A national case-control study of Ewing's sarcoma family of tumours in Australia

Genetic analyses identify evidence for a causal relationship between Ewing sarcoma and hernias

Knowledge of Ewing sarcoma (EWS) risk factors is exceedingly limited; however, multiple small, independent studies have suggested a possible connection between hernia and EWS. By leveraging hernia summary statistics from the UK Biobank and a recently published genome-wide association study of EWS (733 EWS cases and 1,346 controls), we conducted a genetic investigation of the relationship of 5 hernia types (diaphragmatic, inguinal, umbilical, femoral, and ventral) and EWS. We discovered a positive causal relationship between inguinal hernia and EWS (OR 1.27, 95% confidence interval [CI] 1.01-1.59, and p = 0.041) through Mendelian randomization analysis. Further analyses suggested shared pathways through three genes: HMGA2, LOX, and FBXW7. Diaphragmatic hernia showed a stronger causal relationship with EWS among all of the hernia types (OR 2.26, 95% CI 1.30-3.95, p = 0.004), but no statistically significant local correlation pattern was observed. No evidence of a causal or genetic relationship was observed between EWS and the other three hernia types, including umbilical hernia, despite a previous report indicating an OR as high as 3.3. The finding of our genetic analysis provided additional support to the hypothesis that EWS and hernias may share a common origin.

Parental occupational and environmental risk factors for childhood bone cancer in Mansoura oncology center: a case control study

Cancer is the most frequently diagnosed disease-related cause of death among children and adolescents. This study was conducted to test association of occupational, environmental risk factors such as exposure to pesticides, radiations, hazardous chemicals and smoking among children with bone cancer. A retrospective case control study was conducted in Oncology center Mansoura University (OCMU). Study groups included bone cancer cases (n = 51) and an age and sex matched control group (n = 67). An interview-based questionnaire included demographic data, occupational and environmental risk factors for both children and parents. Exposure to n nitrose compounds from burning incense among children, paternal smoking and consanguinity are significantly different between cases and control. (p < 0.05). Paternal smoking and consanguinity are significant predictors for childhood bone cancer. It is recommended to add surveillance for environmental and occupational exposures to childhood bone cancer patients.

Review: Ewing Sarcoma Predisposition

Ewing sarcoma is a rare tumor developed in bone and soft tissues of children and teenagers. This entity is biologically led by a chromosomal translocation, typically including EWS and FLI1 genes. Little is known about Ewing sarcoma predisposition, although the role of environmental factors, ethnicity and certain polymorphisms on Ewing sarcoma susceptibility has been studied during the last few years. Its prevalence among cancer predisposition syndromes has also been thoroughly examined. This review summarizes the available evidence on predisposing factors involved in Ewing sarcoma susceptibility. On the basis of these data, an integrated approach of the most influential factors on Ewing sarcoma predisposition is proposed.

High Birth Weight Increases the Risk for Bone Tumor: A Systematic Review and Meta-Analysis

There have been several epidemiologic studies on the relationship between high birth weight and the risk for bone tumor in the past decades. However, due to the rarity of bone tumors, the sample size of individual studies was generally too small for reliable conclusions. Therefore, we have performed a meta-analysis to pool all published data on electronic databases with the purpose to clarify the potential relationship. According to the inclusion and exclusion criteria, 18 independent studies with more than 2796 cases were included. As a result, high birth weight was found to increase the risk for bone tumor with an Odds Ratio (OR) of 1.13, with the 95% confidence interval (95% CI) ranging from 1.01 to 1.27. The OR of bone tumor for an increase of 500 gram of birth weight was 1.01 (95% CI 1.00–1.02; p = 0.048 for linear trend). Interestingly, individuals with high birth weight had a greater risk for osteosarcoma (OR = 1.22, 95% CI 1.06–1.40, p = 0.006) than those with normal birth weight. In addition, in the subgroup analysis by geographical region, elevated risk was detected among Europeans (OR = 1.14, 95% CI 1.00–1.29, p = 0.049). The present meta-analysis supported a positive association between high birth weight and bone tumor risk.

Medication Exposures and Subsequent Development of Ewing Sarcoma: A Review of FDA Adverse Event Reports

Background. Ewing sarcoma family of tumors (ESFT) are rare but deadly cancers of unknown etiology. Few risk factors have been identified. This study was undertaken to ascertain any possible association between exposure to therapeutic drugs and ESFT. Methods. This is a retrospective, descriptive study. A query of the FDA Adverse Event Reporting System (FAERS) was conducted for all reports of ESFT, January 1, 1998, through December 31, 2013. Report narratives were individually reviewed for patient characteristics, underlying conditions and drug exposures. Results. Over 16 years, 134 ESFT reports were identified, including 25 cases of ESFT following therapeutic drugs and biologics including immunosuppressive agents and hormones. Many cases were confounded by concomitant medications and other therapies. Conclusions. This study provides a closer look at medication use and underlying disorders in patients who later developed ESFT. While this study was not designed to demonstrate any clear causative association between ESFT and prior use of a single product or drug class, many drugs were used to treat immune-related disease and growth or hormonal disturbances. Further studies may be warranted to better understand possible immune or neuroendocrine abnormalities or exposure to specific classes of drugs that may predispose to the later development of ESFT.

The epidemiology of sarcoma

Sarcomas account for over 20% of all pediatric solid malignant cancers and less than 1% of all adult solid malignant cancers. The vast majority of diagnosed sarcomas will be soft tissue sarcomas, while malignant bone tumors make up just over 10% of sarcomas. The risks for sarcoma are not well-understood. We evaluated the existing literature on the epidemiology and etiology of sarcoma. Risks for sarcoma development can be divided into environmental exposures, genetic susceptibility, and an interaction between the two. HIV-positive individuals are at an increased risk for Kaposi's sarcoma, even though HHV8 is the causative virus. Radiation exposure from radiotherapy has been strongly associated with secondary sarcoma development in certain cancer patients. In fact, the risk of malignant bone tumors increases as the cumulative dose of radiation to the bone increases (p for trend <0.001). A recent meta-analysis reported that children with a history of hernias have a greater risk of developing Ewing's sarcoma (adjusted OR 3.2, 95% CI 1.9, 5.7). Bone development during pubertal growth spurts has been associated with osteosarcoma development. Occupational factors such as job type, industry, and exposures to chemicals such as herbicides and chlorophenols have been suggested as risk factors for sarcomas. A case-control study found a significant increase in soft tissue sarcoma risk among gardeners (adjusted OR 4.1, 95% CI 1.00, 14.00), but not among those strictly involved in farming. A European-based study reported an increased risk in bone tumors among blacksmiths, toolmakers, or machine-tool operators (adjusted OR 2.14, 95% CI 1.08, 4.26). Maternal and paternal characteristics such as occupation, age, smoking status, and health conditions experienced during pregnancy also have been suggested as sarcoma risk factors and would be important to assess in future studies. The limited studies we identified demonstrate significant relationships with sarcoma risk, but many of these results now require further validation on larger populations. Furthermore, little is known about the biologic mechanisms behind each epidemiologic association assessed in the literature. Future molecular epidemiology studies may increase our understanding of the genetic versus environmental contributions to tumorigenesis in this often deadly cancer in children and adults.

The contrasting age-incidence patterns of bone tumours in teenagers and young adults: Implications for aetiology

Bone tumours comprise 0.2% of cancers overall but 5.7% in 15-24 year olds. To explore the relationship with adolescence we have analysed age-incidence patterns of bone tumours in a large national dataset. Data on incident cases of bone tumours in 0-84 year olds in England, 1979-2003, were extracted from national cancer registration data. Incidence rates per million person-years by 5-year age-group, sex, morphology and primary site were calculated and adjusted to the world standard population. Nine thousand one hundred forty-six cases were identified giving an overall age-standardized rate of 7.19 per million person-years. The distribution by morphology was: osteosarcoma, 34.2%; chondrosarcoma, 27.2%; Ewing sarcoma, 19.3%; other, 19.4%. The distribution varied by age. Ewing sarcoma was most common in 0-9 year olds, osteosarcoma in 10-29 year olds and chondrosarcoma in 30-84 year olds. 29.2% of all tumours occurred in 0-24 year olds. Highest incidence of osteosarcoma and Ewing sarcoma in females was in 10-14 year olds. In males, peak incidence occurred at 15-19 years and exceeded that in females. Chondrosarcoma incidence steadily increased with age. The proportions of Ewing sarcomas occurring in respective bones were consistent with those of the adult skeleton by weight. In osteosarcoma tumours of long bones of lower limb were markedly over-represented in the adolescent peak, being six times more than at any other site. Variation in incidence patterns with age and site suggests pubertal bone growth to be a key factor in osteosarcoma while different biological pathways could be relevant for Ewing sarcoma.

Relationship between height at diagnosis and bone tumours in young people: a meta-analysis

OBJECTIVE

Some evidence exists that patients with osteosarcoma and Ewing sarcoma are taller than the general population. However, previous studies are under-powered, lack comprehensive data and show inconsistencies.

METHODS

Relevant studies linking osteosarcoma and Ewing sarcoma with height at diagnosis were identified in two major online databases, Medline (1950 to 2009) and Embase (1980 to 2009). Outcomes in individual studies were reported as standard deviation (SD) scores or percentages of study population with height at diagnosis above the median of the reference population. We performed separate random-effects meta-analyses for each outcome and tumour type.

RESULTS

14 studies examined the height of patients with osteosarcoma or Ewing sarcoma. Meta-analyses on SD scores found patients with osteosarcoma were 0.260 SD (95% CI: 0.088-0.432) taller than the reference population (five studies). A meta-analysis on percentages found 62% (95% CI: 57%-67%) of patients were estimated to have a height above the median (six studies). Patients with Ewing sarcoma were 0.096 SD (95% CI 0.004-0.188) taller (four studies). Only one study reported the percentage of Ewing sarcoma patients with height above the median.

CONCLUSION

The average height of patients with osteosarcoma, but not Ewing sarcoma, was significantly above the average height of the reference population by 2-3 centimetres. The observed differences indicate the involvement of pubertal longitudinal bone growth in osteosarcoma development while different biological pathways could be relevant for Ewing sarcoma.

Complex genotype sarcomas display familial inheritance independent of known cancer predisposition syndromes

BACKGROUND

The low incidence of sarcomas in the general population makes heritable contribution to disease risk difficult to discern beyond highly penetrant Mendelian syndromes.

METHODS

The Utah Cancer Registry (UCR) and Utah Population Database were interrogated for sarcoma diagnostic codes grouped by genetic type, either complex genotype/karyotype sarcoma or balanced translocation-associated sarcoma. The genealogic index of familiality (GIF) was calculated and relative risks (RR) of disease estimated for first-, second-, and third-degree relatives of sarcoma probands. Cancer patterns in pedigrees of sarcoma probands were examined to rule out known hereditary cancer syndromes.

RESULTS

A total of 229 balanced translocation type and 1,161 complex genotype type sarcomas with at least three generations of ancestral genealogy data were identified in the UCR. There was no evidence for excess relatedness for the balanced translocation group by using the GIF test (P = 0.657) and no significantly elevated RRs. In the complex genotype group, we observed significantly elevated GIF (P = 0.03). Modest RRs corroborated the GIF analysis, in which excess relatedness existed in distant relationships. No recognized cancer syndromes were identified among high-risk pedigrees.

DISCUSSION

We identified strong familiality among complex genotype sarcomas, independent from known cancer predisposition syndromes. In the absence of significantly elevated RRs for close relatives, the high GIF argues for a strong genetic-rather than environmental-component to complex genotype sarcoma risk. We observed no significant familial risk of developing balanced translocation-associated sarcomas, but the sample was small.

IMPACT

There exists yet to be deciphered heritable risk for developing complex genotype sarcomas.

Is There a Predisposition Gene for Ewing's Sarcoma?

Ewing's sarcoma is a highly malignant tumor of children and young adults. The molecular mechanisms that underlie Ewing's Sarcoma development are beginning to be understood. For example, most cases of this disease harbor somatic chromosomal translocations that fuse the EWSR1 gene on chromosome 22 with members of the ETS family. While some cooperative genetic events have been identified, such as mutations in TP53 or deletions of the CDKN2A locus, these appear to be absent in the vast majority of cases. It is therefore uncertain whether EWS/ETS translocations are the only consistently present alteration in this tumor, or whether there are other recurrent abnormalities yet to be discovered. One method to discover such mutations is to identify familial cases of Ewing's sarcoma and to then map the susceptibility locus using traditional genetic mapping techniques. Although cases of sibling pairs with Ewing's sarcoma exist, familial cases of Ewing's sarcoma have not been reported. While Ewing's sarcoma has been reported as a 2nd malignancy after retinoblastoma, significant associations of Ewing's sarcoma with classic tumor susceptibility syndromes have not been identified. We will review the current evidence, or lack thereof, regarding the potential of a heritable condition predisposing to Ewing's sarcoma.

Surgery significantly improves survival in patients with chordoma

STUDY DESIGN

Retrospective database review using Surveillance, Epidemiology, and End Results database, National Cancer Institute.

OBJECTIVE

To determine current treatment outcomes and demographic characteristics and to define the prognostic factors and impact of surgery on survival.

SUMMARY OF THE BACKGROUND DATA

Rarity of the disease has limited the number of population-based studies addressing the issues of prognostic factors and the current treatment outcomes.

METHODS

A total of 962 patients with chordoma, diagnosed between 1973 and 2005, were identified in the Surveillance, Epidemiology, and End Results database. Patient demographics and clinical characteristics, incidence, year of diagnosis, location, size and stage at diagnosis, treatment(s), and survival were extracted. Kaplan-Meier, log-rank, and Cox regression were used to analyze the significance of prognostic factors.

RESULTS

Race specific incidence per 100,000 persons in 2005 shows whites to have the highest (0.473) incidence, followed by Asians/Pacific Islanders (0.091), and Afro-Americans (zero), respectively. The incidence difference between whites and Afro-Americans over time is statistically significant (P < 0.001). The age adjusted incidence reveals a peak in eighth decade of life. Survival was not impacted by race. Age category <59, Hispanic ethnicity, size <8 cm, and surgical resection were all independent predictors of better overall survival. Analysis revealed that survival outcomes were very similar in patients with "in-operable disease" and those in which "surgery was recommended but not performed" suggesting that benefits of resection cannot be solely attributed to selection bias.

CONCLUSION

With high local recurrence rates and the significant functional morbidity associated with surgical resections, clinicians are left wondering if surgery constitutes an appropriate treatment option. Our study clearly demonstrates that surgery significantly improves the overall survival for patients with chordoma. We have further identified age <59 and size of primary tumor <8 cm as important prognostic factors determining the outcome with substantial statistical significance.

Epidemiology of bone tumours in children and young adults

Although the epidemiology of malignant bone tumours in children and young adults has been explored, no definitive causation of any specific tumour has yet been identified. We performed a literature review (1970-2008) to find all papers covering possible aetiological factors involved in the development of bone tumours in children and young adults. Several associations have been reported with some consistency: the presence of hernias and Ewing sarcoma; high fluoride exposure and osteosarcoma; and parental farming and residence on a farm, younger age at puberty and family history of cancer for all bone tumours, especially osteosarcoma. Clearly further research is needed to confirm or refute these putative risk factors. It is likely that studies of gene-environment interactions may prove to be the most fruitful of future research.

Ewing sarcoma demonstrates racial disparities in incidence-related and sex-related differences in outcome: an analysis of 1631 cases from the SEER database, 1973-2005

BACKGROUND

Previous reports of Ewing sarcoma cohorts suggested that there is a difference in incidence according to racial origin. However, to the authors' knowledge, this finding has never been tested in a population-based database, and the impact of race on clinical outcome and the significance of known risk factors stratified to racial groups have not been reported.

METHODS

Patients who had Ewing sarcoma diagnosed between 1973 and 2005 were identified in the Surveillance, Epidemiology, and End Results database. Patient demographic and clinical characteristics; incidence; year of diagnosis; tumor location, tumor size, and disease stage at diagnosis; treatment(s); cause of death; and survival were extracted. Kaplan-Meier, log-rank, and Cox regressions were used to analyze the significance of prognostic factors.

RESULTS

Race-specific incidence indicated that Caucasians have the highest incidence (0.155), followed by Asians/Pacific Islanders (0.082), and African Americans (0.017). The difference in incidence between Caucasians and African Americans was 9-fold and significant (P<.001). The incidence of Ewing sarcoma increased over the past 3 decades among Caucasians (P<.05). Survival was not impacted by race. Local disease stage, primary tumor location in the appendicular skeleton, and tumor size

CONCLUSIONS

To the authors' knowledge, this is the first report focusing on racial disparity in incidence of Ewing sarcoma. Caucasians were affected more frequently, although outcomes were similar between races. It is noteworthy that being a woman constituted a survival benefit only among the Caucasian patients. Further studies will need to clarify the reasons for racial disparities in incidence and for sex differences in survival.

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MESH Headings

• Adolescent
• Adult
• Black People
• Bone Neoplasms/epidemiology
• Bone Neoplasms/ethnology
• Bone Neoplasms/mortality
• Child
• Child, Preschool
• Female
• Hispanic or Latino
• Humans
• Incidence
• Infant
• Infant, Newborn
• Middle Aged
• Prognosis
• Racial Groups
• Risk Factors
• SEER Program
• Sarcoma, Ewing/epidemiology
• Sarcoma, Ewing/ethnology
• Sarcoma, Ewing/mortality
• Sex Distribution
• White People
• Black or African American

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Affiliation(s)

Muhammad U Jawad Department of Orthopedics, University of Miami Miller School of Medicine, Miami, Florida 33136, USA
Michael C Cheung
Elijah S Min
Michaela M Schneiderbauer
Leonidas G Koniaris
Sean P Scully

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Factores de riesgo para los tumores óseos malignos pediátricos

INTRODUCTION

Cancer is the result of the interaction of two kinds of determinants: genetic (endogenous) and environmental (exogenous). In the last few decades, pediatric oncology as a whole has progressed, including knowledge of malignant osseous tumors (MOT). Although advances have been made in diagnostic and therapeutic aspects, little progress has taken place in our knowledge of the risk factors involved in their etiopathogenesis.

OBJECTIVE

This review has three objectives: a) to provide an update on MOT-related risk factors in the child and adult population; b) to disseminate knowledge of the main MOT-related risk factors among our colleagues in order to promote research into these factors, diagnosis and future prevention, and c) to request help from our colleagues in the Environment and Pediatric Cancer research project.

MATERIAL AND METHODS

We performed a systematic review of the literature published in the last 30 years on risk factors implicated in the etiopathogenesis of MOT, using Medline, Cancerlit, Science Citation Index and Embase. The search profiles used were: pediatric/childhood malignant bone tumors, pediatric/ childhood bone cancer/neoplasm, osteosarcoma/bone sarcoma/Ewing's sarcoma and risk factors/etiology/epidemiology. The most interesting articles were selected and the most relevant references contained therein were retrieved.

RESULTS

MOT represent 6-7 % of all pediatric neoplasms. The most frequent types are osteosarcoma (OS) and Ewing's sarcoma (ES), representing 56 % and 34 % respectively. OS-related risk factors are the following: a) previous osseous disease (Paget's disease); b) familial-genetic factors (hereditary retinoblastoma, Li-Fraumeni syndrome, Rothmund-Thompson syndrome, Bloom syndrome, familial OS, Diamond-Blackfan anemia); c) chemical factors (antineoplastic drugs); d) physical factors (ionizing radiation); e) biologic factors; f) parental occupation, and g) other factors (artificial osseous implants and traumatisms). ES-related risk factors are the following: a) ethnic-cultural (Caucasian race); b) genetic factors; c) parental occupation (herbicide, pesticide and fertilizer exposure); d) maternal obstetric history, and e) other factors (parental smoking and inguinal hernia).

CONCLUSIONS

Most causes of MOT are unknown. Based on different levels of scientific evidence, the main factors implicated in the etiopathogenesis of OS are: Paget's disease, hereditary retinoblastoma, Li-Fraumeni syndrome, antineoplastic drugs, and ionizing radiation. The main factors related to ES are: Caucasian race, parental occupation, parental smoking, and surgery for inguinal hernia. The main obstacles to greater knowledge of MOT-related factors are: a) their multiple origin; b) the low prevalence in the population; c) lack of environmental health training in pediatrics, and d) the low public and private investment in this research field.

Hernias and Ewing's sarcoma family of tumours: a pooled analysis and meta-analysis

BACKGROUND

Ewing's sarcoma family of tumours has been associated with a history of hernia and with a parental occupation of farming. However, the causes of these tumours remain unknown. We therefore aimed to investigate the association between hernia and Ewing's sarcoma family of tumours.

METHODS

We did a pooled analysis of two case-control studies and a meta-analysis of three case-control studies of Ewing's sarcoma family of tumours that had adequate information on history of hernia. The primary endpoint was development of a tumour from the Ewing's sarcoma family. 138 patients with such a tumour and 574 controls were included in the pooled analysis, and 357 patients with these tumours and 745 controls were included in the meta-analysis. Risk was assessed by an odds ratio (OR) and 95% CI by use of multivariate analysis with unconditional logistic regression for the pooled analysis and random effects model for the meta-analysis.

FINDINGS

Pooled analysis showed that children with Ewing's sarcoma family of tumours were more likely to have had an umbilical hernia than were controls (odds ratio [OR] 3.3 [95% CI 1.3-8.0]). Meta-analysis showed that children with Ewing's sarcoma family of tumours were more likely to have had a hernia (3.2 [1.9-5.7]).

INTERPRETATION

Ewing's sarcoma family of tumours and hernias (particularly inguinal hernias) have common embryological pathways of neuroectodermal origin, and environmental factors, such as farming, might link the two entities.

Parental occupational exposures and Ewing's sarcoma

A case-control study of Ewing's sarcoma (ES) was conducted to search for occupational exposures associated with ES. The study consisted of 196 cases and 196 random-digit controls matched on geographical region, gender, ethnic origin and birth date. A questionnaire was administered to mothers of participants to obtain information on medical conditions, medications, and parental occupations during and after the index pregnancy. An occupational exposure expert coded jobs and industries for possible and probable exposure to selected occupational hazards. Risk of ES was increased with probable parental exposure to wood dusts during their usual occupation post pregnancy (odds ration [OR] = 3.2; 95% confidence interval [CI] = 1.1-9.2). Other exposures, including a priori suspected risk factors such as exposure to pesticides and farm animals, were not significantly associated with ES. A history of household pesticide extermination was associated with ES among boys aged 15 or younger (OR = 3.0; 95% CI = 1.1-8.1), but not among girls or older boys. Our results suggest that earlier reports of associations of ES with parental farm employment may have been describing risks associated with organic dusts encountered when working on a farm, rather than agricultural exposures or other farming related exposures.

Epidemiology and genetics of childhood cancer

Childhood cancer is rare everywhere in the world, with age-standardized annual incidence usually between 70 and 160 per million at age 0-14 years. Greater variation is seen between populations for some specific tumour types. Some of the largest variations are geographical and are attributable to environmental factors, whereas variation mainly on ethnic lines seems likely to be a marker of genetic predisposition. A wide range of familial and genetic syndromes is associated with an increased risk of childhood cancer. Virtually all the excess risk of cancer among first-degree relatives of children with cancer can be accounted for by known hereditary syndromes. Studies of weak predisposition and gene-environment interaction have so far shown limited consistency. There are very few established environmental or exogenous risk factors and most of these are infective agents. Many putative risk factors can hardly ever be investigated epidemiologically except by interview or questionnaire studies. Some recent examples illustrate the continuing problems of participation bias and recall bias.