Very Late Local Relapse of Ewing's Sarcoma of the Head and Neck treated with Aggressive Multimodal Therapy

Ewing sarcoma with very late metastasis in the skull: a case report

Background

Ewing sarcoma is a malignant bone tumor; however, its prognosis has improved since the development of modern chemotherapy. Although Ewing sarcoma outcomes have improved, issues related to late complications, secondary malignant neoplasms, and late recurrence or metastasis have emerged.

Case presentation

We report a case of Ewing sarcoma that recurred in the occipital bone 21 years after primary tumor treatment. A 45-year-old Japanese woman with a history of Ewing sarcoma 21 years prior, was referred to our hospital due to a severe headache. A tumor was detected in the left occipital bone, and the biopsy revealed Ewing sarcoma. Metastasis was suspected because the patient had been treated for Ewing sarcoma of the left clavicle 21 years prior. There have been several cases of local recurrence or metastasis, occurring 15–20 years after the onset of the initial disease. To our knowledge, very late metastasis of Ewing sarcoma in the skull has not been reported.

Conclusion

We report a rare case of very late metastasis of Ewing sarcoma in the skull with a review of the literature. Delayed metastasis secondary to Ewing sarcoma can occur in the lung, which is the most common site for metastasis, as well as other regions of the body, such as the cranium.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13256-022-03656-5.

Aggressive primary sinonasal Ewing sarcoma with intraorbital and intracranial extension

Ewing sarcoma (ES) of the extraskeletal form is a rare occurrence and even rarer to manifest in the sinonasal tract. We describe a case of an advanced sinonasal ES with orbital and intracranial extension that was managed with chemotherapy and endoscopic surgery. Despite completing chemotherapy and surgical resection, the tumor progressed rapidly even before postoperative radiotherapy, and subsequently, she succumbed to death due to sepsis. We would like to discuss the management challenges, pitfalls, and surgical approach which may improve the outcome of this complicated disease.

Resection of Ewing Sarcoma in the Paranasal Sinus Via the Endoscopic Modified Lothrop (Draf III) Approach

Ewing sarcoma is a rare type of bone tumor that typically occurs in the head and neck regions. Appropriate management strategies remain controversial. Herein, we report a case of Ewing sarcoma originating from the ethmoid sinus in a 38-year-old woman. The patient initially presented with unilateral nasal obstruction. Pathologic examination revealed a tumor composed of small round blue cells under hematoxylin and eosin staining with positive expressions for CD-99, CK, and FLI-1. The patient was successfully treated with neoadjuvant chemotherapy followed by complete surgical excision via the endoscopic modified Lothrop (Draf III) approach, adjuvant chemotherapy, and radiation therapy. There was no recurrence or complication up to the writing of this article. This study presents an appropriate management strategy for an extensive case of Ewing sarcoma invading the frontal sinus using an endoscopic approach.

Treatment, outcomes, and demographics in sinonasal sarcoma: a systematic review of the literature

Background

Sarcomas comprise a diverse group of soft tissue mesenchymal malignancies. The sinuses and nasal region are a relatively rare site of sarcomas.

Methods

Retrospective review of the literature on sinonasal sarcomas from 1987-2017. Data were analyzed for demographics, treatment type, stage, and histopathologic type. Kaplan-Meier analysis was used to assess and compare survival.

Results

A total of 198 cases of sinonasal sarcoma were identified and analyzed. The median age at diagnosis was 39 years. Overall 5-, 10-, and 20-year survival was 61.3%, 58.9%, and 49.1%, respectively, and disease-free 5-, 10-, and 20-year survival was 53.2%, 49.1%, and 38.3%, respectively. Lymph node metastasis was present at diagnosis in 3.0% of cases, and distant metastasis was present in 3.5% of cases. On univariate analysis T stage, overall stage, treatment type, histopathologic subtype, and presence of distant metastasis significantly affected survival. On multivariate analysis overall stage alone significantly predicted overall survival. Open vs. endoscopic surgery, total radiation dose, and presence of neck metastasis did not significantly affect survival. Combined modality treatment was associated with higher survival rates than single modality therapy.

Conclusions

Sinonasal sarcoma is a relatively rare malignancy. Lower T and overall stage, lack of distant metastasis, and multimodality therapy were associated with improved survival. Certain histopathologic subtypes were associated with poorer survival.

Electronic supplementary material

The online version of this article (10.1186/s12901-018-0052-5) contains supplementary material, which is available to authorized users.

Endoscopic Treatment of Ewing Sarcoma of the Sinonasal Tract

The extra-skeletal form is an unusual type of Ewing sarcoma (ES) arising from soft tissue and in the literature there are reports of less than 50 patients describing the tumor in the paranasal sinuses and skull base. The histological diagnosis is crucial to plan the correct treatment and the molecular confirmation is mandatory in equivocal patients. A multimodality treatment with chemotherapy, surgery and radiotherapy improved the outcomes of these diseases during the last decades and a free-margin resection with the endoscopic transnasal technique is one of the most recent ways to manage these pathologies in selected patients, reducing the morbidities of the external approaches and preserving the quality of life of the patient.Here, the authors present the first patient of primary sinonasal ES free from disease after 5 years of follow-up and treated with an endoscopic endonasal approach and a second patient of sinonasal metastases of ES treated with and endoscopic transnasal approach.

Multimodality Treatment in Ewing's Sarcoma Family Tumors of the Maxilla and Maxillary Sinus: Review of the Literature

The Ewing sarcoma family of tumors (ESFT) encompasses a group of highly aggressive, morphologically similar, malignant neoplasms sharing a common spontaneous genetic translocation that affect mostly children and young adults. These predominantly characteristic, small round-cell tumors include Ewing's sarcoma of the bone and soft tissue, as well as primitive neuroectodermal tumors (PNETs) involving the bone, soft tissue, and thoracopulmonary region (Askin's tumor). Extraosseous ESFTs are extremely rare, especially in the head and neck region, where literature to date consists of sporadic case reports and very small series. We hereby present a review of the literature published on ESFTs reported in the maxilla and maxillary sinus region from 1968 to 2016.

Regenerative therapy with mesenchymal stem cells at the site of malignant primary bone tumour resection: what are the risks of early or late local recurrence?

PURPOSE

There is concern that regenerative cell-based therapies at the site of malignant primary bone tumours could result in increased risk of local tumour recurrence. We therefore investigated the long-term risks for site-specific recurrences in patients who had received an autologous bone marrow derived mesenchymal stem cell suspension to improve healing at the host-to-allograft bone junction of the reconstruction after bone tumour resection.

METHODS

A total of 92 patients were treated from 1993 to 2003 with bone marrow-derived mesenchymal stem cells after bone tumour resection. Patients were monitored for cancer incidence from the date of first operation (1993) until death, or until 31 December 2013. The mean follow-up time was 15.4 years (range ten to 20 years). The average number of MSCs returned to the patient was 234,000 MSCs ± 215,000. The primary outcome was to evaluate the risk of tumorigenesis recurrence at the cell therapy treatment sites with radiographs and/or MRIs. The relative risk of cancer recurrence was expressed as the ratio of observed and expected number of cases according to three different control populations.

RESULTS

Thirteen recurrences were found at the treatment sites among the 92 patients. The expected number of recurrences based on incidence in the three cohort populations was between 15 and 20 for the same cancer, age and sex distribution. The standardized incidence ratio (equal to observed cancers divided by expected cancers) for the entire follow-up period and for all recurrences was between 0.65 and 0.86 (95 % CI 0.60-1.20).

CONCLUSION

This study found no increased cancer local recurrence risk in patients after application of autologous cell-based therapy using bone marrow-derived mesenchymal stem cells at the treatment site after an average follow-up period of 15.4 years, ranging from ten to 20 years.

Multidisciplinary therapy including proton beam radiotherapy for a Ewing sarcoma family tumor of maxillary sinus in a 4-year-old girl

BACKGROUND

Although complete resection offers the best chance for controlling head and neck Ewing sarcoma family tumors (ESFTs), it is occasionally unfeasible because of possible functional and cosmetic side effects. Planning multidisciplinary treatment for head and neck ESFT is challenging.

METHODS AND RESULTS

A 4-year-old girl had left-sided excessive tearing, nasal obstruction, and exophthalmos for 4 months. A CT scan showed a mass filling the left maxillary sinus and extending to the left orbital wall. After a diagnosis of ESFT was established with biopsy, the patient was treated with vincristine, doxorubicin, cyclophosphamide/ifosfamide etoposide (VDC/IE) regimen over 50 weeks; partial maxillectomy was performed at week 15 and was followed by proton radiotherapy. The patient has remained tumor-free for 16 months, with preservation of facial form and function.

CONCLUSION

Partial resection combined with proton radiotherapy may enable maximal tumor control and minimal functional and cosmetic side effects in children with head and neck ESFT.

Ewing's family of tumors of the sinonasal tract and maxillary bone

The Ewing's family of tumors (EFT) are malignant neoplasms affecting children and young adults. Most cases arise in the long bones or the pelvis. Primary EFT of head and neck is uncommon and primary sinonasal EFT is even rarer. Previous studies have not focused on the sinonasal region specifically, and the published literature on sinonasal EFT consists of sporadic case reports. Fourteen cases of sinonasal EFT were available and had H&Es for review and immunohistochemical stains for CD99, S100, keratins, synaptophysin and desmin. FISH or RT-PCR was performed for EWSR1 abnormalities on 8 cases. The 14 identified patients included 5 males and 9 females, ranging from 7-70 years of age (mean 32.4 years). Tumors involved nasal cavity (5), sinuses (5) or both (4). Five patients had dural, orbital or brain involvement. The majority involved bone radiologically and/or microscopically. All cases were composed of small cells with variable cytoplasmic clearing. Focal or prominent nesting was noted in most cases. All cases were positive for CD99. Keratins (AE1/3 and/or CAM5.2), S100 and synaptophysin were positive in 4, 3 and 5 cases, respectively. All cases were negative for desmin. The 8 cases tested by FISH or RT-PCR were positive for EWSR1 abnormalities. Follow-up in 8 patients ranged from 1-168 months (average 11.3 m) showing 1 death due to metastatic disease, 1 death due to local disease, 1 patient alive with metastases and 5 patients disease-free at last follow-up. Interestingly, however, an analysis of the literature suggests a better prognosis for sinonasal EFT than EFT overall.

Late recurrence in pediatric cancer: a report from the Childhood Cancer Survivor Study

BACKGROUND

An increasing percentage of childhood cancer patients are surviving their disease, but there is limited research on late recurrence. We sought to estimate late recurrence rates for the most common pediatric cancers and to determine risk factors for late recurrence.

METHODS

The incidence of late recurrences, or first recurrences that occurred more than 5 years after diagnosis, was analyzed for the most common pediatric cancers using data from the Childhood Cancer Survivor Study, a retrospective cohort of 5-year survivors of childhood and adolescent cancers who were diagnosed between 1970 and 1986. A total of 12,795 survivors with no history of recurrence within 5 years after their original cancer diagnosis were included in the analysis, with a total of 217,127 person-years of follow-up. Cumulative incidence of late recurrence at 5, 10, 15, and 20 years after diagnosis was calculated using death as a competing risk. Adjusted relative rates of late recurrence were obtained using multivariable Poisson regression. All statistical tests were two-sided.

RESULTS

Overall, 5-year survivors of pediatric cancers experienced a cumulative incidence of recurrent disease of 4.4%, 5.6%, and 6.2% at 10, 15, and 20 years, respectively. Cumulative incidence varied by diagnosis: Survivors of Ewing sarcoma and astrocytoma had the highest 20-year cumulative incidences at 13.0% (95% confidence interval [CI] = 9.4 to 16.5) and 14.4% (95% CI = 12.3 to 16.6), respectively. In multivariable analysis, the greatest risk factors for late recurrence included diagnosis, combination treatment with chemotherapy and radiation, earlier treatment era, and fewer years since diagnosis (P < .001 for all).

CONCLUSION

Late recurrence is a risk for some pediatric cancers. By understanding diagnosis-specific risks, patients, families, and their medical providers can be better informed of the probability of cure.