Ewing sarcoma

Case contributed by Dr Hani Makky Al Salam


Right hip pain worsening over the last 6 months.

Patient Data

Age: 14 years
Gender: Female

Note: This case has been tagged as "legacy" as it no longer meets image preparation and/or other case publication guidelines.



The right iliac bone demonstrates an ill-defined lytic lesion, with a wide zone of transition. The medial part of the acetabular cortex is poorly seen, potentially representing extension into the joint.

In addition, there is some fullness and increased density of the soft tissues immediately medial to this region within the pelvis, suggesting extension beyond the bone. There are smaller patchy translucencies of the right proximal femur, the inferior pubic ramus and the tuber ischii, as well.

MRI pelvis


Multiple intramedullary bone lesions involving both femora and the pelvis bilaterally. Evidence of bilateral acetabular bone involvement with expansion and a soft-tissue component which is more pronounced on the right, extending both posterolateral to the bone (into the gluteus musculature) and medially (into the pelvis). 

Distribution of Ewing sarcoma


Distribution of Ewing sarcoma. Most frequent locations are the large long bones and the pelvis.

Layout and distribution: Frank Gaillard 2009, Line drawing of skeleton: Patrick Lynch 2006, Creative Common NC-SA-BY



Permeative and lytic lesion predominantly around the right acetabulum is demonstrated with multiple other lesions seen in the axial and appendicular skeleton. CT reviewed on other window settings demonstrated no convincing solid organ metastases. 

Bone scan

Nuclear medicine

The flow and blood pool images of the pelvis show moderate increased tracer uptake involving both hip joint regions, more pronounced on the right side indicating evidence of hyperemia. 

On total body skeletal images, the skull shows multiple foci of heterogeneous and diffuse tracer uptake with a focal more intense uptake involving the left orbital ridge most likely metastatic in nature. Further diffuse and heterogeneous uptake (likely metastatic deposits) in:

  • multiple ribs on both sides
  • both scapula
  • both humeri
  • right iliac bone
  • both acetabulum/ischium
  • left iliac crest
  • both femora

Multiple vertebral bodies in the thoracolumbar region also show heterogeneous moderate tracer uptake worrisome for metastasis.

A CT guided bone biopsy confirmed Ewing sarcoma as the primary diagnosis.

Case Discussion

This case demonstrates the features of very widespread bony disease from Ewings sarcoma of the pelvis. 

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