Delayed Diagnosis of Ewing Sarcoma: A Case Series

Background: Ewing Sarcoma, the second most common bone cancer in adolescents, affects young adults between the ages of 15 to 24. Ewing Sarcoma presents with a variety of non-specific symptoms, including pain and possible mass; the average delay in diagnosis is 6 months. Physician-related delays, defined as the time when a patient first presents to a physician to the time of diagnosis, account for 63.6% of delays. Adolescent (15-19 years old) patients have a notably longer patient-related delay, defined as the time when a patient first notices a symptom to the time they present to a physician, contributing to an overall longer delay in diagnosis. Patients diagnosed without metastasis have a 70% survival rate, whereas patients with metastasis present have only a 20% survival rate. By reviewing three cases of delayed diagnosis in Ewing Sarcoma, we aim to increase awareness of providers to improve earlier diagnosis of Ewing Sarcoma. Methods: Electronic medical records of three patients were reviewed at Cook Children’s Medical Center. Case Information: Three cases of adolescent Ewing Sarcoma diagnosed between 2010-2018 were evaluated. One patient was diagnosed with sciatica followed by a herniated disc after a car accident and had a six-month delay. The patient did not respond to treatment and was referred to a pain management specialist. At diagnosis, the patient had metastasis to multiple areas and is currently undergoing treatment. The other two patients had delays of approximately 12 months and were being treated by either a chiropractor or physical therapist. Both patients associated their pain to the musculoskeletal system and delayed going to a physician. One patient had metastasis to multiple sites at diagnosis, while the other patient had no metastasis. Both patients are currently in remission. Conclusions: Ewing Sarcoma presents with nonspecific symptoms and can have lengthy delays in diagnosis. Timely diagnosis is important because longer delays can result in metastasis, a need for more intensive therapy, and a worse prognosis. As demonstrated by these cases, pain onset, proper imaging guidelines, age-specific statistics, avoiding specialty bias, and enhanced provider awareness are important considerations in developing an appropriate differential diagnosis and earlier recognition of Ewing Sarcoma. In presenting these cases we seek to improve awareness and suspicion of Ewing Sarcoma among practitioners evaluating patients such as we have described.