Management of Ewing Sarcoma of Distal Fibula in Child: A Case Report

Abstract

Introduction: Ewing's sarcoma is the second most common primary malignant bone tumor in children and adolescents, after osteosarcoma. It is a rare tumor, with the axial skeleton being the preferred site of development, followed by the long bones. Diagnosis is evoked by imaging and confirmed by histology. Treatment is based on intensive chemotherapy with local surgical treatment in operable forms, and in some cases, radiotherapy. There are only a few sporadic cases in the literature describing distal fibular localization.

Case report: We report the case of a 7-year-old child who presented with pain on the lateral aspect of the left ankle without local inflammatory signs. Radiological findings revealed a metaphyseal-diaphyseal osteolytic tissue process of the left fibula, and histology concluded that it was Ewing's sarcoma. We proceeded with neoadjuvant polychemotherapy followed by segmental resection of the distal fibula with an anteroexternal tibial rod, plus tibiotalar, and talocalcaneal arthrodesis without recourse to radiotherapy.

Conclusion: The management of Ewing's sarcoma is constantly evolving. Its distal fibular location in a growing limb makes it even more difficult. It must be personalized, multidisciplinary, and carried out in specialized centers.

Keywords: Ewing’s sarcoma; chemotherapy arthrodesis; distal fibula.

Figure 1

(a and b) Radiograph of the left ankle. Type II osteolysis with soft-tissue involvement and Codman’s triangle, located distal to the fibula.

Figure 2

(a-c) Sagittal and axial coronal sections of the ankle. Pre-chemotherapy magnetic resonance imaging showing an aggressive osteolytic process in heterogeneous T2 hypersignal measuring 22×20×50 mm without effraction of the distal fibular growth plate.

Figure 3

(a and b) Magnetic resonance imaging (MRI) sagittal and coronal sections of the ankle postchemotherapy showing a regression of the volume of the tissue process by 70% compared with the initial MRI equivalent to 8×11×35 mm.

Figure 4

(a-c) Several views of the resection of the tumor taking the fibula with a posterior tibial rod. (d) Macroscopic examination of the tumor with an appearance of post-chemotherapy fibrosis.

Figure 5

(a and b) Immediate post-operative: tibiotalar and talocalcaneal arthrodesis.

Figure 6

(a and b) Final follow-up at 2 years and 3 months.

Figure 7

(a-c) Total plantigrade bearing with good healing.

Figure 8

Pangonogram: no lower-limb length inequality.