Cooperative Ewing's Sarcoma Studies 81/86: pathologico-anatomic and immunohistochemical findings and differential diagnosis of Ewing sarcoma

158 cases of the Cooperative Ewing's Sarcoma Trials (CESS 81/86), which have been documented at the Pediatric Tumor Registry, Kiel, were studied by conventional light microscopy and immunohistochemistry. There were 77 cases of typical Ewing's sarcoma with 70 cases being located in the skeleton and 7 in soft tissues. Of the 14 cases of atypical Ewing's sarcoma 7 cases each were localized in bone and in soft tissue, respectively. In contrast to typical Ewing's sarcoma, cells of atypical Ewing's sarcoma were larger and displayed more heterochromatin. Both, typical and atypical Ewing's sarcoma reacted positively for vimentin. Other stains were negative, notably the neuron specific enolase (NSE). In 55 cases a diagnosis of malignant peripheral neuroectodermal tumor (MPNT) was made. Histologically most of these tumors resembled atypical Ewing's sarcoma. By immunohistochemistry positive reactions were found for NSE, vimentin, protein S-100, neurofilaments and glial fibrillary acidic protein. In 3 cases a diagnosis of small cell osteosarcoma was made. There were 2 cases of undifferentiated sarcoma of bone, 2 cases of soft tissue sarcoma of undetermined histogenesis and 2 cases of rhabdomyosarcoma. Of the 4 tumors which could be investigated for response to polychemotherapy, 1 each corresponded to grade II and III, respectively, and 2 to grade IV according to the classification of histologic grade of regression established by Salzer-Kuntschik et al. (1983).     

Monoclonal antibody MB2: a potential marker for Ewing's sarcoma and primitive neuroectodermal tumor

The small round-cell tumors of childhood present difficulties in diagnosis when differentiation is not apparent. Immunohistochemistry is helpful; however, the only antigen consistently detected in Ewing's sarcoma is vimentin, which may also be detected in the other types of small-cell neoplasms. The monoclonal antibody (MAb) MB2 is marketed as a B-lymphocyte marker that can be used on paraffin-embedded tissue. To determine its specificity, we performed immunohistochemical staining on pediatric tumors with MB2. These included 55 cases of small round-cell tumors (lymphomas, Ewing's sarcoma, peripheral primitive neuroectodermal tumors [PNET], neuroblastomas, rhabdomyosarcomas, and nephroblastomas). MB2 positivity was detected in all B-cell lymphomas and in seven of nine cases of Ewing's sarcoma and three PNET. In neuroblastomas only differentiating ganglion cells were positive. In rhabdomyosarcomas only large rhabdomyoblasts were positive. Blastema of nephroblastomas was negative. Thus, in cases of poorly differentiated small round-cell tumors, MB2 was positive in all B-cell lymphomas, most Ewing's sarcomas and all cases of PNET. Lymphomas were distinguished by staining for leukocyte-common antigen and PNET by neuron-specific enolase. Therefore, the addition of MB2 to a discrete panel of antibodies may prove useful in the diagnosis of Ewing's sarcoma and PNET.     

Magnetic resonance imaging of primary orbital Ewing's sarcoma

The authors describe the MRI findings of a primary orbital Ewing's sarcoma in a 5-year-old boy, who underwent an extensive tumour surgery as these findings were mistaken for more chemoresistant sarcomas such as rhabdomyosarcoma. This case illustrates the fact that MR findings of primary orbital Ewing's sarcoma may be different from those of Ewing's sarcoma present elsewhere in the body. An accurate preoperative diagnosis may therefore result in a more conservative approach and prove extremely useful in such tumours.     

Monoclonal Antibody MB2: a Potential Marker for Ewing's Sarcoma and Primitive Neuroectodermal Tumor

The smalt round-cell tumors of childhood present difficulties in diagnosis when differentiation is not apparent. Immunohistochemislry is helpful; however, the only antigen consistently detected in Ewing's sarcoma is vimentin, which may also he detected in the other types of small-cell neoplasms. The monoclonal antibody (MAb) MB2 is marketed as a B-lymphocyte marker that can be used on paraffin-embedded tissue. To determine its specificity, we performed immunohistochemical staining on pediatric tumors with MB2. These included 55 cases of small round-cell tumors (lymphomas, Ewing 's sarcoma, peripheral primitive neuroectodermal tumors [PNET], neuroblastomas, rhabdomyosarcomas, and nephroblastomas). MB2 positivity was detected in all B-cell lymphomas and in seven of nine cases of Ewing's sarcoma and three of three PNET. In neuroblastomas only differentiating ganglion cells were positive. In rhabdomyosarcomas only large rhabdomyoblasls were positive. Blastema of nephroblastomas was negative. Thus, in cases of poorly differentiated small round-cell tumors, MB2 was positive in all B-cell lymphomas, most Ewing's sarcomas and all cases of PNET. Lymphomas were distinguished by staining for leukocyte-common antigen and PNET by neuron-specific enolase. Therefore, the addition of MB2 to a discrete panel of antibodies may prove useful in the diagnosis of Ewing's sarcoma and PNET.     

Leydig cell tumor after treatment for Ewing's sarcoma

Leydig cell tumors account for 3% of testicular tumors and have never been reported after treatment for Ewing's sarcoma. We report the unusual occurrence of a patient who developed a Leydig cell tumor of the testis 18 years after successful treatment for Ewing's sarcoma. Additional monitoring for second malignancies may become appropriate as long-term survival continues to improve for patients with Ewing's sarcoma.     

Cushing's syndrome caused by Ewing's sarcoma secreting corticotropin releasing factor-like peptide.

Procedures were carried out in a 12-year-old girl to relate Ewing's sarcoma of the left tibia with Cushing's syndrome. Computed tomography revealed a normal pituitary and hypothalamus but bilateral adrenal hyperplasia without focal enlargement, thus readily excluding hypothalamic-pituitary-adrenal tumor. Negative results from a high-dose dexamethasone suppression test do not support pituitary-dependent Cushing's disease. Ewing's sarcoma was diagnosed on tibial biopsy. The regression of the physical and biochemical findings of Cushing's syndrome subsequent to amputation of the left lower leg strongly suggests ectopic Cushing's syndrome caused by Ewing's sarcoma. Immunohistochemical studies of the resected bone were negative for corticotropin but positive for corticotropin releasing factor-like peptide. We conclude that this is the first reported case of ectopic Cushing's syndrome in a child that is caused by Ewing's sarcoma secreting corticotropin releasing factor-like peptide.     

Improved detection of metastatic Ewing's sarcoma with the use of bone marrow scintigraphy

Prognosis in Ewing's sarcoma is inversely related to the extent of the disease at the time of presentation. The most common sites of metastases are the lungs and skeleton. Bone marrow metastases may be present but clinically silent. We report the use of Technetium (Tc)-99m bone marrow scintigraphy to detect sites of marrow involvement by metastatic Ewing's sarcoma. This method of evaluation allowed identification of sites of involvement by Ewing's sarcoma that were not available by any other method of evaluation. In several instances, information provided by this method was pivotal in the management of these patients. Based on this small series of patients, bone marrow scintigraphy appears to be a sensitive modality in the detection of metastatic disease in patients with Ewing's sarcoma. Better understanding of the role of bone marrow scanning and its correlation with other diagnostic procedures in Ewing's sarcoma will require further study.     

Resection of a primarily inoperable Ewing's sarcoma of the pelvis (author's transl)

A primarily inoperable Ewing's sarcoma in a 10 yrs. old boy arising from the pelvis was totally resected following preoperative T-6 chemotherapy and radiotherapy. A new approach to the treatment of Ewing's sarcoma is discussed.     

Megachemotherapy followed by autologous stem cell transplantation in children with Ewing's sarcoma

Twenty-one children with high-risk Ewing's tumor received high-dose chemotherapy with a PBSCT. Aim of the study was evaluation of efficiency and safety of this procedure. All but three patients have meta-static disease at presentation. There were 11 females and the median age at diagnosis was 12 yr (range 4.5-18 yr). Megachemotherapy consisted of melphalan 140 mg/m2/busulfan 16 mg/kg in 12 patients, melphalan 140 mg2/treosulfan 10.0 g/m2 in two patients and melphalan with other drugs in seven patients. Eight of 11 patients transplanted in CR survived with a median follow-up 24 month (range 14-60) and probability of 2-year OS is 0.68 and DFS is 0.63. There was no severe regimen-related toxicity in this group. Children transplanted without remission died: Two of them due to transplant related causes and eight had progression of disease in a median time 7 month after PBSCT. Megachemotherapy with PBSCT is a safe procedure in children with Ewing's sarcoma in remission. Autologos transplantation in children with metastatic Ewing's sarcoma seems to improve their outcome. Patients with Ewing's sarcoma, resistant to conventional therapy and with recurrent disease did not benefit from megachemotherapy. New approaches such as anti-tumor vaccination or using of imatinib are reasonable to introduce in patients with relapsed or resistant to therapy Ewing's tumor.     

Acute nonlymphocytic leukemia developing during the course of Ewing's sarcoma

Two children with Ewing's sarcoma developed acute nonlymphocytic leukemia (ANLL) during the course of their illness. One patient developed ANLL after apparently successful treatment of his primary malignancy with radiation therapy and multiagent chemotherapy. In the second patient, acute leukemia developed before the administration of radiotherapy or systemic chemotherapy. The development of secondary ANLL after Ewing's sarcoma has been reported only twice previously, most likely representing a therapy-induced complication. The occurrence of ANLL in Patient 2 prior to therapy suggests that these two disorders may have a more than treatment-related association. Close follow-up of long-term survivors of Ewing's sarcoma with surveillance for secondary acute leukemia is advised.     

High-dose melphalan therapy for the treatment of children with refractory neuroblastoma and Ewing's sarcoma

Neuroblastoma and Ewing's sarcoma are examples of pediatric cancers in which disseminated disease is often present at diagnosis or develops later in spite of combination therapy. The demonstration that marrow-ablative doses of chemotherapy can increase tumor cell kill, and that autologous bone marrow can be cryopreserved and reinfused into the patient to reverse such marrow ablation, has stimulated interest in this approach to refractory childhood cancers. We present results of treating eighteen patients with recurrent neuroblastoma and Ewing's sarcoma resistant to conventional therapy. We used supralethal doses of melphalan, supported by reinfusion of previously cryopreserved autologous bone marrow. Seven of 10 neuroblastoma and six of eight Ewing's sarcoma patients had complete or partial responses, lasting for a median of 6 months (neuroblastoma) and 3 months (Ewing's sarcoma). Prolonged hospitalization, pancytopenia complicated by sepsis, and reversible gastrointestinal toxicity were the major side effects. These results suggest this approach should be tested in therapeutic trials at an earlier disease stage in children who have cancers with a predictably bad prognosis.     

缺氧反应元件增强单纯疱疹病毒胸苷激酶/GCV对乏氧环境Ewing肉瘤细胞杀伤作用的研究

目的 构建一种由缺氧反应元件（hypoxia responsive element,HRE）调控的单纯疱疹病毒胸苷激酶（herpes simplex virus-thymidine kinase,HSV-TK）基因的真核表达载体,观察HRE能否增强HSV-TK／GCV（gancyclovir,GCV）系统对乏氧环境中的人Ewing’s肉瘤细胞系SK-ES细胞的杀伤作用,为弥补放、化疗的不足,探索有效的治疗方法。方法 （1）将合成的HRE片断,插入到pIRES2-EGFP（pIRES2-EGFP）的双顺反子荧光蛋白报告基因的真核启动子的增强子部位,获得重组质粒pHRE;以PCR法扩增HSV-TK基因中TK基因片断,将其克隆到pIRES2-EGFP及pHRE的双顺反子荧光蛋白报告基因上游的多克隆位点,获得重组质粒pTK及pHRE-TK。（2）通过脂质体将pHRE-TK、pHRE、pTK及pIRES2-EGFP导入SK-ES细胞,分别在乏氧（O2浓度为3％）和富氧（O2浓度为21％）环境中培养,荧光显微镜观察报告基因增强性绿色荧光蛋白表达变化,并进行荧光吸光度分析;再予以GCV处理5d后,用MTT法检测GCV对培养细胞的杀伤效果。结果 （1）测序结果证实,重组质粒pHRE含HRE片断,pTK及pHRE-TK含HSV-TK片断,均为单拷贝正向插入,序列正确。（2）对比各组细胞EGFP荧光吸光度值发现：①在乏氧环境中培养,pHRE和pHRE-TK组细胞荧光吸光度值高于在富氧环境培养的荧光吸光度值（P〈0.01）;②在乏氧环境培养,pHRE组和pHRE-TK组细胞荧光吸光度值高于pTK组和pIRES2-EGFP组（P〈0．01）;③在富氧环境培养的各组细胞之间荧光吸光度值差异无统计学意义（P〉0．05）。（3）对比GCV对各组细胞杀伤效果发现：①在乏氧、富氧两种环境培养的pHRE-TK和pTK组细胞对GCV的敏感性均高于pHRE组细胞（P〈0.01）,敏感性随GCV浓度增加而增大;②在乏氧环境培养的pHRE-TK组细胞对GCV的敏感性高于pTK组（P〈0．01）,而在富氧环境中培养的pHRE-TK组与pTK组细胞对GCV的敏感性差异无统计学意义（P〉0.05）;③在乏氧环境培养的pHRE-TK组细胞对GCV的敏感性高于在富氧环境中培养的pHRE-TK组细胞（P〈0.01）;而在乏氧、富氧两种环境培养的pTK组细胞对GCV的敏感性差异无统计学意义（P〉0.05）。结论 （1）成功地构建了含有HRE及HSV-TK基因片断的真核表达载体。（2）在缺氧的SK-ES细胞内,HRE使报告基因EGFP表达增强。（3）HRE能增强HSV-TK／GCV系统对乏氧环境中的SK-ES细胞的杀伤效率。     

Ewing's sarcoma in the occipital bone. Case report.

The head is a very rare primary site for Ewing's sarcoma which occurs most often in the long bones of the extremities and in the pelvis. This report describes an unusual case of Ewing's sarcoma arising from the occipital bone in a seven year old girl. The tumour compressed the venous sinuses, thus lowering the intracranial pressure resulted in temporary recovery which made the diagnosis difficult.     

Extraskeletal Ewing's sarcoma. Anatomo-clinical study of a new case

A case of extraskeletal Ewing's sarcoma arising in right lumbar region with involvement of epidural space is described in a 16 years old girl. The diagnosis of Ewing's sarcoma was done from cytochemical and electron microscopic studies which showed intra-cellular glycogen granules whereas cytologic and immunological analysis eliminated lymphoid malignancies. This case emphasized the interest of these techniques, adjunctive to routine light microscopic examination for the pursuit of a specific diagnosis in the small round cell neoplasm.     

Ewing's sarcoma: therapeutic experience (author's transl)

Since 1978, four patients with Ewing's sarcoma have been on a treatment-regimen based on the T-6 and T-2 Protocols according to Rosen. Preoperative chemotherapy produced tumor regression and thus enabled surgical resection in three cases. In the first case, radiation therapy was felt necessary because the surgical resection was performed after the first course of the T-6 Protocol and cells suspected to be malignant were found on histological examination of the resected tumor. The experience prompted us to refrain from using radiation therapy in the next two cases but to conduct the surgical resection after two cycles of T-6 Protocol. Here, histological examinations of the resected tumors showed no evidence of malignant cells. The fourth patient had a pathologic fracture in addition to the tumor. In this case, it was possible, by means of chemotherapy to heal the fracture and also to produce a regression of the tumor. Because of the radiation morbidity, we believe that it is a notable progress in the treatment of Ewing's sarcoma if radiation therapy can be avoided.     

Diagnosis of neuroblastoma metastasis in bone marrow with a panel of monoclonal antibodies

Neuroblastoma, along with rhabdomyosarcoma, Ewing's sarcoma, and acute lymphoblastic leukemia/lymphoma, is one of the small, round-cell tumors of childhood. All of these malignancies show a propensity to metastasize to bone marrow. Occasionally when the clinical picture is unclear and the tumor is particularly anaplastic, it can be difficult to arrive at a diagnosis by conventional histological and biochemical procedures. In the present study, a panel of nine monoclonal antibodies was used to undertake a detailed analysis of seven bone marrows contaminated with tumor cells: six cases of stage IV neuroblastoma, and one case of stage IV-S neuroblastoma. The antibody profiles obtained were compared with those deduced from the studies of over 20 marrows from patients with acute lymphoblastic leukemia. A comparison of these data with those obtained from the studies of rhabdomyosarcoma and Ewing's sarcoma cell lines and tissues suggests that when high levels of tumor cells are present in the marrow, it is possible to obtain a confident diagnosis of either neuroblastoma or acute lymphoblastic leukemia. In addition, the immunocytological identification of neuroblasts in bone marrow enables accurate staging without histological examination.     

Lenticular lesions: not always an epidural hematoma

Ewing's sarcoma is a tumor of the bone, which occurs most often in the diaphysis of long and flat bone. The most common sites of metastasis are the lungs and bones. Less frequently, the primary site is an intracranial or pelvic lesion (either as a soft tissue or a bone lesion). We report a case of a 16-year-old female with an extraosseous intracranial lesion, who presented with a history of minor trauma, unilateral facial swelling, and head pain. Though head computed tomography scan showed a lesion consistent with an epidural hematoma, further exploration revealed Ewing's sarcoma.     

Neurectodermal malignant tumor of the soft tissues after treatment with immunosuppressive agents of lipoid nephrosis]

Immunosuppressive drugs are known to increase the risk of inducing neoplasia, especially acute leukaemia when high doses are used. A case of nephrosis in a 10 year-old boy treated with chlormethine (cumulative dose: 0.8 mg/kg) and chlorambucil (cumulative dose: 10 mg/kg) is reported. Four years after the beginning of the treatment an extraskeletal Ewing's sarcoma occurred. Since the review of literature failed to find any malignancy induced by such an immunosuppressive treatment for nephrosis, the question whether or not this extraskeletal Ewing's sarcoma was attributable to this treatment remains unanswered.     

Bone mineral density and bone metabolism in children treated for bone sarcomas

In adolescent bone sarcoma patients, bone mass acquisition is potentially compromised at a time in which it should be at a maximum. To evaluate the problem we measured bone mineral density (BMD) and serum markers of bone formation and resorption in a series of pediatric patients with bone tumors. BMD was measured by dual-energy x-ray absorptiometry, at clinical remission, for lumbar spine and the neck of the femur in 38 osteosarcoma and 25 Ewing's sarcoma patients. Mean age was 20.65 and 19.13 y respectively. Serum markers of bone metabolism were: OC, PICP, ICTP, 25-OH vit D and 1,25-(OH)(2) vit D, IGF-I, IGFBP-3 and intact PTH. Serum was sampled throughout anti-tumoral treatments and follow-up. We analyzed 85 samples from 59 osteosarcoma patients and 54 samples from 36 Ewing's sarcoma patients. Patients had decreased lumbar and femoral BMD. The decrease was more pronounced in pubertal patients compared with those who had completed pubertal development at the time of disease diagnosis. Multivariate analysis indicated that sex, age, weight and BMI were significant in lumbar BMD depletion. Weight and BMI were significant in femoral BMD depletion. Serum markers of bone formation (PICP and OC) and resorption (ICTP) were, throughout, lower than reference values. Significant alterations in other markers were also observed. Up to a third of osteosarcoma and Ewing's sarcoma patients in clinical remission had some degree of BMD deficit. The corresponding increased risk of pathologic bone fractures constitutes a reduction in future quality of life.     

Ewing's sarcoma

This patient had Ewing's sarcoma of the femur, which was originally misinterpreted by radiograph and by biopsy as osteomyelitis. For approximately 1 year the patient was treated for osteomyelitis. The lesion was slowly progressive and near the end of the first year became more active, and pulmonary metastases appeared. The natural behavior of this one case of Ewing's sarcoma demonstrates that it is not necessarily an overwhelmingly aggressive tumor. In addition, the point is made that pathologists should pay careful attention to necrotic material so that the suggestion of necrotic tumor can be made rather than dismissing the biopsy as nondiagnostic.