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Ewing Sarcoma - Childhood - Overview

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2015

ON THIS PAGE: You will find some basic information about this disease and the parts of the body it may affect. This is the first page of Cancer.Net’s Guide to Childhood Ewing Sarcoma. To see other pages, use the menu on the side of your screen. Think of that menu as a roadmap to this full guide.

Ewing sarcoma is part of a group of cancers called the Ewing Family of Tumors that affect the bones or nearby soft tissue. Cancer occurs when healthy cells change and grow uncontrollably, forming a mass called a tumor. A tumor can be cancerous or benign. A cancerous tumor is malignant, meaning it can grow and spread to other parts of the body. A benign tumor means the tumor can grow but will not spread.

Where Ewing tumors develop

Depending on the type, Ewing tumors develop in different places.

  • Ewing sarcoma. Also called Ewing tumor of the bones, Ewing sarcoma is the most common type of EFT. Ewing sarcoma most often develops in the leg, pelvis, rib, arm, or spine.

  • Extraosseous Ewing (EOE). EOE is a tumor that grows in the soft tissue outside the bone. An EOE is usually found in the thigh, pelvis, spine, chest, or foot.

  • Peripheral primitive neuroectodermal tumor (PPNET). PPNET is a rare tumor found in the bones and soft tissues. This includes Askin's tumor, which is a PPNET of the chest wall.

This section covers Ewing sarcoma diagnosed in children and teenagers. For more information about Ewing sarcoma in adults, please read Cancer.Net's Guide to Bone Cancer.

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If you would like additional introductory information, explore these related items. Please note these links will take you to other sections on Cancer.Net:

The next section in this guide is Statistics, and it helps explain how many children and teenagers are diagnosed with this disease, as well as general survival rates. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Ewing Sarcoma - Childhood - Statistics

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2015

ON THIS PAGE: You will find information about how many children and teens are diagnosed with this type of cancer each year and some general survival information. Remember, survival rates depend on several factors. To see other pages, use the menu on the side of your screen.

Each year, about 225 children and teenagers in the United States are diagnosed with a Ewing tumor, most of which will be Ewing sarcoma. Ewing tumors make up about 1% of all childhood cancers. Most Ewing tumors are diagnosed in teenagers, but they can also affect children and young adults in their 20s and 30s.

The five-year survival rate is the percentage of people who survive at least five years after the tumor is found. The five-year survival rate for people with a Ewing tumor that that has not spread is about 70%. If the tumor has metastasized (spread) at the time of diagnosis, the five-year survival rate is about 15% to 30%. The survival rate is slightly higher for people with a tumor that has only spread to the lungs compared with a tumor that has spread to other organs.

Cancer survival statistics should be interpreted with caution. These estimates are based on data from a number of people with this type of cancer in the United States, so the actual risk for a particular individual may be different. It is not possible to tell a person how long he or she will live with a Ewing tumor. Because the survival statistics are measured in five-year intervals, they may not represent advances made in the treatment or diagnosis of Ewing sarcoma. Learn more about understanding statistics.

Statistics adapted from the American Cancer Society.

The next section in this guide is Medical Illustrations, and it offers drawings of body parts often affected by this disease. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Ewing Sarcoma - Childhood - Medical Illustrations

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2015

ON THIS PAGE: You will find a basic drawing of the major bones in the body. To see other pages, use the menu on the side of your screen.

Adolescent Skeletal Anatomy
Larger Image

The next section in this guide is Risk Factors, and it explains what factors may increase the chance of developing Ewing sarcoma. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Ewing Sarcoma - Childhood - Risk Factors

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2015

ON THIS PAGE: You will find out more about the factors that increase the chance of developing this type of cancer. To see other pages, use the menu on the side of your screen.

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do.  

Doctors and researchers do not know what causes most cancers in children and teens, but the following factors may raise a person’s chance of developing Ewing sarcoma:

  • Genetic changes. Changes in a tumor cell's chromosomes appear to be responsible for Ewing sarcoma, but the disease is not inherited. This means that it isn’t passed down from a father or mother to a child. The genetic changes occur for no known reason.

    A high percentage of Ewing sarcoma cells have a chromosomal translocation, which means that small pieces of genetic material have swapped places inside the tumor cell. Usually the translocation is between chromosomes 11 and 22, although it may also occur between chromosomes 21 and 22, 7 and 22, and 17 and 22. The fusion of these bits of genetic material results in the uncontrolled growth of Ewing sarcoma cells.

  • Age. About two-thirds (64%) of all people with Ewing sarcoma are between the ages of 10 and 20. Ewing sarcoma is rare in adults older than 30 and in very young children.

  • Gender. Ewing sarcoma is more common among boys than girls.

  • Race/ethnicity. Ewing sarcoma occurs most frequently in white people and is rare in black people in the United States and Africa. Ewing sarcoma has been reported in Japan and is uncommon in China.

The next section in this guide is Symptoms and Signs, and it explains what body changes or medical problems this disease can cause. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Ewing Sarcoma - Childhood - Symptoms and Signs

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2015

ON THIS PAGE: You will find out more about body changes and other things that can signal a problem that may need medical care. To see other pages, use the menu on the side of your screen.

Children and teens with Ewing sarcoma may experience the following symptoms or signs. Sometimes, teens with Ewing sarcoma do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer.

  • Stiffness, pain, swelling, or tenderness in the bone or in the tissue surrounding the bone. About 85% of children and teens with Ewing sarcoma have pain.

  • A lump near the surface of the skin that may feel warm and soft to the touch

  • A fever that doesn't go away

  • A broken bone that happens without an injury. A tumor growing in the bone can cause the bone to become weak or fracture.

If you are concerned about one or more of the symptoms or signs on this list, please talk with your child’s doctor. Your doctor will ask how long and how often your child has been experiencing the symptom(s), in addition to other questions. This is to help find out the cause of the problem, called a diagnosis.

If cancer is diagnosed, relieving symptoms remains an important part of your child’s cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your child’s health care team about symptoms he or she experiences, including any new symptoms or a change in symptoms.

The next section in this guide is Diagnosis, and it explains what tests may be needed to learn more about the cause of the symptoms. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Ewing Sarcoma - Childhood - Diagnosis

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2015

ON THIS PAGE: You will find a list of the common tests, procedures, and scans that doctors can use to find out what’s wrong and identify the cause of the problem. To see other pages, use the menu on the side of your screen.

Doctors use many tests to diagnose Ewing sarcoma and find out if it has spread to another part of the body, called metastasis. Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the tumor has spread.

This list describes options for diagnosing this type of cancer, and not all tests listed will be used for every person. Your child’s doctor may consider these factors when choosing a diagnostic test:

  • Age and medical condition

  • Type of tumor suspected

  • Signs and symptoms

  • Previous test results

In addition to a physical examination, the following tests may be used to diagnose Ewing sarcoma:

  • Blood tests. A complete blood count (CBC) is a blood test that counts the number of each type of blood cell. Abnormal levels of white blood cells, red blood cells, and platelets can be a sign that the tumor has spread. The doctor may also check liver and kidney function and look for high levels of a particular blood enzyme called lactate dehydrogenase or LDH, which sometimes helps signal the presence of a tumor in the body.

Imaging tests

  • X-ray. An x-ray is way to create a picture of the organs and tissues inside of the body, using a small amount of radiation. Doctors can usually find bone tumors with an x-ray.

  • Bone scan. A bone scan uses a radioactive tracer to look at the inside of the bones. The tracer is injected into a patient’s vein. It collects in areas of the bone and is detected by a special camera. Healthy bone appears gray to the camera, and areas of injury, such as those caused by a tumor, appear dark.

  • Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. For Ewing sarcoma, a CT scan of the chest will be done to see if the tumor has spread to the lungs. A CT scan can also be used to measure the tumor’s size. Sometimes, a special dye called a contrast medium is given before the scan to provide better detail on the image. This dye can be injected into a patient’s vein or given as a liquid to swallow.

  • Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive sugar substance is injected into the patient’s body. This sugar substance is taken up by cells that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body. For Ewing sarcoma, an integrated PET/CT scan is often more sensitive than a PET scan alone.

  • Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. MRI can also be used to measure the tumor’s size. A special dye called a contrast medium is given before the scan to create a clearer picture. This dye can be injected into a patient’s vein or given as a liquid to swallow.

Surgical tests

  • Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. If the tumor is in an arm or leg, an orthopedic oncologist or an interventional radiologist who has experience with Ewing sarcoma should perform the biopsy. An orthopedic oncologist is a doctor who specializes in cancers of the musculoskeletal system.

    During the procedure, the doctor may take a sample of the tumor, bone marrow (see below), or both. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. A pathologist then analyzes the sample(s) removed during the biopsy. A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease.

  • Bone marrow aspiration and biopsy. These two procedures are similar and often done at the same time to examine the bone marrow. Bone marrow has both a solid and a liquid part. A bone marrow aspiration removes a sample of the fluid with a needle. A bone marrow biopsy is the removal of a small amount of solid tissue using a needle.

    A pathologist then analyzes the sample(s). A common site for a bone marrow aspiration and biopsy is the hipbone in the lower back. The skin in that area is usually numbed with medication beforehand, and other types medication to block the awareness of pain may be used. 

Other laboratory tests

Other laboratory tests may be done on the tissue sample(s) removed during a biopsy to learn more about the tumor.

  • Immunohistochemistry. This test detects Ewing sarcoma cells in the tissue sample.

  • Cytogenetic tests and reverse transcription polymerase chain reaction (RT-PCR). These tests find out if the genetic changes that characterize Ewing sarcoma cells are present in the sample.

After diagnostic tests are done, your child’s doctor will review all of the results with you and your child. If the diagnosis is cancer, these results also help the doctor describe the cancer; this is called staging.

The next section in this guide is Stages, and it explains the system doctors use to describe the extent of the disease. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Ewing Sarcoma - Childhood - Stages

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2015

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread. This is called the stage. To see other pages, use the menu on the side of your screen.

Staging is a way of describing where the tumor is located, if or where it has spread, and whether it is affecting other parts of the body. Doctors use diagnostic tests to find out the cancer’s stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient’s prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

Although there is no official staging system for Ewing sarcoma, the following criteria help doctors describe Ewing sarcoma and work together to plan the best treatments:

  • Localized Ewing sarcoma. The tumor is only found in the bone where it began or has just spread to nearby tissues.

  • Metastatic Ewing sarcoma. The tumor has spread from the bone where it began to another part of the body, such as the lungs, other bones, or bone marrow. Rarely, the disease spreads to the lymph nodes, brain, or spinal cord. Approximately 25% of children and teens with Ewing sarcoma will have obvious evidence of tumor spread at the time of diagnosis. Whether the tumor has spread is the most important factor used to determine a person’s treatment options and prognosis.

  • Recurrent Ewing sarcoma. Recurrent Ewing sarcoma is a tumor that has come back after treatment. If the cancer does return, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.

Information about the cancer’s stage will help the doctor recommend a specific treatment plan. The next section in this guide is Treatment Options. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Ewing Sarcoma - Childhood - Treatment Options

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2015

ON THIS PAGE: You will learn about the different ways doctors use to treat children and teens with Ewing sarcoma. To see other pages, use the menu on the side of your screen.

In general, cancer in children and teenagers is uncommon, so it can be hard for doctors to plan treatments unless they know what has been most effective in other children. That’s why more than 60% of children with cancer are treated as part of a clinical trial. Clinical trials are research studies that compare standard treatments (the best known treatments available) with newer approaches to treatments that may be more effective. Clinical trials may test approaches such as a new drug, a new combination of standard treatments, or new doses of current therapies. Studying new treatments involves careful monitoring using scientific methods, and all participants are followed closely to track their health and progress.

To take advantage of these newer treatments, children and teens with Ewing sarcoma should be treated at a specialized cancer center. Doctors at these centers have extensive experience in treating this age group and have access to the latest research. A doctor who specializes in treating children and teens with cancer is called a pediatric oncologist. If a pediatric cancer center is not nearby, general cancer centers sometimes have pediatric specialists who are able to be part of your child’s care.

In many cases, a team of doctors works with a child and the family to provide care; this is called a multidisciplinary team. Pediatric cancer centers often have extra support services for children and their families, such as child life specialists, dietitians, physical and occupational therapists, social workers, and counselors. Special activities and programs to help your child and family cope may also be available.

Children and teenagers with Ewing sarcoma should be treated in clinical trials specifically designed for their disease. A typical treatment plan for Ewing sarcoma includes systemic therapy that treats the entire body, such as chemotherapy or stem cell transplantation, combined with localized therapy. Localized therapy focuses on treating the tumor itself using surgery and/or radiation therapy. When more than one treatment is used, it is called combination therapy.

Doctors make treatment decisions based on the stage of the disease and the age of the child, while trying to avoid or reduce long-term side effects of treatment. Descriptions of the most common treatment options for Ewing sarcoma are listed below. Your child’s care plan may also include treatment for symptoms and side effects, an important part of cancer care. Take time to learn about all of your child’s treatment options and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your child’s doctor and what your child can expect while receiving the treatment. Learn more about making treatment decisions.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Chemotherapy is given by a pediatric or medical oncologist, a doctor who specializes in treating cancer with medication. Some children and teens may receive chemotherapy in their doctor’s office, while others may go to a hospital or outpatient clinic.

Systemic chemotherapy gets into the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally). However, chemotherapy for Ewing sarcoma is usually injected into a vein or muscle; it is rarely given by mouth.

When possible, treatment for Ewing sarcoma begins with chemotherapy. After this neoadjuvant chemotherapy, the doctor may use localized surgery or radiation therapy (see below) followed by additional chemotherapy to eliminate any remaining cancer cells. Sometimes, the doctor may use surgery or radiation therapy first and then give chemotherapy.

A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time. Children and teens with Ewing sarcoma should receive cyclophosphamide (Cytoxan, Neosar), doxorubicin (Adriamycin), etoposide (Toposar, VePesid), ifosfamide (Ifex), and/or vincristine (Oncovin, Vincasar PFS). For children and teens with Ewing sarcoma that has not spread to other parts of the body, the standard schedule is to receive chemotherapy every two weeks. Patients with metastatic Ewing sarcoma may also be treated with the above medications and dactinomycin (Cosmegen).

The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.

Children and teens receiving chemotherapy for Ewing sarcoma may be at risk for developing neutropenia, which is an abnormally low level of a type of white blood cell called neutrophils. All white blood cells help the body fight infection. Your child’s doctor may give your child medications to increase his or her white blood cell levels. These medications are called white blood cell growth factors, also known as colony-stimulating factors (CSFs). Treating neutropenia is an important part of the overall treatment plan.

Learn more about the basics of chemotherapy and preparing for treatment. The medications used to treat Ewing sarcoma are continually being evaluated. Talking with your child's doctor is often the best way to learn about the medications prescribed for your child, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases.

Surgery

Surgery is the removal of the tumor and some surrounding healthy tissue during an operation. When possible, surgical removal of the tumor should happen after chemotherapy. Surgery may also be needed to remove any remaining cancer cells after chemotherapy or radiation therapy. An orthopedic oncologist is usually the doctor who will perform the surgery. Learn more about the basics of cancer surgery.

Often a tumor can be removed without causing disability. However, if the tumor occurs in an arm or leg, surgery to remove much of the bone may affect the limb's ability to function. Bone grafts from other parts of the body may help reconstruct the limb, and a prosthesis made of metal or plastic bones or joints can replace lost tissue. Physical therapy after surgery can help children and teens learn to use the limb again. Support services are available to help children and teens cope with the emotional effects of the loss of a limb. Learn more about rehabilitation.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other high-energy particles to destroy tumor cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. For Ewing sarcoma, radiation therapy is used when surgery is not possible or did not remove all of the tumor cells, as well as when chemotherapy was not effective.

The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation therapy is given using implants, it is called internal radiation therapy or brachytherapy. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time. Intraoperative radiation therapy, which is given inside the body during surgery, is being studied in clinical trials.

Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished. In the long term, radiation therapy can also interfere with normal bone growth and increase the risk of developing a secondary cancer. Learn more about the basics of radiation therapy.

Stem cell transplantation/bone marrow transplantation

For Ewing sarcoma, stem cell transplantation is an experimental approach that is still being researched to find out how effective it is as a treatment option. It should only be done as part of a clinical trial.

A stem cell transplant is a medical procedure in which bone marrow that contains cancer is replaced by highly specialized cells, called hematopoietic stem cells, that develop into healthy bone marrow. Hematopoietic stem cells are blood-forming cells found both in the bloodstream and in the bone marrow. Today, this procedure is more commonly called a stem cell transplant, rather than bone marrow transplant, because it is the stem cells in the blood that are typically being transplanted, not the actual bone marrow tissue.

Before recommending transplantation, doctors will talk with the patient and family about the risks of this treatment and consider several other factors, such as the type of tumor, results of any previous treatment, and the child’s age and general health.

There are two types of stem cell transplantation depending on the source of the replacement blood stem cell: allogeneic (ALLO) and autologous (AUTO). ALLO uses donated stem cells, while AUTO uses the patient’s own stem cells. AUTO transplants are the type used to treat Ewing sarcoma.

The goal of stem cell transplantation is to destroy all of the cancer cells in the marrow, blood, and other parts of the body using high doses of chemotherapy and/or radiation therapy and then allow replacement blood stem cells to create healthy bone marrow. Learn more about the basics of stem cell and bone marrow transplantation.

Getting care for symptoms and side effects

Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a child’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care is any treatment that focuses on reducing symptoms, improving quality of life, and supporting patients and their families. Any person, regardless of age or type and stage of cancer, may receive palliative care. It works best when palliative care is started as early as needed in the cancer treatment process.

Children and teens often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional support, and other therapies. Your child may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, or radiation therapy. Talk with your child’s doctor about the goals of each treatment in the treatment plan.

Before treatment begins, talk with your child’s health care team about the possible side effects of the recommended treatment plan and palliative care options. And during and after treatment, be sure to tell your child’s doctor or another health care team member if your child experiences a problem so it can be addressed as quickly as possible. Learn more about palliative care.   

Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.

A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it is important to talk with your child’s doctor about the possibility of the cancer returning. Understanding your child’s risk of recurrence and the treatment options may help everyone feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence

If the cancer does return after the original treatment, it is called recurrent disease. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence). Recurrence is most common within the first two years after treatment has finished. However, late recurrences that develop up to five years after treatment are more common with Ewing sarcoma than with other types of childhood cancers.

If there is a recurrence, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you, your child, and your child’s doctor will talk about the treatment options. The next round of treatment will depend on where and when the cancer recurred and how it was first treated. The doctor may recommend chemotherapy, including cyclophosphamide and irinotecan (Camptosar), temozolomide (Temodar, Methazolastone), and topotecan (Hycamtin); radiation therapy; and/or surgery to remove new tumors. Stem cell transplantation may also be recommended. Your child’s doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.

Patients with recurrent Ewing sarcoma and their parents often experience emotions such as disbelief or fear. Patients and families are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with a recurrence.

If treatment fails

Although treatment is successful for the majority of children and teens with cancer, sometimes it is not. If a child’s cancer cannot be cured or controlled, this is called advanced or terminal disease. This diagnosis is stressful, and advanced cancer may be difficult to discuss. However, it is important to have open and honest conversations with your child’s doctor and health care team to express your family’s feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families.

Parents or guardians are encouraged to think about where the child would be most comfortable: at home, in a home-like setting elsewhere, in the hospital, or in a hospice environment. Hospice care is a type of palliative care for people who are expected to live less than six months. It is designed to provide the best possible quality of life for people who are near the end of life. Nursing care and special equipment can make staying at home a workable alternative for many families. Some children may be happier if they can arrange to attend school part-time or keep up other activities and social connections. The child’s health care team can help parents or guardians decide on an appropriate level of activity. Making sure a child is physically comfortable and free from pain is extremely important as part of end-of-life care. Learn more about caring for a terminally ill child and advanced cancer care planning.

The death of a child is an enormous tragedy, and families may need support to help them cope with the loss. Pediatric cancer centers often have professional staff and support groups to help with the process of grieving. Learn more on grieving the loss of a child.

The next section in this guide is About Clinical Trials, and it offers more information about research studies that are focused on finding better ways to care for children and teens with cancer. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Ewing Sarcoma - Childhood - About Clinical Trials

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2015

ON THIS PAGE: You will learn more about clinical trials, which are the main way that new medical approaches are tested to see how well they work. To see other pages, use the menu on the side of your screen.

What are clinical trials?

Doctors and scientists are always looking for better ways to care for children and teens with Ewing sarcoma. To make scientific advances, doctors create research studies involving volunteers, called clinical trials. In fact, every drug that is now approved by the U.S. Food and Drug Administration (FDA) was previously tested in clinical trials.

Many clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Children and teens who participate in clinical trials are often among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.

There are also clinical trials that study new ways to ease symptoms and side effects during treatment and managing the late effects that may occur after treatment. Talk with your child’s doctor about clinical trials regarding side effects.

Deciding to join a clinical trial

Parents and children decide to participate in clinical trials for many reasons. For some, a clinical trial is the best treatment option available. Because standard treatments are not perfect, people are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other people volunteer for clinical trials because they know that these studies are the only way to make progress in treating Ewing sarcoma. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with Ewing sarcoma.

Sometimes parents have concerns that, in a clinical trial, their child may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials in this way is rare overall and not done at all in childhood cancer research. Find out more about placebos in cancer clinical trials.

Patient safety and informed consent

To join a clinical trial, parents and children must participate in a process known as informed consent. During informed consent, the doctor should list all of the child's options so that the parent and child understand the standard treatments and how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different from the risks of standard treatment. Finally, the doctor must explain what will be required of each parent and child in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment.

People who participate in a clinical trial may stop participating at any time for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. Clinical trials are also closely monitored by experts who watch for any problems with each study. It is important that parents of patients participating in a clinical trial talk with their child’s doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if the patient chooses to leave the clinical trial before it ends. 

Finding a clinical trial

Research through clinical trials is ongoing for all types of cancer. For specific topics being studied for Ewing sarcoma, learn more in the Latest Research section.

Cancer.Net offers a lot of information about cancer clinical trials in other areas of the website, including a complete section on clinical trials and places to search for clinical trials for a specific type of cancer.

In addition, this website offers free access to a video-based educational program about cancer clinical trials, located outside of this guide.

The next section in this guide is Latest Research, and it explains areas of scientific research currently going on for this type of cancer. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Ewing Sarcoma - Childhood - Latest Research

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2015

ON THIS PAGE: You will read about the scientific research being done now to learn more about this type of cancer and how to treat it. To see other pages, use the menu on the side of your screen.

Doctors are working to learn more about Ewing sarcoma, how to best treat it, and how to provide the best care to children and teens diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your child’s doctor about the diagnostic and treatment options best for your child.

  • New chemotherapy. Researchers are evaluating the use of cyclophosphamide, topotecan, and vincristine in addition to standard chemotherapy for patients with newly diagnosed, localized Ewing sarcoma.

  • Allogeneic stem cell transplantation. In an ALLO stem cell transplant (see the Treatment Options section for a description), the child is treated with high doses of chemotherapy and/or radiation therapy to destroy as many tumor cells as possible and to prevent the child's immune system from rejecting the donated stem cells. After the high-dose therapy is given, stem cells obtained from a healthy donor, usually a sibling, are infused into the patient's bloodstream. ALLO stem cell transplants combined with sirolimus (Rapamune) and other drugs have been shown to inhibit growth of Ewing cells in the laboratory.

  • Bilateral lung radiation. The effectiveness of bilateral lung radiation is being examined in patients with metastatic Ewing sarcoma. During this treatment, radiation therapy is given to both lungs after the child has completed chemotherapy. For some patients, autologous (AUTO) stem cell transplant is recommended.

  • Insulin-like growth factor receptor-1 (IGF-1R) antibodies. The IGFR is an important growth protein for sarcomas. Blocking its activity may be an important new way to improve sarcoma treatment. This new type of treatment is being studied in combination with chemotherapy for people newly diagnosed with metastatic Ewing sarcoma.

  • Palliative care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current Ewing sarcoma treatments in order to improve patients’ comfort and quality of life.

Looking for More About the Latest Research?

If you would like additional information about the latest areas of research regarding Ewing sarcoma, explore these related items that will take you outside of this guide:

  • To find clinical trials specific to your child’s diagnosis, talk with your child’s doctor or search online clinical trial databases now.

  • Visit ASCO’s CancerProgress.Net website to learn more about the historical pace of research for childhood cancer. Please note this link takes you to a separate ASCO website.

  • Visit the website of the Conquer Cancer Foundation to find out how to help support research for every cancer type. Please note this link takes you to a separate ASCO website. 

The next section in this guide is Coping with Side Effects, and it offers some guidance in how to cope with the physical, emotional, and social changes that cancer and its treatment can bring. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Ewing Sarcoma - Childhood - Coping with Side Effects

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2015

ON THIS PAGE: You will find out more about steps to take to help your child cope with physical, social, and emotional side effects. This page includes several links outside of this guide to other sections of this website. To see other pages, use the menu on the side of your screen.

Fear of treatment side effects is common after a diagnosis of cancer, but it may help to know that preventing and controlling side effects is a major focus of your child’s health care team. This is called palliative care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

There are possible side effects for every cancer treatment, but patients don’t experience the same side effects when given the same treatments for many reasons. That can make it hard to predict exactly how you will feel during treatment.

Common side effects from each treatment option for Ewing sarcoma are described in detail within the Treatment Options section. Learn more about cancer and different treatments, along with ways to prevent or control them. Side effects depend on a variety of factors, including the cancer’s stage, the length and dosage of treatment(s), and your child’s overall health.

Talking with the health care team about side effects

Before treatment begins, talk with your child’s doctor about possible side effects of each type of treatment your child will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them.

And, ask about the level of caregiving your child may need during treatment and recovery, as family members and friends play an important role in the care of children and teens with Ewing sarcoma. Learn more about caregiving.

In addition to physical side effects, there may be emotional and social effects as well. Patients and their families are encouraged to share their feelings with a member of the health care team who can help with coping strategies, including concerns about managing the cost of cancer care. These strategies can be different based on the age of your child or teen

During and after treatment, be sure to tell the health care team about the side effects your child experiences, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care. Learn more by reading the Follow-Up Care section of this guide or talking with your child’s doctor.

The next section in this guide is Follow-up Care, and it explains the importance of check-ups after cancer treatment is finished. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Ewing Sarcoma - Childhood - Follow-Up Care

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2015

ON THIS PAGE: You will read about your child’s medical care after cancer treatment is finished and why this follow-up care is important. To see other pages, use the menu on the side of your screen.

Care for children diagnosed with cancer doesn’t end when active treatment has finished. Your child’s health care team will continue to check to make sure the cancer has not returned, manage any side effects, and monitor your child’s overall health. This is called follow-up care. All children treated for cancer, including Ewing sarcoma, should have life-long, follow-up care by a doctor or health care team familiar with the late effects of chemotherapy and radiation therapy.

This plan may include regular physical examinations and/or medical tests to monitor your child’s recovery for the coming months and years. Based on the type of treatment your child received, the doctor will determine what examinations and tests are needed to check for long-term side effects and the possibility of secondary cancers. Follow-up care usually includes bone scans, CT scans, MRI scans, and x-rays. Your child’s doctor can recommend the necessary screening tests. Learn more about the importance of follow-up care.

Watching for recurrence

One goal of follow-up care is to check for a recurrence. Cancer recurs because small areas of cancer cells may remain undetected in the body. Over time, these cells may increase in number until they show up on test results or cause signs or symptoms.

During follow-up care, a doctor familiar with your child’s medical history can give you personalized information about the risk of recurrence. Your doctor will also ask specific questions about your child’s health. Some children may have blood tests or imaging tests as part of regular follow-up care, but testing recommendations depend on several factors, including the type and stage of cancer originally diagnosed and the types of treatment given.

Managing long-term and late side effects

Sometimes, side effects may linger beyond the active treatment period. These are called long-term side effects. In addition, other side effects called late effects may develop months or even years afterwards. Late effects can occur almost anywhere in the body and include physical problems, such as heart and lung problems and second cancers, as well as emotional and cognitive (memory, thinking, and attention) problems, such as anxiety, depression, and learning difficulties.

Based on the type of treatment your child received, the doctor will recommend what examinations and tests are needed to check for late effects. Children and teens who received chemotherapy will need to be monitored for potential problems with their sexual development and fertility (ability to have children). Other late effects may include delayed or stunted growth and delayed or missed developmental milestones. Your child may be referred to an endocrinologist, a doctor who specializes in problems with glands and the endocrine system, to identify and manage these late effects. Follow-up care should also address your child’s quality of life, including any developmental or emotional concerns.

The Children's Oncology Group (COG) has studied both the physical and psychological effects that childhood cancer survivors face. Based on these studies, COG has created recommendations for long-term follow-up care for childhood, adolescent, and young adult cancer survivors that can be found on a separate website: www.survivorshipguidelines.org.

Keeping a child’s personal health record

You are encouraged to organize and keep a personal record of the child’s medical information. The doctor will help you create this. That way, as the child enters adulthood, he or she has a clear, written history of the diagnosis, the treatment given, and the doctor’s recommendations about the schedule for follow-up care. ASCO offers forms to help create a treatment summary to keep track of the cancer treatment your child received and develop a survivorship care plan once treatment is completed.

Some children continue to see their oncologist, while others transition back to the general care of their family doctor or another health care professional. This decision depends on several factors, including the type and stage of cancer, side effects, health insurance rules, and your family’s personal preferences. Talk with your health care team about your child’s ongoing medical care and any concerns you have about his or her future health.

If a doctor who was not directly involved in your child’s cancer care will lead the follow-up care, be sure to share the cancer treatment summary and survivorship care plan forms with him or her, as well as all future health care providers. Details about the specific cancer treatment given are very valuable to the health care professionals who will care for your child throughout his or her lifetime.

The next section in this guide is Survivorship, and it describes how to cope with challenges in everyday life after a cancer diagnosis. Or, use the menu on the side of your screen to choose another section to continue reading this guide. 

Ewing Sarcoma - Childhood - Survivorship

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2015

ON THIS PAGE: You will read about how to cope with challenges in everyday life after your child’s cancer diagnosis. To see other pages, use the menu on the side of your screen.

What is survivorship?

The word survivorship means different things to different people, but it often describes the process of living with, through, and beyond cancer. In some ways, survivorship is one of the most complex aspects of the cancer experience because it is different for every patient and his or her family.

After active cancer treatment ends, children and their families may experience a mixture of strong feelings, including joy, concern, relief, guilt, and fear. Some people say they appreciate life more after a cancer diagnosis. Other families stay very anxious about their child’s health and become uncertain of how to cope with everyday life.

One source of stress may occur when frequent visits to the health care team end following treatment. Often, relationships built with the cancer care team provide a sense of security during treatment, and children and their families miss this source of support. This may be especially true as new worries and challenges surface over time, such as any late effects of treatment, educational issues, emotional challenges, sexual development and fertility concerns, and/or financial issues.

Every family faces different concerns and challenges. With any challenge, a good first step is being able to recognize each fear and talk about it. Effective coping requires:

  • Understanding the challenge your family is facing,

  • Thinking through solutions,

  • Asking for and allowing the support of others, and

  • Feeling comfortable with the course of action your family chooses.

It may be helpful to join an in-person support group or online community of childhood cancer survivors. Support groups also exist for parents of children diagnosed with cancer. This allows you to talk with people who have had similar first-hand experiences. Other options for finding support include talking with a friend or member of your health care team, individual counseling, or asking for assistance at the learning resource center of the center where you received treatment.

Changing role of caregivers

Parents, other family members, and friends may also go through periods of transition. A caregiver plays a very important role in supporting a child diagnosed with cancer, providing physical, emotional, and practical care on a daily or as-needed basis. Many caregivers become focused on providing this support, especially if the treatment period lasts for many months or longer.

However, as treatment is completed, the caregiver's role often changes. Eventually, the need for caregiving related to a child’s cancer diagnosis will become much less or come to an end as your child gets older. Family counselors at pediatric cancer centers can help with this transition. You can also learn more about adjusting to life after caregiving in this article.

Healthy living after cancer

Survivorship often serves as a strong motivator to make positive lifestyle changes, often for the family as a whole.

Children who have had cancer can enhance the quality of their future by following established guidelines for good health into and through adulthood, including not smoking, maintaining a healthy weight, eating well, managing stress, participating in regular physical activity, getting human papillomavirus (HPV) vaccinations, and using sunscreen. Talk with the doctor about developing a plan that is best for your child’s needs. Learn more about making healthy lifestyle choices.

In addition, it is important that your child has recommended medical check-ups and tests (see Follow-Up Care) to take care of his or her health. Cancer rehabilitation may be recommended, and this could mean any of a wide range of services such as physical therapy, family or individual counseling, nutritional planning, and/or educational assistance. The goal of rehabilitation is to help survivors and their families regain control over many aspects of their lives and remain as independent and productive as possible.

Talk with your doctor to develop a survivorship care plan that is best for your child’s needs.

Looking for More Survivorship Resources?

For more information about cancer survivorship, explore these related items. Please note these links will take you to other sections of Cancer.Net:

  • Survivorship Resources: Cancer.Net offers a lot of information and resources to help survivors cope, including specific sections for children, teens, and young adults. There is also a main section on survivorship for people of all ages.

  • ASCO Answers Cancer Survivorship Guide: This 44-page booklet (available as a PDF) can help with the transition into life after treatment. It includes blank treatment summary and survivorship care plan forms.

  • Cancer.Net Patient Education Video: View a short video led by an ASCO expert that provides information about childhood cancer survivorship.

The next section offers Questions to Ask the Doctor to help start conversations with your child’s cancer care team. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Ewing Sarcoma - Childhood - Questions to Ask the Doctor

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2015

ON THIS PAGE: You will find some questions to ask your child’s doctor or other members of the health care team to help you better understand your child’s diagnosis, treatment plan, and overall care. To see other pages, use the menu on the side of your screen.

Talking often with the doctor is important to make informed decisions about your child’s health care. These suggested questions are a starting point to help you learn more about your child’s cancer care and treatment. You are also encouraged to ask additional questions that are important to you and your family. You may want to print this list and bring it to your child’s next appointment or download Cancer.Net’s free mobile app for an e-list and other interactive tools to manage your child’s care.

Questions to ask after getting a diagnosis

  • What type of Ewing tumor has been diagnosed?

  • Where exactly is the tumor located?

  • Can you explain the pathology report (laboratory test results) to me?

  • What stage is the cancer? What does this mean?

Questions to ask about choosing a treatment and managing side effects

  • What are my child’s treatment options?

  • What clinical trials are open to my child? Where are they located, and how do I find out more about them?

  • What treatment plan do you recommend? Why?

  • What is the goal of each treatment? Is it to eliminate the cancer, help my child feel better, or both?

  • What are the possible side effects of each treatment, both in the short term and the long term?

  • Who will be part of my child’s health care team, and what does each member do?

  • Who will be coordinating my child’s overall treatment?

  • Does this center specialize in the treatment of children, adolescents, and young adults with cancer?

  • How will treatment affect my child’s daily life? Will he or she be able to go to school and perform his or her usual activities?

  • Could this treatment affect my child’s ability to become pregnant or have children in the future? If so, should my family talk with a fertility specialist before treatment begins?

  • If I’m worried about managing the costs related to cancer care, who can help me with these concerns?

  • What support services are available to my child? To the rest of my family?

  • Whom should I call for questions or problems?

  • Is there anything else I should be asking?

Questions to ask about having chemotherapy

  • What chemotherapy will my child receive?

  • What is the goal of this treatment?

  • Where will my child receive chemotherapy? At a hospital, clinic, or home?

  • How often will my child receive this treatment?

  • How long will it take to give this treatment?

  • What side effects can we expect during treatment?

  • What are the possible long-term effects of having this treatment?

  • What can be done to prevent or manage these side effects?

  • How can I best prepare my child for each treatment?

Questions to ask about having radiation therapy

  • Will my child receive radiation therapy?

  • What is the goal of this treatment?

  • How long will it take to give this treatment?

  • What side effects can we expect during treatment?

  • What are the possible long-term effects of having this treatment?

  • What can be done to prevent or manage these side effects?

Questions to ask about having surgery

  • Will my child need to have surgery?

  • What type of surgery do you recommend? Why?

  • How long will the operation take?

  • How long will my child need to stay in the hospital?

  • Can you describe what my child’s recovery from surgery will be like?

  • What are the possible long-term effects of having this surgery?

Questions to ask about planning follow-up care

  • What is the risk of the cancer returning? Are there signs and symptoms we should watch for?

  • Is there anything my child can do to reduce his or her risk of getting another type of cancer?

  • What long-term side effects or late effects are possible based on the cancer treatment my child received?

  • If needed, what types of rehabilitative services are available?

  • What follow-up tests will my child need, and how often will he or she need them?

  • How do I get a treatment summary and survivorship care plan to keep in my child’s personal records?

  • Who will be coordinating my child’s follow-up care?

  • What survivorship support services are available to my child? To my family?

The next section in this guide is Additional Resources, and it offers some more resources on this website beyond this guide that may be helpful to you and your family. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Ewing Sarcoma - Childhood - Additional Resources

This section has been reviewed and approved by the Cancer.Net Editorial Board, 05/2015

ON THIS PAGE: You will find some helpful links to other areas of Cancer.Net that provide information about cancer care and treatment. This is the final page of Cancer.Net’s Guide to the Ewing Sarcoma. To go back and review other pages, use the menu on the side of your screen.

Cancer.Net includes many other sections about the medical and emotional aspects of being diagnosed with cancer, both for the child and their family members and friends. This website is meant to be a resource for you and your loved ones from the time of diagnosis, through treatment, and beyond.

Beyond this guide, here are a few links to help you explore other parts of Cancer.Net:

This is the end of Cancer.Net’s Guide to the Ewing Sarcoma. Use the menu on the side of your screen to select another section, to continue reading this guide.