Primary intracranial Ewing sarcoma/ peripheral primitive neuroectodermal tumor, an entity of unacquaintance: a series of 8 cases

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.

Central Nervous System Metastases in Pediatric Patients With Ewing Sarcoma

Metastatic central nervous system (CNS) involvement is rare in pediatric primary extracranial Ewing sarcoma (ES). We describe the incidence and course of 6 patients with extracranial ES who developed metastatic CNS lesions treated at a single institution. The median time to CNS disease detection was 16.3 months (10.0-28.3 months). Event-free and overall survival after CNS disease detection were 1.9 months (0.4 to 10.3 months) and 4.6 months (1.1 to 50.9 months), respectively. One patient was alive at the time of analysis. Clinical status and ability to obtain disease control should be considered when making decisions regarding aggressive interventions in these patients with poor prognosis.

Primary Intracranial Ewing Sarcoma With EWSR1-FLI1 Gene Translocation Mimicking a Meningioma and a Multidisciplinary Therapeutic Approach: A Case Report and Systematic Review of Literatures

Ewing sarcoma and peripheral primitive neuroectodermal tumor (ES/pPNET) is an undifferentiated malignant tumor that is most prevalent in children and young adults and often radiologically mimics a meningioma. A 38-year-old female patient visited our hospital with complaints of right-sided tinnitus, right hemiparesis, and imbalance. She underwent preoperative imaging and was subsequently diagnosed as having a meningioma on the petrous ridge. After partial resection, EWSR1-FLI1 gene fusion was confirmed, and she was diagnosed with ES/pPNET. The tumor was successfully treated using a multidisciplinary approach of adjuvant chemo- and radiotherapy. This case is noteworthy because it is an extremely rare case of an intracranial ES/pPNET, and it is worth sharing our clinical experience that the tumor was successfully treated through a multidisciplinary therapeutic approach even though complete resection was not achieved.

Clinicodemographic characteristics of extraosseous ewing sarcoma: A comparative meta-analysis of pediatric and adult patients

Background

Evidence suggests different presentation patterns and prognosis of extraosseous Ewing Sarcoma (EES) based on age. Thus, we carried out this study to test the difference between children and adult EES cases regarding clinicodemographic characteristics and prognosis.

Methods

A total of 4 databases were explored yielding 18 relevant studies for data synthesis. Outcomes included the comparison of demographic and clinical characteristics as well as prognosis between children and adults with EES. Log odds ratio (logOR) and its 95% confidence interval (CI) were pooled across studies. Statistical models/methods were selected based on heterogeneity.

Results

Our analysis included a total of 1261 children and 1256 adults. When we compared these two age categories, we did not observe a significant difference in the risk of developing EES [logOR = -0.13; 95% CI: -0.65: 0.39; I2 = 88.42%]. No significant differences regarding gender, tumor location, and size (≤5 vs. >5 cm), EWSR1 positivity, or management modality. We did not observe significant difference regarding clinical outcomes, such as 5-year overall survival and event-free survival, recurrence, mortality, no evidence of disease, and secondary metastasis.

Conclusions

Our findings highlight the absence of an association between the age category of patients and the incidence of EES, as well as its clinical outcomes.

Primary Intracranial Ewing Sarcoma Invading the Superior Sagittal Sinus with EWSR1-FLI1 Gene Fusion and EWSR1 Gene Mutation: A Case Report and Literature Review

BACKGROUND

Primary intracranial Ewing sarcoma (ES) is an extremely rare intracranial malignant tumor, mostly occurring in children and adolescents. Because of its rarity, the magnetic resonance imaging (MRI) features and treatment strategies of primary intracranial ES are still unclear.

METHODS

The purpose of this study was therefore to report a case of primary intracranial ES, whose molecular features included both EWSR1-FLI1 (EWS RNA binding protein 1- Friend leukemia integration 1) gene fusion and EWSR1 gene mutation. It is worth noting that this is the first reported case of ES invading the superior sagittal sinus and mostly causing occlusion. At the same time, there were polymorphisms of four drug metabolism-related enzymes in the tumor. Subsequently, we conducted a literature review to characterize the clinical features, imaging findings, pathological features, treatments, and prognoses of primary intracranial ESs.

RESULTS

A 21-year-old female was admitted to the hospital with headache with nausea and vomiting for 2 weeks. An MRI showed a 3.8 × 4.0 cm large heterogeneous mass in the bilateral parietal lobe with peritumoral edema. The tumor invaded the superior sagittal sinus and mostly caused occlusion of the middle segment of the superior sagittal sinus. The mass was successfully removed using a neuromicroscope. Postoperative pathology indicated a primary intracranial ES. High throughput sequencing (next generation sequencing) showed that there was EWSR1-FLI1 gene fusion and EWSR1 gene mutation in the tumor, with polymorphisms of four drug metabolism-related enzymes and low tumor mutational burden. Subsequently, the patient received intensity modulated radiation therapy. The patient has signed an informed consent form.

CONCLUSIONS

The diagnosis of primary intracranial ES depended on histopathology, immunohistochemistry staining, and genetic testing. At present, total tumor resection combined with radiotherapy and chemotherapy is the most effective treatment. We report the first case of primary intracranial ES invading the superior sagittal sinus and causing middle segment occlusion, accompanied by EWSR1-FLI1 gene fusion and EWSR1 gene mutation.

EXTRASKELETAL EWING'S SARCOMA IN PEDIATRIC PATIENT RARE CASE: A CASE REPORT

This study reports a 12-year-old male was referred to our institute with a mass in the right ear. The mass was rapidly growing thus needing an immediate surgical attention. MRI revealed an exophytic, hyper vascular mass extending to the right jugular fossa and, the middle ear, and to the right acoustic meatus, suggestive of a right glomus jugulare tumor. Angiography showed a hypervascular lesion with robust feeding from the superficial temporal artery and right occipital artery. After surgery, the patient rapidly recover and he was discharged home on the 5th day after surgery. Three months after surgery, the lump reappeared and grew rapidly as before.

Management and outcome of unusual pediatric brain tumors: challenges experienced at a tertiary care center of a developing country

PURPOSE

Primary brain tumors are the most frequent solid pediatric tumors, accounting for 40-50% of all cancers in children. Eighty to ninety percent of the 250,000 new cases of pediatric cancer each year are discovered in low and middle-income nations, where nearly 88 percent of the world's children reside. This article aims to emphasize the unusual presentation, management, and surgical outcome of complex pediatric brain tumors.

METHODS

We performed a retrospective study of patients who were admitted to the neurosurgery department with unusual pediatric brain tumors between March 1, 2019, and March 1, 2022. The study included pediatric patients up to age 18 years. We included those pediatric brain tumors whose (i) location was uncommon, or (ii) presented with unusual clinical presentation, or (iii) histopathology suggested to be a rare tumor, or (iv) radiological features were atypical.

RESULTS

We included 9 cases of rare unusual pediatric brain tumors. Three out of 9 cases required preoperative embolization due to its hypervascular nature on digital subtraction angiography (DSA). All patients underwent surgical excision within 24-48 h of tumor devascularization. One out of 9 cases died in follow-up period due to pleural effusion and distant metastasis to lungs.

CONCLUSION

Treatment considerations for unusual pediatric brain tumors include a comprehensive multidisciplinary approach, including community-based screening and proper referral system for early treatment, a variety of treatment modalities, and sophisticated follow-up strategy. Government shall work in coherence with tertiary centers to spread social awareness and provide various financial scheme to prevent treatment dropouts.

Extraosseous Ewing Sarcoma in Children: A Systematic Review and Meta-Analysis of Clinicodemographic Characteristics

Background: We conducted this systematic review to provide comprehensive evidence on the prevalence, clinical features and outcomes of young extraosseous Ewing sarcoma (EES) cases. Methods: PubMed, Scopus, Web of Science, and Google Scholar were searched for articles reporting the occurrence of EES among children and adolescents (<21 years). The primary outcome included the rate of occurrence of EES among children and adolescents, while the secondary outcomes included the descriptive analyses of the demographic characteristics, tumor characteristics, and clinical outcomes of the affected cases. The data are reported as the effect size (ES) and its corresponding 95% confidence interval (CI). Results: A total of 29 studies were included. Twenty-four reported instances of childhood disease among all the EES cases [ES = 30%; 95%CI: 29−31%], while five studies reported extraosseous cases among the pediatric EES cases [ES = 22%; 95%CI: 13−31%]. The thorax is the most common location of childhood EES [33%; 95%CI: 20−46%] followed by the extremities [31%; 95%CI: 22−40%]. Concurrent chemotherapy and radiotherapy [57%; 95%CI: 25−84%] was the most commonly implemented management protocol in the pediatric EES cases. The rate of no evidence of disease and 5-year overall survival was 69% for both outcomes. Mortality occurred in 29% of cases, while recurrence and secondary metastasis occurred in 35% and 16% of cases, respectively. Conclusions: Our findings provide insight into the clinical features and outcomes of EES among children and adolescents.

Case report: Primary intracranial EWs/PNET in adults: Clinical experience and literature review

Introduction

Adult primary intracranial Ewing sarcomas (EWs)/primitive neuroectodermal tumors (PNETs) are extremely rare, with only 30 patients published before us. The imaging features and treatment strategies of primary intracranial EWs/PNETs are unclear due to its rarity. The aim of this study was to investigate the clinical features, imaging findings, treatment, survival analysis, and prognosis of adult EWs/PNETs, and a systematic review was conducted based on the patient we treated and published literature.

Case description

A 19-year-old male patient suffered from head pain due to an accidental fall on a motorcycle that occurred more than 10 days before going to the hospital, and underwent computed tomography (CT) examination; it was found that the left temporo-occipital fossa was occupied. Magnetic resonance imaging (MRI) was recommended to understand the nature of the lesion, and the result showed that it has a high probability of being a meningioma. He underwent surgical removal of the mass under general anesthesia, and surprisingly, postoperative pathology revealed EWs/PNET. The disease has a high degree of malignancy, and the patient developed multiple metastases throughout the body 5 years after surgery.

Conclusion

Primary intracranial EWs/PNETs in adult patients are rare, of which imaging findings should be considered as one of the differential diagnoses of meningioma, hemangiopericytoma, and malignant triton tumor. Larger solid-cystic masses with septum-like enhancement may be relatively specific imaging findings of intracranial EWs/PNETs. The prognosis of primary adult intracranial EWs/PNETs is poor. Radical tumor resection combined with radiotherapy and chemotherapy is currently the main and possibly the most effective treatment method.

Superiority of 11 C-Choline PET/CT in the Delineation of a Rare Intracranial Diffuse Embryonic Tumor

ABSTRACT

Intracranial diffuse embryonal tumor in the adult is rare. We report a young woman with a diffuse embryonal malignancy in the saddle area, which was depicted well by 11 C-choline PET/CT, superior to 18 F-FDG PET/CT and contrast-enhanced MRI. Under the guiding of 11 C-choline PET/CT, the biopsy was successfully performed and the diagnosis was established. This case highlights that 11 C-chione PET/CT may be useful to diagnose and delineate the intracranial diffuse embryonic tumors.

The prognostic factors of Ewing sarcoma/peripheral primitive neuroectodermal tumor: A retrospective analysis of 67 patients at a single center

To investigate the characteristics and factors that impact the prognosis of Ewing sarcoma/peripheral primitive neuroectodermal tumor (ES/pPNET) patients. We retrospectively analyzed ES/pPNET patients diagnosed at our hospital from January 2011 to December 2020. We used 1-way analysis of variance to investigate whether the age differences between different subgroups were statistically significant and used the Kaplan-Meier method and Cox regression model for the survival analysis. Of the 67 included patients, 13 had central nervous system PNET, and 54 had ES/pPNET. The median survival time of the 54 ES/pPNET patients was 18 months; the 1-year, 3-year and 5-year progression-free survival rates were 37.0% and 9.3% and 1.9%, respectively; and the 1-year, 3-year and 5-year overall survival (OS) rates were 66.7%, 27.8%, and 7.4%, respectively. The 1-way analysis of variance results showed no statistically significant age difference between the different subgroups (P = .127 between the central nervous system PNET and ES/pPNET groups, P = .764 between different subgroups within the ES/pPNET group). The univariate survival analysis showed that metastasis at diagnosis and the treatment method were independent factors affecting the OS rate of ES/pPNET patient (P = .003 and 0.000, respectively). The multivariate survival analysis also showed that the treatment method and metastasis at diagnosis were related factors affecting OS (P = .025 and 0.001, respectively). The prognosis of patients with primitive neuroectodermal tumors is poor. The treatment method and metastasis at the time of diagnosis influences ES/pPNET patient survival time, but there is no significant tumor site-dependent correlation with patient age or sex.