Extraskeletal Ewing Sarcoma from Head to Toe: Multimodality Imaging Review

Radiographics. 2022 Jul-Aug;42(4):1145-1160. doi: 10.1148/rg.210226. Epub 2022 May 27.


Extraskeletal Ewing sarcoma (EES) is a rare subtype in the Ewing sarcoma family of tumors (ESFT), which also includes Ewing sarcoma of bone (ESB) and, more recently, primitive neuroectodermal tumors. Although these tumors often have different manifestations, they are grouped on the basis of common genetic translocation and diagnosis from specific molecular and immunohistochemical features. While the large majority of ESFT cases occur in children and in bones, approximately 25% originate outside the skeleton as EES. Importantly, in the adult population these extraskeletal tumors are more common than ESB. Imaging findings of EES tumors are generally nonspecific, with some variation based on location and the tissues involved. A large tumor with central necrosis that does not cross the midline is typical. Despite often nonspecific findings, imaging plays an important role in the evaluation and management of ESFT, with MRI frequently the preferred imaging modality for primary tumor assessment and local staging. Chest CT and fluorine 18 fluorodeoxyglucose PET/CT are most sensitive for detecting lung and other distant or nodal metastases. Management often involves chemotherapy with local surgical excision, when possible. A multidisciplinary treatment approach should be used given the propensity for large tumor size and local invasion, which can make resection difficult. Despite limited data, outcomes are similar to those of other ESFT cases, with 5-year survival exceeding 80%. However, with metastatic disease, the long-term prognosis is poor. ©RSNA, 2022.

Publication types

  • Review

MeSH terms

  • Adult
  • Bone Neoplasms* / diagnostic imaging
  • Bone Neoplasms* / pathology
  • Child
  • Humans
  • Multimodal Imaging
  • Neuroectodermal Tumors, Primitive*
  • Positron Emission Tomography Computed Tomography
  • Sarcoma, Ewing* / diagnostic imaging
  • Sarcoma, Ewing* / therapy
  • Toes / pathology