Current Status of Management and Outcome for Patients with Ewing Sarcoma

Results of the Latin American Pediatric Oncology Group (GALOP) Trial for Patients With Metastatic Ewing Sarcoma: Multicentric study of Interval-Compressed Multiagent and Metronomic Chemotherapy

BACKGROUND

GALOP investigators developed a multicenter protocol to standardize treatment for newly diagnosed metastatic Ewing sarcoma (ES) in South America.

METHODS

Prospective trial. Induction chemotherapy consisted of 9 alternating interval-compressed cycles (every 14 days) of vincristine, doxorubicin, cyclophosphamide, and ifosfamide-etoposide; local and metastatic site control; and 5 consolidation cycles (every 21 days), followed by MCT with cyclophosphamide and vinblastine for 1 year.

RESULTS

Between 2011 and 2019, 198 patients were recruited from 34 centers in Argentina, Brazil, Chile, and Uruguay. Characteristics include: male patients (60.6%), median age of 12.3 years (range, 0.8-31.1); axial primary localization (62.1%), size >8 cm (70.2%); and bone origin (71.2%). Metastatic sites were lung, extra-lung, and combined in 43.4%, 31.3%, and 25.3%, respectively. The overall response rate was 79.3%, and local treatment was performed in 85.3% of patients. With a median follow-up of 65.1 months (95% CI: 53.9-76.4), the 5-year overall survival (OS) and event-free survival (EFS) were 33.1% (95% CI: 25.9-40.4) and 27.8% (95% CI: 21.5-34.3), respectively. The 5-year OS was 44.9%, 31.3%, and 15.6% for lung, extra-lung, and combined, respectively (p < 0.001). The median interval between induction chemotherapy cycles was 17 days, with a febrile neutropenia rate of 19.3%. Metronomic chemotherapy (MCT) was administered to 100 patients (50.5%), demonstrating good tolerability, with 58 patients completing at least 75% of the scheduled cycles.

CONCLUSION

The implementation of a multicenter protocol incorporating MCT for metastatic ES proved feasible across Latin America.

The O-glycosyltransferase C1GALT1 promotes EWSR1::FLI1 expression and is a therapeutic target for Ewing sarcoma

Ewing sarcoma (ES) is an aggressive bone cancer driven by the oncogenic fusion-protein EWSR1::FLI1, which is not present in normal cells and is therefore an attractive therapeutic target. However, as a transcription factor, EWSR1::FLI1 is considered undruggable. Factors that promote EWSR1::FLI1 expression, and thus whose inhibition would reduce EWSR1::FLI1 protein levels and function, are potential drug targets. Here, using genome-scale CRISPR/Cas9 knockout screening, we identify C1GALT1, a galactosyltransferase required for the biosynthesis of many O-glycoproteins, as a factor that promotes EWSR1::FLI1 expression. We show that C1GALT1 acts by O-glycosylating the pivotal Hedgehog (Hh) signaling component Smoothened (SMO), thereby stabilizing SMO and stimulating the Hh pathway, which we find directly activates EWSR1::FLI1 transcription. Itraconazole, an FDA-approved anti-fungal agent that is known to inhibit C1GALT1, reduces EWSR1::FLI1 levels in ES cell lines and suppresses growth of ES xenografts in mice. Our study reveals a therapeutically targetable mechanism that promotes EWSR1::FLI1 expression and ES tumor growth.

An Unusual Case of Cutaneous Ewing Sarcoma of the Anterior Abdominal Wall in an Adult Patient

Ewing sarcoma is a malignant small round blue cell tumor most commonly found in the bones of children and adolescents. Cutaneous Ewing sarcoma, originating in the skin and subcutaneous tissues, is exceedingly rare, especially in adults. We present the case of a 57-year-old woman who developed a progressively enlarging mass on her anterior abdominal wall. The lesion grew over several months and became increasingly erythematous. The mass was initially misdiagnosed as a soft tissue infection and the patient was treated with antibiotics followed by attempted incision and drainage with no clinical resolution. Imaging studies, including a contrast-enhanced CT scan, revealed a lobulated heterogeneous soft tissue mass measuring 5 x 3.9 x 5.2 cm, abutting and possibly infiltrating the left rectus muscle. The patient subsequently underwent radical resection with close but negative margins. Histopathological examination demonstrated small round blue cells arranged in solid sheets with associated vasculature. Immunohistochemical staining was positive for GATA3 and showed CD56 positivity, while negative for multiple other markers, aiding in excluding alternative diagnoses. Molecular studies confirmed the diagnosis of Ewing sarcoma. Postoperative management involved a multidisciplinary approach, including plans for systemic chemotherapy and consideration of adjuvant radiation therapy due to the high risk of local recurrence in the setting of close margins. Cutaneous Ewing sarcoma typically presents as a rapidly enlarging mass that may resemble benign conditions such as sebaceous cysts or inflammatory processes. The key to its identification is histopathological evaluation, including immunohistochemical staining, as well as molecular testing to detect characteristic genetic translocations like the EWSR1-FLI1 fusion gene. Early and accurate diagnosis is crucial due to the tumor's aggressive nature and high potential for metastasis. Implementing a multidisciplinary treatment plan encompassing surgery, chemotherapy, and possibly radiation therapy is essential for improving patient outcomes.

Integrative analysis of Ewing's sarcoma reveals that the MIF-CD74 axis is a target for immunotherapy

BACKGROUND

Ewing's sarcoma (EwS), a common pediatric bone cancer, is associated with poor survival due to a lack of therapeutic targets for immunotherapy or targeted therapy. Therefore, more effective treatment options are urgently needed.

METHODS

Since novel immunotherapies may address this need, we performed an integrative analysis involving single-cell RNA sequencing, cell function experiments, and humanized models to dissect the immunoregulatory interactions in EwS and identify strategies for optimizing immunotherapeutic efficacy.

RESULTS

EwS is infiltrated by immunosuppressive myeloid populations, T and B lymphocytes, and natural killer cells. We found that SLC40A1 and C1QA macrophages were associated with a poor prognosis, whereas CD8+ T-cell infiltration was associated with a good prognosis. A comparative analysis of paired samples revealed that in tumors with a good chemotherapeutic response, macrophages presented increased antigen presentation and reduced release of protumor cytokines, whereas CD8+ T cells presented increased cytotoxicity and reduced exhaustion. An interaction analysis revealed a vast immunoregulatory network and identified MIF-CD74 as a crucial immunoregulatory target that can simultaneously promote M2 polarization of macrophages and inhibit CD8+ T-cell infiltration. Importantly, MIF blockade effectively reshaped the tumor immune microenvironment, turning cold tumors hot and inhibiting tumor growth.

CONCLUSIONS

Our integrative analysis revealed that the MIF/CD74 axis is a promising target for the treatment of Ewing sarcoma and provides a rationale for this novel immunotherapy.

[Surgical treatment of intracerebral metastases of Ewing sarcoma in children. Case report and review]

BACKGROUND

Metastatic brain lesions following Ewing sarcoma of bones and soft tissues in children are extremely rare and have unfavorable prognosis. There are few publications devoted to this issue. Survival rates after craniotomy are extremely low.

The authors describe a patient with metastatic form of Ewing sarcoma and two intracerebral (supra- and infratentorial) metastases. Total resection with subsequent radio- and chemotherapy were followed by stable remission for 23 months.

Pharmacological targeting of P300/CBP reveals EWS::FLI1-mediated senescence evasion in Ewing sarcoma

Ewing sarcoma (ES) poses a significant therapeutic challenge due to the difficulty in targeting its main oncodriver, EWS::FLI1. We show that pharmacological targeting of the EWS::FLI1 transcriptional complex via inhibition of P300/CBP drives a global transcriptional outcome similar to direct knockdown of EWS::FLI1, and furthermore yields prognostic risk factors for ES patient outcome. We find that EWS::FLI1 upregulates LMNB1 via repetitive GGAA motif recognition and acetylation codes in ES cells and EWS::FLI1-permissive mesenchymal stem cells, which when reversed by P300 inhibition leads to senescence of ES cells. P300-inhibited senescent ES cells can then be eliminated by senolytics targeting the PI3K signaling pathway. The vulnerability of ES cells to this combination therapy suggests an appealing synergistic strategy for future therapeutic exploration.

Allograft-prosthesis composite after proximal femur bone tumor resection in pediatric age: Is it effective in preserving bone stock?

Purpose

The purpose of the study was to answer the following questions. What was functional results of pediatric patients receiving a short stem allograft-prosthesis composite of the proximal femur? What was complication rate and revision-free implant survival? Was it possible to preserve the bone stock of the proximal femur in pediatric patients?

Methods

We reviewed 10 pediatric patients treated with proximal femur resection for a primary bone tumor and reconstruction with short stem allograft-prosthesis composite, with at least 24 months follow-up. The median age was 9 years (4-13) at surgery. The mean resection length was 15 cm (6-29). In six cases, fixation was performed with a short plate positioned under the great trochanter while in four cases a long plate extended over the great trochanter was employed.

Results

Nine complications that required surgical revision were assessed in six patients (one wound dehiscence, two nonunions, two fractures, one acetabular wear, three hypometria), while allograft-prosthesis composite removal was required in three patients. The revision-free survival was 57% (95% confidence interval 33%-100%) at 5 and 10 years. The graft removal-free survival was 75% (95% confidence interval 50%-100%) at 5 and 10 years. The mean Musculo-Skeletal Tumor Society Score was 28 (20-30).

Conclusions

Allograft-prosthesis composites with short stem and compression plate represents an effective reconstructive option after proximal femur resection for primary bone tumors in growing patients, preserving bone stock. The use of a compression plate extended over the greater trochanter seemed to reduce failure rate.

Ewing Sarcoma in the Pediatric Population: Predictors of Survival Within the United States

INTRODUCTION

Bone and joint tumors are the third most common cause of pediatric cancer-related deaths in the United States. Although there have been improvements in survival rates among pediatric cancer patients over the past few decades, bone and joint cancers remain the exception. Considering current clinical trials involving novel targeted therapies, the establishment of updated mortality rates and predictors of survival for this cancer would be prudent. This investigation sought to determine updated 5-year survival rates and predictors of survival among pediatric Ewing sarcoma (ES) of bone treated within the United States.

METHODS

The National Cancer Database was retrospectively inquired for all pediatric ES cases within the most updated bone and joint public use file available in September 2022. The reported data were truncated to only include patients with reported 5-year vital (ie, survival) status. Cox proportional hazard regression was conducted on both the truncated data and the entire cohort to validate the findings. The patients were then separated into alive versus deceased cohorts, and univariate regression analysis was done followed by multivariable regression of notable variables of interest.

RESULTS

Overall, an aggregated 5-year survival rate of 74.5% was found in the included patient cohort. Patients with localized cancer had a comparatively improved 5-year survival rate of 84.70% as opposed to those with macrometastatic disease on presentation with a survival rate of 50.4%. Patient demographic-, tumor-, and treatment-specific variables all demonstrated an effect on survival. The multivariable predictors of worse mortality were found to include older age, larger tumor size (>8 cm), macrometastatic disease on presentation, and positive surgical margins.

CONCLUSION

This analysis serves to establish updated survival rates of pediatric ES treated within the United States to set standards for comparison among future studies. Continued multi-institutional and international collaboration is needed to optimize current treatment results and develop novel targeted therapies.

The survival disparity between children and adolescents and young adults (AYAs) with Ewing sarcoma in the Netherlands did not change since the 1990s despite improved survival: A population-based study

BACKGROUND

Adolescents and young adults (AYAs) with Ewing sarcoma have a worse prognosis than children. Population-based survival evaluations stratifying findings by important clinical factors are, however, limited. This Dutch population study comprehensively compared survival of children and AYAs with Ewing sarcoma over three decades considering diagnostic period, tissue of origin, tumor site, and disease stage.

METHODS

Data on all children (0-17 years, N = 463) and AYAs (18-39 years, N = 379) diagnosed with Ewing sarcoma in the Netherlands between 1990-2018 were collected from the Netherlands Cancer Registry with follow-up until February 2023. Five-year relative survival was calculated using the cohort method. Multivariable analyses were conducted through Poisson regression.

RESULTS

Children with Ewing sarcoma had a significantly higher 5-year relative survival than AYAs (65 % vs. 44 %). An increasing trend in survival was noted reaching 70 % in children and 53 % in AYAs in 2010-2018. Results were similar for Ewing bone sarcoma and extraosseous Ewing sarcoma. AYAs had a poorer prognosis than children for most tumor sites and regardless of disease stage. Survival probabilities were 60 % vs. 78 % for localized disease and 20 % vs. 33 % for metastatic disease. Multivariable-regression analysis, adjusted for follow-up time, diagnostic period, sex, disease stage, and tumor site, confirmed increased excess mortality among AYAs compared with children (excess HR: 1.7, 95 % CI: 1.3-2.1).

CONCLUSIONS

Despite survival improvements since the 1990s, AYAs with Ewing sarcoma in the Netherlands continue to fare considerably worse than children. This survival disparity was present irrespective of tissue of origin, tumor site, and disease stage.

Regulatory effects of statins on Akt signaling for prevention of cancers

Statins, which are primarily used as lipid-lowering drugs, have been found to exhibit anti-tumor effects through modulating and interfering with various signaling pathways. In observational studies, statin use has been associated with a significant reduction in the progression of various cancers, including colon, lung, prostate, pancreas, and esophagus cancer, as well as melanoma and B and T cell lymphoma. The mevalonate pathway, which is affected by statins, plays a crucial role in activating Rho, Ras, and Rab proteins, thereby impacting the proliferation and apoptosis of tumor cells. Statins block this pathway, leading to the inhibition of isoprenoid units, which are critical for the activation of these key proteins, thereby affecting cancer cell behavior. Additionally, statins affect MAPK and Cdk2, which in turn reduce the expression of p21 and p27 cyclin-dependent kinase inhibitors. Akt signaling plays a crucial role in key cancer cell features like proliferation, invasion, and apoptosis by activating multiple effectors in downstream pathways such as FOXO, PTEN, NF-κB, GSK3β, and mTOR. The PI3K/Akt signaling is necessary for many events in the metastatic pathway and has been implicated in the resistance to cytostatic drugs. The Akt/PTEN axis is currently attracting great interest for its role in carcinogenesis. Statins have been shown to activate the purinergic receptor P2X7 and affect Akt signaling, which may have important anti-cancer effects. Hence, targeting Akt shows promise as an effective approach to cancer prevention and therapy. This review aims to provide a comprehensive discussion on the specific impact of statins through Akt signaling in different types of cancer.

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.

Malignant tumour in pregnancy: Ewing-like sarcoma of the gluteal region

We report a case of an Ewing-like sarcoma of the gluteal region with ongoing growth during the second trimester of pregnancy and noted during the third trimester. This lesion was consequently studied to infer its malignant potential. Several examinations were conducted to characterise this lesion, such as ultrasound and MR, which showed signs of tumourous invasion of the deep tissues of the gluteal region.Given that the pregnancy was at the end of the third trimester, the decision was made to schedule the delivery at 37 weeks of gestation and treat the tumour afterwards to balance maternal and fetal health.This case illustrates the need for a detailed investigation and guidance by a multidisciplinary team to provide prenatal counselling regarding a malignant tumour during pregnancy.

Factors Influencing the Outcome of Patients with Primary Ewing Sarcoma of the Sacrum

Background

Ewing sarcoma (EwS) is a rare and highly malignant bone tumor primarily affecting children, adolescents, and young adults. The pelvis, trunk, and lower extremities are the most common sites, while EwS of the sacrum as a primary site is very rare, and only few studies focusing on this location are published. Due to the anatomical condition, local treatment is challenging in sacral malignancies. We analyzed factors that might influence the outcome of patients suffering from sacral EwS.

Methods

We retrospectively analyzed data of the GPOH EURO-E.W.I.N.G 99 trial and the EWING 2008 trial, with a cohort of 124 patients with localized or metastatic sacral EwS. The study endpoints were overall survival (OS) and event-free survival (EFS). OS and EFS were calculated using the Kaplan-Meier method, and univariate comparisons were estimated using the log-rank test. Hazard ratios (HRs) with respective 95% confidence intervals (CIs) were estimated in a multivariable Cox regression model.

Results

The presence of metastases (3y-EFS: 0.33 vs. 0.68; P < 0.001; HR = 3.4, 95% CI 1.7 to 6.6; 3y-OS: 0.48 vs. 0.85; P < 0.001; HR = 4.23, 95% CI 1.8 to 9.7), large tumor volume (≥200 ml) (3y-EFS: 0.36 vs. 0.69; P=0.02; HR = 2.1, 95% CI 1.1 to 4.0; 3y-OS: 0.42 vs. 0.73; P=0.04; HR = 2.1, 95% CI 1.03 to 4.5), and age ≥18 years (3y-EFS: 0.41 vs. 0.60; P=0.02; HR = 2.6, 95% CI 1.3 to 5.2; 3y-OS: 0.294 vs. 0.59; P=0.01; HR = 2.92, 95% CI 1.29 to 6.6) were revealed as adverse prognostic factors.

Conclusion

Young age seems to positively influence patients` survival, especially in patients with primary metastatic disease. In this context, our results support other studies, stating that older age has a negative impact on survival. Tumor volume, metastases, and the type of local therapy modality have an impact on the outcome of sacral EwS. Level of evidence: Level 2. This trial is registered with NCT00020566 and NCT00987636.

Ewing's sarcoma of proximal femur: case report of extreme osteotomy with 3D-printed prosthesis for the reconstruction

Background: Resection and reconstruction of malignant bone tumors at the proximal femur in adolescent patients has remained a clinical challenge. Considering the growth and development requirements of adolescents, there is no unified standard for the reconstruction of bone defects at the proximal femur. Here, we report a case of 3D-printed titanium alloy customized prosthesis for the construction of proximal femoral bone defects in an adolescent patient with Ewing's sarcoma of the proximal femur. Case presentation: A 7-year-old female patient presented to a local hospital with left hip pain, and was diagnosed with Ewing's sarcoma on the proximal left femur. The patient received two courses of neoadjuvant chemotherapy before surgery according to the standard protocol. Considering growth and development problems associated with adolescents, we adopted a customized 3D-printed prosthesis of proximal femur for preservation of the femoral head and part of the femoral neck in the affected limb. Clinical outcomes, recorded after 12 months of follow-up, revealed excellent functional recovery and satisfactory functional scores of the affected limb, with no immediate complications. Conclusion: 3D-printed prosthesis is a feasible method for preserving femoral head and reconstruction of bone defects in adolescents' proximal femur.

Multi-modal efficacy of a chimeric vesiculovirus expressing the Morreton glycoprotein in sarcoma

Vesiculoviruses are attractive oncolytic virus platforms due to their rapid replication, appreciable transgene capacity, broad tropism, limited preexisting immunity, and tumor selectivity through type I interferon response defects in malignant cells. We developed a synthetic chimeric virus (VMG) expressing the glycoprotein (G) from Morreton virus (MorV) and utilizing the remaining structural genes from vesicular stomatitis virus (VSV). VMG exhibited in vitro efficacy by inducing oncolysis in a broad range of sarcoma subtypes across multiple species. Notably, all cell lines tested showed the ability of VMG to yield productive infection with rapid replication kinetics and induction of apoptosis. Furthermore, pilot safety evaluations of VMG in immunocompetent, non-tumor-bearing mice showed an absence of toxicity with intranasal doses as high as 1e10 50% tissue culture infectious dose (TCID50)/kg. Locoregional administration of VMG in vivo resulted in tumor reduction in an immunodeficient Ewing sarcoma xenograft at doses as low as 2e5 TCID50. In a murine syngeneic fibrosarcoma model, while no tumor inhibition was achieved with VMG, there was a robust induction of CD8+ T cells within the tumor. The studies described herein establish the promising potential for VMG to be used as a novel oncolytic virotherapy platform with anticancer effects in sarcoma.

Outcomes of Pediatric Patients With Metastatic Ewing Sarcoma Treated With Interval Compression

BACKGROUND

Interval compression (IC), a regimen of alternating vincristine/doxorubicin/cyclophosphamide and ifosfamide/etoposide every 2 weeks, improves survival for localized Ewing sarcoma (ES), with uncertain effect on metastatic disease.

MATERIALS AND METHODS

We reviewed the charts of pediatric patients with metastatic ES treated with IC at our center between January 2013 and March 2020. We calculated event-free survival and overall survival (OS) and used log-rank tests for univariate comparisons.

RESULTS

We identified 34 patients 2.7 to 17.1 years of age (median: 11.6 y). Twenty-six patients (76%) had pulmonary metastases, and 14 (41%) had extrapulmonary metastases. All patients received local control therapy: surgery only (n=7, 21%), radiotherapy only (n=18, 53%), or both (n=9, 26%). The estimated 3-year OS and event-free survival were 62%±9% and 39%±9%, respectively. Patients with pulmonary-only and extrapulmonary metastasis had a 3-year OS of 88%±8% and 27%±13%, respectively ( P =0.0074). Age group (above vs. below 12 y), or primary tumor site did not affect survival, but local control therapy did (surgery only, 83%±15%; combined surgery and radiation, 30%±18%; radiation only, 15%±10%; P =0.048).

CONCLUSION

IC yielded similar outcomes for patients with metastatic ES to other reported regimens. We suggest including this approach to other blocks of therapy.

In vitro evaluation of growth reticence and anticancer potential of 5α,8α-epidioxy-24ᶓ-methylcholesta-6,22-dien-3β-ol and ergosta-5,7,22-trien-3β-ol bioactive isolated from an edible mushroom Lentinus tuberregium (fr.)

The focus point of this current work is to evaluate the anticancer and growth inhibitory efficacy of compounds 5α,8α-epidioxy-24ᶓ-methylcholesta-6,22-dien-3β-ol (LT1), and Ergosta-5,7,22-trien-3β-ol (LT2) of Lentinus tuberregium (Fr.) on three cell lines such as A673 (Rhabdomyosarcoma), MCF7 (breast cancer), and HCT116 (colorectal carcinoma) by MTT assay. LT1 and LT2 exerted maximal growth inhibition in the order as A673 > HCT116 > MCF7. Comparatively, LT1 was more potent in causing cell growth inhibition than LT2 in the A673 cancer cell line. Based on the MTT assay, A673 cells alone proceeded further as a model to evaluate the anticancer potential of LT1 and LT2 at three different semilogarithmic concentrations (3, 10, 30 μM). The cells exposed with compounds at 24 and 48 h were analyzed by flow cytometry. Exposure of LT1 at 3 and 10 μM concentrations for 24 h caused a G2-M arrest. At 10 μM concentration, cells also accumulated in the G0-G1 phase, indicating a G1 block. These effects were only transient as prolonged exposure (48 h) of LT1 treatment brought back the cell population to normalcy. Both the compounds only at 30 μM concentration have the potential to induce a hypodiploid peak (sub G0), indicating an induction of apoptosis which was explicit by nuclear condensation and fragmentation of nuclei in cells. The dose-dependent and compound-specific apoptotic induction was further confirmed by caspase activity higher in LT1 than LT2. The results highlight the significant growth inhibitory activity and anticancer potential of LT1 and LT2 which are recommended for further in-depth analysis.

Ewing's sarcoma masquerading as an odontogenic infection

ABSTRACT

Ewing's sarcoma (ES) is a small, blue, malignant, round cell tumor of unknown origin. ES is the fourth most common malignant bone tumor, whereas among children, it is found to be the second most common primary malignant bone tumor after osteosarcoma. Swelling is usually the first clinical presentation, followed by pain. ES is an aggressive tumor showing rapid growth and metastasis with complex diagnosis. Because mandibular involvement is rare, it can be misdiagnosed as an odontogenic infection/tumor. We report an unusual case of ES in a 13-year-old female treated for an odontogenic infection before a diagnosis of ES was finally made to make the clinicians aware of this rare entity. Emphasis is also given that ES and odontogenic infections/tumors can masquerade each other with delays in diagnosis and the possibility of devastating results.

Bone marrow mesenchymal stem cell-derived exosomal LINC00847 inhibits the proliferation, migration, and invasion of Ewing sarcoma

BACKGROUND

Ewing sarcoma (ES) is one of the most lethal primary bone tumors with a poor survival rate. Current evidence suggests that extracellular vesicles (EVs) derived from bone marrow mesenchymal stem cells (BMSCs) loaded with abundant biological functional lncRNAs confer therapeutic benefits against the development of various tumors.

AIM

This study aimed to investigate the role of exosomal lncRNAs from BMSCs in the pathogenesis of ES.

METHODS

Bioinformatic analysis and quantitative real time-polymerase chain reaction (qRT-PCR) experiments were used to detect the expression level of LINC00847 in ES tissues and cells. Cell biology experiments examined the effect of in vitro proliferation, migration, and invasion abilities and the biological function of BMSCs-derived LINC00847. Finally, we constructed a LINC00847-associated competitive endogenous RNA (ceRNA) network by in silico methods. Gene Set Enrichment Analysis (GSEA) was conducted to reveal the potential molecular mechanism of LINC00847.

RESULTS

We found that LINC00847 was markedly downregulated in ES. Overexpression of LINC00847 inhibited ES cell proliferation, migration, and invasion. Furthermore, BMSCs-derived EVs inhibited the proliferation, migration, and invasion of ES cells by delivering LINC00847. We constructed a LINC00847 related-ceRNA network contains five miRNAs (miR-18a-5p, miR-18b-5p, miR-181a-5p, miR-181c-5p, and miR-485-3p) and four mRNAs (GFPT1, HIF1A, NEDD9, and NOTCH2).

CONCLUSIONS

Overall, this study found that BMSCs-EVs-derived exosomal LINC00847 inhibited ES cell proliferation, migration, and invasion. The ceRNA regulatory mechanism of LINC00847 may participate in the pathogenesis of the malignant phenotype of ES.

RELEVANCE FOR PATIENTS

These findings suggest that BMSCs-derived exosomal lncRNAs may be used for the personalized treatment of tumors, providing a novel theoretical framework for treating ES.

High-dose chemotherapy followed by autologous stem cell transplantation for adult patients With first relapse of Ewing's sarcoma: A single institution experience

The prognosis of patients with Ewing's sarcoma family of tumors (ESFT) relapse is poor; the 5-year overall survival (OS) is 13%. We evaluated the effectivity of high-dose therapy (HDT) with autologous stem cell transplantation (ASCT) in adult patients with ESFT relapse. Between January 2010 and January 2021, we retrospectively analyzed 20 patients with ESFT who received HDT upon relapse. A combination of busulfan with melphalan was used as a conditioning regimen before ASCT. The median follow-up from diagnosis and from first relapse was 46.08 months (range; 10.71-186.87) and 14.41 months (range; 4.34-104.11), respectively. The median of age patients was 21.2 years (range, 17.6-25.3), and 10 (50%) patients were female. The tumor originated from the bone in 13 patients and soft tissue in 7 patients. Twelve patients had early (<2 years) relapse, and 8 patients had late (>2 years) relapse. Before HDT, 13 (65%) and 7 (35%) patients had pulmonary and extrapulmonary metastasis, respectively. After induction chemotherapy, 14 patients achieved complete response. The median OS1 and OS2 were 51.6 months (95% confidence interval [CI], range: 16.2-87) and 15.7 months (95% CI, range: 10.2-21.2), respectively. The 1-, 2-, and 5-year OS rates were 50%, 30%, and 15%, respectively. One patient died (sepsis) 1 month after ASCT. In univariate analyses, a disease-free interval (DFI) of < 2 years (P = .008) and incomplete response (P = .021) before ASCT were poor prognostic factors for OS2.HDT with ASCT can result in long-term survival of patients with ESFT relapse. HDT should be considered an important treatment opt ion in patients with a DFI > 2 years and complete response before transplantation.

Ewing's Sarcoma of Mandible: Practical Approach to a Challenging Case

As a rare entity, sarcomas of the head and neck are challenging cases. In this paper, we represent a unique case of Ewing sarcoma of mandible, serving as an example of multidisciplinary team importance in a developing country.

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.

Primary Ewing's sarcoma of sphenoid sinus: A case report and literature review

Background

Primary Ewing's sarcoma of sphenoid sinus, observed in children and adolescents, is an extremely rare malignancy. Such rarity makes the imaging features and treatment strategies for Ewing's sarcoma of sphenoid sinus unclear. This study aimed to offer guidance for treating this very disease by describing a patient with a rare primary Ewing's sarcoma of sphenoid sinus and reviewing the available data in the literature.

Case description

A case of Ewing's sarcoma in sphenoid sinus treated with multidisciplinary treatment approaches, including tumor resection, radiotherapy, chemotherapy, and antiangiogenic therapy, was presented in this study. Moreover, literature for Ewing's sarcoma in the head was systematically searched, and two cases in the sphenoid sinus and five cases in the sphenoid bone were identified. Furthermore, the clinical features, imaging findings, pathological characteristics, treatment, and prognosis were summarized.

Conclusion

Tumor resection combined with radiotherapy and chemotherapy may provide favorable results for patients with Ewing's sarcoma of sphenoid sinus and bone. However, more reports are still necessary to further clarify optimal management.

Multimodality treatment of pediatric Ewing sarcoma: A single-center 10-year analysis of outcomes

BACKGROUND

Ewing sarcoma, a malignancy originating from the bone or soft tissues most commonly diagnosed in adolescents, requires multimodality therapy. Although both surgical resection and radiation therapy are effective local control modalities, there are limited data comparing outcomes in patients treated with surgery versus radiation. We sought to determine whether there were differences in 5-year local failure-free survival, event-free survival, and overall survival based on the modality used for local control.

METHODS

Patients treated for Ewing sarcoma at a single tertiary pediatric hospital between 2010 and 2020 were included for retrospective analysis. Patient and tumor demographics, treatment information, and patient response to therapies were collected from the medical record. Outcome measures were local failure-free survival, event-free survival, and overall survival at 5 years from diagnosis.

RESULTS

Sixty-one patients met inclusion criteria. All patients received chemotherapy, and 68.9% of patients presented with localized disease. Of these, 23.8% were treated with radiation alone; the remaining 76.2% underwent resection ± radiation. A total of 52.4% of patients with localized disease achieved R0 resection. Only 3 patients experienced local progression; there was no difference between treatment groups. There was no significant association between local control modality and event-free survival or overall survival in patients with localized disease, regardless of margin status.

CONCLUSION

There was no significant difference in 5-year local failure-free survival, event-free survival, or overall survival in Ewing sarcoma patients treated with radiation versus surgery ± radiation, regardless of whether or not R0 resection was achieved. Future directions include a multi-institutional study to allow for further subgroup analysis and increased sample size.

The Prognostic Role of the C-Reactive Protein and Serum Lactate Dehydrogenase in a Pediatric Series of Bone Ewing Sarcoma

Simple Summary

Ewing sarcoma is a rare and aggressive tumor of childhood and adolescence. Over the years, different prognostic factors have been explored to stratify high-risk patients. The roles of C-reactive protein (CRP) and serum lactate dehydrogenase (LDH) as potential new prognostic factors would be a useful and simple for risk stratification, but they have rarely been investigated. In our work, we analyze the role of LDH and CRP as prognostic factors in a population of pediatric and adolescent patients affected by Ewing sarcoma. Our study confirms the potential prognostic role of LDH at diagnosis as an independent prognostic factor. LDH evaluation is not expensive, and it can be beneficial for developing countries where diagnostic and staging resources in the pediatric oncology field are poor.

Abstract

Background: Ewing sarcoma (ES) is a rare and aggressive pediatric cancer. Numerous studies have attempted to identify new prognostic biomarkers. The predictive value of serum LDH and CRP has not been clearly described, to date. Methods: The objective of our retrospective study was to investigate the prognostic value of LDH and CRP levels and their association with overall survival in a series of ES patients. Results: Between 2004 and 2019, 89 ES patients were included. In a univariable analysis, high levels of LDH and CRP were associated with the worst prognosis. In a multivariable analysis, only higher LDH values remained associated with a lower survival. The high-LDH-level group experienced all 21 deaths registered in our population (24%) and about 90% of disease progressions. The 5-year overall survival was 66.4% in the high-LDH-level group, while no deaths were observed in the low-LDH-level group. The 5-year progression-free survival was 57.9% in the high-LDH-level group versus 80.4% in the low-LDH-level group. Conclusions: In our study, LDH levels at diagnosis were strongly correlated with the prognosis, and they might be considered a prognostic factor in Ewing sarcoma. The LDH value, along with its very low cost and its reproducibility in almost all centers, make it suitable as a potential prognostic biomarker in clinical practice.

Impact of local treatment modality on overall- and disease-specific survival for nonmetastatic pelvic and sacral Ewing sarcoma

PURPOSE

The ideal local treatment modality for pelvic and sacral Ewing sarcoma (EWS) is controversial.

METHODS

We present the data from the American College of Surgeon's National Cancer Database (NCDB) and the National Cancer Institute's Surveillance, Epidemiology and End Result (SEER) database to investigate the impact of local treatment modalities on survival for nonmetastatic pelvic and sacral Ewing sarcoma. Local treatment includes "surgery," "radiation," and a combination of "surgery and radiation."

RESULTS

A total of 235 cases from SEER and 285 cases from NCDB were analyzed. Patients with "localized" stage (intraosseous) in the SEER database did not show any statistically significant difference in the disease-specific survival (DSS) for any of the local treatment modalities. Similar findings were observed for overall survival among patients with American Joint Committee on Cancer (AJCC) stage II and III in the NCDB database. However, patients with nonmetastatic disease, particularly regional disease (extraosseous), showed improved DSS with surgery only, in the SEER.

CONCLUSION

We found similar levels of efficacy for different treatment modalities for patients with intraosseous and AJCC II and III pelvic and sacral EWS. "Radiotherapy" is the most common local treatment modality employed in the United States. A prospective, randomized controlled trial with a direct head-to-head comparison is needed for a definitive conclusion.

Prognostic significance of survivin expression in pediatric ewing sarcoma

Survivin is an inhibitor of apoptosis protein that inhibits caspases and blocks cell death. It is undetectable in most normal adult tissues. High survivin expression has been detected in various tumors and has been correlated with therapy resistance and poor outcome. We conducted this study to examine survivin expression in pediatric Ewing sarcoma (ES) and evaluate its role in predicting clinical outcome. Formalin-fixed paraffin-embedded tumor tissues from 108 pediatric ES patients were examined by immunostaining with survivin rabbit monoclonal antibodies. Survivin was detected in tumor tissues of 72 (66.7%) patients. High expression (≥50%) was detected in 18 (16.7%) patients. High survivin expression was shown to be a significant univariate parameter for poorer overall (OS) and event free survival (EFS) with p value 0.033, and 0.037 respectively. It was confirmed as an independent factor in multivariate analysis for OS (p: 0.041; HR: 1.97 with 95% CI of 1.03-3.79) and EFS (p: 0.049; HR: 1.86 with 95% CI of 1.00-3.46). These results suggest that high survivin expression identifies a group of patients with poor prognosis and this may help to refine risk adapted treatment; however, this needs to be confirmed in prospective studies.

A Rare Cause of Neck Lump in an Infant

A 5 month old girl presented to the Paediatric Emergency Department with a rapidly growing neck mass over 24 hours. She was systemically well and otherwise asymptomatic. On examination she had a mobile, soft and non-tender 5 cm x 5 cm neck mass. Blood tests were unremarkable with normal inflammatory markers. Point of Care Ultrasound (POCUS) was done which showed a solid left sided neck mass with increased vascularity but no evidence of collection or abscess. Given the atypical presentation and rapid growth the patient was commenced on empirical antibiotics and was discussed with both tertiary ENT and Oncology teams. An MRI was performed which was indeterminate. Biopsy of the neck mass was positive for Ewing Sarcoma. This is a rare case of Ewing Sarcoma in an infant. POCUS can be used to rule out common pathology and abnormal lymph nodes, aiding in ongoing investigation and management in neck lumps.

LncRNA FOXP4-AS1 Promotes Progression of Ewing Sarcoma and Is Associated With Immune Infiltrates

Ewing sarcoma (ES) is a highly malignant primary bone tumor with poor prognosis. Studies have shown that abnormal expression of lncRNA influences the prognosis of tumor patients. Herein, we established that FOXP4-AS1 was up-regulated in ES and this correlated with poor prognosis. Further analysis illustrated that FOXP4-AS1 down-regulation repression growth, migration, along with invasion of ES. On the contrary, up-regulation of FOXP4-AS1 promoted the growth, migration, as well as invasion of ES. To explore the mechanism of FOXP4-AS1, Spearman correlation analysis was carried out to determine genes that were remarkably linked to FOXP4-AS1 expression. The potential functions and pathways involving FOXP4-AS1 were identified by GO analysis, Hallmark gene set enrichment analysis, GSEA, and GSVA. The subcellular fractionation results illustrated that FOXP4-AS1 was primarily located in the cytoplasm of ES cells. Then a ceRNA network of FOXP4-AS1 was constructed. Analysis of the ceRNA network and GSEA yielded two candidate mRNAs for FOXP4-AS1. Results of the combined survival analysis led us to speculate that FOXP4-AS1 may affect the expression of TMPO by sponging miR-298, thereby regulating the malignant phenotype of ES. Finally, we found that FOXP4-AS1 may modulates the tumor immune microenvironment in an extracellular vesicle-mediated manner. In summary, FOXP4-AS1 correlates with poor prognosis of ES. It promotes the growth, migration, as well as invasion of ES cells and may modulate the tumor immune microenvironment.

The basic characteristics of extracellular vesicles and their potential application in bone sarcomas

Bone sarcomas are rare cancers accompanied by metastatic disease, mainly including osteosarcoma, Ewing sarcoma and chondrosarcoma. Extracellular vesicles (EVs) are membrane vesicles released by cells in the extracellular matrix, which carry important signal molecules, can stably and widely present in various body fluids, such as plasma, saliva and scalp fluid, spinal cord, breast milk, and urine liquid. EVs can transport almost all types of biologically active molecules (DNA, mRNA, microRNA (miRNA), proteins, metabolites, and even pharmacological compounds). In this review, we summarized the basic biological characteristics of EVs and focused on their application in bone sarcomas. EVs can be use as biomarker vehicles for diagnosis and prognosis in bone sarcomas. The role of EVs in bone sarcoma has been analyzed point-by-point. In the microenvironment of bone sarcoma, bone sarcoma cells, mesenchymal stem cells, immune cells, fibroblasts, osteoclasts, osteoblasts, and endothelial cells coexist and interact with each other. EVs play an important role in the communication between cells. Based on multiple functions in bone sarcoma, this review provides new ideas for the discovery of new therapeutic targets and new diagnostic analysis.

Bone sarcoma: success through interdisciplinary collaboration

PURPOSE

Osteosarcoma and Ewing sarcoma are the most frequent malignant bone tumours of childhood and adolescence. This review summarizes the oncologist's view of these diseases and their treatment.

METHODS

A non-systematic literature review was performed, the personal impressions and experience of the authors is described.

RESULTS

Local therapy and chemotherapy, each on their own, will not cure patients with malignant bone sarcomas. Together, they present a highly efficacious combination. While the most effective drugs were defined decades ago, progress since then has been limited. It is hoped that substances shown to be active in relapsed disease will be forwarded into even more efficacious frontline treatments. Good palliative therapy is necessary when cure is no longer an option.

CONCLUSION

Close interdisciplinary collaboration is the key to successful treatment of bone sarcomas in paediatric patients.

Age as a Prognostic Factor in Patients with Ewing Sarcoma-The Polish Sarcoma Group Experience

Ewing sarcoma (ES) is a rare and aggressive disease that requires multidisciplinary treatment with the use of chemotherapy, radiotherapy, and surgery. Our retrospective study aimed to analyze the prognostic factors and treatment results in different age groups of patients. Between 1998 and 2018, 569 patients with ES were treated in two referral centers. The patients were divided into four age groups (≤10 years; 11–18 years; 19–25, and >25). The treatment results and prognostic factors were assessed for each group. For statistical analyses, we used the Chi2 test, the Kaplan–Meier estimator with a log-rank test, and the multivariate Cox model. Five-year overall survival (OS) rate was 56%. In the age subgroups: ≤10 years, 11–18 years, 19–25 years, and >25 years, the 5-year OS rates were 75%, 58%, 41%, and 52%, respectively. Favorable prognostic factors: female gender (p = 0.024), non-axial localization (p = 0.005), VIDE regimen (p < 0.001), and surgery as a local treatment (p < 0.001) dominated in the group ≤10 years. In multivariate analysis, male (HR = 1.53), axial localization (HR = 1.46), M1 status at presentation (HR = 2.64), and age > 10 years (HR = 2.29) were associated with shorter OS. The treatment results in ES are significantly better in children aged ≤10 years; the challenge is to provide therapy for adolescents and young adults. The diagnostics and treatment of ES patients must be provided in referral centers.

A New Proximal Femur Reconstruction Technique after Bone Tumor Resection in a Very Small Patient: An Exemplificative Case

For patients too young to be fitted with an expandable prosthesis, limb salvage surgery requires other strategies. The main problems are related to the impossibility of implanting an expandable prosthesis to the residual bone growth that is much too big in relation to the bone size, with the precocious implant loosening and/or the residual absence of bone growth, as well as the problem of limb length and shape difference. In this paper, we report a possible reconstruction solution using a composite prosthesis for an Ewing’s sarcoma of the proximal femur in an infant patient. After resection, a femoral stem was cemented into the distal third of a homoplastic humerus; a carbon fiber plate was used to stabilize the bone/homograft interface. At the one-year follow-up, the patient was free of disease and able to walk with only a slight limp. This case report describes a possible solution for very small patients. An adult humerus is of the right size to replace a child’s lower limb segments, and the distal humerus can be shaped, maintaining a cortex stiff enough to support a prosthesis. Very young patients might obtain a faster osteointegration of the graft than adults, due to their higher biological activity and, in this case, the diapasonal shape of the allograft might also have contributed to accelerated fusion. Moreover, the use of a graft to fit the prosthesis avoids loosening issues due to canal widening, hypothetically providing more growing time before system failure and revision surgery. However, although this technique is promising, further studies are necessary to confirm our findings and to verify if this procedure allows easier future prosthesis implantation.