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Ali A, Shahbaz U, Nadeem A, Umar S, Ahmed A. Abdominal distention, immunopositivity, and aggressive nature: A rare Ewing's sarcoma of the adrenal gland. Radiol Case Rep 2024; 19:1935-1939. [PMID: 38449484 PMCID: PMC10915781 DOI: 10.1016/j.radcr.2024.02.024] [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: 10/19/2023] [Revised: 01/23/2024] [Accepted: 02/06/2024] [Indexed: 03/08/2024] Open
Abstract
This case report describes a 32-year-old Pakistani male patient with an Ewing sarcoma (ES) of the adrenal gland. Presenting complaints were abdominal distention, pain, low-grade fever, and weight loss. Initial studies, including imaging and tumor markers, ruled out any other possible origins of the mass. A percutaneous biopsy verified the tumor's neuroendocrine origin. Extensive involvement of nearby anatomical structures was discovered through exploratory laparotomy, rendering total resection difficult. Based on the presence of malignant, round, blue cells that were positive for specific immunostaining markers, the histopathology report supported the diagnosis of an ES with a staging of T3N0M0. Chemotherapy, in accordance with the VAC-IE protocol, was administered after debulking surgery. Subsequent imaging and close monitoring revealed no metastatic or residual tumors. Adrenal ES is an uncommon, aggressive tumor that mandates prompt diagnosis and management. This case report highlights the value of early detection and multimodal therapy in enhancing patient outcomes for this rare malignancy.
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Affiliation(s)
- Anam Ali
- Department of Medicine, Jinnah Hospital, Allama Shabbir Ahmad Usmani Road, Lahore, Punjab, Pakistan
| | - Usman Shahbaz
- Department of Medicine, Jinnah Hospital, Allama Shabbir Ahmad Usmani Road, Lahore, Punjab, Pakistan
| | - Arsalan Nadeem
- Department of Medicine, Allama Iqbal Medical College, Allama Shabbir Ahmad Usmani Road, Lahore, Punjab, Pakistan
| | - Sumayya Umar
- Department of Medicine, Allama Iqbal Medical College, Allama Shabbir Ahmad Usmani Road, Lahore, Punjab, Pakistan
| | - Abdullah Ahmed
- Department of Medicine, Allama Iqbal Medical College, Allama Shabbir Ahmad Usmani Road, Lahore, Punjab, Pakistan
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Manatakis DK, Tsouknidas I, Mylonakis E, Tasis N, Antonopoulou MI, Acheimastos V, Mastoropoulou A, Korkolis DP. Primary adrenal Ewing sarcoma: A systematic review of the literature. World J Clin Cases 2023; 11:6782-6791. [PMID: 37900999 PMCID: PMC10600854 DOI: 10.12998/wjcc.v11.i28.6782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/18/2023] [Accepted: 09/12/2023] [Indexed: 09/25/2023] Open
Abstract
BACKGROUND Ewing sarcoma (ES) is a malignant neoplasm of neuroectodermal origin and is commonly observed in children and young adults. The musculoskeletal system is the main body system impacted and ES is rarely seen in the visceral organs particularly the adrenal gland. AIM To present a comprehensive review of primary adrenal ES, with emphasis on diagnosis, therapy and oncological outcomes. METHODS A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020. PubMed/ MEDLINE, EMBASE and Google Scholar bibliographic databases were searched to identify articles from 1989 to 2022 and included patients with ES/primitive neuroectodermal tumor (PNET) of the adrenal gland. PubMed, Google Scholar and EMBASE medical databases were searched, combining the terms "adrenal", "ES" and "PNET". Demographic, clinical, pathological and oncological data of patients were analyzed by SPSS version 29.0. RESULTS A total of 52 studies were included for review (47 case reports and 5 case series) with 66 patients reported to have primary adrenal ES. Mean age at diagnosis was 26.4 ± 15.4 years (37.9% males, 57.6% females, sex not reported in 3 cases). The most frequent complaint was abdominal/flank pain or discomfort (46.4%) followed by a palpable mass (25.0%), and the average duration of symptoms was 2.6 ± 3.1 mo. The imaging modality of choice was computed tomography scan (81.5%), followed by magnetic resonance imaging (20.4%). Preoperative staging revealed that 17 tumors (27.9%) were metastatic and 14 patients had inferior vena cava or renal vein neoplastic thrombus at initial diagnosis. Open adrenalectomy was performed in the majority of cases (80.0%), of which 27.9% required more extensive resection. Minimally invasive surgery was attempted in 8.2% of tumors. Complete surgical resection was achieved in 89.4% of the patients. Adjuvant therapy was administered to 32 patients, in the form of chemotherapy (62.5%), radiotherapy (3.1%) or combination (34.4%). Median overall survival was 15 mo and 24-mo overall survival was 40.5%. Median disease-free survival was 10 mo and 24-mo disease-free survival was 33.3%. CONCLUSION The significant progress in molecular biology and genetics of ES does not reflect on patient outcomes. ES remains an aggressive tumor with a poor prognosis and high mortality.
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Affiliation(s)
| | - Ioannis Tsouknidas
- General Surgery, Lankenau Medical Center, Main Line Health, Wynnewood, PA 19096, United States
| | - Emmanouil Mylonakis
- 2nd Department of Surgery, Athens Naval and Veterans Hospital, Athens 11521, Greece
| | - Nikolaos Tasis
- 2nd Department of Surgery, Athens Naval and Veterans Hospital, Athens 11521, Greece
- Department of Surgical Oncology, St Savvas Cancer Hospital, Athens 11522, Greece
| | | | | | | | - Dimitrios P Korkolis
- Department of Surgical Oncology, St Savvas Cancer Hospital, Athens 11522, Greece
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3
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Secondary Ewing's sarcoma of the temporo-occipital region developed 12-years after medulloblastoma treatment. Braz J Otorhinolaryngol 2022; 88 Suppl 4:S226-S229. [PMID: 35184979 DOI: 10.1016/j.bjorl.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 09/21/2021] [Accepted: 01/10/2022] [Indexed: 12/16/2022] Open
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Gebauer J, Higham C, Langer T, Denzer C, Brabant G. Long-Term Endocrine and Metabolic Consequences of Cancer Treatment: A Systematic Review. Endocr Rev 2019; 40:711-767. [PMID: 30476004 DOI: 10.1210/er.2018-00092] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/21/2018] [Indexed: 02/08/2023]
Abstract
The number of patients surviving ≥5 years after initial cancer diagnosis has significantly increased during the last decades due to considerable improvements in the treatment of many cancer entities. A negative consequence of this is that the emergence of long-term sequelae and endocrine disorders account for a high proportion of these. These late effects can occur decades after cancer treatment and affect up to 50% of childhood cancer survivors. Multiple predisposing factors for endocrine late effects have been identified, including radiation, sex, and age at the time of diagnosis. A systematic literature search has been conducted using the PubMed database to offer a detailed overview of the spectrum of late endocrine disorders following oncological treatment. Most data are based on late effects of treatment in former childhood cancer patients for whom specific guidelines and recommendations already exist, whereas current knowledge concerning late effects in adult-onset cancer survivors is much less clear. Endocrine sequelae of cancer therapy include functional alterations in hypothalamic-pituitary, thyroid, parathyroid, adrenal, and gonadal regulation as well as bone and metabolic complications. Surgery, radiotherapy, chemotherapy, and immunotherapy all contribute to these sequelae. Following irradiation, endocrine organs such as the thyroid are also at risk for subsequent malignancies. Although diagnosis and management of functional and neoplastic long-term consequences of cancer therapy are comparable to other causes of endocrine disorders, cancer survivors need individually structured follow-up care in specialized surveillance centers to improve care for this rapidly growing group of patients.
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Affiliation(s)
- Judith Gebauer
- Experimental and Clinical Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Claire Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, United Kingdom.,Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Thorsten Langer
- Division of Pediatric Hematology and Oncology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Christian Denzer
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Endocrinology and Diabetes, Ulm University Medical Center, Ulm, Germany
| | - Georg Brabant
- Experimental and Clinical Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany.,Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
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Khandwala K, Hilal K, Fadoo Z, Minhas K. Metachronous renal Ewing sarcoma/primitive neuroectodermal tumour in a survivor of Burkitt lymphoma. BMJ Case Rep 2018; 2018:bcr-2017-224071. [PMID: 29895547 DOI: 10.1136/bcr-2017-224071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present a case of a 14-year-old girl who was diagnosed with Burkitt lymphoma in 2014. She was managed with chemotherapy and remained in remission for 3 years. On her surveillance imaging in 2017, a left-sided renal neoplastic mass was incidentally discovered. She underwent nephrectomy and pathology of the resected specimen revealed small cell tumour of the kidney with features favouring renal Ewing sarcoma/primitive neuroectodermal tumour. Molecular genetic analysis by fluorescence in situ hybridisation was performed which showed translocation of 22q12, thereby confirming the diagnosis. This is a rare secondary malignancy and an unusual association. This case highlights the importance and diagnostic dilemmas of rare secondary tumours in patients with such haematological malignancies and discusses its possible pathogenetic aspects.
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Affiliation(s)
| | - Kiran Hilal
- Department of Radiology, Aga Khan University, Karachi, Pakistan
| | - Zehra Fadoo
- Department of Haematology and Oncology, Aga Khan University, Karachi, Pakistan
| | - Khurram Minhas
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
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Eddaoualline H, Mazouz K, Rafiq B, El Mghari Tabib G, El Ansari N, Belbaraka R, El Omrani A, Khouchani M. Ewing sarcoma of the adrenal gland: a case report and review of the literature. J Med Case Rep 2018; 12:69. [PMID: 29544549 PMCID: PMC5855992 DOI: 10.1186/s13256-018-1601-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 02/01/2018] [Indexed: 01/10/2023] Open
Abstract
Background Ewing sarcoma/primitive neuroectodermal tumor is a family of highly malignant proliferation of neuroectodermal origin, most often skeletal, adrenal localization is extremely rare. Only few cases have been reported in the literature. Classical management includes radical surgery with adjuvant chemotherapy or radiotherapy or both. This case report is the only one where recurrence was surgically removed, and it confirms the importance of adjuvant treatment, and the efficacy of neoadjuvant chemotherapy. Case presentation We report the case of a 23-year-old Moroccan woman presenting with flank pain. An abdominal computed tomography scan showed a large and enhancing left suprarenal mass. After radical nephrectomy, histologic examination revealed a small round cell proliferation. The diagnosis of Ewing sarcoma was confirmed by molecular analysis; time to final diagnosis was 5 months due to financial and coordination issues. Computed tomography (on an asymptomatic patient) revealed a locoregional recurrence, our patient received 12 cycles of the vincristine, doxorubicin and cyclophosphamide/ifosfamide and etoposide protocol used in an alternating schedule, with partial radiologic response (62%) and pathologic complete response, then underwent adjuvant radiotherapy of 45 Gy. The young women is still in remission after 36 months of follow-up. Conclusions Our patient had an early recurrence due to absence of adjuvant treatment, but did respond well to neoadjuvant chemotherapy with a pathologic complete response. Management of adrenal Ewing sarcoma could be extrapolated from skeletal one with good outcomes even in locoregional recurrence.
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Affiliation(s)
- Hanane Eddaoualline
- Radiation Oncology Department, Mohammed VI University Hospital, Marrakech, Morocco.
| | - Khadija Mazouz
- Radiation Oncology Department, Mohammed VI University Hospital, Marrakech, Morocco
| | - Bouchra Rafiq
- Endocrinology Department, Mohammed VI University Hospital, Marrakech, Morocco
| | | | - Nawal El Ansari
- Endocrinology Department, Mohammed VI University Hospital, Marrakech, Morocco
| | - Rhizlane Belbaraka
- Medical Oncology Department, Mohammed VI University Hospital, Marrakech, Morocco
| | - Abdelhamid El Omrani
- Radiation Oncology Department, Mohammed VI University Hospital, Marrakech, Morocco
| | - Mouna Khouchani
- Radiation Oncology Department, Mohammed VI University Hospital, Marrakech, Morocco
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Adrenal mass of unusual etiology: Ewing sarcoma in a young man. Radiol Case Rep 2018; 12:838-844. [PMID: 29484083 PMCID: PMC5823311 DOI: 10.1016/j.radcr.2017.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 06/19/2017] [Accepted: 07/03/2017] [Indexed: 11/21/2022] Open
Abstract
Ewing sarcoma and peripheral primitive neuroectodermal tumor belong to the Ewing sarcoma (ES) family of tumors originating from a primitive neural tube. We report a 31-year-old man who was admitted to the urology clinic with complaints of fever, nausea, and dysuria. A right-sided adrenal mass was detected during ultrasonography. The lesion was then evaluated with magnetic resonance imaging, which showed areas of necrosis amid heterogeneous solid areas. Whole body scan with 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography and bone scan studies showed pulmonary and osseous metastatic foci. The mass and right kidney were removed by an open approach. An immunohistochemical and molecular workup enabled the diagnosis of ES. The patient also underwent radiotherapy and chemotherapy. The patient remained in fairly good health during the 18-month follow-up period, but showed progression of all metastatic foci and died 26 months after treatment. In conclusion, adrenal ES should be included in the differential diagnosis of nonfunctional adrenal lesions despite its rare occurrence.
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Ewing Sarcoma of the Bone With EWS/FLI1 Translocation After Successful Treatment of Primary Osteosarcoma. J Pediatr Hematol Oncol 2017; 39:6-9. [PMID: 27918348 DOI: 10.1097/mph.0000000000000721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Although prognosis in patients with localized osteosarcoma has been dramatically improved by the introduction of multiple chemotherapy agents known as combination chemotherapy, there is growing concern about the development of secondary malignant neoplasms. We report the case of a 13-year-old girl in whom the diagnosis of Ewing sarcoma of bone localized on the shaft of left femur was made 2 years after successful treatment without radiotherapy for osteosarcoma of right proximal femur. EWS-FLI1 fusion gene was detected by reverse transcriptase-polymerase chain reaction. To our knowledge, this is the first case with Ewing sarcoma of the bone as a secondary malignant neoplasm developed in osteosarcoma survivor. We collected 15 cases, included this case, with secondary Ewing sarcoma family of tumor by utilizing the PubMed search and might consider the causes of this secondary cancer.
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Ewing's Sarcoma as a Second Malignancy in Long-Term Survivors of Childhood Hematologic Malignancies. Sarcoma 2016; 2016:5043640. [PMID: 27524931 PMCID: PMC4976151 DOI: 10.1155/2016/5043640] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 06/19/2016] [Indexed: 12/20/2022] Open
Abstract
Modern multimodal treatment has significantly increased survival for patients affected by hematologic malignancies, especially in childhood. Following remission, however, the risk of developing a further malignancy is an important issue. The long-term estimated risk of developing a sarcoma as a secondary malignancy is increased severalfold in comparison to the general population. Ewing's sarcoma family encompasses a group of highly aggressive, undifferentiated, intra- and extraosseous, mesenchymal tumors, caused by several types of translocations usually involving the EWSR1 gene. Translocation associated sarcomas, such as Ewing sarcoma, are only rarely encountered as therapy associated secondary tumors. We describe the clinical course and management of three patients from a single institution with Ewing's sarcoma that followed successfully treated lymphoblastic T-cell leukemia or non-Hodgkin lymphoma. The literature on secondary Ewing's sarcoma is summarized and possible pathogenic mechanisms are critically discussed.
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Zhang L, Yao M, Hisaoka M, Sasano H, Gao H. Primary Ewing sarcoma/primitive neuroectodermal tumor in the adrenal gland. APMIS 2016; 124:624-629. [PMID: 27197626 DOI: 10.1111/apm.12544] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 03/26/2016] [Indexed: 01/10/2023]
Abstract
Primary Ewing sarcoma or primitive neuroectodermal tumor (PNET) of the adrenal gland is extremely rare. We report a case of Ewing sarcoma or PNET of the adrenal in a 48-year-old Chinese woman. The patient was hospitalized with left upper quadrant abdominal pain and swelling that had been present for 1 year. Computed tomography (CT) images revealed a circumscribed mass in the left adrenal region measuring 12 cm in its greatest dimension, and the mass was surgically resected. Macroscopically, the mass (13 × 10 × 8 cm3 ) in the left adrenal gland was encapsulated, soft, appearing grayish white and yellow, and with foci of cystic degeneration, necrosis, and hemorrhage on cross-sectional. Non-tumorous adrenal tissue was compressed, but identifiable at the periphery of the specimen. Histologically, compact short spindle and oval tumor cells were arranged in sheets. Tumor cells tested positive for vimentin, CD99, Bcl-2, NKX2.2, EMA, and CD117, and weakly positive for FLI-1 on immunohistochemical analysis and showed rearrangement of the EWSR1 on fluorescence in situ hybridization analysis. Post-adrenalectomy, after being recurrence free for 4.5 years, the patient relapsed and a localized recurrence was detected on a follow-up CT scan.
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Affiliation(s)
- Lian Zhang
- Department of Pathology, The Second Hospital of Jilin University, Changchun, China
| | - Min Yao
- Department of Pathology, The Second Hospital of Jilin University, Changchun, China
| | - Masanori Hisaoka
- Department of Pathology and Oncology, School of Medicine, University of Occupational Environmental Health, Kitakyushu, Japan
| | - Hironobu Sasano
- Department of Anatomic Pathology Laboratory, Tohoku University School of Medicine, Sendai, Japan
| | - Hongwen Gao
- Department of Pathology, The Second Hospital of Jilin University, Changchun, China
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Vanhapiha N, Knuutila S, Vettenranta K, Lohi O. Burkitt lymphoma and Ewing sarcoma in a child with Williams syndrome. Pediatr Blood Cancer 2014; 61:1877-9. [PMID: 24753445 DOI: 10.1002/pbc.25055] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 03/10/2014] [Indexed: 11/08/2022]
Abstract
Williams syndrome (WS) is a relatively rare multisystem neurodevelopmental disorder caused by a hemizygous deletion of contiguous genes on chromosome 7q11.23. Although WS does not predispose carriers to cancers, alterations of chromosome 7 are common in several human neoplasms. We report here a patient with WS and two different cancers, Burkitt lymphoma and Ewing sarcoma. Array-CGH analysis of the patient blood revealed a constitutive 1.4 million base pair deletion at 7q11.23, compatible with WS diagnosis.
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Affiliation(s)
- Nelli Vanhapiha
- Tampere Center for Child Health Research, University of Tampere Medical School and Tampere University Hospital, Tampere, Finland
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Cole M, Parajuli S, Laske D, Goldstein L, Morrison T, Mukherjee A, Tumelty K, Tetzlaff E, von Mehren M, Inniss S. Peripheral primitive neuroectodermal tumor of the dura in a 51-year-old woman following intensive treatment for breast cancer. AMERICAN JOURNAL OF CASE REPORTS 2014; 15:294-9. [PMID: 25045413 PMCID: PMC4102603 DOI: 10.12659/ajcr.890656] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Accepted: 03/24/2014] [Indexed: 12/11/2022]
Abstract
PATIENT Female, 51. FINAL DIAGNOSIS Ewing sarcoma. SYMPTOMS Visual disturbances. MEDICATION -. CLINICAL PROCEDURE -. SPECIALTY Oncology. OBJECTIVE Rare disease. BACKGROUND Primitive neuroectodermal tumor/Ewing sarcoma (PNET/EWS) is a round blue cell sarcoma that shows varying degrees of neuroectodermal differentiation. PNET/EWS as a primary intracranial tumor is extremely uncommon. CASE REPORT We report a unique case of peripheral PNET presenting as an intracranial mass in an adult following chemotherapy and radiotherapy for a solid tumor. A 51-year-old woman with previously treated left breast cancer was evaluated for a newly developed brain mass. She underwent craniotomy with resection. Surgical pathology was consistent with a peripheral PNET/EWS with Ewing sarcoma gene translocation. She was treated appropriately with vincristine, cyclophosphamide, and doxorubicin (later dactinomycin) alternating with ifosfamide and etoposide. CONCLUSIONS Although development of PNET/EWS presenting along the CNS is exceedingly rare in adults, establishing the proper diagnosis of this "small blue cell tumor" is critical. The further distinction between central PNET and peripheral PNET can greatly impact both prognosis and treatment. Our case also highlights the importance of considering the impact of prior intensive therapies, including radiation and chemotherapy, on predisposing to future PNET/EWS.
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Affiliation(s)
- Marion Cole
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA, U.S.A
| | - Shobha Parajuli
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA, U.S.A
| | - Douglas Laske
- Department of Neurosurgery, Temple University School of Medicine, Philadelphia, PA, U.S.A
| | - Lori Goldstein
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA, U.S.A
| | - Tara Morrison
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA, U.S.A
| | - Abir Mukherjee
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA, U.S.A
| | - Kathryn Tumelty
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA, U.S.A
| | - Eric Tetzlaff
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA, U.S.A
| | - Margaret von Mehren
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA, U.S.A
| | - Susan Inniss
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA, U.S.A
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