UTILITY OF BONE MARROW ASPIRATION AND BIOPSY (BMAB) IN INITIAL STAGING

OF EWING SARCOMA (EWS)

Lisa M. Kopp, Winston W. Huh, Cynthia E. Herzog, Chengcheng Hu, Andrea White-Collins, Beatriz Rozo, Angela Yarborough, Pooja Hingorani

Background

• Pediatric and adolescents patients with newly diagnosed Ewing Sarcoma (EWS) have a bilateral bone marrow aspiration and biopsy (BMAB) performed as part of the initial staging evaluation

• BMAB is a painful procedure that is performed using general anesthesia

Background

• The NCCN guidelines on bone cancer recommend the option of either a BMAB or MRI of the spine and pelvis in newly diagnosed adult patients

• The necessity of a BMAB in staging pediatric and adolescent EWS patients in addition to radiological evaluation has not been previously established

Objectives

• To evaluate the association between imaging determined non-metastatic EWS and BM metastasis in pediatric and adolescent patients

• To evaluate the association between BM metastasis and other clinical characteristics of pediatric and adolescent EWS patients

Methods• Retrospective review involving 3 institutions

• Eligibility: Patients less than 40 years of age with newly diagnosed EWS between the years 2000-2012; available initial staging scans and BM evaluation

• 116 patients

• Initial staging reviewed– Imaging (MRI primary site, CT chest, Bone scan) – Bone Marrow Aspiration and Biopsy

Patient CharacteristicsNon-metastatic

(n=85) Metastatic (n=31)

Gender Male Female

47 (55.3%)38 (44.7%)

18 (58.1%)13 (41.9%)

Age at Diagnosis* 13 (1, 38) 16 (3, 25)Primary Tumor Site Pelvis Non-pelvis

15 (17.6%)70 (82.4%)

14 (45.2%)17 (54.8%)

Primary Tumor Size (cm)*, ** 7.5 (1.3, 26.0) 11.2 (3.5, 35.0)

* Median (range)** Primary tumor size of metastatic patients was significantly higher that that of non-metastatic patients (p-value = 0.017 by Wilcoxon rank-sum test)

Metastatic Patients

• Metastatic site:

• Patients with multiple metastatic sites:

Lung alone Bone alone BM alone Multiple

13 (41.9%) 2 (6.5%) 0 (0.0%) 16 (51.6%)

Lung Bone BM Lymph Nodes

9 (56.3%) 14 (87.5%) 13 (81.3%) 2 (12.5%)

BMAB Results

• None of the 85 non-metastatic patients determined by imaging had positive BMAB

• A positive pelvic primary site was not correlated with a positive bone marrowBMAB Correlation with pelvic primary site (n=116)

Pelvic Non-Pelvic P-value

BMAB positive 6 70.087

BMAB negative 23 80

BMAB Results

• 13 of 31 metastatic patients by imaging had positive BMAB

Number of Bony Metastatic Sites (bone scan, n=28)

BMAB positive BMAB negative P-value

3.5 (1.0, 11.0) 0.0 (0.0, 2.0) < 0.0001

Association of Metastasis by Imaging and BMAB

BMAB ResultsBone Metastasis Lung Metastasis

Yes No Yes No

Positive 12 1 6 7

Negative 4 14 16 2

P-value for association* 0.0002 0.017

*Fisher’s exact test was used to evaluate association.

Conclusion

• Pediatric and adolescent Ewing sarcoma patients with non-metastatic disease by imaging may have a bone marrow aspiration and biopsy eliminated as part of initial staging

• In patients with metastatic disease there is a high correlation between bone marrow metastasis and the number of bony metastatic sites

Acknowledgments

University of Arizona

• Phoenix Children’s Hospital– Pooja Hingorani, MD– Andrea White-Collins, NP

• University of Arizona – Mel and Enid Zuckerman College of Public Health– Chengcheng Hu, PhD

University of Texas MD Anderson Cancer Center Children’s Cancer Hospital

– Winston W. Huh, MD– Cynthia E. Herzog, MD, MPH– Beatriz Rozo, NP– Angela Yarbarough, NP