Imaging findings of Ewing's sarcoma in the mandible

Ewing's Sarcoma of Mandible: A Case Report with Review of Literature

Background

Ewing sarcoma (ES), a rare malignancy, comprises whatever the age, 4-15% of all primary bone tumors. It represents 1% of all malignant tumors in children and is the fourth most common bone malignancy after myeloma, osteosarcoma, and chondrosarcoma.

Case description

A 12-year-old boy came to the Oral Surgery Department of Bretonneau Hospital referred by his dentist with a rapidly evolving swelling in the left mandibula for 6 weeks, which was initially diagnosed as a facial cellulitis. Cone beam computed tomography (CBCT) showed a poorly defined, expansile, and osteolytic tumor on the left side of the mandible. Clinical and radiographic findings were in favor of an aggressive primitive bone tumor. A mandibular biopsy under general anesthesia was performed in the Department of Surgical Oncology at Institut Curie in Paris, revealing an ES.

Conclusion

Mandibular ES can mimic dental infections when swelling is the main clinical manifestation, which can lead to a delayed diagnosis. A correlation between clinical, radiological, histopathological, and immunohistochemical with cytogenetics is needed to confirm the diagnosis. Moreover, smaller tumors have better survival.Dentists must therefore be aware of the clinical signs of ES in order to quickly refer patients to a specialized department.

How to cite this article

Bellut N, Lutz CM, Lesnik M, et al. Ewing's Sarcoma of Mandible: A Case Report with Review of Literature. Int J Clin Pediatr Dent 2024;17(2):187-190.

A rare case of Ewing's sarcoma of the maxillary sinus

Ewing's sarcoma is generally an aggressive, poorly differentiated bone and soft tissue tumor affecting children and young adults, it accounts for 4%-6% of all primary bone tumors and primary facial locations occur in only 1%-4% of all cases, primarily in the mandible and calvaria. Involvement of the paranasal sinuses is rare. Here we report the case of an 11-year-old girl with no medical, surgical, or traumatic history, who presented for 1 month and progressive evolution of swelling of the left cheek, associated with pain, nasal obstruction, rhinorrhea, and a slight weight loss not quantified. A craniofacial computed tomography (CT) scan showed a mixed lytic and condensing lesional tissue process centered on the left maxillary sinus, heterogeneously enhanced after contrast injection, lysing the walls of the sinus extended to the homolateral nasal cavity and slightly infiltrating the adjacent soft tissues. An incisional biopsy was performed and the pathological study proved that it was Ewing's sarcoma. She was put on neoadjuvant chemotherapy using 6 courses of vincristine, doxorubicin, ifosfamide, etoposide which resulted in a partial regression of the tumor size by 50%. Then the patient was put on combined chemotherapy and radiotherapy. A follow-up CT scan after 6 courses of vincristine, actinomycin, cyclophosphamide, and 17 sessions of radiotherapy showed lesion stability. Maxillary Ewing's sarcoma is a rare and aggressive tumor. Therefore, early diagnosis, combination therapy, and long-term follow-up are suggested in such cases to improve the survival rate.

A Pattern-based Imaging Approach to Pediatric Jaw Lesions

Jaw lesions in the pediatric population, although infrequently encountered in clinical practice, can cause functional impairment and cosmetic disfiguring. It is further complicated by the difficulty in diagnosis due to complex anatomy and facial developmental process during infancy and childhood. Intraosseous pediatric jaw lesions may vary from odontogenic to nonodontogenic types with nonspecific clinical features in most cases. They deserve careful attention by a systematic approach to provide a relevant diagnosis or differential diagnosis for timely management. Imaging plays a major role in diagnosis with orthopantomograph being the foremost investigation, followed by cross-sectional imaging, essentially computed tomography as a problem-solving tool. This article highlights the imaging spectrum of various jaw lesions in the pediatric population with a pattern-based approach for radiological diagnosis.

The oral surgeon in the front-line of the diagnosis of Ewing sarcoma: a case report

Introduction: Ewing's sarcoma is a primary malignant bone tumor that affects children and young adults. In rare cases, it affects the bones of the face. The diagnosis is difficult because signs are non-specific. Positive diagnosis is based on a cytogenetic examination showing a specific translocation of the EWS gene. Treatment involves a sequence including chemotherapy, oncological surgery and radiotherapy. Observation: The case presented is that of a 4-year old girl initially sent for suspicion of dental cellulitis. On clinical examination, she had recent mandibular dental mobility and a gingival mucosa swelling. Signs of bone lysis interesting the mandibular symphysis was observed on the orthopantomogram. She had no pain or symptoms indicating neoplasia. This atypical situation led to a bone biopsy who revealed the diagnostic of mandibular Ewing's sarcoma. A suitable medical care in a specialized unit was able to be started without delay. Discussion: The literature reports other cases also wrongly diagnosed as an infectious pathology of dental origin. Conclusion: This case shows that the diagnosis of mandibular Ewing's sarcoma must be evoked in front of any atypical mandibular lesion of the child, regardless of his age or sex. Physicians and dental surgeons specialized in oral surgery are then in the foreground to help establish early diagnosis and ensure rapid management by limiting the functional and aesthetic sequelae related to localization.

Ewing's Sarcoma of the maxillofacial region: A case report

Ewing's sarcoma (ES) is an uncommon malignancy, especially in the head and neck region, with only 30 cases reported so far. The mandible is more affected than the maxilla. It represents the most frequent small round cell bone tumor of childhood and adolescence. This report presented a case of 19-year-old male with primary ES in the right side of maxilla, maxillary sinus, zygoma and temporal fossa areas. The clinical, radiographic, histopathologic features and main histopathologic differential diagnosis of ES were reviewed to avoid potential diagnostic pitfalls.

Ewing's Sarcoma Family Tumors in the Jaws: Case Report, Immunohistochemical Analysis and Literature Review

Due to the low incidence of the Ewing's Sarcoma (ES) family tumors, the available epidemiology is likely to be unreliable, and at present, there are no standard diagnostic or clinical guidelines outlining their management. This report describes a case of peripheral primitive neuroectodermal tumor (ES/pPNET) which initially mimicked cystic lesions, and describes a comparison between ES and ES/pPNET in the jaws by the World Health Organization classification. This review addressed 63 cases published in the English literature between 1950 and 2016. The majority of cases were ES. Both ES and ES/pPNET mimicked other benign entities such as traumatic, cystic and inflammatory lesions. The patients who died of their disease had a history of metastatic tumors, and primary tumor located in the mandible and maxilla for ES and ES/pPNET, respectively. The differentiation of the ES family tumors from other small blue-cell tumors may be difficult and requires familiarity with histological and immunohistochemical features.

Ewing sarcoma of the oral cavity. A review

Objectives

A review is made of the clinical, diagnostic, therapeutic and survival characteristics of Ewing sarcoma (ES) of the oral cavity.

Material and Methods

A systematic literature search was carried out, with restrictions referred to time (1960-2014), language (English and Spanish) and type of study (case reports, letters, datasets, reviews). The following MeSH terms and boolean operators were used: Ewing AND Sarcoma AND [tongue, jaw, maxilla, cheek, condyle OR temporomandibular, floor AND mouth, gum OR gingiva, palate OR palatal, lip, uvula, head AND neck].

Results

Seventy-one cases of ES of the oral cavity were documented from 53 articles. The main differences versus ES of other locations were a younger age at manifestation, a shorter time from symptoms onset to diagnosis, and swelling as the most frequent clinical manifestation versus swelling and pain in the rest of disease locations. The way in which ES manifests in the oral cavity is varied and comprises dental displacement (19.7%), dental mobility (7%), root reabsorption (5.6%), destruction of the dental follicle (4.2%), premature exfoliation (4.2%) and paresthesia of the chin (2.8%). Metastatic neck adenopathies appear in 11.3% of the cases. Significant differences in survival are observed between patients with a complete diagnosis of ES (hematoxylin-eosin staining, PAS positivity, CD99 positivity) and those with an incomplete diagnosis.

Conclusions

Ewing sarcoma of the oral cavity presents a series of specific features that distinguish it from ES of other locations.

Key words:Primitive neuroectodermal tumor, PNET, Ewing sarcoma, Ewing tumor, sarcoma, oral cavity.

Ewing's Sarcoma of Mandible: An Impressive Case of Spontaneous Mandible Regeneration

Ewing's sarcoma (ES) is an uncommon aggressive bone malignancy that mainly affects children and adolescents. Mandible involvement is quite rare and usually represents metastasis from another skeletal site. Combined therapy including wide surgical resection and preoperative and postoperative chemotherapy has been demonstrated as the mainstay of therapeutic approach. As improved therapeutic modalities have significantly increased survival over the last decades, functional and esthetic reconstruction of the postmandibulectomy defect is usually necessary for patient's total rehabilitation. We report a case of ES of the mandible with special consideration to the postresection spontaneous structural and functional regeneration of the mandible.

HOW TO CITE THIS ARTICLE

Chatzistefanou I, Kabesi S, Paraskevopoulos K, Koliouskas D, Antoniades K. Ewing's Sarcoma of Mandible: An Impressive Case of Spontaneous Mandible Regeneration. Int J Clin Pediatr Dent 2016;9(3):273-277.

Goldenhar Syndrome: A Case Report with Review

Goldenhar syndrome is a rare condition which is characterized by a multitude of anomalies involving craniofacial structures, vertebrae, internal organs and usually occurs unilaterally. The etiology of this syndrome is unclear since it varies genetically and is linked to a plethora of reasons. Herein, we report a case of Goldenhar syndrome with hemifacial microsomia and microtia along with systemic involvement which was clinically and radio-graphically assessed. Many classical signs of the syndrome were present in the patient along with few rare ones. The various aspects of this rare disease have been discussed with emphasis on timely diagnosis and multidisciplinary approach to manage it.

HOW TO CITE THIS ARTICLE

Goswami M, Bhushan U, Jangra B. Goldenhar Syndrome: A Case Report with Review. Int J Clin Pediatr Dent 2016;9(3):278-280.

Multimodality Treatment in Ewing's Sarcoma Family Tumors of the Maxilla and Maxillary Sinus: Review of the Literature

The Ewing sarcoma family of tumors (ESFT) encompasses a group of highly aggressive, morphologically similar, malignant neoplasms sharing a common spontaneous genetic translocation that affect mostly children and young adults. These predominantly characteristic, small round-cell tumors include Ewing's sarcoma of the bone and soft tissue, as well as primitive neuroectodermal tumors (PNETs) involving the bone, soft tissue, and thoracopulmonary region (Askin's tumor). Extraosseous ESFTs are extremely rare, especially in the head and neck region, where literature to date consists of sporadic case reports and very small series. We hereby present a review of the literature published on ESFTs reported in the maxilla and maxillary sinus region from 1968 to 2016.

Pure Erythroid Leukemia Mimicking Ewing Sarcoma/Primitive Neuroectodermal Tumor in an Infant

Pure erythroid leukemia (PEL) is a rare type of acute myeloid leukemia (AML) with a very aggressive clinical course. Presentation as a myeloid/erythroid sarcoma is exceedingly rare. We describe an infantile PEL presenting as a multifocal myeloid sarcoma, clinically and pathologically mimicking Ewing sarcoma/PNET family of tumors. The patient died 8 weeks after the initial presentation due to widespread disease. Our case shows that PEL needs to be considered in the differential diagnosis of small round blue cell tumors in infancy. A meticulous workup including immunohistochemistry, flow cytometry, molecular, and cytogenetic studies was required to reach the diagnosis.

Ewing's Sarcoma Localized in the Mandible: A Case Report

Ewing's sarcoma is one of the most aggressive primary bone tumours. Ewing's sarcoma arising from the bones of the head and neck region is extremely rare; only 4-9% of all Ewing's sarcoma originate in this region. We report a case of Ewing's sarcoma localized in the mandible because of its unusual presentation.

Ewing's sarcoma of maxilla: A rare case report

Ewing's sarcoma is uncommon malignancy of childhood, frequently involving the mandible. The occurrence in maxilla is rare. It is histopathologically characterized by sheets of round cells positive for CD99. Although the prognosis is poor but early diagnosis and long term follow up can improve the survival.

This article presents a rare case of Ewing's sarcoma of maxilla in a 15 year old male patient showing excessive fibro-osseous response which is not a frequent presentation. A retrospective analysis of cases of Ewings sarcoma of maxilla published in the English litreture is reviewed. In our case, diagnosis was confirmed by immunohistochemistry where sheets of round tumor cells were positive for CD 99. Ewings sarcoma of maxilla is a rare and aggressive tumor. Hence early diagnosis, combined therapy and long term follow up is suggested in such cases.

Ewing's sarcoma in mandibular similar to dental abscess

Ewing's sarcoma is a rare malignant neoplasm that comprises approximately 4-6% of primary bone tumors. In most cases, femur and pelvis are affected, and less commonly the head and neck areas (in the jaws, usually the mandible). These tumors have been reported more frequently in males, mostly aged 5-20 years old.

Systemic symptoms and signs such as fever, weight loss, anemia, leukocytosis, and elevated erythrocyte sedimentation rate (ESR) may be the first signs in oral Ewing's sarcoma. Such signs and symptoms are also seen in odontogenic infections and abscess. In one case, the patient went to a dentist with pain, swelling, and abscess similar to odontogenic infection and patient's tooth was pulled due to misdiagnosis. This tumor has an aggressive clinical behavior and is identified with rapid growth and high probability of metastasis at diagnosis. Thus, it is necessary to differentiate it from a dental abscess. As for the treatment of Ewing's sarcoma, first the tumor must undergo chemotherapy to reduce its size and, eventually, it undergoes extensive surgery.

This case report deals with a 16-year-old patient wrongly diagnosed with odontogenic infection and abscess, and hospitalized. As the symptoms did not remit, biopsy was carried out and the patient was operated on with Ewing's sarcoma diagnosis.

A Radiological Review of Ewing's Sarcoma of Mandible: A Case Report with One Year Follow-up

Ewing's sarcoma (ES) is an uncommon round cell tumor with an aggressive course affecting mainly children and young adults. Only 1% of cases is reported with jaw involvement and have mandibular predilection. Radiographic finding in ES reflect many destructive nature of the lesion, like osteolysis, cortical erosion, periostitis and soft tissue mass. A case of ES of the mandible is reported with special consideration to the radiological appearance.

How to cite this article: Krishna KBB, Thomas V, Kattoor J, Kusumakumari P. A Radiological Review of Ewing's Sarcoma of Mandible: A Case Report with One Year Follow-up. Int J Clin Pediatr Dent 2013;6(2):109-114.

Anatomy and pathology of the masticator space

Objective

This article reviews and illustrates the anatomy and pathology of the masticator space (MS).

Background

Pathology of the masticator space includes inflammatory conditions, vascular lesions, and tumours. Intrinsic tumours of this space can be benign and malignant, and they may arise from the mandibular ramus, the third division of the trigeminal nerve, or the mastication muscles. Malignant tumours may appear well defined and confined by the masticator fascia, without imaging signs of aggressive extension into neighbouring soft tissues. Secondary invasion of the masticator space can also occur with tumours of the nasopharynx, oropharynx, oral cavity, and parotid glands. Perineural tumour spread (PNS), especially along the trigeminal nerve, can also occur with masticator space malignancies.

Conclusion

Masses of the MS are difficult to evaluate clinically, and computed tomographic (CT) and magnetic resonance (MR) images are essential for the diagnosis and characterisation of these lesions. Malignant tumours may appear well defined and confined by the fascia. Thus, when a mass is identified, a biopsy should be done promptly. PNS may occur in tumours involving the MS and its recognition on imaging studies is essential to plan the appropriate treatment.

Teaching points

• Differentiating between intrinsic and extrinsic lesions is essential to the differential diagnosis

• Infections of the MS may cross the fascia and mimic neoplasms on imaging studies

• Malignant tumours may show no aggressive signs, such as bone erosion or violation of the fascia

• Perineural spread (PNS) is often clinically silent and frequently missed at imaging and leads to tumour recurrence

[Importance of SPECT/CT for resolving diseases of the jaw]

CLINICAL/METHODICAL ISSUE

Diseases of the jaw, such as osteomyelitis, condylar hyperactivity and tumors need adequate imaging to evaluate the extension and activity for therapy planning.

STANDARD RADIOLOGICAL METHODS

Conventional planar scintigraphy, orthopantomography, computed tomography (CT) and magnetic resonance imaging (MRI) can be used for the evaluation of jaw diseases.

METHODICAL INNOVATIONS

Single photon emission computed tomography/computed tomography (SPECT/CT) provides metabolic and morphologic information in one imaging step and is becoming increasingly more available in larger hospitals.

PERFORMANCE

The SPECT/CT is superior to planar scintigraphy alone, CT and orthopantomography in the evaluation of the extension and activity of osteomyelitis and jaw tumors.

ACHIEVEMENTS

In our hospital SPECT/CT has replaced the other imaging modalities in the evaluation of osteomyelitis and condylar hyperactivity.

PRACTICAL RECOMMENDATIONS

If available SPECT/CT should be performed for the evaluation of osteomyelitis of the jaw.

Ewing's sarcoma of the mandible

Ewing's sarcoma is a malignant tumor of bones that primarily affects children and young adults. The true origin of this small round cell lesion still remains controversial. It was originally described by James Ewing in 1921 as arising from undifferentiated osseous mesenchymal cells; however, recent studies suggest that Ewing's tumor might be neuroectodermally derived from various degrees of differentiation of the primitive neural tissues. This paper reports a rare case of ES of the mandible in an 11-year-old girl, which had been previously misdiagnosed and treated as a dental abscess. In the clinical examination, a hard immobile expansive mass of 2 cm diameter was observed on the left side of the mandible. Radiographic examination revealed a diffuse radiolucent lesion with ill-defined borders and wide vestibular bone plate destruction. Microscopically, the tumor was composed by monotonous small round cells that exhibited immunoreactivity for CD99, vimentin and desmin. Surgical resection of mandible followed by mandibular reconstruction was adopted. The patient was subjected to multiagent chemotherapy with Vincristine [VC], Dactinomycin [AC], Cyclophosphamide [CP] and Doxorubicin [AD]).

Mis- or Missed Diagnosis: A Series of Four Cases

Diagnosis forms the backbone of treatment planning. Accurate diagnosis is essential to initiate the appropriate treatment at the apt time. Diagnosis involves eliciting the signs and symptoms of the patient and their accurate interpretations. The subtle signs that can go unnoticed lead to misdiagnosis and subsequent agony to the patient. Alertness on part of the clinician is important to avoid this error. Reported in this paper are four cases that were wrongly diagnosed either due to lack of clinical experience or due to omission of careful clinical, radiographic, and histopathological examinations.

Therapy and outcome of primitive neuroectodermal tumor of the jaw

Data pertaining to outcomes in jaw primitive neuroectodermal tumor (PNET) are lacking. Eleven cases of jaw PNET (five maxillary and six mandibular) were treated at our cancer center with the same chemotherapeutic agents from June 2003 to January 2009. Four patients underwent surgery after neoadjuvant chemotherapy and all received local radiotherapy. At median follow-up of 56 months (range: 19-77 months), 7/11 patients are in sustained remission. There was no difference in outcome with respect to site of tumor, and whether surgery was performed or not. These results support the use of chemoradiation as initial modality of treatment rather than going for extensive and mutilating surgery.

Ewing's sarcoma of the mandible in a young child

Ewing's sarcoma (ES) is a malignancy primarily affecting bone tissue that is commonly diagnosed in adolescents and young adults. Its occurrence in the head and neck region is unusual and generally involves the mandible and maxilla. An extensive review of the literature shows only few cases of the oral ES in patients under the age of 5. This paper reports a rare case of ES of the mandible in a 4-year-old girl, which had been previously misdiagnosed and treated as a dental abscess. In the clinical examination, a hard immobile expansive mass of 5 cm in diameter was observed on the left side of the mandible. Radiographic examination revealed a radiolucent lesion with ill-defined borders and wide vestibular bone plate destruction. Microscopically, the tumor was composed by monotonous small round cells that exhibited immunoreactivity for CD99, vimentin and pancytokeratin. The patient was subjected to multiagent chemotherapy with ifosfamide, carboplatin, etoposide, vincristine, cyclophosfamide and doxorrubycin (VAC/ICE regimen). However, after the first chemotherapeutic cycle, the patient died due to disseminated infection. This case elucidates the importance of professional knowledge of the relevant aspects of malignant lesions such as ES.

Ewing sarcoma of the mandible mimicking an odontogenic abscess - a case report

Ewing sarcoma (ES) of the mandible is rare and can be mistaken for inflammation of dental origin. We present a 24-year old male patient which underwent radical tumour surgery and primary reconstruction with a microvascular osteoseptocutaneous free fibular flap as well as postoperative adjuvant chemotherapy. Incomplete osseous tumour resection required a second intervention. This case report recapitulates the clinical and histopathological findings in oral ES, demonstrates its sometimes difficult diagnosis and discusses the (dis-)advantages of primary osseous reconstruction in ablative tumour surgery.