Extraskeletal neuroectodermal tumour of the vagina: a single case report and review

An unusual presentation of extraskeletal vaginal Ewing sarcoma: A case report

Ewing sarcoma (ES) is a rare, aggressive malignancy that typically arises from bone and is seen more in adolescents and young adults. In contrast, extraskeletal Ewing sarcoma (EES) is more prevalent in adults and women [1,2]. There is no standard treatment for extraskeletal tumors, especially those in sensitive areas, such as the vagina, where resection may cause a large cosmetic or functional deformity. This case features a woman in her 20s who presented with painless vaginal bleeding and was found to have a 4 × 5 × 4-mm EES of the posterior vaginal wall. The presentation raised both reproductive and functional concerns, as the patient was young, sexually active and of childbearing age. The patient underwent treatment with radiation therapy and chemotherapy every 3 weeks. Given the lack of guidance and proclivity of EES to metastasize, it is paramount to proceed with standard-of-care treatment even if it is small and there is a lack of metastatic disease. For women with vaginal EES who are of childbearing age, brachytherapy rather than surgical resection may be a more favorable option when considering the location and the potential impact of vaginectomy.

Extraosseous Ewing Sarcoma in a Pelvic Region: A Case Report

Ewing sarcoma is the second most common malignant bone tumour in children. It rarely originates from extraskeletal soft tissue sites such as the upper thigh, buttocks, upper arm and shoulder. Primary extraosseous Ewing sarcoma located in the pelvic region is rare. We report a 17-year-female who had gradual onset of progressive lower abdominal mass and pain. A computed tomography scan revealed well defined lobulated heterogeneously enhancing lesion noted in the pelvic region measuring approximately 12.9 x 9.8 x 9.3 cm. Incisional biopsy showed a small round blue cell tumour which was strongly positive for Cluster of Differentiation 99, vimentin, Friend Leukaemia Integration 1 with 40% Ki-67. Following treatment with chemotherapy, surgery and radiotherapy, there was complete resolution of the tumour. Although extraosseous Ewing sarcoma is rare, it can occur virtually in any soft tissue site. Therefore, clinicians need to distinguish it from soft tissue sarcoma because rapid progression, early diagnosis and timely treatment are crucial for a favourable prognosis.

Keywords

Ewing sarcoma; neoadjuvant chemotherapy; radiation therapy.

Importance of studying primitive neuroectodermal tumors and extraosseous Ewings sarcoma of the vagina and vulva

Primitive neuroectodermal tumor (PNT) and Ewing's sarcoma are rare, round-cell tumors, characterized by the presence of the t(11; 22)(q24; q12) chromosomal translocation. A review of the literature revealed only 38 previously reported cases of vulvar PNT and Ewing's sarcoma and 15 vaginal PNT and Ewing's sarcoma. Although rare, these types of tumors should be taken into consideration when making a differential diagnosis for vulvar or vaginal tumors. The currently available data is limited, and therefore, case reports are essential for improving knowledge and management of these types of extremely rare tumors. However, further molecular and histopathological studies are essential for an improved understanding of these conditions and for an early, correct diagnosis. Although the gathered and presented data from the present review are limited, the literature demonstrates that the outcome of these types of cancer are more favorable compared with outcomes observed for carcinomas in more typical locations.

Case Report: Primary Ewing Sarcoma of the Penis With Multiple Metastases

Background: Ewing sarcoma is the second most common malignant bone tumor in children, but it rarely originates from extra-skeletal sites. The commonly involved sites of soft tissue include paravertebral spaces, lower extremities, the pelvis, head, and neck, while primary extra-skeletal Ewing sarcoma (EES) located in the genitals is extremely rare. Case Presentation: We report a young patient who presented to our hospital with a painful erection of the penis and limited motion of the left hip. Magnetic resonance imaging showed a hyperintense mass with invasion of adjacent tissue in the penis and a heterogeneously high signal lesion in the left proximal femur. ¹⁸F-fluorodeoxyglucose positron-emission tomography detected widespread metastatic lesions in the bilateral lung and multiple skeletons. An incisional biopsy of the penis was performed; the histopathological findings and EWS gene translocation identified by molecular analysis confirmed the diagnosis of Ewing sarcoma. Subsequently, the punch-biopsy specimen from the left femur showed undifferentiated small round cells, a finding consistent with the microscopic presence of Ewing sarcoma metastasis. However, after the first course of multiagent chemotherapy, the penile mass did not obtain stabilization but instead grew progressively with surface ulceration and multidrug resistant bacteria infection. Despite receiving antibiotics and maximal supportive therapy, the patient died from sepsis and lung metastasis complications in the intensive care unit 2 months later. Conclusion: This case indicates that although EES as a subtype of Ewing sarcoma is rare, it can occur virtually in any soft tissue site, even in the genitals. Therefore, clinicians need to distinguish this entity from other soft tissue sarcomas with rapid progression since early diagnosis and timely treatment of EES are pivotal for a favorable prognosis.

Primitive Neuroectodermal Tumors of the Female Genital Tract: A Morphologic, Immunohistochemical, and Molecular Study of 19 Cases

Primary primitive neuroectodermal tumor (PNET) of the female genital tract is rare, and its proper classification remains unclear. The clinical, histologic, and immunophenotypic features as well as EWSR1 rearrangement status of 19 gynecologic PNETs, including 10 ovarian, 8 uterine, and 1 vulvar tumors, are herein reported. Patient age ranged from 12 to 68 years, with a median age of 20 and 51 years among those with ovarian and uterine PNETs, respectively. Morphologic features of central nervous system (CNS) tumors were seen in 15 PNETs, including 9 medulloblastomas, 3 ependymomas, 2 medulloepitheliomas, and 1 glioblastoma, consistent with central PNET. The remaining 4 PNETs were composed entirely of undifferentiated small round blue cells and were classified as Ewing sarcoma/peripheral PNET. Eight PNETs were associated with another tumor type, including 5 ovarian mature cystic teratomas, 2 endometrial low-grade endometrioid carcinomas, and a uterine carcinosarcoma. By immunohistochemistry, 17 PNETs expressed at least 1 marker of neuronal differentiation, including synaptophysin, NSE, CD56, S100, and chromogranin in 10, 8, 14, 8, and 1 tumors, respectively. GFAP was positive in 4 PNETs, all of which were of central type. Membranous CD99 and nuclear Fli-1 staining was seen in 10 and 16 tumors, respectively, and concurrent expression of both markers was seen in both central and Ewing sarcoma/peripheral PNETs. All tumors expressed vimentin, whereas keratin cocktail (CAM5.2, AE1/AE3) staining was only focally present in 4 PNETs. Fluorescence in situ hybridization was successful in all cases and confirmed EWSR1 rearrangement in 2 of 4 tumors demonstrating morphologic features of Ewing sarcoma/peripheral PNET and concurrent CD99 and Fli-1 expression. In conclusion, central and Ewing sarcoma/peripheral PNETs may be encountered in the female genital tract with central PNETs being more common. Central PNETs show a spectrum of morphologic features that overlaps with CNS tumors but lack EWSR1 rearrangements. GFAP expression supports a morphologic impression of central PNET and is absent in Ewing sarcoma/peripheral PNET. Ewing sarcoma/peripheral PNETs lack morphologic features of CNS tumors.

Primary Ewing Sarcoma Presenting as a Vulvar Mass in an Adolescent: Case Report and Review of Literature

BACKGROUND

Extraosseous Ewing sarcoma (ES) tumors presenting in the genitourinary tract are highly uncommon. Few cases of primary vulvar and vaginal cases of ES have been published.

CASE

A 15-year-old adolescent presented with a bothersome 5-cm mass located on her left labium minorum. Following excision, a diagnosis of a primary ES was made. The patient was treated with multiagent chemotherapy and was doing well 20 months after treatment completion.

SUMMARY AND CONCLUSION

Based on the few available case reports and our reported case, it appears that extraosseous ES arising in superficial sites such as the vulva have better prognosis and should be treated with complete excision and multiagent chemotherapy.

Extraosseous Ewing sarcoma of the vagina: a rare entity

Ewing sarcoma, a highly malignant neoplasm of the bone, usually occurs during childhood. About 15% are extraosseous. The Ewing family of tumors (EFTs) are extremely rare in the vagina. A 40-year literature review from 1970 to 2010 revealed only nine cases. A 32-year-old woman presented with a painless vaginal mass. A wide excision was performed. Histopathology, immunohistochemistry and molecular studies confirmed extraosseous vaginal Ewing sarcoma. Despite aggressive chemotherapy with a good initial response, she developed local recurrence and metastasis to the spine and pelvis and succumbed 22 months later. A previous infiltrating ductal breast cancer, treated and in remission complicated the picture. We present the tenth case of vaginal Ewing sarcoma and the fourth to be confirmed by molecular studies. We stress the importance of molecular techniques in definitely diagnosing EFTs, especially those arising at unusual sites, particularly in the context of a previous diagnosis of breast cancer.

Paravaginal peripheral primitive neuroectodermal tumor: A rare tumor

Peripheral primitive neuroectodermal tumor (PNET) of the female genital tract, particularly those in the vaginal and paravaginal region, are extremely rare. A 36-year-old woman presented with clinical features similar to that of a case of cervical fibroid. It was only after surgery that the histopathology suggested it to be a malignant round cell tumour and was CD99 positive. She underwent adjuvant chemotherapy with the Ifosfamide and Etoposide alternating with Vincristine, Doxorubicin, and Cyclophosphamide regime and radical radiotherapy. She is disease free at 12 months of follow-up. The importance of immunostaining and adequate histopathology report lies in the fact that the correct diagnosis thus achieved enabled us to manage a rare case of paravaginal PNET with a multimodality approach.

Primary Vaginal Ewing Sarcoma

Ewing sarcoma (ES) and primitive neuroectodermal tumor (PNET) are round-cell sarcomas with varying degrees of neuroectodermal differentiation; they are considered members of the same family of tumors based on their common genetic profile. ES/PNET are very infrequent in the female genital tract, the vagina being the rarest gynecological location, with 7 cases reported to date. The authors present a case of vaginal ES/PNET with typical morphological and immunohistochemical features. EWS gene rearrangement was demonstrated by fluorescent in situ hybridization analysis. Of the 7 previously reported cases, only 2 have molecular confirmation. The age at presentation for vaginal ES/PNET is slightly higher than that for these neoplasms in bone and soft tissues, with only 1 reported patient younger than 30 years. The outcome seems to be similar to that of other superficially sited ES/PNET and more favorable than for those observed in the more typical locations. However, the currently available data are limited, and therefore, a larger number of cases is necessary to draw any firm conclusions.

Primary Ewing's sarcoma/primitive neuroectodermal tumor of the vagina in a 54-year-old woman: a case report

BACKGROUND

Ewing's sarcoma (ES)/primitive neuroectodermal tumor (PNET) of the genital tract of women is uncommon. Presentation in vagina is exceedingly rare.

CASE

A 54-year-old Chinese woman presented with complaints of vaginal bleeding with fragmented bits occasionally. Physical examination revealed two nodules about 4 cm × 3 cm in the vagina. The immunohistochemical stains revealed a rare presentation of a primitive neuroectodermal tumor. The patient was treated with whole-pelvis external beam radiation, vaginal cylinder intracavitary brachytherapy, intracavitary afterloading radiotherapy and bilateral groin area radiotherapy. She died of clinical recurrence after 18 months of treatment.

CONCLUSION

This is the oldest but virgin case, treated with radiation completely, of primitive neuroectodermal tumor located in the vagina reported in the literature.

Primary metastasized extraskeletal Ewing sarcoma of the vulva: report of a case and review of the literature

PURPOSE

Ewing's sarcoma (ES) and primitive neuroectodermal tumor (PNET) are closely related malignant neoplasms, usually affecting the skeletal system. Extraosseous ES/PNETs are uncommon, with occasional reports of tumors affecting the genitourinary tract. Only few cases of primary vulvar Ewing's sarcoma/PNET have previously been reported.

METHODS

We present a patient with primary vulvar Ewing's sarcoma with pulmonary metastasis who presented at the Department of Gynecology and Obstetrics, University of Schleswig-Holstein, Campus Luebeck.

RESULTS

The present report is the third case of a primary vulvar Ewing's sarcoma and the first constellation with pulmonary metastasis at diagnosis in the current literature. We present the diagnostic and therapeutic management including surgery, chemotherapy and radiation.

CONCLUSION

The treatment of the Ewing's sarcomas and PNETs requires a multidisciplinary systemic approach. Despite its rarity, the differential diagnosis of vulvar sarcoma must be considered in young women.