Fracture after therapy for Ewing sarcoma may indicate continuing disease activity

NEW YORK (Reuters Health) – If a long-bone fracture occurs after the completion of chemotherapy for Ewing sarcoma, there is a high likelihood of ongoing disease.

A team, at the University of Tennessee College of Medicine and St. Jude Children's Research Hospital, both in Memphis, Tennessee, conducted a retrospective review of 93 patients between the ages of 4 to 18 years with long-bone Ewing sarcoma treated at St. Jude between 1962 AND 1999.

Dr. Lars M. Wagner and colleagues found that fractures occurred in 14 patients, or 15% of the study group. All of the fractures occurred in either the femur or the tibia, and 9 of the 14 fractures occurred after radiotherapy had begun. In three of these cases, fracture was associated with either local recurrence or a second malignancy.

Writing in the December issue of the Journal of Pediatric Hematology/Oncology, the investigators caution that these late fractures "may mimic stress fractures or radiation necrosis on plain radiographs, and there often may be considerable delay in diagnosis." Thy found diagnostic delays of 4 to 13 months, meaning that therapeutic intervention was also delayed.

"The use of dynamic contrast-enhanced magnetic resonance imaging can help distinguish late fractures associated with malignancy from those associated with benign causes such as radionecrosis," Dr. Wagner and colleagues note.

The team says their approach to the management of these children with late fractures after therapy is "external stabilization, with aggressive neoadjuvant chemotherapy to cause tumor shrinkage." Then surgery is performed with the aim of achieving "local control with limb salavage if possible."

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