Primary Ewing's sarcoma of the sphenoid bone with unusual imaging features: a case report

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.

Primary Calvarial Ewing Sarcoma: A Case Series

Background Calvarial Ewing tumor is a relatively rare differential among bony neoplasms. We present our experience of managing primary calvarial Ewing sarcoma (EWS), highlighting their clinical and radiological findings.

Method In a retrospective analysis, we evaluated our 12-year database for pathologically proven EWS. A literature search was conducted for the comparative presentation and update on the management and outcome.

Result From January 2008 to December 2020, we managed eight patients (male:female = 5:3; age range 6 months to 19 years, mean 11.5 years) harboring primary calvarial EWS. All cases underwent wide local excision; two patients required intradural tumor resection, while one required rotation flap for scalp reconstruction. Mean hospital stay was 8 days. All patients received adjuvant chemo- and radiotherapy. Three patients remained asymptomatic at 5 years of follow-up, while two patients died.

Conclusion Primary calvarial EWS is a rare entity. It usually affects patients in the first two decades of life. These tumors can be purely intracranial, causing raised intracranial pressure symptoms, which may exhibit rapidly enlarging subgaleal tumors with only cosmetic deformities or symptoms of both. Radical excision followed by adjuvant therapy may offer a favorable long-term outcome.

Spheno-orbital Lesions-A Major Review of Nonmeningioma Causes

PURPOSE

To review the imaging features of the broad range of nonmeningioma lesions of the greater wing of the sphenoid (GWS) bone and adjacent orbit to assist clinicians in differentiating these lesions from each other and from the most common lesion of the GWS and adjacent orbit, meningioma.

METHODS

We reviewed 32 cases of spheno-orbital lesions involving the GWS from our own practice, as well as 109 published cases (total 141), with emphasis on available imaging features on computerized tomography (CT) and MRI. Features that might assist in differentiating meningioma from its mimics were analyzed for each lesion, including the presence of an osteoblastic or hyperostotic response, bone erosion or osteolysis, homogeneous hypo- or hyperintensity on T2-weighted MRI, leptomeningeal involvement, and the absence of a "dural tail" on contrast-enhanced MRI. The clinical and imaging features were also briefly summarized for each diagnostic group.

RESULTS

The largest diagnostic group was metastasis (67 cases, 47.5%). The most useful imaging features that helped differentiate meningioma from its mimics were the presence of bone erosion and the absence of a "dural tail." Other features were helpful in a small minority of cases only. Metastatic prostate cancer was the largest single group (21 cases), and 18 (85.7%) of these were osteoblastic and most closely mimicked meningioma. Prostate cancer patients were generally older than males with GWS meningioma. Almost all other (44/46, or 95.7%) metastatic lesions showed evidence of bone erosion. Almost half (30 of 61, 49.2%) of patients with metastasis presented without a known diagnosis of malignancy. Among children 16 years of age and less, Langerhans cell histiocytosis (10 cases), dermoid cyst (5), and Ewing's sarcoma (5) were the most common diagnoses.

CONCLUSIONS

A combination of a careful history and both CT and MRI gives information, which can best guide the management of patients with spheno-orbital lesions. Metastatic prostate cancer to the GWS most closely mimics GWS meningioma but can in most cases be differentiated on clinical and imaging features. Older males with hyperostotic lesions of the GWS should be investigated for prostate cancer. Other metastatic lesions and primary tumors of the GWS, as well as benign and structural lesions can readily be differentiated from meningioma on clinical and imaging features.

Primary Ewing's sarcoma with orbit involvement: Survival and visual outcomes after eye-sparing multidisciplinary management in eight patients

BACKGROUND

To describe the clinical presentation, treatment, and overall prognosis in eight patients with primary Ewing's sarcoma (ES) involving the orbit.

METHODS

A retrospective interventional study of all biopsy-proven cases of primary ES involving the orbit was done.

RESULTS

There were seven males and one female with a median age of 14 years. Imaging showed osseous involvement in all eight cases with extraorbital extension in four. Complete tumor resection was done in four, partial resection in three, and biopsy followed by sinus surgery in one. EWSR1 gene rearrangement analysis was done to confirm diagnosis. All patients received multidrug systemic chemotherapy and seven patients received adjuvant radiotherapy. Eye salvage was achieved in all patients. At a mean follow-up duration of 52.63 months, seven patients were doing well with no evidence of disease.

CONCLUSIONS

ES involving the orbit is sensitive to chemotherapy and radiation. Aggressive multimodality treatment can help salvage the globe and improve overall survival.

Spinal Ewing Sarcoma Metastatic to Bilateral Orbits

A 39-year-old woman with primary spinal Ewing sarcoma and known lung metastases presented with painless bilateral decreased visual acuity over a 1-month period. Examination revealed bilateral disc edema. MRI of the brain/orbits showed metastatic lesions to the dura and bilateral orbits. Venous sinus thrombosis extending to the jugular vein was also noted. To the authors' knowledge, this is the first case of bilateral orbital metastasis and papilledema secondary to Ewing sarcoma and related hypercoagulability.

A review of nasal, paranasal, and skull base tumors invading the orbit

Tumors that invade the orbit are uncommon. The majority are meningiomas arising from the sphenoid ridge (66%). Others are bone and cartilage tumors arising from the surrounding bones of the orbit, pituitary adenomas, and epithelial tumors arising from the paranasal sinuses and nasal cavity. Meningiomas occur more often in women, whereas epithelial tumors have a predilection for men. Meningiomas and epithelial tumors typically present in the sixth decade of life, whereas bone tumors tend to affect individuals in their third decade of life. Patients often present with a combination of ophthalmological and otorhinolaryngological symptoms, including proptosis, pain, decreased visual acuity, restrictions in motility of the eye, epistaxis, and nasal obstruction. Sarcomas and benign bone and cartilage tumors arise from surrounding structures, whereas carcinomas usually arise from the paranasal sinuses. Surgery is the mainstay of treatment. Depending on the aggressiveness and histology of the tumor, surgery may be combined with radiation and chemotherapy. The prognosis is generally poor, but varies depending on histology and cell origin, size of the tumor, and degree of invasion. Meningiomas and benign bone tumors have the best prognoses. Sinonasal undifferentiated carcinomas, small-cell neuroendocrine carcinomas, osteosarcomas, and rhabdomyosarcomas have poorer prognoses.

Myths in the Diagnosis and Management of Orbital Tumors

Orbital tumors constitute a group of diverse lesions with a low incidence in the population. Tumors affecting the eye and ocular adnexa may also secondarily invade the orbit. Lack of accumulation of a sufficient number of cases with a specific diagnosis at various orbital centers, the paucity of prospective randomized studies, animal model studies, tissue bank, and genetic studies led to the development of various myths regarding the diagnosis and treatment of orbital lesions in the past. These myths continue to influence the diagnosis and treatment of orbital lesions by orbital specialists. This manuscript discusses some of the more common myths through case summaries and a review of the literature. Detailed genotypic analysis and genetic classification will provide further insight into the pathogenesis of many orbital diseases in the future. This will enable targeted treatments even for diseases with the same histopathologic diagnosis. Phenotypic variability within the same disease will be addressed using targeted treatments.

Childhood Ewing Sarcoma of the Orbit

In the span of the last 48 years, only 33 cases of children with orbital Ewing sarcoma have been reported. This study is to present 3 cases that were admitted to Children's Cancer Hospital Egypt 57357, during the period from 2009 to 2013. We have 2 cases treated using the hospital standard Ewing sarcoma treatment protocol, to completion, whereas the third discontinued treatment. All tumors have confirmed CD99 positivity, although translocation (11;22) was positive in 1 patient and negative in the third. With earlier diagnosis and adequate surgical resection and integration of chemotherapy and radiotherapy 1 patient survived for about 4 years, whereas the other 2 cases died due to disease progression or recurrence.

CT and MRI of pediatric skull lesions with fluid-fluid levels

Fluid-fluid levels can occur whenever different fluid densities are contained within a cystic or compartmentalized lesion, usually related to the evolution of hematoma or necrosis. Review of the literature demonstrated that throughout the skeletal system, the most common etiology for fluid-fluid levels is aneurysmal bone cyst, but there are no dedicated studies of the pediatric calvaria, to our knowledge. In this report, we present clinicopathologic characteristics and CT and MR imaging of 11 patients with pediatric skull mass lesions demonstrating fluid-fluid levels. MR imaging demonstrated more fluid-fluid levels compared with CT in all cases. The etiologies of skull lesions with fluid-fluid levels were Langerhans cell histiocytosis in 4 (36.6%), aneurysmal bone cysts in 3 (27.2%), cephalohematoma in 3 (27.2%), and metastatic neuroblastoma in 1 (9%). Radiologists should be aware of the other etiologies of calvarial lesions with fluid-fluid levels in the pediatric skull.

Dural metastasis of Ewing's sarcoma

BACKGROUND

Metastatic Ewing's sarcoma to the central nervous system is an uncommon condition and debate concerning the true origin of its metastases is still up to date. To the best of our knowledge, only two cases of dural metastatic Ewing's sarcoma have been published in the English medical literature. We present an additional case in a 24-year-old female and discuss the pathogenesis of these unusual tumors with review of the relevant literature concerning their treatment and outcome.

CASE DESCRIPTION

A 24-year-old female with previous history of pelvis Ewing's sarcoma and recently discovered lung metastases, presented with moderate headache for the past 2 weeks and weakness in her left leg for the past 2 days. Computed tomography scan and magnetic resonance imaging revealed an extra-axial right frontoparietal mass invading the superior sagittal sinus but with clear delineation with brain parenchyma. Imaging features were suggestive of a meningioma as no abnormalities in the skull abutting to the tumor were noted. The patient underwent surgical removal of her tumor. Near total resection was achieved and histological examination showed evidence of metastatic Ewing's sarcoma. Postoperative adjuvant radiation and chemotherapy were administered. The patient improved well postoperatively with full recovery of her motor weakness. She is symptom free with no signs of progression, at most recent follow-up, 8 months after surgery.

CONCLUSION

Despite its rarity, metastatic Ewing's sarcoma must be considered in the differential diagnosis of extra-axial dural masses particularly meningiomas.

Ewing's sarcoma of the orbit with intracranial extension: A rare cause of unilateral proptosis

Ewing's sarcoma causing unilateral proptosis along with bifrontal extradural infiltration in a child is an unusual presentation. A female patient presented with features of painless proptosis of the left eye with visual deterioration. Her radiology revealed an infiltrating intraorbital, extraconal tumor with intracranial bifrontal extradural extension causing mass effect. Total excision of the intraorbital and intracranial part of the tumor along with postoperative chemo- and radiotherapy brought about a substantial relief. The clinicoradiological presentation and management of this rare entity are discussed.

Primary Ewing's sarcoma of cranial bones: analysis of ten patients

OBJECTIVE

Ewing's sarcomas are the second most common bone tumors in children and primary involvement of the cranium is uncommon. We analyzed retrospectively the data of ten patients with this rare subset of disease, who had been treated at our institute since 2005. Our aim was to assess the outcomes, recurrence rates and the selection of appropriate treatment methods.

METHODS

The patients were reviewed with respect to their clinical presentations, treatment, and outcomes. Computed tomographic scanning of the brain was performed for all patients. Skeletal surveys with routine radiographs and technetium-99 bone scans to detect extracranial Ewing's sarcomas were performed for all patients. For all ten patients, radical tumor excision was achieved surgically. Chromosomal translocation studies were carried out on paraffin blocks for nine patients, using fluorescence in situ hybridization (FISH) and polymerase chain reaction (PCR). All patients were then subjected to adjuvant multidrug chemotherapy and radiotherapy. The follow-up periods ranged from 2 months to 5 years (mean, 17.6 months).

RESULTS

The predominant presenting features were headaches, increased intracranial pressure, scalp swelling and trigeminal nerve involvement. The erosion of dura and intradural extension was noted in eight patients in our series. All nine patients, in whom FSIH and reverse transcriptase PCR (RT-PCR) was done, tested positive for EWS-FLI1(t22:12) translocation. All patients underwent radical excision within safe limits, followed by chemoradiation. Three patients had local recurrences, which were detected within 12 months after surgery. All three of them died within weeks of presentation with recurrence. One patient experienced a recurrence after 30 months. This recurrent tumor was completely excised, and additional chemotherapy was administered. There was a local recurrence again after 18 months that was treated with surgery and chemoradiation, and the patient is still surviving 5 years after the primary surgery. One patient had metastasis at presentation and died within 2 months of surgery. The remaining five seem to have good outcomes, though the follow-ups were not very long.

CONCLUSION

The treatment of primary Ewing's sarcoma of the cranium still remains to be radical surgery, aggressive multidrug chemotherapy, and radiotherapy. Neoadjuvant chemotherapy may not work in patients with large intracranial extension due to raised pressure making decompression imperative. The outcome is usually good if there is no early recurrence. Early recurrence, presence of metastasis and extremes of age probably bears a poor outcome. However, a larger series is required to confirm these findings.

Cranial Ewing's sarcoma in children

Ewing's sarcoma is a highly malignant neoplasm of bones which accounts for the 10% of primary bone malignancies. Primary Ewing's sarcoma of skull vault is very rare and constitutes 1-6% of all Ewing's sarcomas. We present a case of a primary and a radiation-induced skull Ewing's sarcoma. The symptoms, neuroimaging findings and the treatment for these cases are reviewed. Both children were operated with favorable outcome.

Multiple primary cranial Ewing's sarcoma in adulthood: case report

OBJECTIVE

Ewing's sarcoma is a malignant bone tumor occurring most frequently in the long bones and flat bones as a solitary lesion during the first 2 decades of life. Ewing's sarcoma and peripheral primitive neuroectodermal tumor have recently been considered to be the same entity because of histological and molecular similarities.

CLINICAL PRESENTATION

A 25-year-old man presented with swelling in the right parietal region. Magnetic resonance imaging scans showed 2 mixed intense mass lesions in the right parietal and left frontal areas with heterogeneous gadolinium enhancement. A computed tomographic scan revealed osteolytic changes of the inner calvarial bone. Ga-67 citrate scintigraphy demonstrated abnormal uptake in the right parietal and the left frontal areas consistent with the findings on magnetic resonance imaging scans. There was no uptake lesion beyond the cranium. The patient underwent surgical excision of the right parietal lesion.

INTERVENTION

Histological examinations showed densely packed, small round cells with rosette formation. The cells had scanty clear cytoplasm, and regular vesicular and hyperchromatic nuclei. Electron microscopy showed little differentiation to neuronal tissue, indicating Ewing's sarcoma. After surgical treatment, conventional whole cranial irradiation of 40 Gy and chemotherapy were conducted. The tumor in the left frontal region disappeared. Follow-up examinations showed no evidence of recurrence 1 year after the surgery.

CONCLUSION

Although quite rare, Ewing's sarcoma should be taken into consideration as a differential diagnosis of multiple cranial mass lesions in adulthood.

Fluid-fluid levels in bone neoplasms: variation of T1-weighted signal intensity of the superior to inferior layers--diagnostic significance on magnetic resonance imaging

The diagnostic relevance of the relative T1-weighted (T1W) and T2-weighted (T2W)/short tau inversion recovery (STIR) MRI signal intensity characteristics of the superior to inferior fluid layers within fluid-fluid levels (FFLs) found in bone tumours was investigated. A retrospective analysis was performed of MRI studies of 2,568 patients presenting with a suspected bone tumour over an 8-year period. Final diagnosis was made by biopsy/surgical resection or characteristic imaging/clinical findings. Subjects were divided by the absence/presence of FFLs and benign/malignant histology. Cases with FFLs were sub-categorised by the relative signal intensity of the superior/inferior layer as high/low or low/high on T1W and T2W/STIR sequences. Out of the total of 2,568 cases, 214 (8.3%, CI 7.3-9.5%) had FFLs and 2,354 (91.7%, CI 90.5-92.7%) had no FFLs. All 214 cases with FFLs had T2W/STIR sequences available, all demonstrating high/low signal intensity characteristics; 135/214 (63.1%, CI 56.2-69.6%) were benign and 79/214 (36.9%, CI 30.4-43.8%) were malignant. Out of the 214 patients, 151 had T1W sequences performed; 52 showed high/low signal intensity, of which 30 (57.7%, CI 34.2-71.3%) were benign and 22 (42.3%, CI 28.7-56.8%) were malignant (P = 0.06 compared with no FFL group); 50 showed low/high signal intensity, of which 40 (80%, CI 66.3-90.0%) were benign and ten (20%, CI 10.0-33.7%) were malignant (P = 0.0000, compared with the no FFL group). The low/high and high/low groups had a significantly greater proportion of benign and malignant lesions, respectively (P = 0.015). In conclusion, all FFLs showed high/low signal intensity characteristics on T2W/STIR sequences. Low/high signal on T1W was significantly associated with benign disease. Malignancy may occur slightly more frequently with high/low signal on T1W.