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Sasi A, Chitikela S, Ganguly S, Biswas B, Pushpam D, Kumar A, Khan SA, Kumar VS, Kale SS, Biswas A, Barwad A, Mridha AR, Thulkar S, Bakhshi S. Treatment outcomes in patients with Ewing sarcoma of the spine in a resource-challenged setting: 17-year experience from a single center in India. Pediatr Hematol Oncol 2024; 41:211-223. [PMID: 38189167 DOI: 10.1080/08880018.2023.2296949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/14/2023] [Indexed: 01/09/2024]
Abstract
Ewing sarcoma (ES) of the spine is a rare childhood cancer with sparse literature on treatment outcomes. We aimed to describe survival outcomes and prognostic factors in patients with spinal ES treated at a single institute in a resource-challenged setting. We conducted a retrospective analysis of patients with spinal ES registered at a tertiary care oncology center between 2003-2019. Clinical patient data was retrieved from hospital records. Cox regression analysis was used to identify the association of baseline clinical parameters with event free survival (EFS) and overall survival (OS). A cohort of 85 patients was analyzed including 38 (45%) patients with metastatic disease. The median age was 15 years with 73% being male. Local therapy was administered in 62 (72.9%) patients with surgery alone in 8 (9.4%), radiotherapy alone in 36 (42.4%) and both in 18 (21.2%) patients. A higher proportion of males received local therapy than females (80.3% versus 59.1%; p = 0.049). The median EFS and OS were 20.1 and 28.6 months, respectively. On univariable analysis, age ≤ 15 years, female sex, serum albumin ≤3.5 g/dL and hemoglobin ≤11 g/dL were associated with inferior EFS while younger age, female sex, hypoalbuminemia and metastatic disease were associated with inferior OS. On multivariable analysis, only hypoalbuminemia was predictive for inferior EFS (HR:2.41; p = 0.005) while hypoalbuminemia (HR:2.06;p = 0.033) and female sex (HR:1.83; p = 0.046) were associated with inferior OS. We concluded that hypoalbuminemia confers poor prognosis in ES spine. Survival outcomes are poorer in females treated in our setting, possibly due to prevailing sex-based biases.
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Affiliation(s)
- Archana Sasi
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | | | - Shuvadeep Ganguly
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Bivas Biswas
- Department of Medical Oncology, Tata Medical Centre, Kolkata, India
| | - Deepam Pushpam
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Akash Kumar
- Department of Medical Oncology, National Cancer Institute, Jhajjar, India
| | - Shah Alam Khan
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Shashank Sharad Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Ahitagni Biswas
- Department of Radiation Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Adarsh Barwad
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Asit Ranjan Mridha
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Thulkar
- Department of Radiology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sameer Bakhshi
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
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Gharbi MA, Chahed HE, Slama SB, Teborbi A, Bouzidi R, Nefiss M. One-stage combined approach en bloc vertebrectomy for primary Ewing's sarcoma of mobile spine in an adult patient: 3 years following aggressive surgery for a rare entity. Clin Case Rep 2023; 11:e8170. [PMID: 38028076 PMCID: PMC10651980 DOI: 10.1002/ccr3.8170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Key Clinical Message Currently, there is no consensus on the optimal management of nonmetastatic Ewing's sarcoma of the mobile spine. However, associated to chemotherapy, aggressive surgery with en bloc wide resection seems to improve local control and survival. Abstract Primary Ewing's sarcoma (EWS) of non-sacral spine is extremely rare, especially in middle-age. Therapeutic strategy aims: to large tumor resection, to provide spine stability and to avoid recurrence through chemo and radiotherapy. We report a case of thoracic spine EWS in an adult treated by combined approach en bloc vertebrectomy.
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Affiliation(s)
- Mohamed Amine Gharbi
- Department of Orthopedic and Trauma SurgeryMongi Slim Marsa University Hospital CenterTunisTunisia
- Faculty of Medicine of TunisUniversity of Tunis El ManarTunisTunisia
| | - Houssem Eddine Chahed
- Department of Orthopedic and Trauma SurgeryMongi Slim Marsa University Hospital CenterTunisTunisia
- Faculty of Medicine of TunisUniversity of Tunis El ManarTunisTunisia
| | - Sana Ben Slama
- Faculty of Medicine of TunisUniversity of Tunis El ManarTunisTunisia
- Department of Anatomical PathologyMongi Slim Marsa University Hospital CenterTunisTunisia
| | - Anis Teborbi
- Department of Orthopedic and Trauma SurgeryMongi Slim Marsa University Hospital CenterTunisTunisia
- Faculty of Medicine of TunisUniversity of Tunis El ManarTunisTunisia
| | - Ramzi Bouzidi
- Department of Orthopedic and Trauma SurgeryMongi Slim Marsa University Hospital CenterTunisTunisia
- Faculty of Medicine of TunisUniversity of Tunis El ManarTunisTunisia
| | - Mouadh Nefiss
- Department of Orthopedic and Trauma SurgeryMongi Slim Marsa University Hospital CenterTunisTunisia
- Faculty of Medicine of TunisUniversity of Tunis El ManarTunisTunisia
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Ahmed SK, Keole SR. Proton Therapy in the Adolescent and Young Adult Population. Cancers (Basel) 2023; 15:4269. [PMID: 37686545 PMCID: PMC10487250 DOI: 10.3390/cancers15174269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/14/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Adolescent and young adult cancer patients are at high risk of developing radiation-associated side effects after treatment. Proton beam radiation therapy might reduce the risk of these side effects for this population without compromising treatment efficacy. METHODS We review the current literature describing the utility of proton beam radiation therapy in the treatment of central nervous system tumors, sarcomas, breast cancer and Hodgkin lymphoma for the adolescent and young adult cancer population. RESULTS Proton beam radiation therapy has utility for the treatment of certain cancers in the young adult population. Preliminary data suggest reduced radiation dose to normal tissues, which might reduce radiation-associated toxicities. Research is ongoing to further establish the role of proton therapy in this population. CONCLUSION This report highlights the potential utility of proton beam radiation for certain adolescent young adult cancers, especially with reducing radiation doses to organs at risk and thereby potentially lowering risks of certain treatment-associated toxicities.
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Affiliation(s)
- Safia K. Ahmed
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA;
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Creze M, Ghaouche J, Missenard G, Lazure T, Cluzel G, Devilder M, Briand S, Soubeyrand M, Meyrignac O, Carlier RY, Court C, Bouthors C. Understanding a mass in the paraspinal region: an anatomical approach. Insights Imaging 2023; 14:128. [PMID: 37466751 DOI: 10.1186/s13244-023-01462-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/10/2023] [Indexed: 07/20/2023] Open
Abstract
The paraspinal region encompasses all tissues around the spine. The regional anatomy is complex and includes the paraspinal muscles, spinal nerves, sympathetic chains, Batson's venous plexus and a rich arterial network. A wide variety of pathologies can occur in the paraspinal region, originating either from paraspinal soft tissues or the vertebral column. The most common paraspinal benign neoplasms include lipomas, fibroblastic tumours and benign peripheral nerve sheath tumours. Tumour-like masses such as haematomas, extramedullary haematopoiesis or abscesses should be considered in patients with suggestive medical histories. Malignant neoplasms are less frequent than benign processes and include liposarcomas and undifferentiated sarcomas. Secondary and primary spinal tumours may present as midline expansile soft tissue masses invading the adjacent paraspinal region. Knowledge of the anatomy of the paraspinal region is of major importance since it allows understanding of the complex locoregional tumour spread that can occur via many adipose corridors, haematogenous pathways and direct contact. Paraspinal tumours can extend into other anatomical regions, such as the retroperitoneum, pleura, posterior mediastinum, intercostal space or extradural neural axis compartment. Imaging plays a crucial role in formulating a hypothesis regarding the aetiology of the mass and tumour staging, which informs preoperative planning. Understanding the complex relationship between the different elements and the imaging features of common paraspinal masses is fundamental to achieving a correct diagnosis and adequate patient management. This review gives an overview of the anatomy of the paraspinal region and describes imaging features of the main tumours and tumour-like lesions that occur in the region.
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Affiliation(s)
- Maud Creze
- Department of Radiology, Assistance Publique des Hôpitaux de Paris, GH Université Paris- Saclay, DMU Smart Imaging, Bicêtre Teaching Hospital, Le Kremlin-Bicêtre, France.
- BioMaps, Université Paris-Saclay, Hôpital Kremlin-Bicêtre, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
| | - Jessica Ghaouche
- Department of Radiology, Assistance Publique des Hôpitaux de Paris, GH Université Paris- Saclay, DMU Smart Imaging, Bicêtre Teaching Hospital, Le Kremlin-Bicêtre, France
| | - Gilles Missenard
- Department of Orthopedic Surgery, Assistance Publique des Hôpitaux de Paris, GH Université Paris-Saclay, DMU de Chirurgie Traumatologie Orthopédique-Chirurgie Plastique- Reconstruction, Bicêtre Teaching Hospital, Le Kremlin-Bicêtre, France
| | - Thierry Lazure
- Department of Pathology, Assistance Publique des Hôpitaux de Paris, GH Université Paris-Saclay, DMU Smart Imaging, Bicêtre hospital, Le Kremlin Bicêtre, France
| | - Guillaume Cluzel
- Department of Radiology, Assistance Publique des Hôpitaux de Paris, GH Université Paris- Saclay, DMU Smart Imaging, Bicêtre Teaching Hospital, Le Kremlin-Bicêtre, France
| | - Matthieu Devilder
- Department of Radiology, Assistance Publique des Hôpitaux de Paris, GH Université Paris- Saclay, DMU Smart Imaging, Bicêtre Teaching Hospital, Le Kremlin-Bicêtre, France
| | - Sylvain Briand
- Department of Orthopedic Surgery, Assistance Publique des Hôpitaux de Paris, GH Université Paris-Saclay, DMU de Chirurgie Traumatologie Orthopédique-Chirurgie Plastique- Reconstruction, Bicêtre Teaching Hospital, Le Kremlin-Bicêtre, France
| | | | - Olivier Meyrignac
- Department of Radiology, Assistance Publique des Hôpitaux de Paris, GH Université Paris- Saclay, DMU Smart Imaging, Bicêtre Teaching Hospital, Le Kremlin-Bicêtre, France
- BioMaps, Université Paris-Saclay, Hôpital Kremlin-Bicêtre, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Robert-Yves Carlier
- Department of Radiology, Assistance Publique des Hôpitaux de Paris, GH Université Paris- Saclay, DMU Smart Imaging, Garches Teaching Hospital, Le Kremlin-Bicêtre, France
| | - Charles Court
- Department of Orthopedic Surgery, Assistance Publique des Hôpitaux de Paris, GH Université Paris-Saclay, DMU de Chirurgie Traumatologie Orthopédique-Chirurgie Plastique- Reconstruction, Bicêtre Teaching Hospital, Le Kremlin-Bicêtre, France
| | - Charlie Bouthors
- Department of Orthopedic Surgery, Assistance Publique des Hôpitaux de Paris, GH Université Paris-Saclay, DMU de Chirurgie Traumatologie Orthopédique-Chirurgie Plastique- Reconstruction, Bicêtre Teaching Hospital, Le Kremlin-Bicêtre, France
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Zhang GH, Lin JM, He ZY, Yuan XJ, Li G, Gan XR, Xu WH, Cao SS. A case of giant Ewing's sarcoma (EES)/primitive neuroectodermal tumor (PNET) of the cervicothoracic junction in children with incomplete paralysis of both lower limbs: Case report and literature review. Front Surg 2023; 9:1066304. [PMID: 36684168 PMCID: PMC9852823 DOI: 10.3389/fsurg.2022.1066304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/05/2022] [Indexed: 01/09/2023] Open
Abstract
Background Extraosseous Ewing's sarcoma/primary neuroectodermal tumor (EES/PNET) is a rare, malignant, small round blue cell tumor, which usually involves the larynx, kidneys, and esophagus. The most common metastatic sites are lung and bone. The incidence of epidural EES/PNET was 0.9%, and a detailed search of the PubMed literature found only 7 case reports of epidural ESS/PNET at the cervicothoracic junction in children. Case description We report a case of epidural ESS/PNET at the cervicothoracic junction in a child with chest and back pain as the first symptom, which worsened after half a year and developed incomplete paralysis of both lower extremities and urinary incontinence. She underwent emergency surgery, chemotherapy and radiotherapy, and died of lung metastases 8 months after surgery. Conclusion Primary epidural tumors are mostly benign, such as spinal meningiomas and neuromas. Contrary to what has been previously thought, we report a case of malignant epidural EES/PNET at the cervicothoracic junction without bone destruction; The rarity of epidural EES/PNET at the cervicothoracic junction in children has led to a lack of data, particularly on prognostic factors and recurrence patterns. Due to the difficulty of early diagnosis and high mortality, spine surgeons must explore and increase their awareness of this disease.
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The Role of Neuroaxis Irradiation in the Treatment of Intraspinal Ewing Sarcoma: A Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14051209. [PMID: 35267515 PMCID: PMC8909708 DOI: 10.3390/cancers14051209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/13/2022] [Accepted: 02/22/2022] [Indexed: 12/04/2022] Open
Abstract
The role of cranio-spinal irradiation (CSI) for primary extraosseous intraspinal Ewing sarcoma (EwS) remains unclear. Here, we evaluate clinical and survival outcomes in patients with primary intraspinal EwS treated with CSI as part of multimodal primary therapy regimens. We abstracted patient information, including details on treatment application, efficacy, and tolerance from the literature and our hospital database for a cohort of 24 primary intraspinal EwS patients treated with CSI. Median age was 25.5 years, median CSI dose was 36 Gy and mean boost dose was 12.8 Gy. Sixteen patients (66.7%) achieved complete radiological remission, another 5 patients demonstrated partial response and 1 patient showed no response to treatment. Compared to a cohort of patients treated with focal radiotherapy, CSI patients were more likely to have multifocal disease at time of diagnosis (p = 0.001) and intradural tumor location (p < 0.001). Despite over-representation of these unfavorable characteristics, there was no survival difference between groups (p = 0.58). While CSI shows promising results in the treatment of primary intraspinal EwS, treatment should be considered individually based on tumor and patient characteristics in the absence of prospective trials.
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Indelicato DJ, Vega RBM, Viviers E, Morris CG, Bradfield SM, Ranalli NJ, Bradley JA. Modern Therapy for Spinal and Paraspinal Ewing Sarcoma: An Update of the XXX Experience. Int J Radiat Oncol Biol Phys 2022; 113:161-165. [PMID: 35033584 DOI: 10.1016/j.ijrobp.2022.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE In 2010, we published a comprehensive review of our institutional outcomes treating children with spinal and paraspinal Ewing sarcoma using photon therapy. Multimodality therapy was associated with fair disease control but also with serious toxicity, including a 37% rate of Grade ≥3 toxicity. We therefore sought to assess our more recent experience treating children with more modern technology and treatment regimens. METHODS AND MATERIALS Between 2010 and 2021, 32 pediatric patients with nonmetastatic spinal and paraspinal Ewing sarcoma were treated at XXX and enrolled in a retrospective outcome study. Median age at diagnosis was 9.8 (range, 2.1-21.8) years old. Three, 22, and 7 tumors arose within the cervical, thoracic, and lumbar spine regions, respectively. Median maximum tumor diameter was 5 (range, 3-19) cm. At diagnosis, 28/32 patients had motor, bowel, or bladder deficits. Chemotherapy was delivered per contemporary North American and European interval-compressed regimens. Before radiotherapy, 14 patients underwent gross total resection while 18 underwent a biopsy or subtotal resection with cord decompression. All patients were treated with proton therapy; 6 with hardware stabilization also received a component of intensity-modulated photon therapy. Median prescription dose was 50.4 (range, 45-54) GyRBE. Median maximum dose to the spinal cord was 50.2 (range, 0-54.9) GyRBE. RESULTS With a median follow-up of 4.1 (range, 0.7 - 9.4) years, the 5-year local control, progression-free survival, and overall survival rates were 92%, 79%, and 85%, respectively. Ten of 30 living patients have residual motor, bowel, or bladder deficits. Overall, 22% of patients experienced CTCAE grade 3 late toxicity related to multimodality treatment: kyphosis (n=4), esophagitis (n=2) and chronic kidney disease (n=1). No patients developed grade ≥4 toxicity, new neurologic deficits, or second malignancy. CONCLUSION Modern treatment advances may offer an improved therapeutic ratio for pediatric spinal and paraspinal Ewing sarcoma. With appropriate management, most patients can be cured with recovery of long-term neurologic function and modest side-effects.
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Affiliation(s)
- Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL.
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - Emma Viviers
- University of Florida Health Proton Therapy Institute, Jacksonville, FL
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - Scott M Bradfield
- Department of Pediatrics, Nemours Children's Specialty Care, Jacksonville, FL
| | - Nathan J Ranalli
- Department of Neurosurgery, University of Florida College of Medicine Jacksonville, Jacksonville, FL
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
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Chander VS, Govindasamy R, Tukkapuram VR, Gopal S, Rudrappa S. Multidisciplinary Management of Primary Sacral Tumors: A Tertiary Care Center's Experience and Literature Review. Asian Spine J 2021; 16:567-582. [PMID: 34551502 PMCID: PMC9441426 DOI: 10.31616/asj.2021.0152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 06/08/2021] [Indexed: 11/24/2022] Open
Abstract
Sacral tumors are rare and can be benign or malignant. Their management is multifactorial and is based on the pathology, extent, and local and distant spread. Managing sacral tumors is challenging due to their proximity to visceral and neural structures. Surgical wide excision has been the standard of care for aggressive benign and malignant tumors. Our purpose was to evaluate the outcomes of a multimodal approach to managing primary sacral tumors in Sakra World Hospital, a tertiary spine care center in Bengaluru, India and perform a literature review to determine a workflow pathway. Our study was a retrospective review of patient records and included 15 patients with primary sacral tumors. Eleven surgically treated patients were evaluated clinically and radiologically and underwent biopsy before surgical excision by an all-posterior approach. A multidisciplinary approach that included intraoperative neural monitoring, plastic reconstruction, adjuvant chemotherapy, and radiotherapy was implemented whenever necessary. Sacral root preservation was attempted whenever feasible. Functional outcomes (based on the Visual Analog Scale [VAS] and Biagini scoring system) were analyzed along with disease control, with a minimum of 2 years of follow-up. The mean follow-up was 29±9.8 months. The mean VAS score significantly improved from 7.8±2.6 to 3.7±3.8 (p=0.026). Bowel function showed statistically significant improvement, from a mean score of 0.81±0.47 to 0.63±0.52 (p=0.026) at 2 years of follow-up. The mean pretreatment motor and bladder function scores were 0.53±0.31 and 0.74±0.44, respectively, improving to 0.48±0.33 and 0.68±0.56 at follow-up but without statistical significance. There was no significant loss of function, which is expected in radical sacral resections. In conclusion, primary sacral tumors require a multidisciplinary approach and management for optimal outcomes. A stand-alone posterior approach can be employed to treat most sacral lesions. En-bloc wide resection is the optimal treatment for primary malignant and aggressive benign tumors. Preservation of at least one functional S2 nerve root is imperative to preserve bowel and bladder function.
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Affiliation(s)
- Venugopal Sarath Chander
- Institute of Neurosciences, Sakra World Hospital, Bangalore, India.,Department of Spine Surgery, Sakra World Hospital, Bangalore, India
| | - Ramachandran Govindasamy
- Institute of Neurosciences, Sakra World Hospital, Bangalore, India.,Department of Spine Surgery, Sakra World Hospital, Bangalore, India
| | - Venkata Ramakrishna Tukkapuram
- Institute of Neurosciences, Sakra World Hospital, Bangalore, India.,Department of Spine Surgery, Sakra World Hospital, Bangalore, India
| | - Swaroop Gopal
- Institute of Neurosciences, Sakra World Hospital, Bangalore, India.,Department of Spine Surgery, Sakra World Hospital, Bangalore, India
| | - Satish Rudrappa
- Institute of Neurosciences, Sakra World Hospital, Bangalore, India.,Department of Spine Surgery, Sakra World Hospital, Bangalore, India
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Abstract
STUDY DESIGN Single-center retrospective study. OBJECTIVE We discuss the widespread misdiagnosis of primary extraosseous spinal Ewing Sarcomas (PESES) to begnin tumors leading to poor treatment. SUMMARY OF BACKGROUND DATA PESES is a particular entity of spinal Ewing sarcoma (SES) appearing in a similar shape and features to benign tumors such as schwannomas. This imaging mimicry and subsequent possible misdiagnosis lead to primary surgery, without neoadjuvant chemotherapy, which remains deleterious for survival and progression. METHODS We identified a total of 13 patients: seven women (53.8%) and six men operated between 2001 and 2018 for PESES and initially misdiagnosed as schwannomas or ependymomas. RESULTS The mean age of our series was 35.8 years (range, 18.1-47.2 years). The first clinical symptom was neuralgia (61.5%) followed or associated with nerves deficits (38.5%). Median progression-free survival (PFS) was 31.7 months (SD 5.8). Tumor recurrence rates at 1 and 3 years were respectively 21.2% (SD 3.1) and 60.1% (SD 15.8). Median overall survival (OS) was 61.5 months (SD 16.27). The 1-year, 2-year, and 5-year survival estimates were 100.0%, 88.9% (SD 10.5), and 44.4% (SD 16.6). Six patients (46.13%) died following their SES. In univariate analyses, patients with metastastic PESES had a significantly lower OS than others (41.2 months, P = 0.03). CONCLUSION PESES must be ruled out at diagnosis of a spinal tumor when facing a fast-growing lesion with neurological deficits in a young adult. Thoracoabdominopelvic extension should be carried out. Presurgical biopsy must be performed. In case of PESES, neoadjuvant chemotherapy must be established before considering surgical intervention.Level of Evidence: 4.
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Meazza C, Luksch R, Luzzati A. Managing axial bone sarcomas in childhood. Expert Rev Anticancer Ther 2021; 21:747-764. [PMID: 33593222 DOI: 10.1080/14737140.2021.1891886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Axial osteosarcoma and Ewing sarcoma are rare, aggressive neoplasms with a worse prognosis than with tumors involving the extremities because they are more likely to be associated with larger tumor volumes, older age, primary metastases, and a poor histological response to chemotherapy. The 5-year OS rates are reportedly in the range of 18-41% for axial osteosarcoma, and 46-64% for Ewing sarcoma.Area covered: The treatment of axial bone tumors is the same as for extremity bone tumors, and includes chemotherapy, surgery and/or radiotherapy.Expert opinion: Local treatment of axial tumors is particularly difficult due to their proximity to neurological and vascular structures, which often makes extensive and en bloc resections impossible without causing significant morbidity. The incidence of local relapse is consequently high, and this is the main issue in the treatment of these tumors. Radiotherapy is an option in the case of surgical resections with close or positive margins, as well as for inoperable tumors. Delivering high doses of RT to the spinal cord can be dangerous. Given the complexity and rarity of these tumors, it is essential for this subset of patients to be treated at selected reference institutions with specific expertise and multidisciplinary skills.
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Affiliation(s)
- Cristina Meazza
- Pediatric Oncology Unit, Medical Oncology and Emathology Department, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milano, Italy
| | - Roberto Luksch
- Pediatric Oncology Unit, Medical Oncology and Emathology Department, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milano, Italy
| | - Alessandro Luzzati
- Orthopedic Oncology and Spinal Reconstruction Surgery, Orthopedic Oncology Department, IRCCS Istituto Ortopedico Galeazzi, Milano, Italy
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Kharod SM, Indelicato DJ, Rotondo RL, Mailhot Vega RB, Uezono H, Morris CG, Bradfield S, Sandler ES, Bradley JA. Outcomes following proton therapy for Ewing sarcoma of the cranium and skull base. Pediatr Blood Cancer 2020; 67:e28080. [PMID: 31736243 DOI: 10.1002/pbc.28080] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/08/2019] [Accepted: 10/27/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE Despite the dosimetric advantages of proton therapy, little data exist on patients who receive proton therapy for Ewing sarcoma of the cranium and skull base. This study reports local disease control and toxicity in such patients. MATERIALS/METHODS We reviewed 25 patients (≤21 years old) with nonmetastatic Ewing sarcoma of the cranium and skull base treated between 2008 and 2018. Treatment toxicity was graded per the Common Terminology Criteria for Adverse Events v4.0. The Kaplan-Meier product limit method provided estimates of disease control and survival. RESULTS Median patient age was 5.9 years (range, 1-21.7). Tumor subsites included the skull base (48%), non-skull-base calvarial bones (28%), paranasal sinuses (20%), and nasal cavity (4%). All patients underwent multiagent alkylator- and anthracycline-based chemotherapy; 16% underwent gross total resection (GTR) before radiation. Clinical target volume (CTV) 1 received 45 GyRBE and CTV2 received 50.4 GyRBE following GTR or 54-55.8 GyRBE following biopsy or subtotal resection. Median follow-up was 3.7 years (range, 0.26-8.3); no patients were lost. The 4-year local control, disease-free survival, and overall survival rates were 96%, 86%, and 92%, respectively. Two patients experienced in-field recurrences. One patient experienced bilateral conductive hearing loss requiring aids, two patients developed intracranial vasculopathy, and 6 patients required hormone replacement therapy for neuroendocrine deficits. None developed a secondary malignancy. CONCLUSION Proton therapy is associated with a favorable therapeutic ratio in children with large Ewing tumors of the cranium and skull base. Despite its high conformality, we observed excellent local control and no marginal recurrences. Treatment dosimetry predicts limited long-term neurocognitive and neuroendocrine side effects.
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Affiliation(s)
- Shivam M Kharod
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, Florida
| | - Daniel J Indelicato
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, Florida
| | - Ronny L Rotondo
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, Florida
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, Florida
| | - Haruka Uezono
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, Florida
| | - Christopher G Morris
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, Florida
| | - Scott Bradfield
- Department of Pediatric Oncology, Nemours Children's Health Systems, Jacksonville, Florida
| | - Eric S Sandler
- Department of Pediatric Oncology, Nemours Children's Health Systems, Jacksonville, Florida
| | - Julie A Bradley
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, Florida
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Jha AK, Neupane P, Pradhan M, Sharma KS, Shrestha S, Sigdel PR, Smeland S, Bruland ØS. Ewing Sarcoma in Nepal Treated With Combined Chemotherapy and Definitive Radiotherapy. J Glob Oncol 2019; 5:1-10. [PMID: 30917070 PMCID: PMC6449078 DOI: 10.1200/jgo.19.00015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To our knowledge, we conducted the first prospective oncologic clinical trial in Nepal aimed at providing state-of-the-art chemotherapy to patients with Ewing sarcoma. The efficacy of external-beam radiotherapy (RT) as the sole local treatment modality was explored and deemed justified as a result of the lack of available advanced tumor-orthopedic services in Nepal. PATIENTS AND METHODS Twenty patients, 11 female and 9 male patients between the ages of 6 and 37 years, with newly diagnosed Ewing sarcoma were enrolled. Neoadjuvant combination chemotherapy, comprising well-established drug combinations, was administered in five courses before external-beam RT, during which one course of etoposide and ifosfamide was given. After RT, six additional chemotherapy courses were scheduled. RESULTS RT was tolerated well, providing rapid symptom relief and local tumor control, with no pathologic fractures observed among the 15 patients who received such treatment. Eleven patients completed the entire treatment protocol; seven patients were under continued follow-up, with no evidence of disease in six patients at a median follow-up time of 2.3 years (range, 1.3 to 3.1 years) and one patient alive but with a regional recurrence. Four patients experienced metastatic relapse and died as a result of their disease. Three treatment-related deaths linked to toxicity from chemotherapy occurred. Four of the six patients who refused to complete the treatment protocol and were lost to follow-up experienced progressive disease and were assumed dead. CONCLUSION This study was feasible with RT as the sole local treatment modality in combination with chemotherapy. As a result of the high number of patients lost to follow-up, no firm conclusions can be drawn, but the majority of the patients who completed treatment obtained durable long-term remissions.
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Affiliation(s)
| | | | - Manohar Pradhan
- Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | | | | | | | - Sigbjørn Smeland
- Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Øyvind S Bruland
- Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Hesla AC, Bruland ØS, Jebsen N, Styring E, Eriksson S, Tsagozis P. Ewing sarcoma of the mobile spine; predictive factors for survival, neurological function and local control. A Scandinavian sarcoma group study with a mean follow-up of 12 years. J Bone Oncol 2018; 14:100216. [PMID: 30666289 PMCID: PMC6329704 DOI: 10.1016/j.jbo.2018.100216] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 12/10/2018] [Accepted: 12/24/2018] [Indexed: 01/03/2023] Open
Abstract
Object: Many patients with Ewing sarcoma (ES) of the mobile spine present with neurologic symptoms leading to emergency decompressive surgery. Only rarely is optimal treatment involving neo-adjuvant chemotherapy followed by en bloc excision possible. The purpose of this study was to study treatment, neurologic and oncologic outcome in patients with ES of the mobile spine. Methods: Twenty-four patients diagnosed between 1986 and 2012 were identified through the Scandinavian Sarcoma Group registry. Charts were reviewed in order to assess details in patient characteristics, neurologic status, treatment and outcome. Prognostic factors were analyzed with respect to local control, disease-free survival and overall survival. Results: Neurologic symptoms were frequently observed at presentation, being present in 19/23 patients with documented neurologic status. Most (13/19) patients had a complete neurologic recovery regardless of whether or not emergency decompressive surgery was performed. The majority (18/24) of patients were treated with definitive radiotherapy. However, only 9/17 received the recommended dose of ≥ 50.4 Gy. The disease-free and overall survival rates at 10 years were 48% and 57%, respectively. The local recurrence rates were 19% and 27% at 5 and 10 years, respectively. Only year of diagnosis, categorized into periods with significant changes in chemotherapy protocols, was a significant factor for local recurrence, but there was a trend (p = 0.06) for an increased risk of a local recurrence if emergency decompressive surgery was performed. Conclusion: Patients with ES of the mobile have a relatively favorable prognosis. Nonetheless, local recurrence rate is high for this group of patients for which local treatment mainly relies on definitive radiotherapy. Emergency decompressive surgery may increase the risk for local recurrence.
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Affiliation(s)
- Asle Charles Hesla
- Institute of Molecular Medicine and Surgery, Karolinska Institute & Karolinska University Hospital, 17176 Solna, Sweden
| | - Øyvind Sverre Bruland
- Department of Oncology, Institute for Clinical Medicine, University of Oslo, Oslo University Hospital - Norwegian Radium Hospital, 0310 Oslo, Norway
| | - Nina Jebsen
- Department of Oncology, Haukeland University Hospital, Centre for Cancer Biomarkers University of Bergen, 5021 Bergen, Norway
| | - Emelie Styring
- Department of Orthopaedic Surgery, Skåne University Hospital, Getingevägen 4, 222 41 Lund, Sweden
| | - Sigvard Eriksson
- Department of Orthopaedic Surgery, Sahlgrenska University Hospital, Blå stråket 5, 413 45 Gothenburg, Sweden
| | - Panagiotis Tsagozis
- Department of Orthopaedic Surgery, Karolinska University Hospital, 17176 Solna, Sweden
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14
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Dahm PH, Bhattacharjee M, Huh W, Thapar V. Ewing's Sarcoma of the Cervical Spine. J Pediatr Intensive Care 2017; 7:86-89. [PMID: 31073476 DOI: 10.1055/s-0037-1606256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 07/24/2017] [Indexed: 10/19/2022] Open
Abstract
In this article, we present the case of a 6-year-old female presented to the emergency department with progressive ascending motor weakness leading to cardiac arrest. The recent medical history included neck trauma 1 month prior to admission, 2 weeks of subjective fevers, and 1 day of urinary incontinence. After stabilization, and a review of the recent signs and symptoms, a magnetic resonance imaging of the neck revealed a posterior neck mass from C2 to T2. Neurosurgical removal of the mass was consistent with Ewing's sarcoma. Neck pain is a common presentation in the pediatric population, with the most common cause being traumatic. When coupled with neurological deficits, further studies are warranted to evaluate for organic causes.
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Affiliation(s)
- Paul H Dahm
- Division of Critical Care Medicine, Department of Pediatrics, The University of Texas Health Science Center at Houston, Houston, Texas, United States
| | - Meenakshi Bhattacharjee
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, United States
| | - Winston Huh
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Vandana Thapar
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, United States
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15
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Kutty RK, Peethambaran A, Sunilkumar BS, Balachandran Nair KG, Korde P, Jain SK. Ewing Sarcoma of the Cervical Epidural Space Presenting with Tetraplegia: Case Report and Review of Literature. World Neurosurg 2017; 107:1046.e9-1046.e15. [PMID: 28797979 DOI: 10.1016/j.wneu.2017.07.182] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 07/27/2017] [Accepted: 07/29/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ewing sarcoma (ES) is among the most frequented extremity osseous tumor in childhood. It was first described by James Ewing as diffuse endotheliomas in 1921. The name Ewing sarcoma was coined by Oberling in 1928 as a tribute to the legend who described this disease. ES exists in osseous and extraosseous forms. It shares much of its molecular typing with primitive neuroectodermal tumor (PNET); hence, they are regarded as different ends of the same molecular spectrum. ES, extraosseous ES, PNET, and Askins tumor are the other members of this family termed the Ewing sarcoma family of tumors. Extraosseous ES has been described in various locations of the spine, but its occurrence in the cervical epidural region is uncommon. CASE DESCRIPTION A 12-year-old child presented to us with neck pain and progressive weakness of all 4 limbs. She was investigated and found to have a highly vascular lesion in the cervical epidural region extending from C2 to the C4 region. Embolization therapy was unsuccessful. She deteriorated and eventually had to undergo emergency surgery to decompress the spinal cord. The lesion was biopsied and diagnosed as extraosseous ES. After radiotherapy and chemotherapy, the patient regained most of the power in her limbs. CONCLUSION Extraosseous ES is a rare tumor of the cervical cord in this age group. We report this case to highlight the difficulties encountered in the management of this variant.
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Affiliation(s)
- Raja K Kutty
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India.
| | - Anilkumar Peethambaran
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | | | | | - Paresh Korde
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Sourabh Kumar Jain
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
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Bian C, Chen N, Li XL, Zhou XG, Lin H, Jiang LB, Liu WM, Chen Q, Dong J. Surgery Combined with Radiotherapy to Treat Spinal Tumors: A Review of Published Reports. Orthop Surg 2017; 8:97-104. [PMID: 27384717 DOI: 10.1111/os.12230] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 02/07/2016] [Indexed: 12/11/2022] Open
Abstract
Spinal tumors result in high morbidity and a high rate of lower limb paralysis. Both surgical therapy and radiation therapy (RT) are used to treat spinal tumors; however, how best to combine these two therapies to maximize the benefits and minimize the risks is still being debated. It is also difficult to decide the optimal timing, course and dose of RT, especially in pregnant women and children. The aim of this review is to assist surgeons who are dealing with spinal tumors by providing comprehensive information about advanced techniques for administering RT with greater precision and safety, and about the impact of various ways of combining surgery and RT on therapeutic outcomes. We here review published reports about treating spinal tumors with a combination of these two forms of therapy and attempt to draw appropriate conclusions concerning selection of optimal treatment protocols. Our conclusion is that postoperative radiotherapy, especially with high-precision, low-dose and multiple fractions, and brachytherapy are promising therapies to combined with surgery.
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Affiliation(s)
- Chong Bian
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Nong Chen
- Department of Orthopaedic Surgery, Zhongshan Hospital Qingpu Branch, Fudan University, Shanghai, China
| | - Xi-Lei Li
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiao-Gang Zhou
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hong Lin
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li-Bo Jiang
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wang-Mi Liu
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qian Chen
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian Dong
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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Abstract
Sarcomas are a heterogeneous group of tumors that can occur in a wide array of anatomic sites and age ranges with varying histologies. Proton beam therapy, as compared with advanced x-ray radiation therapy techniques, can substantially lower dose to nontarget tissues. This dosimetric advantage can potentially allow for improvement of the therapeutic ratio in the treatment of many of the sarcomas by either increasing the local control, via increased dose to the target, or by decreasing the normal tissue complications, via lowered dose to the avoidance structures. This article reviews the key dosimetric studies and clinical outcomes published to date documenting the potential role proton beam therapy may play in the treatment of sarcomas.
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18
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Sewell MD, Tan KA, Quraishi NA, Preda C, Varga PP, Williams R. Systematic Review of En Bloc Resection in the Management of Ewing's Sarcoma of the Mobile Spine with Respect to Local Control and Disease-Free Survival. Medicine (Baltimore) 2015; 94:e1019. [PMID: 26166072 PMCID: PMC4504586 DOI: 10.1097/md.0000000000001019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
There is no consensus on the optimal method of local control in Ewing's sarcoma (ES) of the mobile spine. Recent reports have suggested that en bloc resection may improve local control and survival. The authors therefore performed a systematic review to answer the following questions: (1) What is the outcome of en bloc resection for ES of the mobile spine with respect to local control and disease-free survival (DFS)? (2) How should residual ES of the mobile spine be treated?Inclusion criteria were articles published between the years 1960 and 2014 in English that contained more than five patients. This yielded 204 articles, from which 4 were selected for detailed analysis. The literature was graded for quality, summarized, and presented to a group of spinal oncology experts with consensus recommendations made.All 4 studies were retrospective case series graded as very low quality evidence. Local control strategies included radiotherapy (RT) alone, surgery and RT, or surgery alone. There was no standardized outcome reported across studies with respect to the type of surgical procedure, margins, and outcomes of interest such as local recurrence (LR) and DFS. When the en bloc procedures were pooled together, 2 of the 21 patients with available LR data developed LR (9.5%), and 5 of the 7 patients with available DFS data were disease free at a mean of 76 months. The remaining 2 died at 10 and 29 months, respectively. No studies were identified detailing the treatment of residual ES of the mobile spine.There is no consensus on the optimal method of local control for spinal ES or the treatment of residual disease. A weak recommendation supports that when the en bloc resection is technically possible, in combination with RT, this appears to provide superior local control than RT alone, or incomplete excision and RT. The effect on survival is indeterminate.
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Affiliation(s)
- Mathew David Sewell
- From the Princess Alexandra Hospital, Brisbane, Australia (MDS, CP, RW); University of New South Wales, Faculty of Medicine, Sydney, Australia (K-AT); Centre for Spine Studies and Surgery, Queens Medical Centre, Nottingham, UK (NAQ); and The National Centre for Spinal Disorders, Budapest, Hungary (PPV)
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19
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Southern EP, Hohl S, Singh I, Finklestein JZ. Long-Term, Disease-Free Survival of a Patient With a Primitive Neuroectodermal/Ewing Sarcoma in the Mobile Spine With Extracompartmental Extension. Spine Deform 2014; 2:158-164. [PMID: 27927382 DOI: 10.1016/j.jspd.2013.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 10/27/2013] [Accepted: 12/01/2013] [Indexed: 11/30/2022]
Abstract
STUDY DESIGN Case report. INTRODUCTION Long-term survival of a patient with a Ewing sarcoma family of tumors/primitive neuroectodermal tumors of the central spine with pathologic fracture and extradural extension is presented. Literature-based evidence for a survival benefit with modern neoadjuvant chemotherapy and en bloc resection with and without radiotherapy is reviewed. CASE REPORT More than 10-year clinical and radiographic follow-up is given for a 14-cm-diameter tumor originating from the L4 body with pathologic fracture, unilateral pedicle involvement, and extradural canal extension. Neoadjuvant chemotherapy led to 90% tumor regression and the authors' subsequent en bloc resection attempt. The postoperative chemotherapy was resumed early and postoperative radiotherapy was administered owing to positive microscopic margins. The patient is alive more than 10 years after completing treatment and is without evidence of recurrent disease or secondary malignancy. Late effects of chemotherapy are limited to mild cardiomyopathy controlled with medication. CONCLUSIONS The Ewing sarcoma family of tumors of the spinal column accounts for approximately 2% of Ewing sarcoma lesions of the skeletal system; local and systemic relapses are higher than for the extremity sites. Survival is enhanced by en bloc surgical resection in cases where clear margins are obtained, but the prognosis of patients with central (spine and pelvis) sites is typically poor. This case adds to the literature with documentation of high quality of life with long-term, disease-free survival after modern chemotherapy surgical intervention and combined radiotherapy, a finding suggested in recent large Surveillance, Epidemiology, and End Results database studies and smaller case series of this uncommon, high-grade spinal tumor. Neoadjuvant chemotherapy with attempted en bloc resection, and postoperative radiotherapy to the resected tumor bed if there are microscopic positive margins, can still lead to long-term, disease-free survival.
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Affiliation(s)
- Edward P Southern
- Department of Pediatric Orthopaedic Surgery, Children's Hospital of New Orleans and Louisiana State University School of Medicine, 200 Henry Clay Avenue, New Orleans, LA 70118, USA.
| | - Sebastian Hohl
- 1414 West Fair Avenue, Suite 190, Advanced Orthopaedics, Marquette General Hospital, Marquette, MI 49855, USA; Physician Assistant Program, Central Michigan University, 1280 E. Campus DriveHealth Professions Building 1222, Mount Pleasant, MI 48859, USA
| | - Iqbal Singh
- Pediatric Hematology and Oncology Service, Long Beach Memorial Miller Children's Hospital, 2801 Atlantic Avenue, Long Beach, CA 90806, USA; 9173 Tower Pines Cove, Oltewah, TN 37363-9347, USA
| | - Jerry Z Finklestein
- Pediatric Hematology and Oncology Service, Long Beach Memorial Miller Children's Hospital, 2801 Atlantic Avenue, Long Beach, CA 90806, USA
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Faguer R, Petit D, Menei P, Fournier HD. Spontaneous oral extrusion of an acrylic vertebral reconstruction 12 years after a vertebrectomy for a Ewing's sarcoma of the cervical spine: a case report. Neurochirurgie 2013; 59:101-4. [PMID: 23623034 DOI: 10.1016/j.neuchi.2013.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Revised: 03/12/2013] [Accepted: 03/14/2013] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Primary Ewing sarcoma of the cervical spine is rare, particularly in children population. The surgical management remains a challenge to associate the best oncological resection and to prevent spinal deformity. The situation is complicated owing to paucity of adapted instrumentation and their possible interactions with the growing bone. CLINICAL PRESENTATION We described the case of a young 19-year-old woman admitted for an oral extrusion of a bone polymethyl methacrylate (PMMA) allograft 12 years after a C4 circumferential vertebrectomy for primary Ewing's sarcoma. The vertebral anterior reconstruction was slowly repulsed by the growing spine giving way to an autologous bone without kyphosis deformation. CONCLUSION Bone reconstruction remains a challenge after extensive oncological resection particularly in cervical spine of children. Anterior and posterior instrumentation must be associated. The growing spine is not a good host for PMMA allograft and autograft seems to be preferred for anterior column fusion. In spite of the good oncological results, the authors raise the long-term issue of PMMA for vertebral reconstruction in young patients. With a long follow-up, they showed that posterior rigid fixation might prevent the cervical kyphosis.
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Affiliation(s)
- R Faguer
- Department of neurosurgery, University hospital, 4, rue Larrey, 49933 Angers cedex 9, France.
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Vogin G, Helfre S, Glorion C, Mosseri V, Mascard E, Oberlin O, Gaspar N. Local control and sequelae in localised Ewing tumours of the spine: a French retrospective study. Eur J Cancer 2013; 49:1314-23. [PMID: 23402991 DOI: 10.1016/j.ejca.2012.12.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Revised: 11/23/2012] [Accepted: 12/05/2012] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To evaluate both local outcome and sequelae of non-metastatic spinal Ewing tumours (EWT). PATIENTS AND METHODS A French cohort of patients ≤ 50years with localised spinal EWT treated between 1988 and 2009, was analysed in regard to tumour characteristics (e.g. volume, vertebral compartment, spinal cord compression, paraspinal soft tissue invasion), local treatment modalities (surgery (S) and margin quality, radiotherapy (RT) dose), response to treatment (e.g. histological response to neoadjuvant chemotherapy (CT)), tumour local control (LC) and sequelae. RESULTS Seventy-five patients treated in successive trials were evaluated for LC: SFOP-EW88 (n=14), SFOP-EW93 (n=17) and EuroEwing99 (n=44). Fifty-seven patients (79%) presented initial neurological compression and 69% had inaugural decompressive S. Local treatment modality was S+RT (n=50), RT alone (n=19) and S alone (n=6). Surgery was mainly intralesional (66%). Local recurrences had occurred in 19 patients (14 local, 5 loco-regional) with a median interval of 25 months (1-50). After a 7 year median follow-up (1-22 years), the 5-year LC, relapse-free survival (RFS) and overall survival (OS) reached 78.0% (95%CI: 62.6-84.6), 57.0% (95%CI: 45.2-68.9) and 70.0% (95%CI: 59.1-81.0), respectively. Vertebral compartment involved was the only prognostic factor (5-year LC rate 100% versus 71% for favourable and unfavourable compartment, p<0.03). Among 41 five-year survivors, we observed spinal curvature deformation (35%), growth retardation (28%), spinal reduction mobility (40%), spinal pain (25%) and neurological sequelae (32%) without any significant association with a particular local procedure. CONCLUSION RT is the backbone of a successful local treatment of spinal EWT. The place of S remains a pending question. Its actual benefit will likely evolve with new available RT techniques.
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Affiliation(s)
- Guillaume Vogin
- Département de Radiothérapie, Centre Alexis Vautrin, Nancy, France
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[Localized Ewing sarcoma of the spine: a preliminary dose-escalation study comparing innovative radiation techniques in a single patient]. Cancer Radiother 2013; 17:26-33. [PMID: 23333459 DOI: 10.1016/j.canrad.2012.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 11/16/2012] [Accepted: 11/22/2012] [Indexed: 12/25/2022]
Abstract
PURPOSE Although radiosensitive, spinal locations of Ewing's sarcomas are challenging for the radiation oncologist due to poor radiation tolerance of the spinal cord. However, some favorable anatomical compartments - that may represent more than 20% - were associated with a better outcome and could benefit from a radiation dose escalation using the most recent radiation therapy techniques. MATERIALS AND METHODS We performed a dose escalation study on one patient, declined in two scenarios: (1) a tumour located within a single vertebral body and (2) a locally advanced disease involving the vertebral foramen and paraspinal soft tissues. Five dose-levels are proposed: 44.8Gy, 54.4Gy, 59.2Gy, 65.6Gy and 70.4Gy (1.6Gy per session, 8Gy per week). The 3D-conformational technique is compared with static intensity modulated radiation therapy (IMRT), helical tomotherapy, volumetric modulated arc therapy (VMAT), stereotactic body robotic radiation therapy (SBRT) and protontherapy (passive scattering). Two constraints had to be respected in order to skip to the next level: the planned target volume (PTV) coverage must exceed 95% and the D(2%) on the spinal cord shall not exceed a given constraint set at 50Gy in case 1 and 44Gy in case 2 due to initial neurological sufferance. RESULTS Only protontherapy, SBRT, helical tomotherapy and VMAT appear able to reach the last dose level while respecting the constraints in case 1. On the other hand, only helical tomotherapy seems capable of reaching 59.2Gy on the PTV in case 2. CONCLUSION With the most recent radiation therapy techniques, it becomes possible to deliver up to 70.4Gy in a favorable compartment in this sham patient. Unfavorable compartments can receive up to 59.2Gy. Definitive radiation therapy may be an interesting local treatment option to be validated in an early phase trial.
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Abstract
Although most often back pain is of benign origin, it can occasionally be a harbinger of a more serious spinal condition, including spine neoplasm. Knowledge of the typical clinical history of spinal tumors and an understanding of the innervation of the spine and surrounding supporting structures may allow us to better understand when to pursue advanced imaging in the evaluation of spinal pain syndromes. Many radiologists have divided the differential diagnosis of neoplasms of the spine into compartments. These compartments include the extradural compartment, intradural/extramedullary compartment, and the intramedullary compartment.
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Affiliation(s)
- John T Wald
- Department of Radiology, Division of Neuroradiology, Mayo Clinic, Rochester, MN 55901, USA.
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25
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Ibrahim GM, Fallah A, Shahideh M, Tabori U, Rutka JT. Primary Ewing's sarcoma affecting the central nervous system: a review and proposed prognostic considerations. J Clin Neurosci 2011; 19:203-9. [PMID: 22024233 DOI: 10.1016/j.jocn.2011.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Accepted: 06/21/2011] [Indexed: 10/15/2022]
Abstract
Ewing's sarcoma (ES) is a part of a larger family of round blue cell tumors, which occasionally manifest as osseous or extraosseous lesions adjacent to or within the central nervous system (CNS). While a large body of literature exists on ES of bone, data are lacking on tumors with cranial or spinal components that affect the CNS. Here, we perform a systematic review of the literature and summarize the best available evidence on diagnosis, treatment and outcomes of ES affecting the CNS with emphasis on the breadth of clinical presentations, diagnostic tools and emerging management options for these rare and challenging lesions. We include a review of known prognostic factors and propose several new considerations for prognostication of ES affecting the CNS.
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Affiliation(s)
- George M Ibrahim
- Division of Neurosurgery, Hospital for Sick Children, Suite 1503, 555 University Avenue, Toronto, Ontario M5G 1X9, Canada.
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