See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/5763929

Ewing's sarcoma: Imaging features

Article  in  JBR-BTR: organe de la Société royale belge de radiologie (SRBR) = orgaan van de Koninklijke Belgische Vereniging voor Radiologie (KBVR) · September 2007
Source: PubMed

CITATIONS READS

34 2,901

12 authors, including:

Benjamin Peersman Filip M Vanhoenacker

Heilig Hart Ziekenhuis Tienen Algemeen ziekenhuis Sint-Maarten
5 PUBLICATIONS   73 CITATIONS    1,190 PUBLICATIONS   6,117 CITATIONS   

SEE PROFILE SEE PROFILE

Stijn Heyman Bruno Van Herendael

Ziekenhuis Netwerk Antwerpen GasthuisZusters Antwerpen
32 PUBLICATIONS   114 CITATIONS    19 PUBLICATIONS   221 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Quantitative MRI of ACL View project

Research and teaching on Social Media in Radiology View project

All content following this page was uploaded by Paul M Parizel on 01 June 2014.

The user has requested enhancement of the downloaded file.

JBR–BTR, 2007, 90: 368-376.

EWING’S SARCOMA: IMAGING FEATURES

B. Peersman1, F.M. Vanhoenacker1, S. Heyman1, B. Van Herendael1, M. Stam2, P. Brys3, K.L. Verstraete4, I. Samson5,
J. Sybers6, P. Van Dyck1, P.M. Parizel1, A.M. De Schepper1,2

Aim: To define an imaging prototype of Ewing’s sarcoma (ES).

Materials and methods: Sixty-four patients with a histopathologically and/or genetically proven diagnosis of ES
were analyzed for clinical parameters (age, gender and location), radiographic and CT appearance (distribution,
matrix, margins, periosteal reaction, articular extension, cortical reaction and the presence of a pathologic fracture).
Size, local extension, signal intensity, degree and pattern of enhancement, and the presence of skip metastases were
evaluated on MRI.
Distant metastases were recorded on bone scintigraphy and chest CT scan.
Results: Patient’s age ranged between 7-67 (mean 17.9). Male/female ratio was 2.4/1.
Location in the pelvis was most frequent (31%), followed by the femur (20%) and tibia (11%). Most tumors were
mixed lytic-sclerotic (75%), and purely lytic in 25%. Plain films and CT scan showed a spiculated periosteal reaction
in 50%. A Codman’s triangle was seen in 27%.
Articular extension was difficult to assess on radiographs. Cortical permeation and destruction is seen in respectively
31 and 42%, whereas cortical thickening is seen in 20%. Pathologic fracture occurred in 7.8%.
MRI showed a large mass, with a soft tissue component of more than 50% in 67%.
Degree and pattern of enhancement pattern was variable.
Signal intensity on T1- and T2-WI was non-specific.
Joint involvement was seen in 23%. Isolated involvement of the soft tissue (extraskeletal ES) was seen in 1.5%.
Skip metastases at initial presentation were present at initial presentation in 14% and distant metastases in 22%.
Conclusions: ES occurs in young patients. On radiographs/CT, 37.5% are located in the axial skeleton and 62.5% in
the peripheral skeleton. ES is mostly mixed sclerotic-lytic. A spiculated periosteal reaction is most frequent.The most
characteristic finding on MRI is the presence of a large soft tissue mass.

Key-word: Ewing sarcoma.

Ewing’s sarcoma (ES), peripheral from four institutions, and to com- Tumor matrix was scored on a
primitive neuroectodermal tumors pare our findings with the literature. subjective scale as the sclerosis
(PNET), and Askin tumors (AT) are compared to of osteolysis within
referred to as Ewing’s tumors Materials and methods the osseous component of the
(ETs) (1). ES is the second most tumor.
common malignant bone tumor in Sixty-four patients with histologi- The margins of the tumor on radi-
children and young adults, with an cally and/or genetically proven diag- ographs/CT were evaluated and
unknown histogenesis (2). nosis of ES were included. In our graded by the following criteria:
ES is a round-cell sarcoma, show- series, we assembled 52 plain radi- sharp demarcation, partially sharp
ing varying degrees of neuroecto- ographs, 36 CT scans and 62 MRI demarcation (less than 50%
dermal differentiation. These tumors scans. The MR imaging protocol unsharp) and unsharp demarcation
are cytogenetically well described, consisted of at least T1-weighted, T2- (more than 50% unsharp).
and in 85% of the cases, a balanced weighted images (with or without Periosteal reaction was scored as
t(11;22)(q24;12) is found (3). fat suppression) and T1-weighted lamellar or onion peel, interrupted
Most patients complain of pain, images after intravenous adminis- lamellar, Codman’s triangle, sun-
occasionally accompanied by tration of gadolinium chelates in dif- burst or hair-on-end or mixed.
swelling at the affected site. ferent slice directions. Codman’s triangle is due to forma-
Infrequent presenting symptoms We analyzed all patient files for tion of reactive bone between the
include fever, weight loss, cough, clinical parameters, i.e. age, gender elevated intact periosteum and the
anemia and leukocytosis. and location. Secondly, we evaluat- underlying cortex at the zone of
ed the available radiographs/CT transition to the extraosseous
Aim scans for lesion distribution within extension of the tumor. Formation
the skeleton (axial skeleton, flat of long, thin filiform spicules, radiat-
The aim of this article is to define bones or epi-, meta- or diaphyseal ing perpendicularly from the cortex,
an imaging prototype of Ewing’s location within the long bones), is typical for a spicular, sunburst
sarcoma, based on the analysis of a matrix, margins, periosteal reaction periosteal reaction.
large cohort of patients, originating and articular extension. Articular extension on radio-
graphs/CT was defined as cortical
breakthrough of the joint margins
and/or tumor extension on both
sides of the adjacent joint. Cortical
From: 1. Dept. of Radiology University Hospital Antwerp, 2. Dept. of Radiology Leiden reaction was scored by following
University Medical Center, 3. Dept. of Radiology University Hospital Leuven, 4. Dept. criteria, namely cortical destruction,
of Radiology University Hospital Gent, 5. Dept. of Orthopaedic Surgery University cortical permeation and cortical
Hospital Leuven, 6. Vision Lab, University of Antwerp.
Address for correspondence: Dr B. Peersman, MD, Department of Radiology,
thickening or thinning. Also the
University Hospital Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium. presence of a pathologic fracture at
E-mail: benjaminpeersman@hotmail.com. initial presentation was evaluated.
 EWING’S SARCOMA — PEERSMAN et al 369

On MRI, the overall signal intensi-

ty of the tumor (intra- and
extraosseous component) on T1-
weighted images, T2-weighted
images and T2-weighted images
with fat suppression were recorded.
We also evaluated the degree and
pattern of enhancement of the
tumor on T1-weighted images after
intravenous administration of
gadolinium chelates. The tumor
volume was measured on contrast
enhanced T1-weighted images with
fat suppression, by using the
formula craniocaudal x transverse x
anteroposterior diameter x 0.5.
The percentage of bone and soft
tissue component of the tumor was
recorded on a subjective scale. Joint
involvement on MRI was evaluated,
using the same parameters as men-
tioned above (CT) and the presence
of concomitant joint effusion. The
presence of skip metastases within
the same bone was scored on T1-
weighted images. Fig. 1. — Location of ES.
Distant metastases were evaluat- The most frequent location is the pelvis accounting for 31.25%, followed by the
ed on bone scintigraphy and chest femur (20.3%) and the tibia (11%). Location in humerus, fibula, scapula and rib is rare.
CT-scan. Only one extraskeletal ES was seen in our study (posterior aspect of the right knee
joint).
Results

The mean age of the population

is 17.9 years old with a range from 7 The location of the lesions is frequently encountered (40%).
to 67 years. Our population demon- summarized in Fig. 1. Lesion’s matrix is summarized in
strates a male to female ratio of More than 90% of the lesions in Table I and illustrated in Fig. 2.
2.4:1 (45 male patients and the long bones are located in the All tumors present as unsharp
19 female patients). (meta)diaphysis. Extension to the marginated lesions on plain radio-
In the majority of our cases, the epiphysis is rare. graphy/CT (Fig. 3A-C).
lesion is located in the pelvis or A mixed sclerotic-lytic type with a Aggressive spicular periosteal
lower extremity. sclerotic component of 75% is most reaction is frequently encountered

B
Fig. 2. — Lesion matrix.
A. Plain radiograph of the pelvis shows an example of a pure-
ly lytic ES of the left iliac bone.
B. Axial CT image of a mixed sclerotic-lytic type in the right
femoral neck. Note areas of sclerosis (white arrow) combined
A with areas of osteolysis (bone destruction) (black arrow).
370 JBR–BTR, 2007, 90 (5)

Evidence of joint involvement is

present in 23% of cases.
Fig. 5 demonstrates joint exten-
sion on different imaging modalities.
Cortical permeation and destruc-
tion are common findings in our
study (respectively 31 and 42%),
whereas cortical thickening is rather
uncommon (20%). A pathologic
fracture is seen in 7.8% of cases.
The overall signal intensity on T1-
weighted images of the tumor is in
70% of cases equal to that of the
surrounding muscle. In the other
30% we notice an overall signal
intensity higher than surrounding
muscle (Fig. 6).
Seventy-three percent of the
tumors in our series show high sig-
nal intensity on T2-weighted images.
The remainder show signal intensity
equal to that of fat (Fig. 7).
All tumors show an overall signal
intensity higher than muscle but
A B lower than water on T2-weighted
images with fat suppression (Fig. 8).
MRI reveals skip metastases in
14% (Fig. 9). The soft tissue compo-
nent occurs to be more than 50% in
67% of cases (Fig. 10). No specific
degree and pattern of enhancement
can be demonstrated in our series.
Distant metastases are seen in 22%
(14% pulmonary metastases, 5%
bone metastases on bone scintigra-
phy and 3% both).

Discussion

Ewing’s sarcoma (ES) is an

aggressive, highly malignant bone
tumor that belongs to the group of
small round (blue) cell tumors and
occurs predominantly in the second
decade of life. Extraskeletal ES is
extremely rare and occurs in a
slightly older age group. The mean
D age in our study is 17.9 years old.
The male to female ratio in our pop-
C ulation is slightly higher than
described in literature, i.e. 2.4/1 ver-
Fig. 3. — Local tumor extension. sus 3/2 in most studies (3-6).
A. Plain radiograph of the forearm. Codman’s triangle and spicular periosteal reac- ES has a predilection for the
tion at the ulnar side of the radius. Cortex permeation and subtle moth-eaten pattern pelvis and lower extremities (4-7).
of the neighbouring bone. The intra- or extraosseous extension of the lesion is hardly The most frequent location in our
to demonstrate on plain film. study is the pelvis, followed by the
B-C. CT scan also shows the periosteal reaction and cortical permeation. Extension femur, tibia and humerus. In long
of a soft tissue mass towards the ulna (black arrows). bones, lesions are located in the
D. MRI of the same lesion. T1-weighted image after intravenous administration of
gadolinium contrast. Note the sharp margins of the intraosseous extent, in contrast
(meta)diaphysis and rarely extend
with the normal bone marrow. The extraosseous component of the tumor is well into the epiphysis (8).
demonstrated (white arrows). Reinus et al. (6) reviewed the
radiographs of 373 patients and
described the radiographic features
of ES. Findings were divided into
three categories, depending on their
in our study and presents in more ent types of periosteal reaction are frequency of occurrence: common
than 50% of cases. Laminated demonstrated in Fig. 4 and findings (> 30%), uncommon find-
periosteal reaction is not frequently described in order of occurrence in ings (> 10%, < 30%) and rare findings
demonstrated (only 14%). The differ- Table II. (< 10%). Poor margination, soft tis-
 EWING’S SARCOMA — PEERSMAN et al 371

Table I. — Percentage of sclerotic component in lesion matrix were described as uncommon find-
ings. Soft tissue calcification,
saucerization, honeycombing, sharp
margins and vertebra plana were
described as rare findings. Poor
margination, extensive soft tissue
component, sclerotic matrix and
permeation are also common find-
ings in our study. On the other hand,
laminated periosteal reaction is an
uncommon finding in our study
(14%). Although Reinus et al.
described spiculated periosteal
reaction as an uncommon finding ,
it is more than common (> 50%) in
our series. The milder forms of
periosteal reaction, namely laminat-
ed periosteal reaction and onion
skin were described also by Resnick
to be common manifestations
(57%), and the spiculated periosteal
reaction as a less frequent manifes-
tation (28%) (8).
Cortical permeation and destruc-
An exclusively sclerotic lesion is infrequent (6%). A mixed sclerotic-lytic type tion are common findings in our
with a sclerotic component of 75% occurs in 40% of cases. A 50% sclerotic- study (respectively 31 and 42%),
50% lytic type is seen in 20% of the cases. Only 11% present as a lesion with whereas cortical thickening is rather
a sclerotic component of 25%. 23% of ES’s in our study present as a purely uncommon (20%). A pathologic
lytic lesion (sclerotic component of 0%). fracture (7.8%), as well as soft tissue
calcification and sharp margins are
rare findings in our study.
Pathologic fracture was described
as an uncommon finding (14%) by
Reinus et al.
CT scan is a good imaging
Table II. — Type of periosteal reaction frequency modality to evaluate joint extension,
periosteal reaction and matrix of the
lesion. A large soft-tissue mass is
well illustrated by CT-scan, especial-
ly after intravenous administration
of contrast material.
MRI is accurate in the assessment
of the intramedullary tumor extent
in patients with bone sarcoma
which is documented by the excel-
lent correlation between longitudi-
nal T1-weighted images and identi-
cal macrosections of the surgical
specimens. Transverse TSE T2-
weighted images best display the
interface between tumor and adja-
cent soft tissues and the anatomical
relationship with the neurovascular
structures, allowing differentiation
between intracompartmental and
extracompartmental disease.
Contrast between tumor and normal
Frequency of occurrence of the different types of periosteal reaction. The tissue, especially fat-containing tis-
onion peel reaction occurs in 14%, the interrupted lamellar form in 18%, sue, is greatly enhanced by combin-
Codman’s triangle in 27% and the spicular periosteal reaction in 52% of ing TSE with fat-selective presatura-
cases. tion. T1-weighted images after
administration of contrast material
can be successfully combined with
fat-selective presaturation to
enhance contrast resolution (8-23).
sue involvement, permeative com- Spiculated periosteal reaction, corti- Non-homogeneous signal intensity
ponent, laminated periosteal reac- cal thickening and violation, purely is seen on all pulse sequences. No
tion and sclerotic matrix were lytic matrix, pathologic fracture, cys- specific degree and pattern of
described as common findings. tic component and bone expansion enhancement on MRI is seen. Skip
372 JBR–BTR, 2007, 90 (5)

A C

D E F
Fig. 4. — Variable periosteal reaction in different patients.
Plain radiograph of the femur. Lamellar periosteal reaction.
CT scan of the same patient. Lamellar periosteal reaction.
Plain radiograph of the distal ulnar diaphysis. Note the interrupted (arrow) lamellar periosteal reaction, depicting regions of more
aggressive tumor extension into the soft tissue.
D-E. Plain radiograph of the femur and sagittal reformatted CT scan of the forearm in 2 different patients. Codman’s triangle or
spur (arrows).
F-G. Radiographs and CT scan of the femur. Aggressive spicular, ‘sunburst’ periosteal reaction.
 EWING’S SARCOMA — PEERSMAN et al 373

A B

C D
Fig. 5. — Evaluation of local tumor extension (bone and soft tissue component).Evaluation of joint extension by different imag-
ing modalities.
A. Plain radiograph of the pelvis. Sclerotic lesion of the left iliac bone. Evaluation of soft tissue component and articular exten-
sion is not possible.
B. Axial CT scan. Sclerosis is mainly located at the left iliac bone (black arrow) but minor sclerosis on the sacral side of the sacro-
iliac joint suggests articular extension (white arrow).
C. Axial T2-weighted image with fat saturation. We can now clearly demonstrate the articular extension of the tumor and invasion
of the sacrum (white arrow). Note also huge soft tissue component (black arrows).
D. Axial T1-weighted image after intravenous administration of gadolinium chelates. This sequence also demonstrates the articular
extension of the pelvic tumor and tumoral invasion of the sacrum (white arrow). Soft tissue extension is indicated by black arrows.

A B
Fig. 6. — Signal intensity on T1-weighted images.
A. Coronal T1-weighted image of the sacrum. ES of the sacrum (arrows), with a signal intensity equal to
that of the surrounding muscles.
B. Coronal T1-weighted image of the pelvis. Ewing’s sarcoma of the left iliac bone with a large soft-tissue
component (arrows). The overall signal intensity is higher than that of surrounding muscles, but lower than fat.
374 JBR–BTR, 2007, 90 (5)

Fig. 7. — Signal intensity on T2-weighted images.

Axial T2-weighted image of the pelvis. ES of the right iliac
bone, with a large soft tissue component (arrows). The overall
signal intensity is higher than the surrounding muscles, but
lower than fat.

Fig. 9. — Skip metastases.

Coronal T1-weighted image of the left femur. Ewing’s sarco-
ma at the middiaphysis. Note the skip metastases (arrows) in
the distal portion of the femur.

administration of gadolinium
chelates. This is accentuated in diffi-
cult anatomic regions (e.g. pelvis).
We couldn’t compare the value of
MRI and CT scan because the num-
ber of CT-scans available was limit-
Fig. 8. — Signal intensity on fat suppressed T2-weighted ed, many scans contained only
images. images in axial plane and not all
Axial T2-weighted image with fat suppression. ES of the left scans were performed after intra-
iliac bone, with a large soft-tissue component. The overall sig- venous contrast administration.
nal intensity is higher than that of the surrounding muscles, but Other limitations in our study are
lower than water (arrows). due to the retrospective design.
There were indeed slight differences
in the MR protocol between the dif-
ferent institutions and not all
metastases are present in 14% of defining intraosseous tumor length images were available in a full digi-
cases. Jiya et al. described the and was as accurate as CT in tal format (DICOM) rendering more
occurrence of skip lesion in ES to be demonstrating cortical bone and accurate volume measurements
rare (24). Most tumors in our series joint involvement (27). But MRI was impossible.
have a large soft tissue component, definitely superior to CT in demon-
65% presented with a soft tissue strating involvement of muscle Conclusion
component of more than 50%. compartments. They concluded that
MRI is very sensitive, but less MRI is the modality of choice for Ewing’s sarcoma is a highly
specific for the determination of epi- local staging of primary bone sarco- malignant bone tumor that predom-
physeal involvement. It is highly ma. Panicek et al. concluded in 1997 inantly occurs in young patients. The
sensitive for excluding joint involve- that CT and MR imaging are equally most characteristic finding is the
ment although false-positive results accurate in the local staging of presence of a large soft tissue mass,
may occur secondary to synovial malignant bone and soft-tissue neo- which is best demonstrated on MRI.
inflammatory reactions (25, 26). plasms in specific anatomic sites Seventy percent of these tumors
With the recent developments of studied (28). In our study, MRI is the arise in the pelvis or lower extremi-
multiplanar imaging, CT scan is a imaging modality of choice because ty. In contradistinction to the litera-
good alternative in local staging of of its high contrast resolution and ture, a spiculated periosteal reaction
the tumor. Bloem et al. and also the ability to define the margins of is seen in more than half of our
many other authors in the 1980’s the soft-tissue component, especial- patients. Ewing’s sarcoma presents
described that MRI was significantly ly on T2-weighted images and T1- most frequently as a mixed sclerot-
superior to CT and scintigraphy in weighted imaging after intravenous ic-lytic type of tumor, and most
 EWING’S SARCOMA — PEERSMAN et al 375

B
A

D
Fig. 10. — Local tumor extension.
A-B. CT scan of the lower leg. Aggressive tumoral lesion of the fibula with cortical
permeation and destruction. Spicular periosteal reaction. Presence of a large soft tis-
sue component (arrows).
C-D. Sagittal T1-weighted image after intravenous administration of gadolinium
chelates (C) and an axial T2-weighted image (D). ES of the fibula with the presence of
a large soft tissue mass (arrows). The soft tissue extension of the tumor is better appre-
C ciated on MR images in comparison to the CT-images.

tumors occur in the (meta)diaphysis
of the long bones. Cortical destruc-
tion and permeation is a frequently
encountered feature. Plain radiogra-
phy and CT scan are good imaging
modalities to describe periosteal
reaction, lesion’s matrix and cortical
changes. MR imaging remains the
imaging modality of choice for local
tumor evaluation.
Acknowledgments
We are grateful to R. Forsyth
(University of Ghent) and A. Van
Erkel (Leiden University Medical
Center) for their contribution in the
preparation of this manuscript.
References
1. Lazar A., Abruzzo L.V., Pollock R.E.,
Lee S., Czerniak B.: Molecular
Diagnosis of Sarcomas, Chromo-
somal Translocations in Sarcomas.
Arch Pathol Lab Med, 2006, 130:
1199-1207.
2. Udayakumar A.M., Sundareshan T.S.,
Goud T.M., et al.: Cytogenetic charac-
terization of Ewing tumors using fine
needle aspiration samples: a 10-year
experience and review of the litera-
ture. Cancer Genet Cytogenet, 2001,
127: 42-48.
3. Szuhai K., IJszenga M, Tanke H.J.,
Rosenberg C., Hogendoorn P.C.:
Molecular cytogenetic characteriza-
tion of four previously established
and two newly established Ewing
sarcoma cell lines. Cancer Genet
Cytogenet, 2006, 166: 173-179.
4. Schajowicz F.: Marrow tumors. In:
Tumors and tumorlike lesions of the
bone: Pathology, radiology and treat-
ment. Edited by Schajowicz F.,
Second edition. Printed by Springer-
Verlag, Berlin, 1994, pp 301-325.
5. Dahlin D.C., Unni K.K.: Ewing’s tumor.
In: Bone tumors. General aspect and
data on 8,542 cases. Edited by
Dahlin D.C and Unni K.K. Printed by
C.C. Thomas Springfield, Fourth edi-
tion, Illinois, 1986, pp 322-336.
6. Reinus W.R., Gilula L.A., IESS
committee: Radiology of Ewing’s
sarcoma: Intergroup ES study (IESS).
Radiographics, 1984, 4: 929-944.
7. Ilaslan H., Sundaram M., Unni K.K.,
Dekutoski M.B.: Primary Ewing’s
 376 JBR–BTR, 2007, 90 (5)
sarcoma of the vertebral column. 15. Dwyer A.J., Glaubiger D.L.,
Skeletal Radiol, 2004, 33: 506-513. Ecker J.G., Doppman J.L.,
8. Resnick D., Kransdorf M.J.: Tumors Prewitt J.M., Plunkett J.: The radio-
and tumorlike diseases. In: Bone and graphic follow-up with Ewing
Joint imaging. Edited by Resnick D. Sarcoma: A demonstration of a gen-
and Kransdorf M.J., third edition. eral method. Radiology, 1982, 145:
Printed by Elsevier, Philadelphia, 327-331.
2005, pp 1192-1198. 16. Redmond O.M., Stack J.P.,
9. Pommersheim W. J, Chew F.S.: Dervan P.A., Hurson B.J., Carney D.N.,
Imaging, diagnosis, and staging of Ennis J.T.: Osteosarcoma: Use of MR
bone tumors: A primer. Semin imaging and MR spectroscopy in clin-
Roentgenol, 2004, 39: 361-372. ical decision making. Radiology, 1989,
10. Hanna S.L., Fletcher B.D., Kaste S.C., 172: 811-815.
Fairclough D.L., Parham D.M.: 17. Ehman R.L., Berquist T.H.,
Increased confidence of diagnosis of McLeod R.A.: MR Imaging of the mus-
Ewing sarcoma using T2-weighted culoskeletal system: a 5-year apprai-
MR images. Magn Reson Imaging, sal. Radiology, 1988, 166: 313-320.
1994, 12: 559-568. 18. Vogler J.B., Murphy W.A.: Bone
11. Van der Woude H.J., Bloem J.L., marrow imaging. Radiology, 1988,
Hogendoorn P.C.: Preoperative evalu- 168: 679-693.
ation and monitoring chemotherapy 19. Pettersson H., Gillespy T.,
in patients with high grade Hamlin D.J., et al.: Primary muscu-
osteogenic and Ewing’s sarcoma: loskeletal tumors : examination with
review of current imaging modali- MR imaging compared with conven-
ties. Skeletal Radiol, 1998, 27: 57-71. tional modalities. Radiology, 1987,
12. Wilner D.: Ewing sarcoma. In: 164: 237-241.
Radiology of bone tumors and allied 20. Mirowitz S.A., Apicella P.,
disorders. Edited by Wilner D. Reinus W.R., Hammerman A.M.: MR
Printed by WB Saunders, imaging of bone marrow lesions: rel-
Philadelphia, 1982, pp 2462-2573. ative conspicuousness on T1-weight-
13. Boyko O.B., Cory D.A., Cohen M.D., ed, fat-suppressed T2-weighted, and
Provisor A., Mirkin D., DeRosa G.P.: STIR images. AJR Am J Roentgenol,
MR Imaging of osteogenic and 1994, 162: 215-221.
Ewing’s sarcoma. AJR Am J 21. Gillespy T., Manfrini M., Ruggieri P.,
Roentgenol, 1987, 148: 317-322. Spanier S.S., Pettersson H.,
14. Bloem J.L., Bluemm R.G., Springfield D.S.: Staging of
Taminiau A.H., Van Oosterom A.T., intraosseous extent of osteosarco-
Stolk J., Doornbos J.: Magnetic reso- ma: correlation of preoperative CT
nance imaging of primary malignant and MR imaging with pathologic
bone tumors. Radiographics, 1987, 7: macroslides. Radiology, 1988, 167:
425-445. 765-767.
View publication stats
22. Gorospe L., Fernández-Gil M.A.,
Garcia-Raya P., Royo A., Lopez-
Barea F., Garcia-Miguel P.: Ewing’s
sarcoma of the mandible: Radiologic
features with emphasis on magnetic
resonance appearance. Oral Surg
Oral Med Oral Pathol Oral Radiol
Endod, 2001, 91: 728-34.
23. Singh P., Jain M., Singh D.P., Kalra N.,
Khandelwal N., Suri S.: MR findings
of primary Ewing’s sarcoma of
greater wing of sphenoid. Australas
Radiol, 2002, 46: 409-411.
24. Jiya T.U., Wuisman P.I.: Long-term fol-
low-up of 15 patients with non-
metastatic Ewing’s sarcoma and a
skip lesion. Acta Orthop, 2005, 76:
899-903.
25. Norton K.I., Hermann G.,
Abdelwahab I.F., Klein M.J.,
Granowetter L.F., Rabinowitz J.G.:
Epiphyseal involvement in osteosar-
coma. Radiology, 1991, 180: 813-816.
26. Leung J.C., Dalinka M.K.: Magnetic
Resonance Imaging in Primary Bone
Tumors. Semin Roentgenol., 2000,
35: 297-305.
27. Bloem J.L., Taminiau A.H.,
Eulderink F., Hermans J.,
Pauwels E.K.: Radiologic staging of
primary bone sarcoma: MR imaging,
scintigraphy, angiography, and CT
correlated with pathologic examina-
tion. Radiology, 1988, 169: 805-810.
28. Panicek D.M., Gatsonis C.,
Rosenthal D.I., et al.: CT and MR
imaging in the local staging of
primary malignant musculoskeletal
neoplasms: report of the radiology
diagnostic oncology group.
Radiology, 1997, 202: 237-246.