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ORIGINAL ARTICLE
Year : 2020  |  Volume : 16  |  Issue : 4  |  Page : 713-717

Bone marrow aspirations in Ewing sarcomas: Are they still necessary? A single-center retrospective analysis and review of the literature


1 Department of Orthopaedic Surgery, Medical University of Graz, Graz, Austria
2 Department of Pediatrics, Division of Pediatric Haematology and Oncology, Medical University of Graz, Graz, Austria
3 Department of Pathology, Medical University of Graz, Graz, Austria

Date of Submission26-Aug-2016
Date of Acceptance24-Feb-2018
Date of Web Publication24-Oct-2018

Correspondence Address:
Bernadette Breitegger
Department of Orthopaedic Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz
Austria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_941_16

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 > Abstract 


Background and Objectives: Currently, one of the most useful prognostic indicators in Ewing sarcomas (ES) is the presence of metastatic disease at diagnosis. According to various clinical guidelines, the assessment of bone marrow (BM) metastases, using light microscopy examination of bone marrow aspirates and biopsies (BMAB) is mandatory. However, the prognostic value of BM positivity is discussed controversially. Therefore, the primary aim of this study was to retrospectively review BM samples from patients with ES.
Materials and Methods: This retrospective single centre study included 31 patients that were newly diagnosed with ES between 2000 and 2014. Twenty-seven patients had skeletal ES and in 4 patients the tumour was localized in the soft tissue only. Metastases at diagnosis were present in 5 out of 31 patients. BM samples were morphologically and immunohistochemically searched and screened for the presence or absence of BM metastases. Furthermore, in 15 of the 31 patients BM samples were still available and were reanalysed, using nested-polymerase chain reaction.
Results: All BM samples of our 31 ES patients, including the 5 metastatic patients, were, morphologically and immunohistochemically tested negative for tumour cell appearance. The nested-PCR results were also negative in all of our 15 retested patients, including two patients with metastatic disease.
Conclusions: Based on our results and on the contradictory results reported in the literature we recommend a re-evaluation of the necessity and the prognostic value of BMAB in the initial staging process of newly diagnosed ES patients.

Keywords: Bone marrow aspiration/biopsy, bone marrow metastases, Ewing sarcoma


How to cite this article:
Breitegger B, Holzer LA, Beham-Schmid C, Urban C, Liegl-Atzwanger B, Leithner A. Bone marrow aspirations in Ewing sarcomas: Are they still necessary? A single-center retrospective analysis and review of the literature. J Can Res Ther 2020;16:713-7

How to cite this URL:
Breitegger B, Holzer LA, Beham-Schmid C, Urban C, Liegl-Atzwanger B, Leithner A. Bone marrow aspirations in Ewing sarcomas: Are they still necessary? A single-center retrospective analysis and review of the literature. J Can Res Ther [serial online] 2020 [cited 2020 Sep 30];16:713-7. Available from: http://www.cancerjournal.net/text.asp?2020/16/4/713/243504




 > Introduction Top


Currently, one of the most useful adverse prognostic indicators in Ewing sarcomas (ES) is the presence of metastatic disease at diagnosis.[1] At initial diagnosis, between 20% and 25% of patients show metastases, which occur in about 10% of patients in the lung or pleura, and in another 10%, bone/bone marrow (BM) metastases are found.[2] BM metastases are defined by light microscopic BM involvement in aspirate or biopsy samples.[3]

By applying a multimodal treatment including chemotherapy, surgery, and radiotherapy, the prognosis of ES has improved over the past decades. This led to survival rates of about 60%–70% in localized, but only about 20%–40% in metastatic disease.[4] Five-year survival rates of <20% in patients with multiple bone metastases predict a worse outcome than patients harboring lung/pleura metastases which show 5-year survival rates of 20%–40%.[4] It still remains unclear why patients with isolated lung metastases fare better than patients with bone or BM metastases.[5]

According to the 2012 ESMO clinical practice guidelines, taking BM aspiration/biopsy (BMAB) is mandatory, although the prognostic value of positively tested samples has not yet been proven.[2]

Corresponding to the EURO Ewing 99 study protocol from 2006, BMAB examination is also required in the staging process of ES. Furthermore, they define BM metastases by light microscopic evidence of BM involvement in any aspirate or trephine biopsy sample. Molecular evidence (i.e., by real-time polymerase chain reaction [RT-PCR] analysis) alone is, by definition of this protocol, not considered adequate for diagnosis of metastatic BM disease.[3]

The primary aim of this study was to retrospectively review BM samples from patients with ES and as second objective to review published literature concerning BM examination in ES because the prognostic value of BM metastases in ES is discussed controversially.


 > Materials and Methods Top


Dataset

Data were retrieved retrospectively by analysis of a dataset including ES patients that were diagnosed and treated between 2000 and 2014. This dataset provided patient information enclosing age, gender, and data about diagnosis and treatment of the tumor. The main attention was paid to the data concerning BMAB.

A literature search was done using the Medline database to identify relevant literature, published from 1995 to July 2015. The following terms were used: “Ewing sarcoma,” “bone marrow,” “bone marrow metastases,” “bone marrow aspiration/biopsy,” “staging,” and “predictive potential.” Papers providing quantitative results were included, whereas review articles were excluded and divided into groups, based on their findings concerning the value of BM positivity in ES.

Patients

The study included ES patients with molecular secured ES and patients who underwent BMAB. The only exclusion criteria were the lack of secured ES and BMAB evaluation. Based on these criteria, the study population consisted of 31 newly diagnosed ES patients. They were between 1 and 25 years of age (median age, 13.83 years). Twenty-one were male and 10 were female. Twenty-seven patients had skeletal ES, and in 4 patients, the tumor was localized in the soft tissue. Metastases at diagnosis were present in 5 patients. In 3 of these 5 patients, the lungs were the only site of metastases. In 1 of 5 patients, metastases occurred in the bone and 1 of 5 patients had a combination of lung and bone metastases. Patients' characteristics are shown in [Table 1].
Table 1: Patients' characteristics

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Bone marrow assessment

All BM samples were obtained at diagnosis, before treatment. All samples were collected from the iliac crest and were morphologically and immunohistochemically examined by the pathologists. These retrospective findings were searched and screened for the presence or absence of BM metastases.

Furthermore, in 15 of the 31 patients, BM samples were still available and were reanalyzed using nested PCR. Five of the 15 retested BM samples were available from the left and the right side.

Ethics

The study was approved by the Ethics Committee.


 > Results Top


Morphologically, there was no evidence of BM infiltration by the known ES in any of the histopathological findings of our 31 patients. Furthermore, the samples underwent immunohistochemical studies, performed at the unfixed material. In none of our 31 patients, immunohistochemistry showed any evidence of BM infiltration by the known ES. All 31 patients, also the 5 patients with metastases at diagnosis, were morphologically and immunohistochemically free of a tumor in the BM. PCR results were negative in all of our 15 retested patients. These 15 patients included two patients with metastatic disease (1 with bone and 1 with lung metastases). Results of morphological and immunohistochemical analysis and PCR can be seen in [Table 2].
Table 2: Results of immunohistochemistry and polymerase chain reaction analysis

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By searching Medline database, 15 relevant studies were identified and further analyzed [Table 3]. In 7 out of 15 studies, no clear conclusion was drawn whether tumor positive tested BM has any influence on the prognosis in ES patients.[6],[7],[8],[9],[10],[11],[12] Five of 15 studies correlated BM positivity with worse outcome, which was shown in 2 studies only in metastatic patients, in 1 study only in nonmetastatic patients, and in 2 of these 5 studies in both metastatic and nonmetastatic patients.[13],[14],[15],[16],[17] Three out of 15 studies did not show a negative correlation over positive tested BM and disease progression, and 2 of these even suggest the elimination of BMAB in nonmetastatic ES patients.[1],[18],[19]
Table 3: Results of 15 studies concerning BM examination in ES

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 > Discussion Top


Corresponding to international clinical guidelines, BMAB examination is mandatory in the staging process of ES.

In our study, we retrospectively analyzed the presence of tumor cells in BM samples from patients with ES.

As the prognostic value of BMAB in ES patients is discussed controversially, we tried to better specify the need of this investigation in the staging process.

The ideal method to examine BM is not clear. Although according to the 2012 ESMO clinical practice guidelines, BMAB taken at sites distant from the primary tumor or known metastatic lesions are mandatory, they state that the added prognostic value of molecular positivity over light microscopic evaluation has not yet been proven.[2]

Wagner et al. reviewed other methods to assess BM involvement in ES.[20] Additional to morphological and immunohistochemical methods, BM evaluation by using PCR is a common molecular method.[20] Ten of 15 studies described in the literature research above also performed PCR, but corresponding to the EURO Ewing 99 study protocol, molecular evidence (i.e., by RT-PCR analysis) alone is not considered adequate for diagnosis of metastatic BM disease.[3] As described by DuBois et al., a new method to detect ES cells in BM is flow cytometry, where BM cells are stained for cluster of differentiation antigen (CD) 99 and CD45 to detect CD99+ CD45− cells.[21] Ash et al. reported the use of multiparameter flow cytometry to detect ES cells in BM. This method identifies CD99+ and CD90+ tumor cells and being negative for CD45 and other hematopoietic markers.[16] This study, performed in 2001, is the only one where all BM samples (46/46) were tested positive for micrometastatic tumor cells.[16] Furthermore, in this study, 27/45 (60%) BM samples were found to show high CD56 expression, and a significant correlation between disease progression and CD56 expression was described.[16] Another potential method to asses BM in ES patients may be the use of FISH, which identifies translocations involving the EWS gene, but there are no current studies available with regard to this method.[20] A noninvasive method to assess bone and/or BM involvement is F18-fluorodeoxy-D-glucose (FDG)-PET, as demonstrated in the study by Newman et al., where 0/57 nonmetastatic patients showed BM involvement by FDG-PET.[1]

In our study, 0/31 ES patients (5/31 with metastases) showed BM involvement using morphological and immunohistochemical methods, and also, the nested-PCR results were negative in all of our 15 retested patients (2/15 with metastases) at the time of diagnosis. These results are different to the 10/15 studies that also used PCR methods to examine BM because in all of them, positive BM samples were found.[6],[8],[9],[10],[11],[12],[13],[15],[17],[18]

Limitations of our study and the 10 studies using PCR are the small cohorts (including 14–131 ES patients) and the retrospective study design. Neither the number of patients in our study nor the used method seems to be the reason that no positive BM sample was found in our patients.

Altogether the 15 studies included 731 (100%) ES patients and BM involvement was found in 209/731 (28.59%) patients. 127/209 (60.76%) BM-positive patients had known metastases, whereas BM positivity was seen in only 82/209 (39.23%) patients without distant metastases. According to these results, BM involvement seems to be more frequent in metastatic patients. Fagnou et al. also concluded that RT-PCR positivity is frequently found in metastatic ES patients and suggested that the monitoring of BM at diagnosis might be an important criterion for the staging.[13]

Although BMAB generally is a simple and safe procedure, there is a small risk of complications, and the intervention can have considerable impact on individual patients.[22] Other remarkable factors in proceeding BMABs is the need of time, stuff, and equipment.

As far as a negative prognostic effect of positive tested BM in ES is concerned, studies provide controversial results. Only 3/15 studies, identified by the literature search, found a negative effect of positive BM results.[15],[16],[17] Avigad et al. showed that positive RT-PCR BM results were correlated with disease progression and recommended the serial monitoring with RT-PCR for the prediction of disease recurrence.[15] Schleiermacher et al. also recommended the search for occult tumor cells in the staging of ES patients.[17]

In contrary to these recommendations, Zoubek et al. excluded a correlation of RT-PCR BM positivity and early relapse in ES patients.[18] Moreover, in the study by Kopp et al., 0/85 patients without any imaging evidence of osseous metastases had BM involvement.[19] These data indicate futility, not utility of BM metastases examination, and the authors suggest that BMAB may not be further required in the initial staging process of ES patients considered nonmetastatic by imaging.[19] Referring to this study, Peter Anderson published an article evaluating the findings of BM examination in ES. Anderson therefore recommends to first do modern imaging studies such as chest CT and FDG-PET, and if no metastases are found by these imaging modalities, BM analyses can be considered unnecessary.[23] In those patients with metastatic disease, the utility of BM analyses is uncertain.[23] Although it is still recommended in ongoing clinical trials, Valvi and Ziegler came to the conclusion to stop carrying out BMAB in nonmetastatic ES patients.[24]

In our retrospective study, all BM samples of our 31 ES patients, including the 5 metastatic patients, were morphologically and immunohistochemically tested negative for tumor cell appearance. The nested-PCR results were also negative in all of our 15 retested patients. These 15 patients included two patients with metastatic disease.

Ours, and other studies, concerning this topic, are limited by the small cohort and by the retrospective study design.


 > Conclusion Top


Based on our results and on the contradictory results reported in the literature, we recommend a reevaluation of the necessity and the prognostic value of BMAB in the initial staging process of newly diagnosed ES patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Newman EN, Jones RL, Hawkins DS. An evaluation of [F-18]-fluorodeoxy-D-glucose positron emission tomography, bone scan, and bone marrow aspiration/biopsy as staging investigations in Ewing sarcoma. Pediatr Blood Cancer 2013;60:1113-7.  Back to cited text no. 1
    
2.
ESMO/European Sarcoma Network Working Group. Bone sarcomas: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 2012;23 Suppl 7:vii100-9.  Back to cited text no. 2
    
3.
EURO-E.W.I.N.G. 99: EUROpean Ewing tumour Working Initiative of National Groups Ewing Tumour Studies 1999 EE 99 Amended Version 2006. Available from: https://www.skion.nl/workspace/uploads/ ee99_amended_treo__2006_02_14.pdf. [Last accessed on 2018 Jul 20].  Back to cited text no. 3
    
4.
Paulussen M, Bielack S, Jürgens H, Casali PG; ESMO Guidelines Working Group. Ewing's sarcoma of the bone: ESMO clinical recommendations for diagnosis, treatment and follow-up. Ann Oncol 2009;20 Suppl 4:140-2.  Back to cited text no. 4
    
5.
Potratz J, Dirksen U, Jürgens H, Craft A. Ewing sarcoma: Clinical state-of-the-art. Pediatr Hematol Oncol 2012;29:1-1.  Back to cited text no. 5
    
6.
Pfleiderer C, Zoubek A, Gruber B, Kronberger M, Ambros PF, Lion T, et al. Detection of tumour cells in peripheral blood and bone marrow from Ewing tumour patients by RT-PCR. Int J Cancer 1995;64:135-9.  Back to cited text no. 6
    
7.
Oberlin O, Bayle C, Hartmann O, Terrier-Lacombe MJ, Lemerle J. Incidence of bone marrow involvement in Ewing's sarcoma: Value of extensive investigation of the bone marrow. Med Pediatr Oncol 1995;24:343-6.  Back to cited text no. 7
    
8.
Peter M, Magdelenat H, Michon J, Melot T, Oberlin O, Zucker JM, et al. Sensitive detection of occult Ewing's cells by the reverse transcriptase-polymerase chain reaction. Br J Cancer 1995;72:96-100.  Back to cited text no. 8
    
9.
Zoubek A, Pfleiderer C, Ambros PF, Kronberger M, Dworzak MN, Gruber B, et al. Minimal metastatic and minimal residual disease in patients with Ewing tumors. Klin Padiatr 1995;207:242-7.  Back to cited text no. 9
    
10.
West DC, Grier HE, Swallow MM, Demetri GD, Granowetter L, Sklar J, et al. Detection of circulating tumor cells in patients with Ewing's sarcoma and peripheral primitive neuroectodermal tumor. J Clin Oncol 1997;15:583-8.  Back to cited text no. 10
    
11.
Sumerauer D, Vícha A, Kucerová H, Kodet R, Housková J, Bedrnícek J, et al. Detection of minimal bone marrow infiltration in patients with localized and metastatic Ewing sarcoma using RT-PCR. Folia Biol (Praha) 2001;47:206-10.  Back to cited text no. 11
    
12.
Athale UH, Shurtleff SA, Jenkins JJ, Poquette CA, Tan M, Downing JR, et al. Use of reverse transcriptase polymerase chain reaction for diagnosis and staging of alveolar rhabdomyosarcoma, Ewing sarcoma family of tumors, and desmoplastic small round cell tumor. J Pediatr Hematol Oncol 2001;23:99-104.  Back to cited text no. 12
    
13.
Fagnou C, Michon J, Peter M, Bernoux A, Oberlin O, Zucker JM, et al. Presence of tumor cells in bone marrow but not in blood is associated with adverse prognosis in patients with Ewing's tumor. Société française d'oncologie pédiatrique. J Clin Oncol 1998;16:1707-11.  Back to cited text no. 13
    
14.
Oberlin O, Rey A, Desfachelles AS, Philip T, Plantaz D, Schmitt C, et al. Impact of high-dose busulfan plus melphalan as consolidation in metastatic Ewing tumors: A study by the société française des cancers de l'enfant. J Clin Oncol 2006;24:3997-4002.  Back to cited text no. 14
    
15.
Avigad S, Cohen IJ, Zilberstein J, Liberzon E, Goshen Y, Ash S, et al. The predictive potential of molecular detection in the nonmetastatic Ewing family of tumors. Cancer 2004;100:1053-8.  Back to cited text no. 15
    
16.
Ash S, Luria D, Cohen IJ, Goshen Y, Toledano H, Issakov J, et al. Excellent prognosis in a subset of patients with Ewing sarcoma identified at diagnosis by CD56 using flow cytometry. Clin Cancer Res 2011;17:2900-7.  Back to cited text no. 16
    
17.
Schleiermacher G, Peter M, Oberlin O, Philip T, Rubie H, Mechinaud F, et al. Increased risk of systemic relapses associated with bone marrow micrometastasis and circulating tumor cells in localized Ewing tumor. J Clin Oncol 2003;21:85-91.  Back to cited text no. 17
    
18.
Zoubek A, Ladenstein R, Windhager R, Amann G, Fischmeister G, Kager L, et al. Predictive potential of testing for bone marrow involvement in Ewing tumor patients by RT-PCR: A preliminary evaluation. Int J Cancer 1998;79:56-60.  Back to cited text no. 18
    
19.
Kopp LM, Hu C, Rozo B, White-Collins A, Huh WW, Yarborough A, et al. Utility of bone marrow aspiration and biopsy in initial staging of Ewing sarcoma. Pediatr Blood Cancer 2015;62:12-5.  Back to cited text no. 19
    
20.
Wagner LM, Smolarek TA, Sumegi J, Marmer D. Assessment of minimal residual disease in Ewing sarcoma. Sarcoma 2012;2012:780129.  Back to cited text no. 20
    
21.
Dubois SG, Epling CL, Teague J, Matthay KK, Sinclair E. Flow cytometric detection of Ewing sarcoma cells in peripheral blood and bone marrow. Pediatr Blood Cancer 2010;54:13-8.  Back to cited text no. 21
    
22.
Bain BJ. Bone marrow biopsy morbidity and mortality. Br J Haematol 2003;121:949-51.  Back to cited text no. 22
    
23.
Anderson PM. Futility versus utility of marrow assessment in initial Ewing sarcoma staging workup. Pediatr Blood Cancer 2015;62:1-2.  Back to cited text no. 23
    
24.
Valvi S, Ziegler DS. Ganglioglioma arising from desmoplastic medulloblastoma: A Case report and review of literature. Pediatrics 2017;139. pii: e20161403.  Back to cited text no. 24
    



 
 
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  [Table 1], [Table 2], [Table 3]



 

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