumors of the Spine: When Can Biopsy Be Avoided?

Regarding osseous tumors of the spine, characteristic morphology is encountered in hemangioma of the vertebral body, osteoid osteoma (OO), osteochondroma, Paget's disease, and bone islands. In these cases, radiologic imaging can make a specific diagnosis and thereby avoid biopsy, especially when the radiologist has chosen the correct imaging modality to establish the diagnosis, such as thin-slice computed tomography in suspected OO. A benign lesion is suggested by a high amount of fat within the lesion, the lack of uptake of the contrast agent, and a homogeneous aspect without solid parts in a cystic tumor. Suspicion of malignancy should be raised in spinal lesions with a heterogeneous disordered matrix, distinct signal decrease in T1-weighted magnetic resonance imaging, blurred border, perilesional edema, cortex erosion, and a large soft tissue component. Biopsy is mandatory in presumed malignancy, such as any Lodwick grade II or III osteolytic lesion in the vertebral column. The radiologist plays a crucial role in determining the clinical pathway by choosing the imaging approach wisely, by narrowing the differential diagnosis list, and, when characteristic morphology is encountered, by avoiding unnecessary biopsies.

Prognosis and Outcome of Cervical Primary Extraosseous Intradural Extramedullary Ewing Sarcoma: A Systematic Review

Primary spinal extraosseous Ewing sarcoma (ES) is a rare mesenchymal tumor characterized by high malignancy, occurring in a few patients with ES. The occurrence of this tumor in the intradural extramedullary spinal region is infrequent. This systematic review examines primary extraosseous intradural extramedullary ES in the cervical region to provide specific outcomes and evaluate the role of adjuvant chemoradiation in overall prognosis. A systematic review was conducted to identify all cervical primary extraosseous intradural extramedullary ES reported in the literature. The search included the databases of PubMed, Google Scholar, Medline, Embase, and Scopus from inception to June 2021. Inclusion criteria include a reported death outcome or a minimum one-year follow-up.

Our search retrieved 21 articles that involved the cervical spine, but only 11 cases met the inclusion criteria. Of the nine patients who demonstrated disease progression, six experienced local failure, two had distant craniospinal axis failure, and one had systemic metastases. Five patients died of the disease at a median of 11 months after diagnosis. Our analysis showed a one-, two-, and five-year progression-free survival (PFS) of 36.4%, 36.4%, and 12.1%, respectively. The one-, two-, and five-year overall survival rates were 72.7%, 62.3%, and 46.8%, respectively. Three of the five (60%) patients who died received craniospinal radiotherapy. Of the six patients who survived, two received craniospinal radiotherapy (33%), and one received whole spine radiotherapy (17%). This review showed that patients with cervical primary extraosseous intradural extramedullary ES had poor progression-free survival and overall survival rates. The addition of adjunct craniospinal radiotherapy did not improve the prognosis of these patients.

PET/MRI in Pediatric Neuroimaging: Primer for Clinical Practice

Modern pediatric imaging seeks to provide not only exceptional anatomic detail but also physiologic and metabolic information of the pathology in question with as little radiation penalty as possible. Hybrid PET/MR imaging combines exquisite soft-tissue information obtained by MR imaging with functional information provided by PET, including metabolic markers, receptor binding, perfusion, and neurotransmitter release data. In pediatric neuro-oncology, PET/MR imaging is, in many ways, ideal for follow-up compared with PET/CT, given the superiority of MR imaging in neuroimaging compared with CT and the lower radiation dose, which is relevant in serial imaging and long-term follow-up of pediatric patients. In addition, although MR imaging is the main imaging technique for the evaluation of spinal pathology, PET/MR imaging may provide useful information in several clinical scenarios, including tumor staging and follow-up, treatment response assessment of spinal malignancies, and vertebral osteomyelitis. This review article covers neuropediatric applications of PET/MR imaging in addition to considerations regarding radiopharmaceuticals, imaging protocols, and current challenges to clinical implementation.

Pediatric idiopathic intervertebral disc calcification (IIDC): a challenging case

Idiopathic intervertebral disc calcification is a rare condition in children with a very good prognosis. As there are no biological markers, imaging is invaluable for diagnosing this "do not touch" lesion. While the characteristic feature is nucleus pulposus calcification at one or more cervical or thoracic levels, it is important that practitioners be able to recognize atypical patterns so that biopsy can be avoided. Here we report a case of pediatric idiopathic intervertebral disc calcification with contiguous vertebral involvement and anterior longitudinal ligament ossification.

Primary Extraosseous Spinal Ewing Sarcomas: Should We Be More Aware About Diagnosis?

STUDY DESIGN

Single-center retrospective study.

OBJECTIVE

We discuss the widespread misdiagnosis of primary extraosseous spinal Ewing Sarcomas (PESES) to begnin tumors leading to poor treatment.

SUMMARY OF BACKGROUND DATA

PESES is a particular entity of spinal Ewing sarcoma (SES) appearing in a similar shape and features to benign tumors such as schwannomas. This imaging mimicry and subsequent possible misdiagnosis lead to primary surgery, without neoadjuvant chemotherapy, which remains deleterious for survival and progression.

METHODS

We identified a total of 13 patients: seven women (53.8%) and six men operated between 2001 and 2018 for PESES and initially misdiagnosed as schwannomas or ependymomas.

RESULTS

The mean age of our series was 35.8 years (range, 18.1-47.2 years). The first clinical symptom was neuralgia (61.5%) followed or associated with nerves deficits (38.5%). Median progression-free survival (PFS) was 31.7 months (SD 5.8). Tumor recurrence rates at 1 and 3 years were respectively 21.2% (SD 3.1) and 60.1% (SD 15.8). Median overall survival (OS) was 61.5 months (SD 16.27). The 1-year, 2-year, and 5-year survival estimates were 100.0%, 88.9% (SD 10.5), and 44.4% (SD 16.6). Six patients (46.13%) died following their SES. In univariate analyses, patients with metastastic PESES had a significantly lower OS than others (41.2 months, P = 0.03).

CONCLUSION

PESES must be ruled out at diagnosis of a spinal tumor when facing a fast-growing lesion with neurological deficits in a young adult. Thoracoabdominopelvic extension should be carried out. Presurgical biopsy must be performed. In case of PESES, neoadjuvant chemotherapy must be established before considering surgical intervention.Level of Evidence: 4.

An overview of the tumors affecting the spine-inside to out

Spine tumors may arise within or surrounding the spinal cord and/or vertebral column. Spinal tumors can be benign or malignant. Based on their epicenter, they may be classified as intradural-intramedullary, intradural-extramedullary, or extradural. Of these, extradural lesions are the most common, and are typically metastatic. Primary bone tumors of the spinal column comprise 5% of all primary skeletal tumors. The majority of primary spinal column tumors are benign, with malignant tumors comprising only 20%. Overall, spine metastases are the most common malignant spine tumor, and these usually arise from primaries such as lung, breast, and prostate cancers. The advent of improved systemic therapies leading to improved survival and the frequent use of imaging has positioned metastatic spine disease as the new epidemic in oncology. For spine tumors, establishing the correct diagnosis is heavily reliant on magnetic resonance imaging and histological confirmation. In this review, we will provide an overview of the epidemiology, radiological and histopathological features, and the natural history of key primary (benign and malignant) spinal cord and column tumors and metastatic spine tumors. Treatment principles for primary spinal cord or column tumors are aimed toward curative resection, whereas palliative resection forms the treatment principle for most metastatic tumors.

Primary vertebral tumor of axis: A clinical and surgical challenge

We report the case of a 17-year-old male presented to the emergency department with a six weeks history of neck pain and no neurogical deficit. Computed tomography and magnetic resonance imaging revealed an expansile lesion in the axis, with soft tissue and spinal cavity invasion, without mielopathy signs. Tomography-guided mass biopsy was taken. Waiting for histopathologic results, the pacient developed acute tetraparesis and sphincter incompetence. Magnetic resonance revealed that the bone mass had grown with epidural compromise, mielopathy and new vertebral lesions. Medular decompression with laminectomy, excision of the posterior elements of axis with the involved soft tissue mass and occipito-cervical fixation was performed. Neurological recovery was complete. Inmunochemistry revealed an Ewing Sarcoma. Chemoteraphy treatment was given, with partial response. Primary Ewing sarcoma of atlas-axis is a rare entity with poor prognosis. Multidisciplinary approach treatment is needed, with a total surgical resection if it is possible, a real challenge for the surgeon.

Bone up on spinal osseous lesions: a case review series

Spinal osseous neoplasms are frequently encountered and can be challenging when present as solitary lesions. Familiarity with the range of benign and malignant spinal pathology can help the radiologist formulate a comprehensive differential diagnosis. This article focuses on the spectrum of extradural spinal tumors, accounting for the majority of primary spinal tumors, by comparing the epidemiology, pathophysiology, clinical presentation, and characteristic imaging appearance of these lesions. The discussion includes the commonly encountered benign lesions, such as vertebral venous vascular malformation and enostosis, as well as malignant lesions including metastases and lymphoma. The article also includes other less-encountered primary spinal tumors such as plasmacytoma, osteoid osteoma, osteoblastoma, giant cell tumor, eosinophilic granuloma, chordoma, chondrosarcoma, osteosarcoma, Ewing’s sarcoma, and angiosarcoma. Familiarity with the characteristic imaging features can help the radiologist reach an accurate diagnosis and obviate the need for unnecessary invasive procedures such as biopsy and surgery.

Multilevel Pedicular Osteotomies for En Bloc Resection of a Primary Ewing Sarcoma of the Subaxial Cervical Spine with Pedicle Screw Reconstruction

BACKGROUND

Primary Ewing sarcoma of the mobile spine is a rare disease. Its management requires careful surgical planning, because radical, margin-free excision is directly correlated with prognosis. Extensive bone removal in the cervical spine can lead to instability and cause postoperative iatrogenic cervical deformity. Thus, spinal instrumentation plays an important role in restoring postresection spinal stability and improving quality of life.

METHODS

We present a novel technique that allows successful removal of a large Ewing sarcoma of the subaxial cervical spine, infiltrating and traversing the posterior bone elements, and extending into the paraspinal muscles. This technique involves radical en bloc resection of posteriorly located cervical tumors via multilevel pediculotomy, with terminal vertebrae pedicle screw reconstruction.

RESULTS

Terminal vertebrae cervical pedicle screw reconstruction allowed wide surgical excision with satisfactory oncologic and mechanical results.

CONCLUSIONS

This technique enables 1-stage total tumor resection and stabilization and may be a viable alternative to radical en bloc resection of posteriorly located epidural malignant lesions of the cervical spine in selected cases.

Spinal sarcomas and immunity: An undervalued relationship

Sarcomas, especially spine sarcomas, are rare yet debilitating and are underestimated types of cancer. Treatment options for spine sarcomas are limited to chemotherapy, radiotherapy and surgical intervention. Accumulating evidence suggests a complex course associated with the treatment of spine sarcomas as compared to other soft tissue sarcomas in the extremities since adjuvant therapy adds limited success to the oncological outcome. Likewise, the limitations of surgical interventions imposed by the proximity and high sensitivity of the spinal cord, leads to an increased recurrence and mortality rates associated with spine sarcomas. Finding novel treatment options to spine sarcomas as such is inevitable, necessitating a more thorough understanding of the different mechanisms of the underlying etiologies of these tumors. In this review, we discuss the most recent studies tackling the involvement of the immune system; a key player in the emergence of the different types of spine sarcomas and the promising immune-mediated targeted therapy that can be applied in these kind of rare cancers.

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 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.

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.

Multilevel spinal reconstruction in pediatric patients under 4 years old with non-congenital pathology (10-year single-center cohort study)

PURPOSE

To evaluate the influence of anterior fusion option on the short- and long-time outcomes on multilevel spinal reconstructions in young children.

METHODS

Forty-five patients aged under 4 years old (2 years 2 months ± 11 months in average) underwent spinal reconstruction due to tuberculosis spondylitis (35), pyogenic spondylitis (9) and spinal tumors (1) complicated by angular kyphosis exceeded 20° (49.2° ± 14.3° in average). All lesions involved two or more spinal motion segments. Clinical and radiographic data were compared in two groups depended on the types of anterior fusion: titanium mesh cage with bone graft (TMC + BG) (19 patients) and cortical BG only (26). The average follow-up was 5 years 10 months ± 2 years 8 months (min = 3 years; max = 12 years).

RESULTS

The deformity correction was similar in groups. The operation time and blood loss were less in TMC + BG group (p = 0.001) as a times for anterior bone block formation (p < 0.001) and posterior instrumentation removal (p = 0.003). Ten late post-op complications registered include disease's recurrence (1), pseudoarthrosis (6), deformity progression (1) and graft resorption (1). The complication rate was less in TMC + BG than in BG group: two and eight cases consequently, p = 0.024.

CONCLUSIONS

Multilevel spinal reconstruction in early aged patients is safe and effective procedure. The anterior fusion by TMC with bone autograft has advantages of reducing blood loss, operation time, time for anterior block formation and complications rate compared with bone autograft only. These slides can be retrieved under Electronic Supplementary Material.

Primary Ewing sarcoma of the axis-C2: A case report and the review of the literature

INTRODUCTION

Neck pain and torticollis are common symptoms in the pediatric population that rarely requires further investigation. However, in case symptoms persist, then a more meticulously approach should be considered. Underlying conditions such as infections, neck injury, autoimmune disorders or even cervical spine cancer should be excluded from diagnosis. Cervical spine cancer is a rare neurosurgical entity in the pediatric population and even rarer is atlantoaxial Ewing's sarcoma. In this report, we present a rare case of primary Ewing's sarcoma of the axis.

CASE REPORT

A 3.5-year-old female with progressive neck pain and intermittent episodes of torticollis was referred to our outpatient clinic. Imaging studies revealed a malignant tumor located on C2 vertebra. Diagnosis of Ewing's Sarcoma was confirmed via open biopsy and the patient was treated with Euro-EWING 99 chemotherapy.

CONCLUSION

Pediatric neck pain and/or torticollis should raise high suspicion for malignancy of cervical spine. Modern diagnostic means and techniques can assist in the screening and diagnosis of these tumors.

Ewing Sarcoma of the Spine: Prognostic Variables for Survival and Local Control in Surgically Treated Patients

STUDY DESIGN

Multicenter, ambispective observational study.

OBJECTIVE

To quantify mortality and local recurrence after surgical treatment of spinal Ewing sarcoma (ES) and to determine whether an Enneking appropriate procedure and surgical margins (en bloc resection with wide/marginal margins) are associated with improved prognosis.

SUMMARY OF BACKGROUND DATA

Treatment of primary ES of the spine is complex. Ambiguity remains regarding the role and optimal type of surgery in the treatment of spinal ES.

METHODS

The AOSpine Knowledge Forum Tumor developed a multicenter database including demographics, diagnosis, treatment, mortality, and recurrence rate data for spinal ES. Patients were stratified based on surgical margins and Enneking appropriateness. Survival and recurrence were analyzed using Kaplan-Meier curves and log-rank tests.

RESULTS

Fifty-eight patients diagnosed with primary spinal ES underwent surgery. Enneking appropriateness of surgery was known for 55 patients; 24 (44%) treated Enneking appropriately (EA) and 31 (56%) treated Enneking inappropriately (EI). A statistically significant difference in favor of EA-treated patients was found with regards to survival (P = 0.034). Neoadjuvant and postoperative chemotherapy was significantly associated with increased survival (P = 0.008). Local recurrence occurred in 22% (N = 5) of patients with an EA procedure versus 38% (N = 11) of patients with an EI procedure. The timing of chemotherapy treatment was significantly different between the Enneking cohorts (P < 0.001) and all EA-treated patients received chemotherapy treatment. Although, local recurrence was not significantly different between Enneking cohorts (P = 0.140), intralesional surgical margins and patients who received a previous spine tumor operation were associated with increased local recurrence (P = 0.025 and P = 0.018, respectively).

CONCLUSION

Surgery should be undertaken when an en bloc resection with wide/marginal margins is feasible. An EA surgery correlates with improved survival, but the impact of other prognostic factors needs to be evaluated. En bloc resection with wide/marginal margins is associated with local control.

LEVEL OF EVIDENCE

3.

Back Pain in Children- How Sinister?

Incidence of back pain among children and adolescents is gradually increasing. Children undergo extensive diagnostic workup that ultimately results in a nonconfirmative diagnosis. A good history and clinical examination can, to a large extent help differentiate non-specific from organic causes of backache. Diagnostic workup may be initiated if symptoms are severe and/or persistant. The authors review some of the common causes of back pain in pediatric population, clinical presentations, and the relevant investigations along with their management.

Imaging features of primary tumors of the spine: A pictorial essay

Primary tumors of spine are rare accounting for less than 5% of new bone tumors diagnosed every year. These tumors may exhibit characteristic imaging features that can help in early diagnosis and improved prognosis. Plasmacytoma/multiple myeloma and lymphoproliferative tumors are the most common malignant primary spinal tumors. Hemangioma is the most common benign tumor of the spine. Computed tomography is useful to assess tumor matrix and osseous change. Magnetic resonance is useful to study associated soft tissue extension, marrow infiltration, and intraspinal extension. Confusing one tumor with the other based on only imaging findings is not uncommon. However, radiologic manifestations of these tumors need to be correlated with the age, sex, location, and presentation to arrive at a close clinical diagnosis.

The Neurological Compromised Spine Due to Ewing Sarcoma. What First

BACKGROUND:

The vertebral column is an infrequent site of primary involvement in Ewing sarcoma. Yet when Ewing sarcoma is found in the spine, the urge for decompression is high because of the often symptomatic compression of neural structures. It is unclear in alleviating a neurological deficit whether chemotherapy is preferred over decompressive laminectomy.

OBJECTIVE:

To underline, in this case series, the efficiency of initial chemotherapy before upfront surgery in the setting of high-grade spinal cord or cauda equina compression of primary Ewing sarcoma.

METHODS:

Fifteen patients with Ewing sarcoma primarily located in the spine were treated at our institution between 1983 and 2015. Localization, neurological deficit expressed as Frankel grade, and outcome expressed as Rankin scale before and after initial chemotherapy, the recurrence rate, and overall survival were evaluated. The multidisciplinary approach of 1 case will be discussed in detail.

RESULTS:

Nine patients (60%) were female. The age at presentation was 15.0 ± 5.5 years (range: 0.9–22.8 years). Ten patients (67%) were initially treated with chemotherapy, and 1 patient (7%) was treated primarily with radiotherapy followed by chemotherapy. The remaining 4 patients (27%) were initially treated with decompressive surgery. All patients treated primarily nonsurgically improved neurologically at follow-up, showing the importance of chemotherapy as an effective initial treatment option.

CONCLUSION:

Adequate and quick decompression of neural structures with similar results can be achieved by chemotherapy and radiotherapy, avoiding the local spill of malignant cells.

A Unique Case of Primary Ewing's Sarcoma of the Cervical Spine in a 53-Year-Old Male: A Case Report and Review of the Literature

Extraskeletal Ewing's sarcoma (EES) is a rare presentation, representing only 15% of all primary Ewing's sarcoma cases. Even more uncommon is EES presenting as a primary focus in the spinal canal. These rapidly growing tumors often present with focal neurological symptoms of myelopathy or radiculopathy. There are no classic characteristic imaging findings and thus the physician must keep a high index of clinical suspicion. Diagnosis can only be definitively made by histopathological studies. In this report, we discuss a primary cervical spine EES in a 53-year-old man who presented with a two-month history of left upper extremity pain and acute onset of weakness. Imaging revealed a cervical spinal canal mass. After undergoing cervical decompression, histopathological examination confirmed a diagnosis of Ewing's sarcoma. A literature search revealed fewer than 25 reported cases of primary cervical spine EES published in the past 15 years and only one report demonstrating this pathology in a patient older than 30 years of age (age = 38). Given the low incidence of this pathology presenting in this age group and the lack of treatment guidelines, each patient's plan should be considered on a case-by-case basis until further studies are performed to determine optimal evidence based treatment.

Surgical treatment of primary malignant tumors of the sacrum

OBJECTIVES

The objective of the authors was to provide an up-to-date review about the epidemiology, diagnosis, and surgical management of the malignant primary sacral tumors.

METHODS

A PubMed search was conducted using a combination of the following items: (('Spinal Neoplasms'[Mesh]) AND 'Sacrum'[Mesh]) NOT ('Metastasis' OR 'Metastases' OR 'Benign'). The literature review and the author's own surgical experiences were used to assess the current treatment strategies of the malignant sacral tumors.

RESULTS

Twenty case series were identified, which studies discuss in detail the surgical strategies, the postoperative complications, the functional and oncologic outcome, and the recurrence-free and disease-specific survival of this rare patient category.

DISCUSSION

Sacral tumors are rare pathologies. Their management generates a complex medical problem, as they usually are diagnosed in advanced stages with extended dimensions involving the sacral nerves and surrounding organs. The evaluation and complex treatment of these rare tumors require a multidisciplinary approach, optimally at institutions with comprehensive care and experience. Although conventional oncologic therapeutic methods should be used as neoadjuvant or adjuvant therapies in certain histological types, en bloc resection with wide surgical margins is essential for long-term local oncologic control. This is often technically difficult to achieve, as just a few centers in the world perform sacral tumor surgeries on a regular basis, and have enough wide experience. Therefore international cooperation and organization of multicenter tumor registries are essential to develop evidence based treatment protocols.

New therapeutics in spine metastases

The number of patients who will develop metastatic spinal tumors is estimated to be between 5 and 10% of all cancer patients. As the therapy for systemic cancer improves, the number of patients developing symptomatic spinal tumors that require local therapy will increase. Over the last 10 years there has been a dramatic evolution in our ability to treat spinal tumors. These advances have not only been created by improvements in surgical techniques and instrumentation, but also developments in radiographic imaging, radiation therapy and chemotherapy. It is important for spine surgeons, radiologists, and radiation and medical oncologists to continue developing techniques for spinal salvage that will improve pain relief, achieve mechanical stability, improve or maintain neurologic function and sustain local tumor control. The evolution of these technologies will help to provide palliation and improve quality of life for patients with metastatic disease.

A very rare cause of neck pain: primary Ewing sarcoma of the axis

We report the case of a 7-year-old boy who presented with a 1-month history of neck pain, left-sided torticollis, and no neurological deficit. Computed tomography and magnetic resonance imaging revealed an expansile lesion in the axis, with epidural and prevertebral soft tissue components. Histopathologic examination of the biopsy specimen revealed primary vertebral Ewing sarcoma. This is the first case of primary vertebral Ewing sarcoma that has presented with torticollis. It is essential for physicians to be familiar with this condition and the associated imaging findings because early diagnosis of such cases is the key to better prognosis.

Delays in diagnosis of paediatric cancers: a systematic review and comparison with expert testimony in lawsuits

Delayed diagnosis of paediatric cancers is reported regularly and is a source of remorse for physicians and parents and a leading cause of malpractice claims. We did a systematic review of information about the distribution, determinants, and consequences of time to diagnosis of paediatric malignancies and compared these findings with those of court-appointed expert witnesses in malpractice claims in Canada and France. Time to diagnosis varied widely between tumour types in the 98 relevant studies (medians ranged from 2-260 weeks) without any significant decrease with time. Determinants of a long delay in diagnosis included older age, qualification of the first physician contacted, non-specific symptoms, histological type, and tumour localisation. Delayed diagnosis was associated with poor outcome for retinoblastoma and possibly for leukaemia, nephroblastoma, and rhabdomyosarcoma (data were insufficient for definitive conclusions). It was not associated with an adverse outcome for most CNS tumours, osteosarcoma or Ewing's sarcoma, and, paradoxically, was frequently associated with better outcomes than was short time to diagnosis in these cancers. A third of the court-appointed experts provided testimony concordant with the medical literature. The relations between delay in diagnosis and outcome are complex and probably depend more on tumour biology than on parental or medical factors.

Nonmetastatic Ewing's Sarcoma of the Lumbar Spine in an Adult Patient

Although the spine is frequently involved in metastatic Ewing's sarcoma, primary involvement of the spine, beside sacrum, is much less frequent, especially in adult patients. Because of the low incidence of these tumors, there are currently no clinical guidelines outlining their management and a multitude of therapeutic strategies have been employed with varying success. The definitive management of Ewing's sarcoma of the spine, as in other locations, could include the combination of three main modalities: aggressive surgery, radiotherapy, and combined chemotherapy. Whenever possible, en bloc spondylectomy or extralesional resection is preferable, providing a better oncological result with a longer survival and a better preservation of the spine biomechanics. This is the lesson we learned about the case, we present here, of nonmetastatic lumbar localization by Ewing's sarcoma in as adult patient.

High long-term local control with sacrectomy for primary high-grade bone sarcoma in children

BACKGROUND

Sacrectomy may offer curative potential for primary sarcomas of the sacrum. However, it is unclear whether and to what extent sacrectomies achieve local control.

QUESTIONS/PURPOSE

We therefore determined the curative potential, walking ability, continence control, and quality of life for children after sacrectomy for primary bone sarcoma.

METHODS

We retrospectively reviewed eight children with high-grade primary bone sarcomas treated with sacrectomy. The average age of the patients was 14 years (range, 4-18 years). There were six Ewing sarcomas and two osteosarcomas. Five patients underwent partial and three underwent total sacrectomies with all resection margins free of tumor. We recorded local and distant recurrences, functional (Musculoskeletal Tumor Society [MSTS] score) and oncologic outcome (survival), walking ability, bladder and bowel control, independence, and reintegration in society. The average followup was 80 months (range, 54-204 months).

RESULTS

Six patients were alive without evidence of disease at last followup. Three patients had metastases develop and two died of disease 3 and 25 months postoperative. MSTS scores among survivors averaged 17.5 points (range, 5-25 points). Seven of the eight patients were able to ambulate, two independently. All initially were incontinent, but at last followup, two were continent and two were incontinent only under stress. Complications occurred in seven of eight, five of whom required additional surgery.

CONCLUSION

Despite the high incidence of neurologic deficits and complications, sacrectomy achieved local control in patients with high-grade bone sarcomas. Our observations suggest long-term survival and adequate quality of life are possible in the pediatric population.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.