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Table of Contents    
Year : 2017  |  Volume : 65  |  Issue : 4  |  Page : 904-906

Calvarial Ewing's sarcoma, a rare childhood tumor: Report and a review of literature

1 Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
2 Department of Pathology, Regional Cancer Centre, Trivandrum, Kerala, India

Date of Web Publication5-Jul-2017

Correspondence Address:
Prakash Nair
Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum - 695 011, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/neuroindia.NI_777_16

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How to cite this article:
Nair P, Aggarwal V, Kumar K, Mathews A, Abraham M, Nair S. Calvarial Ewing's sarcoma, a rare childhood tumor: Report and a review of literature. Neurol India 2017;65:904-6

How to cite this URL:
Nair P, Aggarwal V, Kumar K, Mathews A, Abraham M, Nair S. Calvarial Ewing's sarcoma, a rare childhood tumor: Report and a review of literature. Neurol India [serial online] 2017 [cited 2020 Jan 18];65:904-6. Available from:


Calvarial Ewing's sarcoma (CEWS) is a round cell sarcoma which occurs rarely in children. The optimum management of CEWS requires a multidisciplinary treatment approach consisting of surgical resection followed by radiotherapy and chemotherapy. We report two cases of CEWS who underwent wide resection followed by adjuvant chemotherapy. We also review the literature on CEWS.

Case 1

A 12-year old child presented with a painless swelling over the vertex of the head. A plain radiograph showed an extra-axial lytic lesion with a sunburst appearance. Magnetic resonance imaging (MRI) with venography revealed an enhancing extradural lesion causing displacement and narrowing of the superior sagittal sinus [Figure 1]a,[Figure 1]b,[Figure 1]c,[Figure 1]d,[Figure 1]e,[Figure 1]f. The patient underwent a wide excision with a 1-cm normal margin. Postoperatively, the patient underwent chemotherapy and radiotherapy and remains disease free after 30 months.
Figure 1: (a and b) Plain skull radiograph showing a lytic lesion with hair.on.end appearance. (c) T2 MRI showed an extra axial lesion with heterogenous intensity. (d) MR venogram showing narrowing and inferior displacement of the superior sagittal sinus. (e) T1 contrast MRI showing enhancement of lesion. (f) Postoperative CT scan showing gross total excision

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Case 2

A 20-month old child presented with a left temporal swelling. The magnetic resonance imaging (MRI) showed an extra-axial lytic lesion with homogenous enhancement [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d. The patient underwent a left temporal craniectomy and gross total excision with a 2-cm margin [Figure 3]a and [Figure 3]b. Postoperatively, he underwent chemotherapy and radiotherapy and remains disease free after 12 months.
Figure 2: (a) Contrast CT scan showing enhancement of the lesion. (b) T2 MRI showing that the lesion is isointense. (c) T1 contrast MRI showing enhancement of the lesion. (d) Postoperative CT scan showing gross total excision

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Figure 3: (a) Ewing's sarcoma – Malignant small round cells in lobules, (H and E X400). (b) Ewing sarcoma – Diffuse and strong membrane staining for MIC2 (CD99), (IHC X400)

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Ewing first described this tumor as a “diffuse endothelioma of the bone” in 1921 in a report of six similar cases along with their radiographic appearances, a description which holds good nearly a century later.[1] EWS is the second most common bony tumor of childhood and adolescence with a male predominance. Its incidence is more common in the temporal bone followed by the frontal and parietal bones.[2] Calvarial EWS commonly presents as a localized scalp swelling; occasionally patients with an intracranial tumor extension present with signs of raised intracranial tension.[3] In the present series, both the patients presented with a painless scalp swelling.

Other symptoms depend upon the location of the lesion, such as proptosis in the case of orbital involvement. There may be anemia, leukocytosis, elevated erythrocyte sedimentation rate (ESR), and elevated serum levels of alkaline phosphatase and C-reactive protein. An elevated lactate dehydrogenase level is associated with a poor prognosis. Investigations performed in a patient with CEWS include a helical computed tomography (CT) scan with reconstruction of the calvarium, MRI of the brain with a MR venogram to assess for the involvement of the sinuses, and a systemic workup to rule out distant metastasis. The appearance of CEWS is very variable. On CT scan images, the EWS may appear to be laminated (onion skin like), sclerotic, spiculated (sunburst appearance), or with a periosteal reaction, with soft tissue calcification seen infrequently.[4] The CT scan reveals an iso- to hyperdense mass, which enhances with contrast. In both our cases, the tumors were hyperdense with a spiculated appearance. MRI reveals a low-to-intermediate signal on T1-weighted images, with a heterogeneous but prominent enhancement on gadolinium administration. “Hair-on-end” pattern of low signal striations may be seen on T2-weighted images. In both our cases, the masses were isointense on T1-weighted and T2-weighted images and exhibited intense enhancement after contrast.

A radioisotope bone scan is essential to rule out metastases and suspected recurrence at the margins following surgical resection. Ewing sarcomas demonstrate increased uptake on both gallium67-citrate and during all three phases of the technetium99m methylene diphosphonate bone scans.[5],[6],[7],[8],[9]

Histological examination reveals that the tumor is composed of sheets of round cells with a scanty cytoplasm, having dark hyperchromatic nuclei. Cytoplasm is periodic acid-Schiff positive because of the presence of glycogen. Immunohistochemistry helps in differentiating it from other small round cell tumors including non-Hodgkin lymphoma, neuroblastoma, rhabdomyosarcoma, mesenchymal chondrosarcoma, retinoblastoma, desmoplastic small round cell tumor, osteosarcoma, synovial sarcoma, malignant peripheral nerve sheath tumor, and melanoma. On immunohistochemistry, the cells are positive for CD99, FLI1, and NSE and negative for desmin, leucocyte common antigen (LCA), and synaptophysin.[10] CD99 is positive in more than 95% of the cases. Eighty-five percent of EWS are associated with translocation t (11;22)(q24;q12) resulting in a chimeric fusion transcript EWSFLI1. In another 10–15% of cases, the translocation t (21;12)(22;12) resulting in EWSERG (Ets-related gene) fusion is seen.[11]

Favorable prognostic factors are age <15 years, female gender, absence of metastases at diagnosis, no regional lymph node involvement, peripheral location of the tumor, no history of treatment for different tumors before Ewing sarcoma is diagnosed, tumor &<8 cm in size, and initial LDH <170 IU/L.[12]

Unfavorable prognostic factors include the fusion transcript detection in marrow or peripheral blood, overexpression of the p53 protein, and a high Ki67 expression; and loss of 16q.[13]

EWS is often treated with neoadjuvant chemotherapy followed by surgical resection. The chemotherapeutic agents used are one of the following: doxorubicin, cyclophosphamide, vincristine, ifosfamide, actinomycin-D, and etopside. The purpose of preoperative chemotherapy is to: (1) eliminate systemic micro-metastases, (2) reduce the tumor size to enable resection along with optimal reconstruction, and (3) select post-operative chemotherapy. After the initial chemotherapy, patients with minimal or no residual viable tumor showed a better outcome.[14]

For tumors involving the calvarium or the skull base, neoadjuvant treatment may help in decreasing the need for extensive resection, and in reducing the size of the defects to be closed, especially in the skull base. Radiotherapy is indicated for patients with tumor still present at the resection margins. As a rule, calvarial lesions are neither biopsied, nor is a routine search made for metastatic deposits at other sites. The aim is to proceed with direct surgical resection of the tumor.

However, recognizing that lesions such as EWS need an extensive preoperative evaluation is essential, we suggest that a needle biopsy must be performed, whenever feasible. In large extracranial calvarial lesions (not causing a rise in the intracranial pressure) located close to large sinuses, or in the skull base, such an approach is more likely to result in better local control of the disease. The size of the skull base defects to be repaired can also be minimized in this manner. Radiotherapy can then be given if there is suspicion of residual disease at the operative site.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Ewing J. Diffuse endothelioma of bone. Proc N Y Pathol Soc 1921;12:17.  Back to cited text no. 1
Singh P, Jain M, Singh DP, Kalra N, Khandelwal N, Suri S. MR findings of primary Ewing's sarcoma of greater wing of sphenoid. Australas Radiol 2002;46:409-11.  Back to cited text no. 2
Agrawal A, Dulani R, Mahadevan A, Vagaha SJ, Vagha J, Shankar SK. Primary Ewing's sarcoma of the frontal bone with intracranial extension. J Cancer Res Ther 2009;5:208-9.  Back to cited text no. 3
Maygarden SJ, Askin FB, Siegal GP, Gilula LA, Schoppe J, Foulkes M, et al. Ewing sarcoma of bone in infants and toddlers. A clinicopathologic report from the Intergroup Ewing's Study. Cancer 1993;71:2109-18.  Back to cited text no. 4
Meyers SP. MRI of bone and soft tissue tumors and tumorlike lesions, differential diagnosis and atlas. Thieme Publishing Group; 2008. ISBN: 3131354216.  Back to cited text no. 5
Kumar R, Prasad KK, Krishnani N, Chhabra DK. Infected Ewing's sarcoma of spine. Neurol India 2000;48:370.  Back to cited text no. 6
Amita R, Sandhyamani S, Nair S, Kapilamoorthy TR, Amita R, Sandhyamani S, et al. Intracranial Ewings Sarcoma/peripheral primitive neuroectodermal tumor. Neurol India 2014;62:432-3.  Back to cited text no. 7
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Shinde SV, Shenoy AS, Savant HV, Balasubramaniam SB. Coexistent intracerebral metastatic melanoma and meningioma. Neurol India 2017;65:110-2.  Back to cited text no. 8
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Naik H, Kharosekar H, Velho V. Black brain caused by primary intracranial malignant melanoma. Neurol India 2016;64:193-4.  Back to cited text no. 9
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Folpe AL, Hill CE, Parham DM, O'Shea PA, Weiss SW. Immunohistochemical detection of FLI1 protein expression: A study of 132 round cell tumors with emphasis on CD99 positive mimics of Ewing's sarcoma/Primitive Neuroectodermal Tumor. Am J Surg Pathol 2000;24:1657-62.  Back to cited text no. 10
Delattre O, Zucman J, Plougastel B, Desmaze C, Melot T, Peter M, et al. Gene fusion with an ETS DNA binding domain caused by chromosome translocation in human tumours. Nature 1992;359:162-5.  Back to cited text no. 11
Karski EE, McIlvaine E, Segal MR, Krailo M, Grier HE, Granowetter L, et al. Identification of discrete prognostic groups in ewing sarcoma. Pediatr Blood Cancer 2016;63:475-3.  Back to cited text no. 12
Abudu A, Mangham DC, Reynolds GM, Pynsent PB, Tillman RM, Carter SR, et al. Overexpression of p53 protein in primary Ewing's sarcoma of bone: Relationship to tumour stage, response and prognosis. Br J Cancer 1999;79:1185-9.  Back to cited text no. 13
Schuck A, Ahrens S, von Schorlemer I, Kuhlen M, Paulussen M, Hunold A, et al. Radiotherapy in Ewing tumors of the vertebrae: Treatment results and local relapse analysis of the CESS 81/86 and EICESS 92 trials. Int J Radiat Oncol Biol Phys 2005;63:1562-7.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3]


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