Ewing's sarcoma of the mobile spine

Treatment outcomes in patients with Ewing sarcoma of the spine in a resource-challenged setting: 17-year experience from a single center in India

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.

Primary epidural lumbar Ewing sarcoma presenting as cauda equina syndrome in an adult patient who underwent surgical decompression: A case report

Ewing sarcoma (ES) is a rare primary neoplasm in the lumbar adult spine and may mimic a benign tumor. In this case, after a patient's three-month history of lower back pain and rapidly progressing leg numbness and weakness, magnetic resonance imaging (MRI) showed a mass in the third lumbar vertebra. At a two-month follow-up, imaging showed a fracture, compression and lesion enlargement. Decompression and fixation confirmed ES, and the patient began combined radiotherapy and chemotherapy. Two months postoperatively, residual ES was suspected on MRI. The patient underwent a second surgery, and histopathology confirmed necrosis. A six-month follow-up after the first surgery showed no tumor recurrence. This case supports the inclusion of ES in the differential diagnosis of pathologic spinal fracture. Early decompression and spinal fixation are critical for preserving neurologic and spinal functions in ES complicated by a compression fracture. Combined adjuvant radiotherapy and chemotherapy remain the standard therapeutic strategy.

Primary Ewing sarcoma/peripheral primitive neuroectodermal tumors in the cranial bone and mobile spine: what is the difference?

BACKGROUND

Primary Ewing sarcoma (ES)/peripheral primitive neuroectodermal tumors (pPNETs) are aggressive bone tumors that rarely occur in the axial skeleton, including the cranial bone and mobile spine. The purpose of this study was to investigate whether there were any differences in patient characteristics, treatment strategies, and outcomes between patients with ES/pPNETs of the cranial bone and those with ES/pPNETs of the mobile spine.

METHODS

A retrospective study was performed on 33 patients with ES/pPNETs who had been surgically treated and pathologically confirmed at our institution between 2010 and 2020. Patient characteristics were compared using Fisher exact tests or independent t tests. Survival rates were estimated via Kaplan-Meier survival analysis and compared using log-rank tests.

RESULTS

Thirteen patients had ES/pPNETs of the cranial bone (39.4%), while 20 patients had ES/pPNETs of the mobile spine (60.6%). Patients with ES/pPNETs of the cranial bone had a younger mean age (14.8 vs 22.6 years; p = 0.047) and longer mean disease duration (2.5 vs 1.9 months; p = 0.008) compared with those of patients with ES/pPNETs of the mobile spine. Kaplan-Meier analysis showed that gross total resection (GTR) and radiotherapy resulted in a longer median survival time. The overall survival rates and progression-free survival rates of patients with ES/pPNETs of the cranial bone versus those of the mobile spine were not significantly different (p = 0.386 and p = 0.368, respectively).

CONCLUSIONS

Patients with ES/pPNETs of the cranial bone were younger compared to patients with ES/pPNETs of the mobile spine. There was no significant difference in the prognosis of patients with ES/pPNETs of the cranial bone versus those of the mobile spine. Taken together, our findings suggest that GTR and radiotherapy offer the best prognosis for improved long-term survival.

Primary epidural lumbar Ewing sarcoma presenting as cauda equina syndrome in an adult patient who underwent surgical decompression: A case report

Ewing sarcoma (ES) is a rare primary neoplasm in the lumbar adult spine and may mimic a benign tumor. In this case, after a patient's three-month history of lower back pain and rapidly progressing leg numbness and weakness, magnetic resonance imaging (MRI) showed a mass in the third lumbar vertebra. At a two-month follow-up, imaging showed a fracture, compression and lesion enlargement. Decompression and fixation confirmed ES, and the patient began combined radiotherapy and chemotherapy. Two months postoperatively, residual ES was suspected on MRI. The patient underwent a second surgery, and histopathology confirmed necrosis. A six-month follow-up after the first surgery showed no tumor recurrence. This case supports the inclusion of ES in the differential diagnosis of pathologic spinal fracture. Early decompression and spinal fixation are critical for preserving neurologic and spinal functions in ES complicated by a compression fracture. Combined adjuvant radiotherapy and chemotherapy remain the standard therapeutic strategy.

Primary Extraosseous Spinal Ewing Sarcomas: Should We Be More Aware About Diagnosis?

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.

Managing axial bone sarcomas in childhood

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.

Spondylectomy for Primary Ewing Lumbar Sarcoma in Children

Primary Ewing sarcoma in the spine is very rare, and the treatment for it is multidisciplinary. There is no consensus regarding the optimal method of local control; however, en bloc resection is associated with an improvement in survival rates. The authors report a case of a 5-year-old girl who initially presented low back pain, and was diagnosed with Ewing sarcoma after being submitted to imaging studies by radiography, magnetic resonance and bone biopsy. A spondylectomy was performed in accordance with the Euro Ewing protocol. At the three-year follow-up, the patient had no restrictions regarding her daily activities, and there has been no evidence of recurrence to date.

Multilevel Pedicular Osteotomies for En Bloc Resection of a Primary Ewing Sarcoma of the Subaxial Cervical Spine with Pedicle Screw Reconstruction

BACKGROUND

Primary Ewing sarcoma of the mobile spine is a rare disease. Its management requires careful surgical planning, because radical, margin-free excision is directly correlated with prognosis. Extensive bone removal in the cervical spine can lead to instability and cause postoperative iatrogenic cervical deformity. Thus, spinal instrumentation plays an important role in restoring postresection spinal stability and improving quality of life.

METHODS

We present a novel technique that allows successful removal of a large Ewing sarcoma of the subaxial cervical spine, infiltrating and traversing the posterior bone elements, and extending into the paraspinal muscles. This technique involves radical en bloc resection of posteriorly located cervical tumors via multilevel pediculotomy, with terminal vertebrae pedicle screw reconstruction.

RESULTS

Terminal vertebrae cervical pedicle screw reconstruction allowed wide surgical excision with satisfactory oncologic and mechanical results.

CONCLUSIONS

This technique enables 1-stage total tumor resection and stabilization and may be a viable alternative to radical en bloc resection of posteriorly located epidural malignant lesions of the cervical spine in selected cases.

Surgical Resection of Primary Ewing's Sarcoma of Bone Improves Overall Survival in Patients Presenting with Metastasis

Background

Metastatic Ewing’s sarcoma (ES) of bone has a poor prognosis. Because there have been few previous studies on the prognostic factors and clinical outcome in patients with ES who have metastases at presentation, the aim of this study was to use the Surveillance, Epidemiology, and End Results (SEER) database to compare the clinical outcome following single and combined radiation treatment and surgery.

Material/Methods

The SEER database was used to identify patients with ES who presented with bone involvement and metastasis between 1973 to 2015. Prognostic analysis was performed using the Kaplan-Meier method and the Cox proportional hazards regression model.

Results

There were 643 patients identified from the SEER database. The 5-year overall survival (OS) and cancer-specific survival (CSS) rates were 33.1% and 34.3%, respectively and the median OS and CSS were 29.0±1.9 and 29.0±2.1 months, respectively. Multivariate analysis identified age <20 years and surgical resection of the primary tumor to be significantly associated with improved OS. Radiation therapy was not an independent predictor of OS or CSS. Radiation therapy alone resulted in a significantly reduced the OS and CSS compared with surgical resection alone. Combined surgery and radiation therapy of the primary tumor did not significantly improve the OS or CSS of patients with ES and metastatic disease when compared with surgery alone.

Conclusions

Age <20 years and surgical resection of the primary tumor were significantly associated with improved OS in patients with primary ES of bone who presented with metastasis.

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

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.

Ewing Sarcoma of the Spine: Prognostic Variables for Survival and Local Control in Surgically Treated Patients

STUDY DESIGN

Multicenter, ambispective observational study.

OBJECTIVE

To quantify mortality and local recurrence after surgical treatment of spinal Ewing sarcoma (ES) and to determine whether an Enneking appropriate procedure and surgical margins (en bloc resection with wide/marginal margins) are associated with improved prognosis.

SUMMARY OF BACKGROUND DATA

Treatment of primary ES of the spine is complex. Ambiguity remains regarding the role and optimal type of surgery in the treatment of spinal ES.

METHODS

The AOSpine Knowledge Forum Tumor developed a multicenter database including demographics, diagnosis, treatment, mortality, and recurrence rate data for spinal ES. Patients were stratified based on surgical margins and Enneking appropriateness. Survival and recurrence were analyzed using Kaplan-Meier curves and log-rank tests.

RESULTS

Fifty-eight patients diagnosed with primary spinal ES underwent surgery. Enneking appropriateness of surgery was known for 55 patients; 24 (44%) treated Enneking appropriately (EA) and 31 (56%) treated Enneking inappropriately (EI). A statistically significant difference in favor of EA-treated patients was found with regards to survival (P = 0.034). Neoadjuvant and postoperative chemotherapy was significantly associated with increased survival (P = 0.008). Local recurrence occurred in 22% (N = 5) of patients with an EA procedure versus 38% (N = 11) of patients with an EI procedure. The timing of chemotherapy treatment was significantly different between the Enneking cohorts (P < 0.001) and all EA-treated patients received chemotherapy treatment. Although, local recurrence was not significantly different between Enneking cohorts (P = 0.140), intralesional surgical margins and patients who received a previous spine tumor operation were associated with increased local recurrence (P = 0.025 and P = 0.018, respectively).

CONCLUSION

Surgery should be undertaken when an en bloc resection with wide/marginal margins is feasible. An EA surgery correlates with improved survival, but the impact of other prognostic factors needs to be evaluated. En bloc resection with wide/marginal margins is associated with local control.

LEVEL OF EVIDENCE

3.

Acute Isolated Paraplegia Revealing an Ewing Sarcoma of the Thoracic Spine

Ewing sarcoma (ES) infrequently affects the spine. Diagnosis is usually made several weeks following growing symptoms. In this report, we present the case of a child with ES localized at the upper thoracic level. ES was revealed by isolated acute complete paraplegia mimicking medullary stroke. The girl was operated for decompressive laminectomy and tumor removal. Afterwards, she received adjuvant therapy. Subsequently, the child showed a slow improvement of her leg sensitivity associated with a partial motor recovery. ES can affect the mobile spine. Acute symptomatology due to intratumoral hemorrhage and sudden spinal cord compression may suggest the diagnosis. Neurological outcomes following ES are generally poor.

Prognostic determinants and treatment outcomes analysis of osteosarcoma and Ewing sarcoma of the spine

BACKGROUND CONTEXT

Osteosarcoma (OGS) and Ewing sarcoma (EWS) are the two classic primary malignant bone tumors. Due to the rarity of these tumors, evidence on demographics, survival determinants, and treatment outcomes for primary disease of the spine are limited and derived from small case series.

PURPOSE

To use population-level data to determine the epidemiology and prognostic indicators in patients with OGS and EWS of the osseous spine.

STUDY DESIGN/SETTING

Large-scale retrospective study.

PATIENT SAMPLE

Patients diagnosed with OGS and EWS of the spine in the Surveillance, Epidemiology, and End Results (SEER) registry from 1973 to 2012.

OUTCOME MEASURES

Overall survival (OS) and disease-specific survival (DSS).

METHODS

Two separate queries of the SEER registry were performed to identify patients with OGS and EWS of the osseous spine from 1973-2012. Study variables included age, sex, race, year of diagnosis, tumor size, extent of disease (EOD), and treatment with surgery and/or radiation therapy. Primary outcome was defined as OS and DSS in months. Univariate survival analysis was performed using the Kaplan-Meier method and the log-rank test. Multivariate analysis was performed using Cox proportional hazards regression models.

RESULTS

The search identified 648 patients with primary OGS and 736 patients with primary EWS of the spine from 1973 to 2012. Mean age at diagnosis was 48.1 and 19.9 years for OGS and EWS, respectively, with OGS showing a bimodal distribution. The median OS and DSS were 1.3 and 1.7 years, respectively, for OGS, with OGS in Paget's disease having worse OS (0.7 years) relative to the mean (log-rank p=.006). The median OS and DSS for EWS were 3.9 and 4.3 years, respectively. Multivariate cox regression analysis showed that age (OS p<.001, DSS p<.001), decade of diagnosis (OS p=.049), surgical resection (OS p<.001, DSS p<.001), and EOD (OS p<.001, DSS p<.001) were independent positive prognostic indicators for spinal OGS; radiation therapy predicted worse OS (hazard ratio [HR] 1.48, confidence interval [CI] 1.05-2.10, p=.027) and DSS (HR 1.74, CI 1.13-2.66, p=.012) for OGS. For EWS, age (OS p<.001, DSS p<.001), surgical resection (OS p=.030, DSS p=.046), tumor size (OS p<.001, DSS p<.001), and EOD (OS p<.001, DSS p<.001) were independent determinants of improved survival; radiation therapy trended toward improved survival but did not achieve statistical significance for both OS (HR 0.76, CI 0.54-1.07, p=.113) and DSS (0.76, CI 0.54, 1.08, p=.126).

CONCLUSIONS

Age, surgical resection, and EOD are key survival determinants for both OGS and EWS of the spine. Radiation therapy may be associated with worse outcomes in patients with OGS, and is of potential benefit in EWS. Overall prognosis has improved in patients with OGS of the spine over the last four decades.

The Neurological Compromised Spine Due to Ewing Sarcoma. What First

BACKGROUND:

The vertebral column is an infrequent site of primary involvement in Ewing sarcoma. Yet when Ewing sarcoma is found in the spine, the urge for decompression is high because of the often symptomatic compression of neural structures. It is unclear in alleviating a neurological deficit whether chemotherapy is preferred over decompressive laminectomy.

OBJECTIVE:

To underline, in this case series, the efficiency of initial chemotherapy before upfront surgery in the setting of high-grade spinal cord or cauda equina compression of primary Ewing sarcoma.

METHODS:

Fifteen patients with Ewing sarcoma primarily located in the spine were treated at our institution between 1983 and 2015. Localization, neurological deficit expressed as Frankel grade, and outcome expressed as Rankin scale before and after initial chemotherapy, the recurrence rate, and overall survival were evaluated. The multidisciplinary approach of 1 case will be discussed in detail.

RESULTS:

Nine patients (60%) were female. The age at presentation was 15.0 ± 5.5 years (range: 0.9–22.8 years). Ten patients (67%) were initially treated with chemotherapy, and 1 patient (7%) was treated primarily with radiotherapy followed by chemotherapy. The remaining 4 patients (27%) were initially treated with decompressive surgery. All patients treated primarily nonsurgically improved neurologically at follow-up, showing the importance of chemotherapy as an effective initial treatment option.

CONCLUSION:

Adequate and quick decompression of neural structures with similar results can be achieved by chemotherapy and radiotherapy, avoiding the local spill of malignant cells.

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

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.

Revision Surgical Treatment of a Second Lumbar Ewing Sarcoma: A Report of a Rare Case

We report a case of a 58-year-old man who presented initially with lumbar pain.According to radiography, computed tomography, magnetic resonance imaging, and bone biopsy results, Ewing sarcoma (ES) was diagnosed. Tumor resection was performed, followed by chemotherapy and radiotherapy; pathology confirmed the diagnosis of ES. After surgery, the tumor recurred twice with progressive symptoms, meriting repeated excisional surgery. At the 4-year follow-up, the patient showed apparent improvement, with return of function and strength and resolution of pain.We discuss its clinical features and treatment in the light of the current knowledge.

Is total en bloc sacrectomy using a posterior-only approach feasible and safe for patients with malignant sacral tumors?

OBJECT In this study the authors' aim was to describe their experience with total en bloc sacrectomy using a posterioronly approach and to assess the outcome of patients with malignant sacral tumors who underwent this procedure at their center. METHODS The authors identified and retrospectively reviewed the records of 10 patients with malignant sacral tumors who underwent a total en bloc sacrectomy via a single posterior approach at their center. The pathological diagnosis was chordoma in 4 patients, chondrosarcoma in 1, osteosarcoma in 1, malignant schwannoma in 1, malignant giant cell tumor in 1, and Ewing's sarcoma in 2. Radiological examination revealed that the tumor involved S1-5 in 7 patients, S1-4 in 1, S1-3 in 1, and S1-2 in 1. RESULTS All 10 patients were stable during the perioperative period. The mean surgery duration was 282 minutes (range 250-310 minutes). The median estimated blood loss was 2595 ml (range 1500-3200 ml). All patients were followed up for 13-29 months (mean 22 months). Two patients had a local recurrence. Two patients died of disease, 1 patient was alive with disease, and 7 patients were alive without evidence of disease. Among the 8 surviving patients, 6 were able to walk without assistive devices, and 2 were able to walk with crutches. The total complication rate was 40% (4 of 10). Wound complications (deep infection and wound healing problems) occurred in 3 patients, and a distal deep vein thrombosis occurred in 1 patient. CONCLUSIONS Total en bloc sacrectomy using a posterior-only approach is feasible and safe in selected patients and is an important procedure for the treatment of primary malignant tumor involving the entire sacrum or only the top portion.

Unusual Presentation of a Primary Ewing's Sarcoma of the Spine with Paraplegia: A Case Report

Ewing's sarcoma is a primary malignancy of the bone affecting individuals in the second decade of life. Primary sarcomas of the spine are rare and the occurrence of Primary Ewing's sarcoma in the spine is very rare. Ewing's sarcoma occurring in the spine is divided into two types, Ewing's sarcoma of sacral spine which are very aggressive with poor prognosis and Ewing's sarcoma of the non sacral spine which is an extremely rare occurrence. Patient may present with neurological deficit when the tumour extends into the spinal canal causing spinal cord compression. Magnetic resonance imaging (MRI) is very sensitive in diagnosing the tumour and defining the extent of the tumour. Here we report an 18-year-old boy who presented with back pain and complete paraplegia of two months duration. The MRI gave a differential diagnosis of infective pathology due to the fluid collection in the paraspinal region, followed by primary malignancy as the second diagnosis. Patient underwent posterior spinal decompression and stabilization, and intaoperatively there was significant collection of pus whose culture showed no growth. The histopathology and immunohistochemistry studies confirmed the diagnosis of Ewing's sarcoma and patient was started on combination chemotherapy and radiotherapy.

Long-Term, Disease-Free Survival of a Patient With a Primitive Neuroectodermal/Ewing Sarcoma in the Mobile Spine With Extracompartmental Extension

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.

Local control and sequelae in localised Ewing tumours of the spine: a French retrospective study

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.

Association of surgical resection and survival in patients with malignant primary osseous spinal neoplasms from the Surveillance, Epidemiology, and End Results (SEER) database

OBJECTIVE

Malignant osseous spinal neoplasms are aggressive tumors associated with poor outcomes despite aggressive multidisciplinary measures. While surgical resection has been shown to improve short-term local disease control, it remains debated whether surgical resection is associated with improved overall survival in patients with malignant primary osseous spinal neoplasms. The aim of this manuscript is to review survival data from a US cancer registry spanning 30 years to determine if surgical resection was independently associated with overall survival.

METHODS

The SEER registry (1973-2003) was queried to identify cases of histologically confirmed primary spinal chordoma, chondrosarcoma, osteosarcoma, or Ewing's sarcoma of the mobile spine and pelvis. Patients with systemic metastasis were excluded. Age, gender, race, tumor location, and primary treatments were identified. Extent of local tumor invasion was classified as confined within periosteum versus extension beyond periosteum to surrounding tissues. The association of surgical resection with overall survival was assessed via Cox analysis adjusting for age, radiotherapy, and tumor invasiveness.

RESULTS

827 patients were identified with non-metastatic primary osseous spinal neoplasms (215 chordoma, 282 chondrosarcoma, 158 osteosarcoma, 172 Ewing's sarcoma). Overall, median survival was histology specific (chordoma, 96 months; Ewing's sarcoma, 90 months; chondrosarcoma, 88 months; osteosarcoma, 18 months). Adjusting for age, radiation therapy, and extent of local tumor invasion in patients with isolated (non-metastatic) spine tumors, surgical resection was independently associated with significantly improved survival for chordoma [hazard ratio (95 % confidence interval; 0.617 (0.25-0.98)], chondrosarcoma [HR (95 %CI); 0.153 (0.07-0.36)], osteosarcoma [HR (95 %CI); 0.382 (0.21-0.69)], and Ewing's sarcoma [HR (95 %CI); 0.494 (0.26-0.96)].

CONCLUSION

In our analysis of a 30-year US population-based cancer registry (SEER), patients undergoing surgical resection of primary spinal chordoma, chondrosarcoma, Ewing's sarcoma, or osteosarcoma demonstrated prolonged overall survival independent of patient age, extent of local invasion, or location. Surgical resection may play a role in prolonging survival in the multi-modality treatment of patients with these malignant primary osseous spinal neoplasms.

Primary Ewing's sarcoma affecting the central nervous system: a review and proposed prognostic considerations

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.

Survival of patients with malignant primary osseous spinal neoplasms: results from the Surveillance, Epidemiology, and End Results (SEER) database from 1973 to 2003

OBJECT

Malignant primary osseous spinal neoplasms are aggressive tumors that remain associated with poor outcomes despite aggressive multidisciplinary treatment measures. To date, prognosis for patients with these tumors is based on results from small single-center patient series and controlled trials. Large population-based observational studies are lacking. To assess national trends in histology-specific survival, the authors reviewed patient survival data spanning 30 years (1973-2003) from the Surveillance, Epidemiology, and End Results (SEER) registry, a US population-based cancer registry.

METHODS

The SEER registry was queried to identify cases of histologically confirmed primary spinal chordoma, chondrosarcoma, osteosarcoma, or Ewing sarcoma using coding from the International Classification of Disease for Oncology, Third Edition. Association of survival with histology, metastasis status, tumor site, and year of diagnosis was assessed using Cox proportional-hazards regression analysis.

RESULTS

A total of 1892 patients were identified with primary osseous spinal neoplasms (414 with chordomas, 579 with chondrosarcomas, 430 with osteosarcomas, and 469 with Ewing sarcomas). Chordomas presented in older patients (60 ± 17 years; p < 0.01) whereas Ewing sarcoma presented in younger patients (19 ± 11 years; p < 0.01) compared with patients with all other tumors. The relative incidence of each tumor type remained similar per decade from 1973 to 2003. African Americans comprised a significantly greater proportion of patients with osteosarcomas than other tumors (9.6% vs 3.5%, respectively; p < 0.01). Compared with the sacrum, the mobile spine was more likely to be the site of tumor location for chordomas than for all other tumors (47% vs 23%, respectively; p < 0.05). Osteosarcoma and Ewing sarcoma were 3 times more likely than chondrosarcoma and chordoma to present with metastasis (31% vs 8%, respectively). Resection was performed more frequently for chordoma (88%) and chondrosarcoma (89%) than for osteosarcoma (61%) and Ewing sarcoma (53%). Overall median survival was histology-specific (osteosarcoma, 11 months; Ewing sarcoma, 26 months; chondrosarcoma, 37 months; chordoma, 50 months) and significantly worse in patients with metastasis at presentation for all tumor types. Survival did not significantly differ as a function of site (mobile spine vs sacrum/pelvis) for any tumor type, but more recent year of diagnosis was associated with improved survival for isolated spinal Ewing sarcoma (hazard ration [HR] 0.95; p = 0.001), chondrosarcoma (HR 0.98; p = 0.009), and chordoma (HR 0.98; p = 0.10), but not osteosarcoma.

CONCLUSIONS

In this analysis of a 30-year, US population-based cancer registry (SEER), the authors provide nationally representative prognosis and survival data for patients with malignant primary spinal osseous neoplasms. Overall patient survival has improved for isolated spine tumors with advancements in care over the past 4 decades. These results may be helpful in providing historical controls for understanding the efficacy of new treatment paradigms, patient education, and guiding level of aggressiveness in treatment strategies.

En Bloc Resection for Primary and Metastatic Tumors of the Spine

BACKGROUND

The efficacy of en bloc resection for spinal tumors is unknown because most of the current evidence is provided by small, single-institution clinical series or case reports.

OBJECTIVE

To combine all previously published reports of en bloc resection for primary and metastatic spinal tumors, to describe the overall pattern of disease-free survival, and to investigate potentially prognostic factors for recurrence.

METHODS

A complete MEDLINE search for all articles reporting survival data for en bloc resection of spinal tumors was undertaken; 44 articles met inclusion criteria from which 306 eligible patients were identified.

RESULTS

There were 229 cases of primary tumors with a mean follow-up of 65.0 months and 77 cases of solitary metastatic tumors with a mean follow-up of 26.5 months. Median time to recurrence was 113 months for the primary group and 24 months for the metastatic group. Disease-free survival rates at 1, 5, and 10 years were 92.6%, 63.2%, and 43.9%, respectively, for the primary group and 61.8%, 37.5%, and 0%, respectively, for the metastatic group; 5-year disease-free survival rates were 58.4% for chordoma and 62.9% for chondrosarcoma. After adjusting for covariates, age, male sex, metastatic tumors, and osteosarcomas were significantly associated with a tumor recurrence.

CONCLUSION

This study provides the largest published series of patients undergoing en bloc resection for spinal tumors. Median time to recurrence reached almost 10 years in patients with primary tumors; however, it was only 2 years in those with isolated metastatic tumors.

Primary Ewing's sarcoma of the cervical vertebra: one case report and literature review

Primary Ewing's sarcoma of the cervical vertebra is extremely rare. However, it is very important for radiologists to be aware of it to be able to provide timely diagnosis and therefore orient the treatment planning of the disease. The purpose of this study is to describe the imaging features of this tumor.

Imaging of back pain in children

While back pain presents less frequently in children than in adults, it still poses a significant clinical challenge with respect to making a firm diagnosis and developing an effective treatment plan. When children have back pain and medical attention is sought, an underlying pathology is usually suspected. Pediatric patients are evaluated, first, with a complete clinical history and examination and, second, by an imaging work-up that is based on initial findings, including the child's age and size, signs and symptoms, and suspected etiology. This article describes 1) the epidemiology of back pain in children, 2) the imaging work-up used, and 3) the correlation of imaging findings with disease entities that may cause back pain in the pediatric patient. The list of diseases giving rise to back pain is not meant to be exhaustive but rather reflective of the most commonly identified pathologies and disorders among young children and adolescents, from athletic injuries to lethal cancers.

Ewing and osteogenic sarcoma: evidence for multidisciplinary management

STUDY DESIGN

Systematic review of the literature and consensus recommendations by an international expert focus group.

OBJECTIVE

To review and classify evidence in the literature regarding: (1) the role of neoadjuvant chemotherapy and (2) impact of extent of surgical resection on clinical outcome, particularly survival and local control, in patients with spinal Ewing sarcoma (ES) and osteosarcoma (OS).

SUMMARY OF BACKGROUND DATA

ES and OS of the spine are currently managed with multimodality treatment involving chemotherapy, radiation therapy, and surgical resection. It is currently unclear if extent of resection, for example, intralesional resection versus marginal or wide resection has an impact on survival or local control of disease.

METHODS

A systematic literature search for the years 1960 to 2008 was performed looking at publications involving treatment of spinal ES and OS. From these 208 articles, 16 were selected for analysis and were reviewed in depth. Studies were presented to a group of spinal oncology experts. Literature was graded for quality, summarized and presented to an international expert group with consensus recommendations generated.

RESULTS

For ES of the spine, 10 studies were analyzed. For OS of the spine, 6 studies were analyzed. For both ES and OS of the spine, moderate level evidence supported a strong recommendation that neoadjuvant chemotherapy offers significant improvements in local control and long-term survival and is essential in multimodality management. For spinal ES, very low level evidence supported a weak recommendation that en bloc surgical resection provides improved local control, but not improved overall survival. Radiation therapy for spinal ES may also be used for local control either alone or to supplement incomplete resection. For spinal OS, very low evidence supported a strong recommendation that en bloc resection provides improved local control and potentially improved overall survival.

CONCLUSION

Patients with ES and OS are currently managed with multiple modalities involving surgery, radiation, and chemotherapy. For both histopathologies, advances in chemotherapy have led to the greatest improvements in survival over the last few decades. Neoadjuvant therapy portents the most favorable local control and long-term survival. En bloc surgical resection may improve overall survival and decrease risk of recurrence.

Primary pediatric intraspinal sarcomas. Report of 3 cases

Sarcomas that arise from within the spinal canal are rare, particularly within the pediatric population. In general, these primary intraspinal sarcomas are highly aggressive, posing unique treatment challenges with respect to surgery and choice of adjuvant therapy. The goal must be to obtain the most complete resection possible to minimize the risk of recurrence and metastasis, while preventing potential neurological deficits that may result from aggressive surgery. Among these primary intraspinal sarcomas are malignant peripheral nerve sheath tumors and members of the Ewing sarcoma family of tumors. The authors present 3 cases of unique spinal sarcomas in children-2 malignant peripheral nerve sheath tumors in patients without neurofibromatosis and an intradural extraosseous Ewing sarcoma arising from the sensory component of a lumbar spinal nerve-and discuss their management and outcome with a review of the current literature.

Primary Ewing sarcoma of the spine mimicking a psoas abscess secondary to spinal infection

STUDY DESIGN

A case of primary Ewing sarcoma of the lumbar spine is presented.

OBJECTIVE

To present and review a rare case of primary Ewing sarcoma of the lumbar spine that required differentiation from spinal infection.

SUMMARY OF BACKGROUND DATA

Primary Ewing sarcoma originating from the spinal column is very rare. Because Ewing sarcoma is one of the most aggressive bone tumors with high proliferative and invasive potential, its clinical symptoms and variety of imaging manifestations can mimic the pathologic findings of other diseases, including infectious diseases.

METHODS

The clinical course, radiologic features, pathology and treatment outcome of a patient with primary Ewing sarcoma of the lumbar spine was documented.

RESULTS

The magnetic resonance imaging findings showed an abnormal marrow signal at the L2 vertebra and significant enlargement of the unilateral iliopsoas muscle. Immunologic and molecular analysis of the surgical specimen provided a diagnosis of Ewing sarcoma. Laminotomy followed by multidisciplinary therapy including chemotherapy and radiation therapy was effective for treating this case.

CONCLUSION

We report a case of Ewing sarcoma that mimicked a psoas abscess secondary to spinal infection. Abnormal magnetic resonance imaging images, as well as a confusing clinical course, made diagnosis difficult. When enlargement of the iliopsoas with a vertebral lesion is detected in a child with low back pain, Ewing sarcoma should be included in the differential diagnosis.

Treatment of nonmetastatic Ewing's sarcoma family tumors of the spine and sacrum: the experience from a single institution

The objective of this study is to determine the best local treatment combined with neoadjuvant chemotherapy for ESFT of the spine and sacrum, for the best local treatment for Ewing sarcoma family tumors (ESFT) according to the primary site is still unclear. Nowadays surgery is used in local treatment of ESFT, but literature is scarce on the best local treatment in sites where surgery is problematic, such as the spine. This study evaluates the outcome and the rate of local recurrence of ESFT in the spine and sacrum when treated with neoadjuvant chemotherapy, and locally by radiotherapy alone or surgery, followed by reduced doses of radiotherapy. Forty-three patients with nonmetastatic ESFT located in the spine and sacrum were treated at our institution between 1983 and 2000 with neoadjuvant chemotherapy, and locally by radiotherapy alone in 26 cases, and surgery followed by radiotherapy at reduced doses in 17. The 5- and 10-year event-free survival (EFS) was 37 and 30%, and the 5- and 10-year overall survival was (OS) 42 and 32%. The prognosis was unrelated to gender and age, tumor volume, chemotherapy protocol, and local treatment. The outcome seemed worse for patients with primary tumors located in the sacrum than for patients with tumors located in the rest of the spine (5-year EFS = 23 vs. 46%). For these patients the results were significantly worse than for those we achieved with neoadjuvant treatment for ESFT located in other sites. However, no differences were observed between patients locally treated with radiotherapy alone and those treated by radiotherapy followed by surgery. We concluded that regardless of the type of local treatment even when associated with neoadjuvant therapy, ESFT in the spine and sacrum has a poor outcome and prognosis is significantly worse than that of primary ESFT in other sites.

STEREOTACTIC RADIOSURGERY FOR THE TREATMENT OF PRIMARY SARCOMAS AND SARCOMA METASTASES OF THE SPINE

OBJECTIVE

Spinal sarcomas pose unique treatment dilemmas because of the difficulty of achieving adequate surgical margins and/or delivering curative radiation doses (65 Gy) in close proximity to the spinal cord. This study used hypofractionated stereotactic radiosurgery (SRS) to deliver higher biologically effective doses to treat primary spinal sarcomas and spinal sarcoma metastases.

METHODS

Twenty-four patients with spinal or paraspinal sarcomas entered an Institutional Review Board-approved registry trial to evaluate SRS efficacy. They were assessed at regular intervals for pain control, disease progression, and complications for a minimum of 12 months or until death.

RESULTS

The median treatment dose for the spinal sarcoma lesions was 30 Gy at the 80% isodose in 3 fractions, with some variation based on tumor size, shape, and dose to adjacent critical structures. Seven patients were treated definitively; all had excellent pain relief and are alive with a mean follow-up period of 33 months. Two patients had complete tumor regression, 3 had partial regression, and 2 experienced recurrences and have been re-treated. Seven patients underwent resection and adjuvant SRS. One of 3 patients treated preoperatively had complete tumor regression, and none of the 4 patients treated postoperatively had a local recurrence with a mean follow-up period of 43.5 months. All 10 patients with sarcoma metastases to the spine (16 lesions) died, with a mean survival of 11.1 months from first spinal metastasis treatment. Complete pain relief was achieved in 8 patients, partial relief in 7 patients, and none in 1 patient. No patient developed radiation myelitis.

CONCLUSION

These preliminary results suggest that SRS may have a role in the definitive treatment of patients with primary spinal sarcomas who are deemed unresectable and as adjuvant treatment in those undergoing surgery and for palliation of sarcoma metastases.

Bone sarcoma of the spine

Primary malignant bone tumors of the vertebral column, i.e., bone sarcomas of the spine, are inherently rare entities. Vertebral osteosarcomas and chordomas represent the largest groups, followed by the incidence of chondro-, fibro-, and Ewing's sarcomas. Detailed clinical and neurological examination, complete radiographic imaging [radiographs, computed tomography (CT), magnetic resonance imaging (MRI)], and biopsy are the decisive diagnostic steps. Oncosurgical staging for spinal tumors can serve as a decision-guidance system for an individual's oncological and surgical treatment. Subsequent treatment decisions are part of an integrated, multimodal oncological concept. Surgical options comprise minimally invasive surgery, palliative stabilization procedures, and curative, wide excisions with complex reconstructions to attain wide or at least marginal resections. The most aggressive mode of surgical resection for primary vertebral column tumors is the total en bloc vertebrectomy, i.e., single- or multilevel en bloc spondylectomy. En bloc spondylectomy involves a posterior or combined anterior/posterior approach, followed by en bloc laminectomy, circumferential (360 degrees) vertebral dissection, and blunt ventral release of the large vessels, intervertebral discectomy and rotation/ en bloc removal of the vertebra along its longitudinal axis. Due to the complex interdisciplinary approach and the challenging surgical resection techniques involved, management of vertebral bone sarcomas is recommended to be performed in specific musculoskeletal tumor centers.

Primary malignant tumors of the spine

Primary malignant tumors of the spine account for less than 5% of primary bone tumors. Data from the SEER program suggest that the most common bone sarcomas are osteosarcoma, chondrosarcoma, Ewing's sarcoma, chordoma, and malignant fibrous histiocytoma/fibrosarcoma. During the last two decades, tremendous progress has been made in clinical aspects, surgical approaches, and reconstruction with instrumentation at all levels of the spine. Stabilization procedures, including vertebroplasty and kyphoplasty, have further allowed palliation of pain and symptom relief from compression fractures. Improved radiation techniques have offered the potential for improved local control. This article reviews the changes in surgical philosophy in the management of malignant spinal tumors during the past two decades.

Surgical management of primary and metastatic sarcoma of the mobile spine

Object

Sarcomas of the spine are a challenging problem due to their frequent and extensive involvement of multiple spinal segments and high recurrence rates. Gross-total resection to negative margins, with preservation of neurological function and palliation of pain, is the surgical goal and may be achieved using either intralesional resection or en bloc excision. The authors report outcomes of surgery for primary and metastatic sarcomas of the mobile spine in a large patient series.

Methods

A retrospective review of patients undergoing resection for sarcomas of the mobile spine between 1993 and 2005 was undertaken. Sarcomas were classified by histology study results and as either primary or metastatic. Details of the surgical approach, levels of involvement, and operative complications were recorded. Outcome measures included neurological function, palliation of pain, local recurrence, and overall survival.

Results

Eighty patients underwent 110 resections of either primary or metastatic sarcomas of the mobile spine. Twenty-nine lesions were primary sarcomas (36%) and 51 were metastatic sarcomas (64%). Intralesional resections were performed in 98 surgeries (89%) and en bloc resections were performed in 12 (11%). Median survival from surgery for all patients was 20.6 months. Median survival for patients with a primary sarcoma of the spine was 40.2 months and was 17.3 months for patients with a metastatic sarcoma. Predictors of improved survival included a chondrosarcoma histological type and a better preoperative functional status, whereas osteosarcoma and a high-grade tumor were negative influences on survival. Multivariate analysis showed that only a high-grade tumor was an independent predictor of shorter overall survival. American Spinal Injury Association scale grades were maintained or improved in 97% of patients postoperatively, and there was a significant decrease in pain scores postoperatively. No significant differences in survival or local recurrence rates between intralesional or en bloc resections for either primary or metastatic spine sarcomas were found.

Conclusions

Surgery for primary or metastatic sarcoma of the spine is associated with an improvement in neurological function and palliation of pain. The results of this study show a significant difference in patient survival for primary versus metastatic spine sarcomas. The results do not show a statistically significant benefit in survival or local recurrence rates for en bloc versus intralesional resections for either metastatic or primary sarcomas of the spine, but this may be due to the small number of patients undergoing en bloc resections.

Primary Ewing sarcoma of lumbar spine with massive intraspinal extension

Primary vertebral Ewing sarcoma-primitive neuroectodermal tumor is uncommon. Although epidural extension has been seen in such tumors, cases with massive intraspinal involvement are decidedly rare. Here we present the case of a 4-year-old girl with back pain and difficulty walking. Magnetic resonance imaging showed a mass filling the spinal canal from T(11) to the L(3)/L(4) levels. Vertebral involvement with extension into the paraspinal soft tissue through neural foramina was seen. Histologically, a small-blue-cell tumor with strong membranous CD99 reactivity was noted. Molecular analysis revealed translocation t(11;22)(q24;q12), thus confirming the diagnosis of Ewing sarcoma-primitive neuroectodermal tumor. Our case emphasizes that vertebral Ewing sarcoma-primitive neuroectodermal tumor may present with massive intraspinal extension and should be included in the differential diagnosis of intraspinal lesions.

Surgical management of spinal mesenchymal tumors

Primary and metastatic spinal mesenchymal tumors are uncommon lesions. Surgical management of these tumors remains a challenge. En bloc wide resection provides the best chance for local tumor control and long-term survival. However, limitations to this technique include technical considerations (including neurovascular anatomy), patient selection, and tumor histology. Intralesional resection provides good neurologic outcomes, but local recurrence rates are high. Postoperative adjuvant chemotherapy with or without radiation may help to delay recurrence and improve outcomes. We present three cases of our surgical experience with spinal mesenchymal tumors for illustrative purposes.