Ewing's Sarcoma of the Petrous Temporal Bone: Case Report and Literature Review

Pediatric Petrous Apex Lesions: A Radiological Classification and Diagnostic Algorithm

The petrous apex (PA) is involved in a myriad of pathological conditions, some of which are exclusive in children. Diagnosis may be difficult due to vague clinical presentation, and local examination is challenging owing to its inaccessible location. This is further complicated by multiple unfused sutures and ongoing PA pneumatization in children. Cross-sectional imaging is vital for the evaluation of the PA lesions, due to their precarious location and proximity to the major neurovascular structures. Several classification systems have been proposed for these lesions based on their site of origin, solid or cystic appearance, surgical or non-surgical (no touch lesions) management, and benign or malignant nature. In this article, we emphasize the distinctive role of different cross-sectional imaging modalities in the diagnosis of pediatric PA lesions, with special attention to normal variants that should not be mistaken for pathology. We also propose a radiological classification and algorithmic approach to aid in the precise diagnosis and facilitate appropriate management of the various PA lesions in children.

Primary Ewing's sarcoma of the temporal bone: a rare entity and review of the literature

Ewing's sarcoma (ES) is the second most common malignant primary bone tumour in children and adolescents. It primarily affects the diaphysis of long bones and pelvis. ES arising from temporal bone is extremely rare. To date, 43 such cases have been described in the literature. Clinical and radiological features are non-specific. Diagnosis is based mainly on immunohistochemistry. The present article presents an extremely rare case of ES of the temporal bone in a 20-year young man, and he was successfully treated with multiagent chemotherapy and radiotherapy.

Skull and Spinal Ewing's Sarcoma in Children: An Institutional Study

Background:

Ewing’s sarcoma is a disease of children and young adults and occurs most often in bone and soft tissues. The intracranial and spinal manifestation of the disease is rare and reported incidence is 1%–6%.

Aims and Objectives:

We conducted this study to determine the surgical outcome of children with skull and spine Ewing’s sarcoma (SSES).

Methods:

This is a prospective analysis of 13 patients of SSES who reported to the Department of Neurosurgery, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India, between 2014 and 2016. All cases after detailed examination, magnetic resonance imaging, and computed tomography scan were subjected to surgery followed by adjuvant therapy comprising chemotherapy and radiotherapy. Outcome was analyzed at 6 months as well at latest follow-up. Neurological function, local recurrence, primary or secondary nature of the disease, distant relapse, and treatment-related complications were analyzed in this study.

Results:

There were eight female and five male patients with a mean age of 12 years (ranging from 4 to 8 years). Pain was the common presenting feature in all cases. Focal neurological deficits corresponding to the anatomical location was seen in six patients. These 13 cases were distributed anatomically as four cases involving the cloves, two cases with occipital bone and lobe involvement, one case of parietal bone and lobe involvement, and six cases of spinal involvement. Surgery was performed in all cases where gross total excision (Ozge C, Calikoglu M, Cinel L, Apaydin FD, Ozgür ES. Massive pleural effusion in an 18-year-old girl with Ewing sarcoma. Can Respir J 2004;11:363-5), near-total excision, and subtotal excision was achieved in these 13 cases (Steinbok P, Flodmark O, Norman MG, Chan KW, Fryer CJ. Primary Ewing’s sarcoma of the base of the skull. Neurosurgery 1986;19:104-7). Subsequently all cases underwent multiagent chemoradiotherapy. Postsurgery pain subsided in 12 (92%) of patients. Ten patients maintained or improved motor function. In seven cranial cases and in six spinal cases, four cases showed improvement whereas three (23%) had deterioration of motor function.

Conclusions:

Surgical outcome of SSES in short-term follow-up is good with current recommended management regimen of maximum excision followed by chemo and radiotherapy. However, metastasis is not uncommon.

Primary Ewing's Sarcoma of the Temporal Bone: A Rare Case Report and Literature Review

Ewing's sarcoma is a malignant, round cell tumor arising from the bones and primarily affecting children and adolescent, accounting for 3 % of all childhood malignancies. Although the long bones and the trunk are typically affected, rare cases of it involving isolated bones throughout the body have been reported. Involvement of the skull bones is rare, constituting 1-6 % of the total Ewing's sarcoma cases but those affecting the cranial bones are rarer still, constituting only 1 %. We describe an 8 months old infant having Ewing sarcoma, of the petrous and mastoid parts of temporal bone along with the occipital bone, whose clinical presentation mimicked mastoiditis with facial nerve palsy. We discuss the clinical and therapeutic course of an extensive primary Ewing sarcoma of the temporal bone, which was treated without performing surgery and review this entity's literature in detail.

Primary Occipital Ewing's Sarcoma with Subsequent Spinal Seeding

Ewing's sarcoma is a primary bone cancer that mainly affects the long bones. This malignancy is particularly common in pediatric patients. Primary cranial involvement accounts for 1% of cases, with occipital involvement considered extremely rare. In this case study, primary occipital Ewing's sarcoma with a posterior fossa mass and subsequent relapse resulting in spinal seeding is reported. A 3-year-old patient presented with a 1-year history of left-sided headaches, localized over the occipital bone with progressive torticollis. Computed tomography (CT) imaging showed a mass in the left posterior fossa compressing the brainstem. The patient then underwent surgical excision followed by adjuvant chemoradiation therapy. Two years later, the patient presented with severe lower back pain and urinary incontinence. Whole-spine magnetic resonance imaging (MRI) showed cerebrospinal fluid (CSF) seeding from the L5 to the S4 vertebrae. Primary cranial Ewing's sarcoma is considered in the differential diagnosis of children with extra-axial posterior fossa mass associated with destructive permeative bone lesions. Although primary cranial Ewing's sarcoma typically has good prognosis, our patient developed metastasis in the lower spine. Therefore, with CNS Ewing's sarcoma, screening of the entire neural axis should be taken into consideration for early detection of CSF seeding metastasis in order to decrease the associated morbidity and mortality.

Modified concentric craniotomy for the removal of a huge calvarial metastatic tumor: technical note

BACKGROUND

It is challenging for neurosurgeons to remove huge tumors involving the skull that may possibly invade the dura or intracranial neural tissue. In this situation, excision of the tumor may cause profound blood loss, unexpected opening of the dura, or neurological injury. We describe a technique of craniotomy in a pediatric patient to avoid surgical complications.

METHODS

A 15-year-old boy had a huge metastatic calvarial Ewing's sarcoma. We removed the tumor successfully with modified concentric craniotomy. First, two oval burr holes are made on both sides of the tumor. The inner craniotomy uses the internal margin of the oval holes, while the outer cut uses the outer margins. The skull bone in between the two craniotomies is removed easily in two pieces and the dura surrounding the tumor can be exposed early in the procedure. In this way, the huge skull tumor can be removed en bloc under direct vision to avoid unwanted complications. Minimal blood and bone loss can be achieved.

RESULTS

Blood transfusion was not necessary during the surgery. The patient did not have new neurological symptoms and signs after surgery.

CONCLUSIONS

The goal of the modified concentric craniotomy is to develop an accessible margin of the dura surrounding the bulky tumor in the early phase of surgery. Blood and bone loss can be reduced significantly.

Ewing's Sarcoma Multifocal Metastases to Temporal and Occipital Bone: A Rare Presentation

Ewing's sarcoma (ES) is a common malignant bone tumour seen to involve long bones, flat pelvic bones and ribs and vertebrae in majority of cases. Here, we present a rare case of aggressive primary ES of pelvic bones with multifocal metastases to temporal bone and occipital bone. The patient presented with facial palsy and an occipital swelling, and was referred for chemotherapy.

Multiple primary Ewing's sarcomas in cerebral cranium of a child: a case report and review of the literature

Ewing's sarcoma is the second most common pediatric bone tumor. Primary Ewing's sarcoma occurring in the cerebral cranium is exceptionally rare, with only one reported case of multiple tumor lesions in adolescence to date. We report a case of a 5-year-old male patient with multiple primary Ewing's sarcomas associated with the cranial bones, the first pediatric case report to date. We also review 71 cases Ewing's sarcoma involving intracranial extension. The purpose of this article is to provide data concerning the clinical and therapeutic course of multiple primary Ewing's sarcomas in associated with cerebral cranium.

Petrous apex lesions in the pediatric population

A variety of abnormal imaging findings of the petrous apex are encountered in children. Many petrous apex lesions are identified incidentally while images of the brain or head and neck are being obtained for indications unrelated to the temporal bone. Differential considerations of petrous apex lesions in children include "leave me alone" lesions, infectious or inflammatory lesions, fibro-osseous lesions, neoplasms and neoplasm-like lesions, as well as a few rare miscellaneous conditions. Some lesions are similar to those encountered in adults, and some are unique to children. Langerhans cell histiocytosis (LCH) and primary and metastatic pediatric malignancies such as neuroblastoma, rhabomyosarcoma and Ewing sarcoma are more likely to be encountered in children. Lesions such as petrous apex cholesterol granuloma, cholesteatoma and chondrosarcoma are more common in adults and are rarely a diagnostic consideration in children. We present a comprehensive pictorial review of CT and MRI appearances of pediatric petrous apex lesions.