Primary vulvar and vaginal extraosseous Ewing's sarcoma/peripheral neuroectodermal tumor: diagnostic confirmation with CD99 immunostaining and reverse transcriptase-polymerase chain reaction

Ewing Sarcoma of the Female Genital Tract: Clinicopathologic Analysis of 21 Cases With an Emphasis on the Differential Diagnosis of Gynecologic Round Cell, Spindle, and Epithelioid Neoplasms

Ewing sarcoma is an uncommon neoplasm considered in the differential diagnosis of tumors with "small round cell" morphology, but its occurrence in the gynecologic tract has only been sporadically documented. Herein, we describe the largest cohort of Ewing sarcoma localized to the female genital tract to date, and emphasize their clinicopathologic resemblance to more common gynecologic neoplasms. Ewing sarcoma (n=21) was retrospectively identified from 5 institutions. The average patient age was 35 (range 6-61) years. Tumor sites included uterus (n=8), cervix (n=4), vulva (n=5), vagina (n=1), broad ligament (n=1), inguinal area (n=1), and pelvis (n=1). Nine of 18 cases in which slides were available for review demonstrated only classic round cell morphology, with the remainder showing a variable combination and prominence of variant ovoid/spindle or epithelioid appearance. Tumors showed diffuse membranous reactivity for CD99 (20/20) and were positive for NKX2.2 (8/8, diffuse) and cyclin D1 (7/7, of which 3/7 were patchy/multifocal and 4/7 were diffuse). They were negative for ER (0/6) and CD10 (0/6). Three cases were initially diagnosed as endometrial stromal sarcomas. EWSR1 rearrangement was confirmed in 20/21 by fluorescence in situ hybridization (n=15) and/or sequencing (n=8). Of the eight tumors that underwent sequencing, 6 harbored FLI1 , 1 ERG, and 1 FEV as the fusion partner. Of 11 patients with available follow-up, 5 died of disease, 1 developed lung metastases and 5 are alive with no evidence of disease. Ewing sarcoma of the gynecologic tract is a rare, aggressive entity that shares some morphologic and immunohistochemical features with other more common gynecologic neoplasms. In addition to the typical round cell appearance, variant spindled/ovoid to epithelioid morphology may also be observed and should prompt consideration of this entity with appropriate immunohistochemical and/or molecular studies.

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

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

Metastatic renal Ewing's sarcoma in adult woman: Case report and review of the literature

Primary renal extra-skeletal Ewing sarcoma is a rare neoplasm, often metastatic at diagnosis, and with a poor outcome. A multimodal approach is often the treatment of choice in this aggressive neoplasm. We present a case of primary renal extra-skeletal sarcoma in a 45-year-old woman who underwent tumor resection without clear margins. After no response to the first cycle of chemotherapy, we documented an early onset of local recurrence. The patient refused any other treatment and died four months after surgery.

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

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

Mesenchymal lesions of the vulva

Mesenchymal lesions of the vulva include site-specific entities limited to the lower genital tract, as well as a range of non-site-specific tumors that are more common at extragenital sites. Site-specific lesions include fibroepithelial stromal polyp, cellular angiofibroma, angiomyofibroblastoma, and aggressive angiomyxoma. Non-site-specific tumors that may occur in the vulva include those of smooth muscle, skeletal muscle, vascular, neural, adipocytic, and uncertain differentiation. This review discusses both site-specific and non-site-specific vulvar mesenchymal lesions including non-neoplastic proliferations, benign neoplasms, locally aggressive neoplasms with a predilection for local recurrence, neoplasms of indeterminate biologic potential, and frankly malignant neoplasms with a high risk of distant metastasis and death. Accurate diagnosis is essential for proper management, and is facilitated by correlation with clinical findings and targeted application of immunohistochemical and molecular studies.

Primary vulvar Ewing sarcoma/peripheral primitive neuroectodermal tumor with pelvic lymph nodes metastasis: A case report and review of literature

Ewing sarcoma (ES) and peripheral primitive neuroectodermal tumors (pPNET) are soft tissue tumors that generally affect the bones. Extraosseous ES/pPNET has been rarely reported. Our patient presented with a 6 × 4 cm right subcutaneous solid vulvar lesion causing pain and discomfort. Pathology and immunohistochemistry staining showed strong positivity for CD99 and vimentin, favoring the diagnosis of ES/pPNET. Magnetic resonance imaging showed a 6-cm lesion in the right vulvar region with enlarged bilateral inguinal and right iliac lymph nodes. Fluorescence in situ hybridization test for translocation t(11;22)(q24;q12) was positive, confirming the diagnosis. The patient received three cycles of neoadjuvant chemotherapy with vincristine, adriamycin, cyclophosphamide alternating with ifosfamide and etoposide with complete response. The patient underwent vulvar radical local excision. Residual tumor measured 1.6 cm with free margins. She received four additional cycles of adjuvant chemotherapy and 30 sessions radiotherapy. She is currently disease free after 37 months. No ES/pPNET cases with pelvic lymph nodes metastasis were ever reported.

Primitive neuroectodermal tumors of the abdominal wall and vulva in children: Report of two cases and review of the literature

BACKGROUND

Primitive neuroectodermal tumors are rare, highly malignant small round cell tumors belonging to the Ewing sarcoma family. The purpose of this article is to present clinical manifestation, histology, treatment, and prognosis of two primitive neuroectodermal tumors (PNETs) in extremely rare anatomic locations, the abdominal wall and vulva.

CASE SUMMARY

Case 1 was a 66-month-old girl with lesions on the abdominal wall; tumor size was about 3.4 cm × 6.1 cm × 2 cm. The patient underwent radical resection of the tumor. After the operation, an alternating vincristine, doxorubicin, and cyclophosphamide/ifosfamide and etoposide (IE) regimen was given for eight cycles, and the patient survived for 66 mo without progression. Case 2 was a 40-month-old girl, with a vulvar lesion; tumor size was about 3.3 cm × 5 cm × 2.5 cm. The tumor was partially resected by surgery. The family left treatment after two cycles of vincristine, pirarubicin, and cyclophosphamide/IE chemotherapy, and the patient died at home six months after surgery.

CONCLUSION

PNET is a rare, fast-growing, highly malignant tumor that requires histologic and molecular analyses for exact diagnosis, and multimodal treatment is required to achieve a good prognosis.

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

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

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

BACKGROUND

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

CASE

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

SUMMARY AND CONCLUSION

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

Vulvar sarcomas: Short guideline for histopathological recognition and clinical management. Part 2

Malignant tumors of the female reproductive system are a serious health and social problem, as they are the second most common cause of death among women, after breast cancer. Vulvar tumors represent only 4% of all gynecological neoplasms, and they are fourth in frequency after tumors of the cervix, uterus, and ovary. Ninety-eight percent of all vulvar tumors are benign and only 2% are malignant. Sarcomas of the vulva comprise approximately 1–3% of all vulvar cancers. They are characterized by rapid growth, high metastatic potential, frequent recurrences, aggressive behavior, and high mortality rate. In Part 1 of this paper, we presented the most common forms of sarcoma of the vulva: leiomyosarcoma, epithelioid sarcoma, malignant rhabdoid tumor, and rhabdomyosarcoma. The second part of this review will focus mainly on the rarest variants of vulvar sarcoma: low-grade fibromyxoid sarcoma, synovial sarcoma, monophasic synovial sarcoma, carcinosarcoma, Ewing sarcoma, myeloid sarcoma, dermatofibrosarcoma protuberans, malignant fibrous histiocytoma, angiomatoid fibrous histiocytoma, liposarcoma, malignant peripheral nerve sheath tumor, and malignant mesothelioma.

Conservative Treatment of Ewing's Sarcoma of the Uterus in Young Women

Ewing sarcoma-primitive neuroectodermal tumors (ES/PNETs) constitute a family of neoplasms characterized by a continuum of neuroectodermal differentiations. ES/PNET of the uterus is rare. There are 48 cases of ES/PNET of the uterus published in the literature as far as we know. We describe a case of Ewing sarcoma of the uterus occurring in a 17-year-old woman presenting with a two-month history of pelvic pain. After surgical excision and microscopic, immunohistochemical, and electron microscopy examination, the diagnosis of Ewing sarcoma of the uterus was suggested. This report will discuss the diagnosis and surgical and clinical management of Ewing uterine sarcoma in young women, according to the available literature. In spite of the rarity of ES/PNETs, they should be taken into account in the differential diagnosis of uterine neoplasms in young women.

Extraosseous Ewing sarcoma of the vagina: a rare entity

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

Primary Ewing's sarcoma of vulva: a case report and a review of the literature

Ewing sarcomas/peripheral primitive neuroectodermal tumors (ES/pPNET) are extremely rare in the vulva. A review of the literature reveals only 14 previously reported possible cases. Here we reported a case of primary extraskeletal Ewing's sarcoma (EES) of the vulva in a 37-year-old woman. Characteristic histologic features of ES/pPNET were present in this case, including a monomorphic population of small round blue cells with cytoplasmic glycogen confirmed by periodic acid-Schiff, membrane staining with CD99 and nuclear staining with FLI-1. After surgery, the patient was found to have pulmonary metastasis and then received six cycles of polychemotherapy. She is still alive with stable disease after 1 year of follow up. Our findings underline the crucial role of immunohistochemical techniques in the differential diagnosis of small round cell tumors in these unusual locations. We also give a summary about the clinical and pathological features of the primary ES/pPNET in the vulva reported previously in the literature.

Primary vulvar Ewing sarcoma/primitive neuroectodermal tumor: a report of one case and review of the literature

BACKGROUND

Ewing sarcoma/primitive neuroectodermal tumors (ES/PNET) are aggressive malignancies characterized by translocation involving the EWS gene. Primary extraskeletal ES/PNET rarely affects the female genital tract.

CASE

We report the case of a 20-year-old female, who presented with a rapidly growing painful mass arising from the left labium majus for six months. Multiple lesions in bones and nodules in lungs were considered metastasis. The diagnosis was established by immunohistochemical stain and reverse transcriptase polymerase chain reaction analysis. The patient ceased treatment and died of respiratory failure one month after discharge.

CONCLUSION

Vulvar ES/PNET mainly affects adolescent females. ES/PNET should be considered in the differential diagnosis of tumors involving the lower gynecologic tract in adolescent female.

Primary Vaginal Ewing Sarcoma

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

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

BACKGROUND

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

CASE

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Primary vaginal Ewing's sarcoma or primitive neuroectodermal tumor in a 17-year-old woman: a case report

Introduction

Primary Ewing's sarcoma or primitive neuroectodermal tumor of the genital tract of women is uncommon. Rarer still is its occurrence in the vagina, with only five cases described so far. Out of these, only one case was confirmed using molecular analysis.

Case presentation

We present an extremely rare case of Ewing's sarcoma or primitive neuroectodermal tumor in a 17-year-old Indian girl. She presented with a vaginal mass that was initially diagnosed as a malignant round cell tumor. Immunohistochemistry showed diffuse positivity for vimentin, membranous positivity for MIC2, and positivity for BCL2 and FLI-1. On the other hand, she was negative for cytokeratin, epithelial membrane antigen, desmin, Myo D-1, myogenin and smooth muscle actin. A diagnosis of primitive neuroectodermal tumor was thus offered. Furthermore, a molecular analysis of our patient using reverse transcription-polymerase chain reaction technique showed positivity for t(11; 22) (q24; q12) (EWSR1-FLI1), thus confirming the diagnosis of a Ewing's sarcoma/primitive neuroectodermal tumor. Our patient was offered chemotherapy on Institutional protocol EFT 2001.

Conclusion

This is a rare case of primary vaginal Ewing's sarcoma or primitive neuroectodermal tumor, which was confirmed with molecular analysis, in the youngest patient known so far. This study reinforces the value of integrating morphological features with membranous MIC2 positivity, along with application of molecular techniques in objective identification of an Ewing's sarcoma or primitive neuroectodermal tumor at uncommon sites.

Peripheral neuroectodermal tumor of the vulva: a case report

BACKGROUND

Peripheral neuroectodermal tumors arising from vulva are extremely rare; only 12 cases have been reported so far. These tumors belong to the Ewing sarcoma family of tumors. They occur in bones and variety of soft tissues of chest wall, pelvis, paravertebral region, and lower extremities. Being aggressive tumors, they have poor prognosis.

CASE

We report a case of a 20-year-old woman who presented with a 20 x 15 x 10-cm pedunculated mass arising from the right labium majus. Judicious use of a panel of markers led to diagnosis of peripheral neuroectodermal tumor. The patient died of metastatic disease.

CONCLUSIONS

Judicious use of a panel of markers and a molecular test, if necessary, helps in confirming the diagnosis. Surgery followed by chemotherapy with or without radiation is the treatment of choice.

Primary vulvar Ewing sarcoma/primitive neuroectodermal tumor: a report of 2 cases and review of the literature

Ewing sarcoma/primitive neuroectodermal tumor (ES/PNET) family of tumor is a very aggressive malignant round cell tumor characterized by translocations involving EWS-FLI1 genes. They are increasingly recognized in extraosseous sites as a result of improvements in diagnostic tools. In this paper, we report 2 additional cases arising in vulva of young adults who have been treated aggressively and have survived fore more than 7 and 4 years successively. Histologic examination showed small round (blue) cell morphology in both cases. The tumor cells contained glycogen and were positive for CD99 and vimentin and negative for keratins, lymphoid markers, S-100, synaptophysin, chromogranin, and desmin. Reverse transcriptase polymerase chain reaction analysis from paraffin-embedded tissue revealed EWS-FLI1 fusion product in 1 case. Collectively, 13 cases of vulvar ES/PNET have been reported in the literature. Only 8 cases have detailed follow-up information with an average follow-up data of 28 months. Ewing sarcoma/PNET should be considered in the differential diagnosis of any undifferentiated tumors involving the lower gynecologic tract and all axillary tests including molecular tests should be performed for correct diagnosis because prolonged survival is possible for this dreadful disease after complete surgical resection, followed by adjuvant therapy.

Miscellaneous Pseudotumors and Mesenchymal Tumors of the Female Genital Tract

Benign and malignant soft tissue tumors and pseudotumors can rarely arise anywhere in the female genital tract. Their pathologic features as well as behavior typically overlap with those described in tumors involving typical locations. However, due to their rarity, not infrequently these tumors represent a diagnostic challenge. Their diagnosis should be based on careful gross examination, thorough sampling, and morphologic evaluation, applying a selected immunohistochemical panel and molecular studies. Accurate classification of these tumors is important because their clinical behavior, prognosis, and therapy differ markedly. This article outlines several mesenchymal lesions reported in the female genital tract, encompassing recent histologic, immunohistochemical, and molecular findings, with special emphasis on problems in the differential diagnosis.

Primary vulvar Ewing's sarcoma/primitive neuroectodermal tumor in a post-menopausal woman: a case report

Ewing's sarcomas/peripheral primitive neuroectodermal tumors (ES/pPNETs) are high-grade malignant neoplasms rarely found outside the skeletal system. Only 12 cases of vulvar ES/pPNET have so far been reported, all involving children or women of child-bearing age. We describe the case of a 52-year-old woman who was admitted to our hospital for the local excision of a 4cm vulvar mass, originally thought to be a Bartholin's gland cyst. It was subsequently found to consist of small round cells positive for anti-CD99 antibody, thus suggesting a diagnosis of ES/pPNET. The demonstration of EWSR1 gene translocations by means of fluorescent in situ hybridization excluded small-cell carcinoma, squamous cell carcinoma of the small type, Merkel cell carcinoma, and lymphoblastic lymphoma. After surgery, the patient received six cycles of polychemotherapy and radiotherapy; she is still alive and well after 1 year of follow-up. Our findings underline the crucial role of molecular biology techniques in the differential diagnosis of small round cell tumors in these unusual locations.

Primary vaginal extraosseous Ewing sarcoma/primitive neuroectodermal tumor with cranial metastasis

Extraosseous Ewing sarcoma is now regarded as a member of the Ewing sarcoma/primitive neuroectodermal tumor (PNET) family. It typically involves the soft tissues of the chest wall, pelvis, paravertebral region, abdominal wall, retroperitoneal region and extremities of children, adolescents and young adults, but it seldom occurs in the female genital tract. We report an extremely rare case of retrospective diagnosis of vaginal extraosseous Ewing sarcoma/PNET which metastasized to the right frontoparietal scalp, skull, and dura. Surgical resection, followed by adjuvant radiotherapy and chemotherapy resulted in a favourable clinical outcome. Both the vaginal and head tumors had similar light microscopic features supporting the diagnosis.

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

A case report and review of an extraskeletal neuroectodermal tumour of the vagina.

BACKGROUND

Ewing's sarcoma (ES) and primitive neuroectodermal tumours (PNETs) account for approximately 6-10% of primary malignant bone tumours and, following osteosarcoma, are the second most common group of bone sarcomas in children. Ewing's sarcoma rarely affects the genitourinary tract. We report a rare case of extraskeletal Ewing's sarcoma diagnosed in a 47-year-old Indian woman presenting with a simple cystic lesion in the posterior wall of the vagina. The histopathology revealed a rare presentation of a primitive malignant extraskeletal neuroectodermal tumour.

CONCLUSION

As our PubMed review found only six previously reported cases of vaginal extraskeletal Ewing's sarcoma. Presentation as vaginal masses helped in early disease detection.

Primary Ewing sarcoma/peripheral primitive neuroectodermal tumor of the vulva

We report a case of Ewing sarcoma/peripheral primitive neuroectodermal tumor (ES/pPNET) arising in the vulva in a 17-year-old adolescent girl. Primary extraskeletal ES/pPNET is uncommon and only rarely affects the female genital tract. Characteristic histologic features of ES/pPNET were present in this case including a monomorphic population of small round blue cells with cytoplasmic glycogen confirmed by periodic acid-Schiff and were immunohistochemically positive for CD99 in a membranous and Fli-1 in a nuclear pattern. The presence of an EWS/Fli-1 fusion transcript was demonstrated by reverse transcription polymerase chain reaction and confirmed by direct sequencing. This report described another very rare case of ES/pPNET arising in the vulva and confirmed by molecular analysis.

Ewing family of tumours involving the vulva and vagina: report of a series of four cases

BACKGROUND

Ewing's sarcoma and peripheral primitive neuroectodermal tumour (pPNET) are now regarded as two morphological ends of a spectrum of neoplasms, characterised by a t(11;22) or other related chromosomal translocation involving the EWS gene on chromosome 22 and referred to as Ewing family of tumours (EFTs). EFTs are extremely rare in the vulva and vagina, a review of the literature revealing only 13 previously reported possible cases, most of which have not had molecular confirmation. In this study, four new cases of EFTs involving the vulva (three cases) or vagina (one case) are reported.

RESULTS

The tumours occurred in women aged 19, 20, 30 and 40 years and ranged in size from 3 to 8 cm. Morphologically, all neoplasms had a lobulated architecture and were composed of solid aggregates of cells. In one case, occasional rosettes were formed. In all the tumours, there was diffuse membranous staining with CD99; nuclear positivity with FLI-1 was present in two cases. Three cases were focally positive with the broad-spectrum cytokeratin AE1/3, all were diffusely positive with vimentin and all were desmin negative. In two cases, a t(11;22) (q24;q12) (EWSR1-FLI-1) chromosomal translocation was demonstrated by reverse transcriptase-PCR (one case) and fluorescence in situ hybridisation (FISH) (one case), and in another case a rearrangement of the EWSR1 gene on chromosome 22 was demonstrated by FISH. In the other case, a variety of molecular studies did not reveal a translocation involving the EWS gene but this tumour, on the balance of probability, is still considered to represent a neoplasm in the EFTs. Follow-up in two cases revealed that one patient developed pulmonary metastasis and died and another is alive without disease at 12 months.

CONCLUSIONS

This report expands the published literature regarding EFTs involving the vulva and vagina and stresses the importance of molecular techniques in firmly establishing the diagnosis, especially when these neoplasms arise at unusual sites.

Primary Ewing's sarcoma-primitive neuroectodermal tumor of the uterus: a case report and literature review

BACKGROUND

Primary Ewing's sarcoma-primitive neuroectodermal tumor (ES-PNET) of the uterus is an extremely rare malignancy.

CASE

A 30-year-old Korean woman presented with abnormal uterine bleeding with uterine enlargement. A computed tomography (CT) scan and magnetic resonance imaging (MRI) of the abdomen and pelvis showed a huge uterine mass measuring 18 x 20 x 21 cm, metastasis to both pelvic and para-aortic lymph nodes, and omental infiltration. The pathology report of the uterine mass described a uniformly hypercellular tumor, which was arranged in diffuse solid sheets of uniform, small, rounded, and sometimes spindle-shaped cells, with scanty cytoplasm. Immunohistochemically, the mass tested positive for vimentin, CD99, and chromogranin. The patient received several courses of combination chemotherapy and radiotherapy but died from tumor progression 16 months after the initial diagnosis.

CONCLUSION(S)

This is a rare case of primary uterine ES-PNET in a woman of reproductive age. A review of the literature indicates that primary uterine ES-PNET requires early diagnosis and multimodality treatment including surgery, chemotherapy, and radiotherapy. The behavior of this tumor is potentially aggressive.

Ewing sarcoma family of tumors in unusual sites: confirmation by rt-PCR

Ewing sarcoma family tumors originating in the palate or adrenal gland are extremely rare and may cause difficulty in diagnosis. More common tumors primary to these sites need to be excluded before one arrives at the correct diagnosis. We have recently diagnosed 2 such cases. The 1st case was that of a 24-year-old woman who presented with a swelling in the right side of the hard palate. The 2nd case was diagnosed in a 28-year-old woman who presented with a mass in the right adrenal gland. In both cases, the diagnosis of Ewing sarcoma family of tumors was confirmed by immunohistochemical studies and reverse transcriptase-polymerase chain reaction (RT-PCR). The hard palate case is the 1st and the adrenal gland the 3rd case of Ewing sarcoma family of tumors arising in these sites, in which the diagnosis was confirmed by RT-PCR and/or cytogenetics. Accurate diagnosis of Ewing sarcoma family of tumors is crucial for the management of patients, and when found in such rare locations, diagnosis should be supported by immunohistochemical and/or molecular genetic studies.

Ewing's sarcoma of the vulva--a case report

Extraosseous Ewing's sarcoma of the vulva is extremely rare with only three such cases described. A 26-year-old woman presented with Ewing's sarcoma of the vulva. She received chemotherapy to shrink the lesion. However, the response was suboptimal and she subsequently received radiotherapy. Although resection was planned, she developed chest metastases within a short period of time and subsequently died.

Primary Ewing's sarcoma–primitive neuroectodermal tumor of the vagina

BACKGROUND

Only three cases of Ewing's sarcoma-primitive neuroectodermal tumor (ES-PNET) occurring in the vagina have been previously reported.

CASE

A 30-year-old Chinese woman presented with a vaginal mass measuring 5 cm in greatest dimension. The tumor was composed of solid sheets of undifferentiated small round cells with numerous Homer-Wright rosettes. Immunohistochemically, it was positive for CD99, FlI-1 protein, synaptophysin, neuron-specific enolase, vimentin, and S-100 protein. The patient underwent wide local excision of the tumor and subsequent total abdominal hysterectomy with postoperative chemotherapy and radiotherapy. She is disease-free 36 months after the initial surgery.

CONCLUSION

This is a rare case of ES-PNET occurring in the vagina and the first showing many distinctive Homer-Wright rosettes. A review of literature indicates that vaginal or vulvar ES-PNET affects younger women, and it may have a relatively favorable outcome.

Peripheral Primitive Neuroectodermal Tumor (PPNET) of Pelvic Origin: Report of a Case Arising from an Unusual Location

We report a rare case of a peripheral primitive neuroectodermal tumor (PPNET) originating from the left ileopsoas muscle in an adult patient with neoplastic thrombosis of the left external iliac vein, the common femoral vein and the left popliteal vein. We performed a median laparotomy with an oblique left inguinal incision to remove the neoplasm, which consisted of a large mass surrounding the iliac-psoas muscles, extending from the transverse apophysis of the spinal column to Scarpa's triangle, and passing through the lacuna musculorum. Histopathological examination revealed a primitive neuroectodermal tumor (PNET) with focal areas of necrosis, hemorrhage and vascular invasion. Immunophenotyping was positive for CD99, NSE, and focally for CK. Ultrastructural examination of the neoplastic cells showed often multiple nuclei with dense chromatin and very large nucleoli. The patient was discharged ten days after the operation. Adjuvant treatment consisted of radiotherapy at a dose of 2000 cGy in five fractions followed by six cycles of chemotherapy. The venous thrombosis was treated by anticoagulant therapy and recanalization of the occluded veins was obtained after two months of therapy. An MRI scan, carried out 12 months later, showed a local relapse, which was treated with chemotherapy and arterial chemoembolization.

Non-Hodgkin's lymphoma involving the gynecologic tract: a review of 88 cases

Non-Hodgkin's lymphoma (NHL) involving the gynecologic tract is unusual and may cause confusion for the pathologist not familiar with its clinical and histologic features. The literature regarding this topic is also confusing, as modern NHL classification systems were not used or patients were not staged according to the Ann Arbor system in many prior reports. In addition, immunophenotypic data is not available for many cases, particularly in older studies. In the past year, there has been an interest in NHL involving the gynecologic tract and 88 cases have been collected. These cases were reviewed in the Pathology Department of M.D. Anderson Cancer Center during the past two decades, and many of these patients were treated at this hospital. In this review, these cases are reported using updated terminology and almost all cases were immunophenotyped using immunohistochemical methods or flow cytometric methods in a small subset of cases. These cases have also been segregated into two groups: 1) localized NHL, that presumably initially arose in the gynecologic tract and therefore are primary; and 2) NHL that involved the gynecologic tract as a part of systemic disease, and therefore most likely represent secondary involvement of the gynecologic tract. The differential diagnosis of NHL involving gynecologic organs is discussed.

Mesenchymal tumors and tumor-like lesions of the female genital tract: a selective review with emphasis on recently described entities

The diverse mesenchymal tumors and tumor-like lesions that occur within the female genital tract include a number of lesions that have only been recently characterized and others about which there is new information. In this group are the aggressive angiomyxoma, angiomyofibroblastoma, and cellular angiofibroma. Criteria for the distinction of these lesions are reviewed, as are the pathologic features of prognostic significance in assessing smooth muscle tumors of the vulva. The diagnostic problems that the epithelioid variant of smooth muscle tumors, both benign and malignant, may pose when they occur in various areas of the genital tract are discussed, particularly with regard to problems encountered in the ovary, a site where the diagnosis often is not considered. Recent information expanding the morphologic spectrum of fibroepithelial polyps of the genital tract is presented, and important non-neoplastic entities, including nodular fasciitis and the postoperative spindle cell nodule, are reviewed. Mesenchymal tumors of the various types seen in the soft tissues may be encountered anywhere in the female genital tract and have been the subject of particular recent interest in the ovary; issues relevant to differential diagnosis are reviewed.