Diagnosis of Ewing’s sarcoma

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Step 1: Presentation, clinical history and examination

“Presentation” is the term used by medical professionals to describe the first time a patient attends a doctor regarding their symptoms. This can be a GP, a clinic or an emergency department. In most cases of Ewing’s sarcoma this will be the first time a patient visits their GP about their symptoms that likely include bone pain and swelling.

The doctor will document a “clinical history” which is general information about the symptoms. They will then examine the affected area, whether it hurts to touch and whether the pain is in the bone or muscle. At this stage, the doctor will be investigating for soft tissue and muscle injuries.

If the doctor is concerned that there is a possible tumour, there are national guidelines that they should follow. National Institute for Clinical Excellence (NICE) guidelines for suspected bone cancer recommend that a patient must receive an urgent referral to hospital for an X-ray.

Step 2: Referral to a hospital

On arrival at the hospital, the patient will undergo an X-ray. The X-ray will produce an image of the bone in the affected area. If the X-ray shows signs of abnormal bone growth, the hospital will conduct more detailed scans of the bone using CT (computerised tomography) or MRI (magnetic resonance imaging).

CT scans are often undertaken after the diagnosis of cancer is confirmed to determine whether it is localised (contained in the bone) or is metastatic (has spread). These scans involve the injection of contrast, before a camera rotates extremely fast around the body taking a number of images used to build up a three dimensional picture of the body.

MRI scans use magnetism and radio waves to build a detailed three dimensional image of the affected bone. MRI scanners can be quite noisy – some machines have a CD player so that patients can listen to their choice of music during the scan. The hospital might also carry out a blood test to check the overall health of the patient, although at present there is no specific blood test for Ewing’s sarcoma.

If the detailed scans confirm an abnormal growth or tumour, the hospital will refer a patient to a specialist Bone Tumour Centre.

Step 3: Referral to a Bone Tumour Centre

Bone Tumour Centres are hospitals that specialise in the diagnosis and surgical treatment of bone cancer. In England, there are five Bone Tumour Centres, at Birmingham, Newcastle, Oswestry, Oxford and Stanmore. Patients in Wales usually travel to Oswestry or Birmingham and in Scotland, the three Centres can be found in Edinburgh, Glasgow and Aberdeen. In Northern Ireland, patients are usually seen in Belfast.

At the Bone Tumour Centre, a multidisciplinary team (MDT) will manage a patient. An MDT is a group of healthcare professionals who are experts in their various fields. They work together to ensure a patient is properly diagnosed and if necessary, treated. An MDT may consist of:

  • An oncologist who is a doctor with expertise in managing patients with cancer. Oncologists specialise in drug treatment and radiation therapy (radiotherapy).
  • A radiologist who is a doctor with expertise in interpreting X-rays and scans.
  • A histopathologist who is a doctor with expertise in the microscopic examination of tissue and cells.
  • An orthopaedic oncology surgeon who is an expert at removing tumours and reconstructing bone.
  • A sarcoma nurse specialist who has undergone highly specialised training in caring for patients with sarcoma.

At the Bone Tumour Centre, the MDT will assess the scans that were completed at the initial hospital and organise for the patient to receive a biopsy. This is the use of a core needle to take a sample of cells from the suspected tumour area, often performed under general anaesthetic. The histopathologist, who is part of the MDT, will assess the biopsy under a microscope and look for abnormal cells that may confirm Ewing’s sarcoma.

Step 4: Diagnosis

Together with the scan and biopsy results, the MDT at the Bone Tumour Centre will determine whether a patient has Ewing’s sarcoma or not. If not, other possible conditions include:

  • Another type of bone cancer, for example, osteosarcoma.
  • Eosinophilic granuloma, which is a non-cancerous bone tumour that is found mainly in children under the age of 10 years.
  • Osteomyelitis, which is an infection inside the bone.

If Ewing’s sarcoma is confirmed, most patients will be referred to their nearest sarcoma oncology treatment centre. The patient will start treatment under the direction of the MDT who are based at the Bone Tumour Centre. The treating hospital may not be the same hospital that the patient went to initially. Treatment usually starts within a few days.

The National Ewing’s sarcoma Multidisciplinary Team Meeting was formed in 2011 and is a unique national forum set up to improve the treatment planning and choices made for Ewing’s sarcoma patients. This forum brings together clinicians and specialists from around the UK to discuss the treatment management and plans for current patients.

Produced: March 2018

Published: December 2018

Review: December 2021

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