Ewing's sarcoma of the vertebral column

Vertebra Plana: A Narrative Clinical and Imaging Overview among Possible Differential Diagnoses

Vertebra plana is a rare radiologic condition characterized by a uniform loss of height of a vertebral body that represents a diagnostic challenge for surgeons. The purpose of this study was to review all possible differential diagnoses that may present with a vertebra plana (VP) described in the current literature. For that purpose, we performed a narrative literature review in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, analyzing 602 articles. Patient demographics, clinical presentation, imaging characteristics and diagnoses were investigated. VP is not a pathognomonic feature of Langerhans cell histiocytosis, but other oncologic and non-oncologic conditions should be considered. The list of differential diagnoses, based on our literature review, can be recalled with the mnemonic HEIGHT OF HOMO: H-Histiocytosis; E-Ewing's sarcoma; I-Infection; G-Giant cell tumor; H-Hematologic neoplasms; T-Tuberculosis; O-Osteogenesis imperfecta; F-Fracture; H-Hemangioma; O-Osteoblastoma; M-Metastasis; O-Osteomyelitis, chronic.

Primary Ewing sarcoma/peripheral primitive neuroectodermal tumors in the cranial bone and mobile spine: what is the difference?

BACKGROUND

Primary Ewing sarcoma (ES)/peripheral primitive neuroectodermal tumors (pPNETs) are aggressive bone tumors that rarely occur in the axial skeleton, including the cranial bone and mobile spine. The purpose of this study was to investigate whether there were any differences in patient characteristics, treatment strategies, and outcomes between patients with ES/pPNETs of the cranial bone and those with ES/pPNETs of the mobile spine.

METHODS

A retrospective study was performed on 33 patients with ES/pPNETs who had been surgically treated and pathologically confirmed at our institution between 2010 and 2020. Patient characteristics were compared using Fisher exact tests or independent t tests. Survival rates were estimated via Kaplan-Meier survival analysis and compared using log-rank tests.

RESULTS

Thirteen patients had ES/pPNETs of the cranial bone (39.4%), while 20 patients had ES/pPNETs of the mobile spine (60.6%). Patients with ES/pPNETs of the cranial bone had a younger mean age (14.8 vs 22.6 years; p = 0.047) and longer mean disease duration (2.5 vs 1.9 months; p = 0.008) compared with those of patients with ES/pPNETs of the mobile spine. Kaplan-Meier analysis showed that gross total resection (GTR) and radiotherapy resulted in a longer median survival time. The overall survival rates and progression-free survival rates of patients with ES/pPNETs of the cranial bone versus those of the mobile spine were not significantly different (p = 0.386 and p = 0.368, respectively).

CONCLUSIONS

Patients with ES/pPNETs of the cranial bone were younger compared to patients with ES/pPNETs of the mobile spine. There was no significant difference in the prognosis of patients with ES/pPNETs of the cranial bone versus those of the mobile spine. Taken together, our findings suggest that GTR and radiotherapy offer the best prognosis for improved long-term survival.

Assessment of Risk of Bias in Osteosarcoma and Ewing's Sarcoma Randomized Controlled Trials: A Systematic Review

Aim: The aim of this study was to systematically assess the risk of bias in osteosarcoma and Ewing’s sarcoma (ES) randomized controlled trials (RCT) and to examine the relationships between bias and conflict of interest/industry sponsorship. Methods: An OVID-MEDLINE search was performed (1976–2019). Using the Cochrane Collaboration guidelines, two reviewers independently assessed the prevalence of risk of bias in different RCT design domains. The relationship between conflicts of interest and industry funding with the frequency of bias was examined. Results: 73 RCTs met inclusion criteria. Prevalence of low-risk bias domains was 47.3%, unclear-risk domains 47.8%, and 4.9% of the domains had a high-risk of bias. Domains with the highest risk of bias were blinding of participants/personnel and outcome assessors, followed by randomization and allocation concealment. Overtime, frequency of unclear-risk of bias domains decreased (χ² = 5.32, p = 0.02), whilst low and high-risk domains increased (χ² = 8.13, p = 0.004). Studies with conflicts of interest and industry sponsorships were 4.2 and 3.1 times more likely to have design domains with a high-risk of bias (p < 0.05). Conclusion: This study demonstrates that sources of potential bias are prevalent in both osteosarcoma and ES RCTs. Studies with financial conflicts of interest and industry sponsors were significantly more likely to have domains with a high-risk of bias. Improvements in reporting and adherence to proper methodology will reduce the risk of bias and improve the validity of the results of RCTs in osteosarcoma and ES.

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.

Managing axial bone sarcomas in childhood

Introduction: Axial osteosarcoma and Ewing sarcoma are rare, aggressive neoplasms with a worse prognosis than with tumors involving the extremities because they are more likely to be associated with larger tumor volumes, older age, primary metastases, and a poor histological response to chemotherapy. The 5-year OS rates are reportedly in the range of 18-41% for axial osteosarcoma, and 46-64% for Ewing sarcoma.Area covered: The treatment of axial bone tumors is the same as for extremity bone tumors, and includes chemotherapy, surgery and/or radiotherapy.Expert opinion: Local treatment of axial tumors is particularly difficult due to their proximity to neurological and vascular structures, which often makes extensive and en bloc resections impossible without causing significant morbidity. The incidence of local relapse is consequently high, and this is the main issue in the treatment of these tumors. Radiotherapy is an option in the case of surgical resections with close or positive margins, as well as for inoperable tumors. Delivering high doses of RT to the spinal cord can be dangerous. Given the complexity and rarity of these tumors, it is essential for this subset of patients to be treated at selected reference institutions with specific expertise and multidisciplinary skills.

Primary sarcomas of the spine: population-based demographic and survival data in 107 spinal sarcomas over a 23-year period in Ontario, Canada

BACKGROUND CONTEXT

Spinal sarcomas are a rare, heterogeneous group of mesenchymal tumors. Current literature reporting demographic variables and survival information is limited to small case series, and a single registry with variable treatment modalities and time periods.

PURPOSE

We report on population-level data regarding all spinal sarcomas diagnosed over a 23-year period in Ontario, Canada, for the purposes of calculating incidence and prevalence of these tumors. Secondarily, survival is assessed by tumor type as well as adjuvant therapies during this time period.

STUDY DESIGN

Retrospective Cohort Study PATIENT SAMPLE: Population-based data from the Institute for Clinical Evaluative Sciences (ICES) between 1993 and 2015.

OUTCOME MEASURES

Outcome measures include incidence and prevalence of spinal osteosarcoma, Ewing's sarcoma, and chondrosarcoma of the spine, as well as 2-, 5-, 10- and 15-year survival and prevalence of adjuvant therapies.

METHODS

Utilizing population-based data from the Institute for Clinical Evaluative Sciences (ICES) between 1993 and 2015, ICD codes were searched and available data extracted for the purposes of reporting basic demographic information and calculation of Kaplan Meyer survival curves. Databases include the Ontario Cancer Registry, Discharge Abstract Database, Ontario Health Insurance Plan, National Ambulatory Care Reporting System, Registered Persons DataBase (death) were analyzed.

RESULTS

One hundred and seven spinal sarcomas were identified, with a mean incidence was 0.38 sarcomas per million population per year, that was stable over time. The mean prevalence was 8.1 sarcomas per million population. The most common diagnosis was Ewing's sarcoma (48 [44.9%] patients), followed by chondrosarcoma (33 [30.8%] patients), and osteosarcoma (26 [24.3%] patients). Chondrosarcoma had the highest survival rates with 77.2% and 64.2% 5- and 10-year survival rates, respectively, followed by Ewing's sarcoma with 48.1% and 44.9% 5 and 10-year survival and osteosarcoma with 36.0% and 30.9% 5- and 10-year survival.

CONCLUSIONS

Spinal sarcoma is a rare disease with variable survival depending on the histologic diagnosis. This population-level study involves a heterogeneous group of patients with variable stages of disease at presentation and variable treatments. Our data fit with the published literature for survival for those treated conservatively and surgically. Our data show considerable improvement in 5- and 10-year mortality when compared with previous population level studies on earlier patient cohorts, likely reflecting improvements in systemic and surgical treatments.

Primary intradural/extradural Ewing's sarcoma of the sacral spine: A case report and literature review

Background:

Ewing’s sarcoma (ES) is a malignant mesenchymal tumor, most often found in the long bones, and usually affecting children and adolescents in the second decade of life. ES of the spine is a clinical rarity.

Case Description:

A 45-year-old male presented with a 3-month history of lower back pain which acutely worsened in conjunction with urinary retention. The magnetic resonance imaging revealed a mass extending from L5 to S2 with additional extension through the left S2-3 neural foramen. The metastatic workup was negative. At surgery, the lesion was both intradural and extradural. Following complete surgical resection, the patient was later treated with radiation and chemotherapy.

Conclusion:

Here, we report an adult male who acutely presented with low back pain attributable to primary intradural/extradural sacral ES.

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.

Imaging of presacral masses--a multidisciplinary approach

Our objective is to describe an approach for retrorectal/presacral mass evaluation on imaging with attention to imaging features, allowing for refinement of the differential diagnosis of these masses. Elaborate on clinically relevant features that may affect biopsy or surgical approach, of which the radiologist should be aware. A review of current literature regarding the diagnosis and treatment of retrorectal/presacral masses was performed with attention to specific findings, which may lend refinement to the differential diagnosis of these masses. Cases were obtained by searching through a radiology database at a single institution after Institutional Review Board approval. Recent advances in imaging and treatment methods have led to the increased role of radiology in both imaging and tissue diagnosis of retrorectal masses. Surgical philosophies surrounding the treatment of these masses have not significantly changed in recent years, but there are a few key factors of which the radiologist must be aware. The radiologist can offer refinement of the differential diagnosis of retrorectal masses and can elaborate on salient findings which could alter the need for neoadjuvant chemoradiation therapy, pre-surgical tissue diagnosis and surgical approach. This article presents an imaging approach to retrorectal/presacral masses with emphasis on findings which can dictate the ultimate need for neoadjuvant therapy and pre-surgical tissue diagnosis and alter the preferred surgical approach. This article consolidates key findings, so radiologists can become more clinically relevant in the evaluation of these masses.

Primitive neuroectodermal tumor/ewing sarcoma presenting with pulmonary nodular lesions

Primitive neuroectodermal tumors (PNETs) and Ewing sarcoma (EWS) belong to the same family of malignant, small, round cell neoplasms of soft tissue or bone origin. EWS-PNETs that arise in the lung parenchyma involvement are extremely rare in adults. A case of a 32-year-old male presenting with chest pain and diffuse pulmonary nodules on chest X-ray and diagnosed with Ewing sarcoma-PNETs will be presented here.

Primary Ewing's sarcoma of cervical vertebra: An uncommon presentation

Ewing's sarcoma is a malignant primary bone tumor primarily seen in the long bones. Primary Ewing's sarcoma of the cranium is quite uncommon occurring in 1% of the cases. We report the occurrence of this rare lesion in a 24-year-old male presenting with progressively increasing swelling in left mastoid region mimicking a mastoid abscess which was later diagnosed on Fine needle aspiration cytology (FNAC) as a small round cell tumor as Ewing's sarcoma. Contrast enhanced computed tomography (CECT) revealed a typical moth eaten appearance in the first and second cervical vertebra.

Primary Ewing's sarcoma of the spine presenting as acute paraplegia

Ewing's sarcoma is a primary bone malignancy with the highest incidence in the second decade of life. Although it mostly affects the metaphyseal region of long growing bones, involvement of spine is not very uncommon especially the sacrum. Nonsacral spinal Ewing's sarcoma is rarer and often mimics a benign condition before spreading extensively. They present with neurologic deficits due to spinal cord compression, but acute onset paraplegia has not been previously reported. A high index of clinical suspicion can clinch the diagnosis early in the course of the disease. A prompt intervention is required to keep neurological damage to a minimum, and a correct combination of surgery, chemotherapy, and radiotherapy is required for better long-term patient outcome. We report a 16-year-old female who presented with acute paraplegia and had an excellent postoperative outcome after radical excision of a D9 Ewing's sarcoma.

Primary Ewing's sarcoma of the cervical vertebra: one case report and literature review

Primary Ewing's sarcoma of the cervical vertebra is extremely rare. However, it is very important for radiologists to be aware of it to be able to provide timely diagnosis and therefore orient the treatment planning of the disease. The purpose of this study is to describe the imaging features of this tumor.

Treatment of nonmetastatic Ewing's sarcoma family tumors of the spine and sacrum: the experience from a single institution

The objective of this study is to determine the best local treatment combined with neoadjuvant chemotherapy for ESFT of the spine and sacrum, for the best local treatment for Ewing sarcoma family tumors (ESFT) according to the primary site is still unclear. Nowadays surgery is used in local treatment of ESFT, but literature is scarce on the best local treatment in sites where surgery is problematic, such as the spine. This study evaluates the outcome and the rate of local recurrence of ESFT in the spine and sacrum when treated with neoadjuvant chemotherapy, and locally by radiotherapy alone or surgery, followed by reduced doses of radiotherapy. Forty-three patients with nonmetastatic ESFT located in the spine and sacrum were treated at our institution between 1983 and 2000 with neoadjuvant chemotherapy, and locally by radiotherapy alone in 26 cases, and surgery followed by radiotherapy at reduced doses in 17. The 5- and 10-year event-free survival (EFS) was 37 and 30%, and the 5- and 10-year overall survival was (OS) 42 and 32%. The prognosis was unrelated to gender and age, tumor volume, chemotherapy protocol, and local treatment. The outcome seemed worse for patients with primary tumors located in the sacrum than for patients with tumors located in the rest of the spine (5-year EFS = 23 vs. 46%). For these patients the results were significantly worse than for those we achieved with neoadjuvant treatment for ESFT located in other sites. However, no differences were observed between patients locally treated with radiotherapy alone and those treated by radiotherapy followed by surgery. We concluded that regardless of the type of local treatment even when associated with neoadjuvant therapy, ESFT in the spine and sacrum has a poor outcome and prognosis is significantly worse than that of primary ESFT in other sites.

Bone sarcoma of the spine

Primary malignant bone tumors of the vertebral column, i.e., bone sarcomas of the spine, are inherently rare entities. Vertebral osteosarcomas and chordomas represent the largest groups, followed by the incidence of chondro-, fibro-, and Ewing's sarcomas. Detailed clinical and neurological examination, complete radiographic imaging [radiographs, computed tomography (CT), magnetic resonance imaging (MRI)], and biopsy are the decisive diagnostic steps. Oncosurgical staging for spinal tumors can serve as a decision-guidance system for an individual's oncological and surgical treatment. Subsequent treatment decisions are part of an integrated, multimodal oncological concept. Surgical options comprise minimally invasive surgery, palliative stabilization procedures, and curative, wide excisions with complex reconstructions to attain wide or at least marginal resections. The most aggressive mode of surgical resection for primary vertebral column tumors is the total en bloc vertebrectomy, i.e., single- or multilevel en bloc spondylectomy. En bloc spondylectomy involves a posterior or combined anterior/posterior approach, followed by en bloc laminectomy, circumferential (360 degrees) vertebral dissection, and blunt ventral release of the large vessels, intervertebral discectomy and rotation/ en bloc removal of the vertebra along its longitudinal axis. Due to the complex interdisciplinary approach and the challenging surgical resection techniques involved, management of vertebral bone sarcomas is recommended to be performed in specific musculoskeletal tumor centers.

Primary thoracolumbar Ewing's sarcoma presenting as isolated epidural mass

BACKGROUND CONTEXT

Ewing's sarcoma is the most common childhood malignancy of bone, but it rarely occurs as a primary extraosseous epidural tumor.

PURPOSE

To heighten awareness and treatment options of this rare (epidural) presentation of Ewing's sarcoma.

STUDY DESIGN

Case report.

METHODS

Retrospective review.

RESULTS

We present a 13-year-old boy with progressive low back and bilateral lower extremity pain and normal neurologic examination. Magnetic resonance imaging showed an extradural tumor in the dorsal epidural space from T11 to L1. He underwent a posterior laminoplasty and gross total resection of tumor; histopathological diagnosis was consistent with Ewing's sarcoma. After surgery, the patient underwent adjuvant chemotherapy and irradiation. At 10 months follow-up, the patient is neurologically intact without evidence of residual disease.

CONCLUSIONS

Ewing's sarcoma of the epidural space should be considered in the differential diagnosis of epidural mass lesions. Because wide surgical margins cannot be obtained, close follow-up with a low threshold for reoperation is mandatory.

Primary tumors of the osseous spine

Primary tumors of the spine are less frequent than metastatic disease, multiple myeloma, and lymphoma. MR imaging is commonly used to evaluate the spine in patients presenting with pain and can further characterize lesions that may be encountered on other imaging studies, such as radiographs, bone scintigraphy, or CT. This article guides radiologists in identifying these lesions and referring physicians to the appropriate patient evaluation. It also offers directions for avoiding all-encompassing broad differential diagnosis lists in situations where the clinical scenario or specific imaging features can significantly limit the diagnostic possibilities.

Primary bone tumors of the spine in children

OBJECT

Tumors originating in the vertebrae in children are difficult to treat. In this paper the authors sought to evaluate the decision-making process and outcome of surgical intervention in this population given the complex issues of spinal stability, continued skeletal growth, intraoperative blood loss, and long-term outcome.

METHODS

To select patients for this study, the authors retrospectively reviewed medical records and images at the University of Iowa Hospitals and Clinics between 1996 and 2005. Their inclusion criteria were age younger than 18 years at the time of diagnosis and histopathological findings confirming that the tumor originated from vertebral bone. Sixteen patients met these requirements. In addition, the authors conducted a comparison with 45 patients in whom similar diagnoses were made prior to 1996. Gross-total resection of all nonmetastatic primary bone tumors is desired, as exemplified in 11 patients in this series; biopsy sampling only was performed in two others. Gross-total resection was also not performed in three patients with eosinophilic granuloma (EG). These three patients underwent nonsurgical treatment, which is different from how patients with EG were treated in the earlier study. Nine histopathological diagnoses were included; with a mean follow-up period of 3.7 years, the survival rate is 94%. The tumor recurred in one patient with a giant cell tumor of the sacrum. The authors performed preoperative tumor embolization and found that it was a useful adjunct to resection. Provocative testing prior to embolization was part of the protocol to reduce ischemic complications. Motion-sparing surgical procedures were performed in which a few segments were fused, preserving axial mobility.

CONCLUSIONS

Overall, early intervention offers the best symptomatic relief, which can only be rendered if sufficient clinical suspicion provokes early diagnostic imaging.

Part II: Spinal-cord neoplasms—primary tumours of the bony spine and adjacent soft tissues

Primary tumours of the bony spine and adjacent soft tissues most frequently present with pain although neurological deficits and spinal deformity can be present too. Knowledge of the spectrum of lesions that can affect the bony spine and the surrounding soft tissues is crucial in directing appropriate investigation and treatment. Patients need individualised approaches and treatment plans in view of the variations in tumour aggressiveness, spinal level, location within the vertebral body or posterior elements, involvement of soft tissues and structures surrounding the vertebral column, neurological deficits, and spinal instability.

Primary Ewing’s sarcoma of the spine: case report

Primary malignant sarcomas of the spine are extremely rare. Because of biological heterogeneity, these tumors have variable sensitivity to radiation and chemotherapy. Adequate local control through complete tumor removal is an important therapeutic goal. However, aggressive resection of tumors in the spinal column must be coupled with restoration of spinal column stability and minimization of neural deficits. The balance of these factors makes treatment of primary sarcomas of the spine challenging, and dictates an individual approach to treatment. We report on a 18 years old man with primary Ewing's sarcoma of the nonsacral spine. The clinical picture and imaging characteristics were analyzed as well as the management modalities and outcome.

Imaging and differential diagnosis of primary bone tumors and tumor-like lesions of the spine

Primary bone tumors and tumor-like lesions of the spine and sacrum are rare. A wide variety of benign and malignant lesions can arise in the spine and sacrum. Specific diagnosis is based on the location, matrix appearance and patient's age at time of presentation. In this location CT is often necessary for matrix characterization, particularly, detection of mineralization. MRI can be helpful for further characterization and radiological differential diagnosis. An overview of age distribution and imaging features including pattern for differential diagnosis is presented for the most frequent primary spinal bone tumors and tumor-like lesions.

Multilevel en bloc spondylectomy and chest wall excision via a simultaneous anterior and posterior approach for Ewing sarcoma

STUDY DESIGN

A case study of a patient with Ewing sarcoma of T8 and T9 with paravertebral and chest wall involvement, who underwent neoadjuvant chemotherapy and subsequent multilevel en bloc spondylectomy and chest wall excision using a simultaneous anterior and posterior approach.

OBJECTIVE

To show the feasibility of treating Ewing sarcoma of the thoracic spine with paravertebral and chest wall extension by multiagent chemotherapy followed by a multilevel en bloc spondylectomy and chest wall excision using a simultaneous anterior and posterior approach.

SUMMARY OF BACKGROUND DATA

Ewing sarcoma is a primary malignant bone tumor that occasionally involves the spinal column. Most patients with Ewing sarcoma of the spine are treated with systemic chemotherapy followed by definitive local control. Radiation therapy is the usual mode of local control in these patients because the spinal column has historically been considered a surgically inaccessible site where wide surgical margins are difficult to obtain. However, en bloc spondylectomy techniques have been described that can probably further decrease the risk of local recurrence, thereby minimizing or even eliminating the need for radiation therapy. To our knowledge, a combined en bloc spondylectomy and chest wall excision in a patient with Ewing sarcoma in the spine has not been previously reported.

METHODS

Neoadjuvant chemotherapy consisting of vincristine, doxorubicin, and cyclophosphamide was administered. After completion of the chemotherapy, an en bloc spondylectomy of T8 and T9 with removal of the chest wall was achieved using a simultaneous anterior and posterior approach to the spine. A stackable carbon fiber cage filled with autograft and allograft bone was inserted between T7 and T10. The spine was stabilized with anterior and posterior instrumentation. The chest wall was reconstructed with contoured polymethylmethacrylate and polypropylene (Marlex, Textile Development Associates, Inc., Franklin Square, NY) mesh.

RESULTS

The patient maintained normal neurologic function, and pain was lessened. The margins were free of tumor, and tumor necrosis was 100%. After surgery, radiotherapy was not administered. No local tumor recurrence or distant metastases were evident at the last follow-up. Balance in the coronal and sagittal planes was maintained. The patient has returned to work and resumed normal activities of daily living.

CONCLUSIONS

Multilevel en bloc spondylectomy and chest wall excision performed using a simultaneous anterior and posterior approach is a safe and effective technique that may be used to achieve adequate margins in select patients with malignant tumors involving the thoracic spine and chest wall. This technique can eliminate the need for radiation therapy in patients with Ewing sarcoma and probably decreases the risk of local recurrence compared with radiation therapy alone.

Ewing's sarcoma of the mobile spine

STUDY DESIGN

A retrospective analysis was performed.

OBJECTIVES

To determine the oncological outcome of patients with nonmetastatic Ewing's sarcoma of the mobile spine treated with systemic multiagent chemotherapy combined with radiation therapy for definitive local control.

SUMMARY OF BACKGROUND DATA

To our knowledge, there are no studies that evaluate the oncological outcome of patients with nonmetastatic Ewing's sarcoma of the mobile spine treated with systemic chemotherapy and radiation therapy for definitive local control.

METHODS

Thirteen patients with nonmetastatic Ewing's sarcoma of the mobile spine were treated with high-dose multiagent chemotherapy combined with radiation therapy for definitive local control from 1971 to 2000 at a single institution. Patients were observed for a minimum of 2 years or until death. Neurological function, local recurrence, distant relapse, and treatment-related complications were evaluated.

RESULTS

There were 8 females and 5 males with a mean age of 19 years (ranging from 7-26 years). The mean follow-up time was 65 months (median 28 months; ranging from 2 to 218 months). All patients presented with pain. Motor deficits were present in 6 patients. Ten patients had a decompressive laminectomy. Improved pain control, as determined by narcotic use, was noted in 12 (92%) patients. Ten patients maintained or improved motor function by at least 1 Frankel grade, while 3 had deterioration of motor function. The disease-free survival rate was 49% and 36% at 5 and 10 years. Five (38%) patients were free of disease at last follow-up. Seven patients developed metastatic disease. Three (23%) patients developed a local recurrence. One of these patients had paraplegia associated with the local recurrence. Five patients developed 8 treatment-related complications. Four of the 10 (40%) patients that had a laminectomy developed progressive kyphosis. Two of these patients also developed late-onset cauda equina syndrome along with the deformity. One of these patients also developed cardiomyopathy associated with adriamycin cardiotoxicity. One patient developed a nonhealing pressure ulcerover a prominent spinous process.

CONCLUSIONS

The current study provides historical data on a relatively homogeneous group of patients withEwing's sarcoma of the mobile spine treated with multiagent chemotherapy combined with radiation therapy for definitive local control. Systemic chemotherapy combined with current spinal resection and reconstruction techniques may lead to improved oncological and clinical outcomes.

Vertebra plana caused by primary Ewing sarcoma: case report and review of the literature

A 7-year-old boy presented with vertebra plana of T11. The presumptive diagnosis suggested by clinical presentation, conventional radiographs, and computed tomographic scans was eosinophilic granuloma. Progressive neurologic symptoms required surgical excision of the lesion and decompression. Histopathologic examination of the surgical specimen confirmed the diagnosis of Ewing sarcoma.

Primary Ewing tumor of the vertebrae: clinical characteristics, prognostic factors, and outcome

BACKGROUND

Fewer than 10% of Ewing family of tumors (EFT) arise in the vertebrae. Little information is available regarding the clinical presentation and outcome of these tumors.

PROCEDURE

We reviewed the clinical features, prognostic factors, and outcome of EFT of the spine identified at our institution between 1962 and 1999.

RESULTS

Thirty-three (10%) of 344 patients with EFT had a primary vertebral tumor. There were 21 (64%) males. Median age at diagnosis was 13.3 years. Six patients had metastatic disease and 10 had tumors > or = 8 cm in diameter. Primary sites were sacral (13), thoracic (10), lumbar (8), and cervical (2) vertebrae. We found no association between the affected spinal region and outcome, although sacral tumors were associated with delayed diagnosis (4 vs. 2 months after onset of symptoms, P = 0.076). Pain (n = 32) and neurologic deficits (n = 31; 82% motor, 58% sensory, 42% bladder, 27% bowel) were the most common presenting features. All patients received combination chemotherapy and local radiotherapy. With a median follow up of 9.7 years, 5-year survival and event-free survival ( +/- SD) estimates were 48.1% (8.9%) and 35.6% (8.6%), respectively, comparable to those of other patients with EFT. Outcome was better for patients with tumor size < 8 cm (P = 0.008) or localized disease (P = 0.084). Treatment era and specific tumor site did not affect outcome.

CONCLUSIONS

Outcomes are similar for primary EFT of the spine and primary EFT in other sites. Unlike others, we found that patients with sacral tumors did not fare worse than patients with tumors at other spinal sites.

Vertebral tumors and pseudotumors

This article discusses lesions that may present as vertebral tumors at radiologic examination. Conditions are discussed in order of decreasing frequency: pseudotumoral lesions, vertebral metastases, bone marrow diseases, and primary vertebral tumors, which are relatively uncommon. The differential diagnosis between nontraumatic benign and malignant vertebral collapses is also discussed.

Ewing's family of tumors involving structures related to the central nervous system: a review

This review consolidates information gleaned from several case reports and larger series on Ewing's sarcoma family of tumors (EFT) involving structures related to and found in the central nervous system (CNS). These tumors involve the skull, the spinal column, adjacent soft tissues, the meninges, and the brain. We have separated the cases by skull region and spinal column level, and we discuss the attendant differences in prognosis following treatment by neurosurgery, radiation, and chemotherapy. Light and electron microscopic features can be used to differentiate EFT from other small round blue cell tumors that involve the CNS (central primitive neuroectodermal tumor, lymphoma, etc.). Recent molecular and genetic findings in EFT provide new diagnostic methods. We conclude that EFT involving the CNS and adjacent structures is not so rare as previously stated and that the prognosis is more favorable, as a rule, than for the more common examples arising in the long bones and pelvis.

Primary tumors of the spine in children. Natural history, management, and long-term follow-up

STUDY DESIGN

Patients 16 years of age and younger with primary vertebral neoplasms diagnosed between 1951 and 1996 at The University of Iowa were reviewed retrospectively with specific consideration given to follow-up.

OBJECTIVE

Follow-up extending beyond the growth of the axial skeleton was used to establish the natural history, management outcome, and current approach to treatment.

SUMMARY OF BACKGROUND DATA

Primary tumors of the spine are uncommon. The treatment of such lesions generally has been based on small series of tumors, or extrapolated from the treatment of tumors in other regions and tumors in adults. Given the unique developing anatomy and dynamic nature of the growing spine in children, delineating appropriate modalities of treatment for these tumors beyond the growth of the axial skeleton is essential.

METHODS

Clinical history, radiographs, radiographic reports, and interviews were used to establish this database. Outcome with respect to the various approaches to treatment was then compared in detail.

RESULTS

Forty-five patients were identified in which follow-up greater than 10 years was available for 58% of patients. There were 29 histologically benign and 16 malignant tumors. Patients presented most frequently with pain (79%) and neurologic deficits (74%). The duration of symptoms was significantly shorter with malignant tumors (11 weeks) compared with benign tumors (26 weeks). Radiographic abnormalities were demonstrated on plain radiographs in 98% of cases. Tumor excision was achieved in 80%. Follow-up studies were available beyond the growth of the axial skeleton in these patients, with an average follow-up of 14 years. Recurrence was seen in 6 of 45 children, and the overall mortality rate was 6.7%, occurring only with malignant tumors.

CONCLUSION

Our current approach to treatment of spinal neoplasms varies from that used in the earlier part of the series and reflects the need for single stage complete resection and stabilization.

Primary spinal column sarcomas

Five cases of primary spinal column sarcomas are presented. Sarcomas primarily originating from paravertebral soft tissues were excluded. Patients' age ranged from 1 to 14 years (mean 8.4 years). The male:female ration was 2:3. Two patients had Ewing's sarcoma (ES) originating from L5-S1 and L4-5 pedicles, respectively; two patients had mesenchymal chondrosarcoma (MCS) originating from L1-2 pedicles and L5 body, respectively; and one patient had osteogenic sarcoma (OS) of C4 body. All patients clinically presented with pain and progressive weakness of the extremities. The time that elapsed between the onset of symptoms and diagnoses ranged from one to five months. All cases were treated with chemotherapy, radiotherapy and subtotal tumour resection with spinal canal decompression. Two cases received posterior spinal fusion operations. Three patients were alive 10 to 98 months following diagnosis. Only the case with ES of L5-S1 pedicles was in complete remission and off therapy at the 98th postoperative month. The two MCS cases were in partial remission, and were receiving chemotherapy at the time of analysis. These tumours caused similar clinical findings and prognoses, and required combined treatment, which consisted of surgery, radiotherapy and chemotherapy; histologically three different types of malignant tumours are presented in the same category. We preferred surgical decompression and stabilization procedures especially for neurologically symptomatic patients, even if they had extensive tumours with high grades. By spinal canal decompression and stabilisation, we did not intend to cure the disease; however, we intended to provide neurological improvement, spinal stabilisation, improved quality of life, early mobilisation of the patient, and cytoreduction by means of surgical tumour ablation, which could render the chemotherapy more effective.

Solitary ivory vertebra due to primary Ewing's sarcoma

Dense sclerosis of most of the vertebral body has been termed as "ivory vertebra". While this condition occurs rather frequently in adults it is not found very often in children.

Primary spinal epidural extraosseous Ewing's sarcoma

The case of a 7-year-old boy with a spinal epidural extraosseous Ewing's sarcoma (EES) is presented. He is in complete remission without neurologic deficit 40 months after diagnosis. Another 15 cases were found in the literature and are discussed together with this patient. Twelve of them were male patients. The mean age of the patients was 17.5 years (range, 4 to 47). Symptoms included back pain and/or radicular pain (100%), paresis of one or both legs (83%), sensory disturbances, and bladder and bowel dysfunction. The mean diagnostic delay was 5.8 months. Each patient underwent laminectomy; complete resection of the tumor was impossible in more than 50% of the cases. Most patients received radiation therapy and/or chemotherapy. Four patients suffered from local recurrence, eight from metastases. Ten (63%) patients died, 1 to 48 months (mean, 16) after diagnosis. The differential diagnosis is discussed, including disk herniation and several benign and malignant tumors.

Histopathological predictive factors in Ewing's sarcoma of bone and clinicopathological correlations. A retrospective study of 261 cases

A retrospective multifactorial analysis on 261 previously untreated patients with Ewing's sarcoma (Es) of bone has been carried out in order to ascertain the prognostic value of several histological variables on survival. Among those cases accepted as Es, 208 (80% of the patients) were considered to be "typical Es", while 40 (15%) displayed a large cell predominance, being subclassified as "atypical large cell Es". Furthermore, 13 patients (5%) possessed tumours of endothelial-like appearance. Eleven cases which displayed a mixed histological configuration were finally included within one of the three previous groups according to their predominant histological pattern. After adjustment for therapeutic regimens and initial location of the tumour, only two histological characteristics remain significant; i.e. the presence of necrosis (p = 0.002) and, to a lesser degree, the presence of filagree "en damier" pattern (p = 0.08), both of which are of poor prognostic value. From this study, it can be assumed that the morphological (and possibly histogenetical) heterogeneity of Es of bone has no prognostic influence on survival.

Spinal Ewing sarcoma: misleading appearances

The plain radiographic and computed tomographic (CT) findings in two unusual cases of spinal Ewing sarcoma are reported. Radiographic features resembling neuroblastoma in one case and aneurysmal bone cyst in the other were present. These findings may be misleading and distinguishing characteristics in each case are discussed.

Primary Ewing's sarcoma of the ribs. A report from the intergroup Ewing's sarcoma study

Thirty-six patients with primary Ewing's sarcoma of the ribs have been reviewed. Of these, 21 had clinically localized disease at diagnosis and were entered on protocol IESS 7299, eight had regional and seven metastatic disease at diagnosis and were entered on protocol 7450. The 21 with localized disease were treated with surgical excision or biopsy, followed by local radiotherapy (in all but one patient) and randomization to one of three chemotherapy regimens. Eleven patients (52%) remain disease-free for periods ranging from 18 to 64 months, respectively. Seven of eight patients who underwent complete surgical excision of the primary lesion remain disease-free, compared with four of 12 (excluding one patient who died disease-free) who remain disease-free after partial excision or biopsy. However, analysis of size of tumor at diagnosis reveals that smaller primary tumors have a better prognosis irrespective of extent of surgery. Protocol IESS 7450, consisted of radiotherapy to all areas of known disease and four drug chemotherapy. Four (50%) with regional disease but none with metastatic disease have remained alive and continuously disease-free. It is concluded that an aggressive approach to Ewing's sarcoma of the ribs is justified by the results, as even regional disease may be curable. The apparent prognostic advantage for those patients undergoing surgical excision may be explained by patient selection.

The prognostic significance of soft tissue extension in Ewing's sarcoma

From January 1969 through December 1977, 28 patients were treated at the University of Florida with the diagnosis of Ewing's sarcoma. All patients received radiation therapy to the primary site and adjuvant chemotherapy according to several different regimens. A retrospective analysis was carried out to determine the prognostic significance of gross extraosseous extension by the primary lesion. Gross soft tissue extension at the primary site was found to be of prognostic importance. Patients with soft tissue extension more often presented with metastatic disease (39 versus 10%). The five-year survival rate for patients presenting without distant metastasis and whose primary lesions were grossly confined to bone was 87% compared to 20% for those with extraosseous extension. The decrease in survival with soft tissue extension resulted from an increase in distant metastasis as well as local failure, and was independent of primary site location. The proportion of patients with extraosseous extension should be reported in subsequent analyses of local control and survival.