Extraskeletal Ewing Sarcoma of the Gastrointestinal and Hepatobiliary Tract: Deceptive Immunophenotype Commonly Leads to Misdiagnosis

Abstract

Ewing sarcoma (ES) is an uncommon mesenchymal neoplasm that typically develops as a bone mass, although up to 30% arise in extraskeletal sites. ES of the gastrointestinal (GI) and hepatobiliary tract is rare and may be misdiagnosed as other, more common neoplasms that occur in these sites. However, the correct classification of extraskeletal ES is important for timely clinical management and prognostication. We reviewed our experience of ES in the GI and hepatobiliary tract in order to further highlight the clinicopathologic features of these neoplasms and document the potential for misdiagnosis in this setting. The archives and consultation files of 6 academic institutions were retrospectively queried for cases of ES occurring in the GI and hepatobiliary tract. The histologic slides and ancillary studies were reviewed and clinical data were retrieved for each case through the electronic medical records, when available. Twenty-three patients with ES in the GI and/or hepatobiliary tract were identified from 2000 to 2022. Of these, 11 were women and 12 were men with a median age of 38 years (range, 2 to 64). Tumor locations included the pancreas (n=5), liver (n=2), stomach (n=3), colorectum (n=3), and small intestine (n=5), as well as tumors involving multiple organs, pelvis and retroperitoneum (n=5). Tumor size varied between 2 cm and 18 cm. Twenty were primary and 3 were metastases. Of the 23 cases, only 17% were initially diagnosed as ES. The most common misdiagnoses involved various forms of neuroendocrine neoplasia due to expression of synaptophysin and other neuroendocrine markers (22%). A wide variety of diagnoses including GI stromal tumor was considered due to aberrant CD117 expression (4%). The diagnosis of ES was ultimately confirmed by detection of the EWSR1 rearrangement in 22 cases. The remaining case was diagnosed using traditional immunohistochemistry. Follow-up information was available in 20 cases, with follow-up time varying between 2 and 256 months. Six patients with follow-up died of disease between 6 and 60 months following initial presentation. Our data indicate ES in the GI and hepatobiliary tract is commonly misdiagnosed leading to a delay in therapy. In light of the attendant therapeutic and prognostic implications, ES should be considered in the differential diagnosis of any GI or hepatobiliary tumor with epithelioid and/or small round cell morphology.

FIGURE 1

Primary tumor location of intra-abdominal Ewing sarcoma.

FIGURE 2

Initial pathologic diagnosis of intra-abdominal Ewing sarcoma.

FIGURE 3

(A) Ewing sarcoma arising in the rectum exhibits a nested epithelioid morphology. The tumor cells demonstrate (B) diffuse positive CD117 expression, (C) strong cytokeratin expression, and (D) patchy synaptophysin expression. The tumor cells also expressed strong CD99 expression (not shown).

FIGURE 4

(A) Gastric Ewing sarcoma exhibits a uniform epithelioid morphology. The tumor cells demonstrate (B) diffuse positive CD99 expression, (C) diffuse positive CD117 expression, and (D) patchy synaptophysin expression.

FIGURE 5

(A) Ewing sarcoma arising in jejunum. The nuclei have a stippled chromatin pattern, suggestive of a neuroendocrine neoplasm. The tumor cells demonstrate (B) diffuse positive CD99 expression, (C) diffuse positive PAX7 expression, and (D) patchy synaptophysin expression.

FIGURE 6

(A) Fine needle aspiration of Ewing sarcoma arising in the abdomen. (B) The constituent cells have scant cytoplasm and uniform, ovoid nuclei that are hyperchromatic, suggestive of a neuroendocrine carcinoma. The tumor cells demonstrate (C) diffuse positive CD99 expression and (D) patchy synaptophysin expression.