Ewing sarcomas are the second most common malignant primary bone tumors of childhood after osteosarcoma, typically arising from the medullary cavity with the invasion of the Haversian system. Ewing sarcomas usually present as moth-eaten, destructive, and permeative lucent lesions in the shaft of long bones, with a large soft tissue component and typical onion skin periostitis. These tumors may also involve flat bones and can appear sclerotic in up to 30% of cases.
Ewing sarcoma typically occurs in children and adolescents between 10 and 20 years of age (95% between 4 and 25 years of age) and has a slight male predilection (M: F 1.5:1) 1,2.
The Ewing sarcoma family of tumors primarily occurs in white patients. In the United States, the incidence in Asians/Pacific Islanders is about one-half that in Caucasians, while the incidence among African Americans is one-ninth that in Caucasians 12.
Presentation is non-specific with local pain being by far the most common symptom. Occasionally a soft tissue mass may be palpable. Pathological fractures also occur. Systemic symptoms including fever may be present. ESR and serum LDH levels are also elevated 14.
Ewing sarcoma is a small round blue cell tumor with regular-sized primitive appearing cells. It is closely related to the soft tissue tumors pPNET, Askin tumor and neuroepithelioma, which collectively are referred to as Ewing sarcoma family of tumors (ESFT) 1. They share not only microscopic appearances but also demonstrate a non-random t(11;22)(q24;q12) chromosome rearrangement.
- lower limb: 45%
- femur most common
- pelvis: 20%
- upper limb: 13%
- spine and ribs: 13% (see thoracic Ewings sarcoma)
- the sacrococcygeal region most common 4
- skull/face: 2%
- long bones: 50-60%
- femur: 25%
- tibia: 11%
- humerus: 10%
- flat bones: 40%
- pelvis: 14%
- ribs: 6% (thoracic Ewing sarcoma)
As far as a location within long bones, the tumor is almost always metadiaphyseal or diaphyseal 2-3:
- mid-diaphysis: 33%
- metadiaphysis: 44%
- metaphysis: 15%
- epiphysis: 1-2%
Ewing sarcomas tend to be large with a wide zone of transition/poorly defined margin. Over 80% of Ewing sarcomas demonstrate extension into adjacent soft tissues. It should be noted that pPNET often extend into bone, making the distinction difficult.
Plain radiograph and CT
The appearance of these tumors is very variable, but they usually have a clearly aggressive appearance. Common findings include 2,14:
Soft tissue calcification is uncommon, seen in less than 10% of cases 2.
- T1: low to intermediate signal
- T1 C+ (Gd): heterogeneous but prominent enhancement
- T2: heterogeneously high signal, may see hair on end low signal striations
Ewing sarcomas demonstrate increased uptake on both Gallium67-citrate and all three phases of the Technetium99m methylene diphosphonate bone scans 6.
Treatment and prognosis
Systemic chemotherapy is the mainstay of treatment with surgery and/or radiotherapy playing a role depending on the location and size of the tumor.
What was once a uniformly fatal tumor now has respectable survival rates, although these vary with location. Spinal tumors for example have up to 86% long term survival compared to 25% of sacrococcygeal tumors 4. The overall 5 year survival is in the order of 50-75% of patients with local disease only at the time of presentation 5.
Prognosis is significantly impacted by the presence of distant metastases at the time of diagnosis, which is far more common for the pelvis (25-30%) compared to extremities (<10%) 5.
Metastases most frequently go to lungs and bones in equal proportions. The spine is the most common site of bone metastases13.
History and etymology
The tumor is named after James Stephen Ewing (1866-1943), an American pathologist, who first described his eponymous tumor in 1920 8,11.
- other Ewing sarcoma family of tumors
- more often has amorphous calcified matrix
- classically perimetaphyseal, Ewing sarcoma also occurs in other locations
- more prevalent around the knee and in the proximal humerus, in other locations Ewing sarcoma is the more frequent of the two
- metastatic disease
- hematological malignancy
- eosinophilic granuloma 9
- neuroblastoma (<age 5) 10
- 1. Burchill SA. Ewing's sarcoma: diagnostic, prognostic, and therapeutic implications of molecular abnormalities. J. Clin. Pathol. 2003;56 (2): 96-102. J. Clin. Pathol. (link) - Free text at pubmed - Pubmed citation
- 2. Maygarden SJ, Askin FB, Siegal GP et-al. Ewing sarcoma of bone in infants and toddlers. A clinicopathologic report from the Intergroup Ewing's Study. Cancer. 1993;71 (6): 2109-18. Pubmed citation
- 3. Moser RP, Davis MJ, Gilkey FW et-al. Primary Ewing sarcoma of rib. Radiographics. 1990;10 (5): 899-914. Radiographics (abstract) - Pubmed citation
- 4. Murphey MD, Andrews CL, Flemming DJ et-al. From the archives of the AFIP. Primary tumors of the spine: radiologic pathologic correlation. Radiographics. 1996;16 (5): 1131-58. Radiographics (abstract) - Pubmed citation
- 5. Halperin EC. Pediatric radiation oncology. Lippincott Williams & Wilkins. (2005) ISBN:0781742528. Read it at Google Books - Find it at Amazon
- 6. Meyers SP. MRI of bone and soft tissue tumors and tumorlike lesions, differential diagnosis and atlas. Thieme Publishing Group. (2008) ISBN:3131354216. Read it at Google Books - Find it at Amazon
- 7. Souhami RL, Tobias JS. Cancer and its management. Wiley-Blackwell. (2003) ISBN:0632055316. Read it at Google Books - Find it at Amazon
- 8. Ewing J. Classics in oncology. Diffuse endothelioma of bone. James Ewing. Proceedings of the New York Pathological Society, 1921. CA Cancer J Clin. 22 (2): 95-8. doi:10.3322/canjclin.22.2.95 - Pubmed citation
- 9. Biswal BM, Lal P, Uppal R, Mallik S. Unifocal Langerhans' cell histiocytosis (eosinophilic granuloma) resembling Ewing's sarcoma. (1994) Australasian radiology. 38 (4): 313-4. Pubmed
- 10. Wolfgang Dähnert. Radiology Review Manual. (2011) ISBN: 9781609139438
- 11. Seyed B. Mostofi. Who's Who in Orthopedics. (2005) ISBN: 9781846280702
- 12. Jawad MU, Cheung MC, Min ES, Schneiderbauer MM, Koniaris LG, Scully SP. Ewing sarcoma demonstrates racial disparities in incidence-related and sex-related differences in outcome: an analysis of 1631 cases from the SEER database, 1973-2005. (2009) Cancer. 115 (15): 3526-36. doi:10.1002/cncr.24388 - Pubmed
- 13. Wilkins RM, Pritchard DJ, Burgert EO Jr, Unni KK. Ewing's sarcoma of bone. Experience with 140 patients. (1986) Cancer. doi:10.1002/1097-0142(19861201)58:11<2551::aid-cncr2820581132>3.0.co;2-y - Pubmed
- 14. Nicolò Riggi, Mario L. Suvà, Ivan Stamenkovic. Ewing’s Sarcoma. (2021) New England Journal of Medicine. doi:10.1056/NEJMra2028910?query=pediatrics
Related Radiopaedia articles
The differential diagnosis for bone tumors is dependent on the age of the patient, with a very different set of differentials for the pediatric patient.
- bone-forming tumors
- cartilage-forming tumors
- bizarre parosteal osteochondromatous proliferation (Nora lesion)
- chondromyxoid fibroma
- juxtacortical chondroma
- fibrous bone lesions
- bone marrow tumors
- other bone tumors or tumor-like lesions
- aneurysmal bone cyst
- benign fibrous histiocytoma
- giant cell tumor of bone
- Gorham massive osteolysis
- haemophilic pseudotumor
- intradiploic epidermoid cyst
- intraosseous lipoma
- musculoskeletal angiosarcoma
- musculoskeletal hemangiopericytoma
- primary intraosseous hemangioma
- post-traumatic cystic bone lesion
- simple bone cyst
- impending fracture risk
- describing a bone lesion