Role of bone marrow biopsy for staging new patients with Ewing sarcoma: A systematic review

Abstract

The incidence of bone marrow metastasis (BMM) in newly diagnosed Ewing sarcoma (ES) is variable across studies. An optimal staging strategy for detecting BMM is not defined. While bone marrow (BM) biopsy and/or aspirate (BMBA) have been the gold standard, [F-18]fluorodeoxyglucose positron emission tomography (FDG-PET) to detect BMM may decrease reliance on BMBA. We conducted a systematic review to assess incidence of BMM and the role of FDG-PET. We observed a pooled incidence of BMM by BMBA of 4.8% in all newly diagnosed ES patients and 17.5% among patients with metastatic disease. Only 1.2% of patients had BMM as their sole metastatic site. FDG-PET detection of BMM compared to BMBA demonstrated pooled 100% sensitivity and 96% specificity, positive predictive value of 75%, and negative predictive value of 100%. In the era of FDG-PET imaging, omission of BMBA may be considered in patients with otherwise localized disease after initial staging studies.

Is It Time to Call Time on Bone Marrow Biopsy for Staging Ewing Sarcoma (ES)?

“…A similar paradigm shift has been adopted in other tumour groups where bone marrow involvement has been identified on functional imaging, such as Hodgkin lymphoma, diffuse large B-cell lymphoma (DLBCL) and small cell lung cancer (SCLC) [58,59]. A recent systematic review also supports functional imaging with FDG-PET/CT for staging newly diagnosed ES patients and omits the BMB in localised disease [49]. We are in agreement with this staging strategy, but further propose that on the basis of modern imaging using FDG-PET/CT and/or WB-MRI that a BMB is also not performed in patients with metastatic disease.…”

“…Other recent studies have questioned the utility of BMB for staging ES [49,50]. In a systematic review that included data on patients from 38 studies with newly diagnosed ES, the pooled incidence of bone marrow metastases was 4.8% in newly diagnosed ES and 17.5% in patients with metastatic disease [49].…”

“…Other recent studies have questioned the utility of BMB for staging ES [49,50]. In a systematic review that included data on patients from 38 studies with newly diagnosed ES, the pooled incidence of bone marrow metastases was 4.8% in newly diagnosed ES and 17.5% in patients with metastatic disease [49]. In four select studies that used FDG-PET/CT for staging newly diagnosed ES comprising 142 patients [25,[43][44][45] the sensitivity, specificity, PPV and NPV of FDG-PET/CT to detect bone marrow metastases compared with BMB was 100, 96, 75 and 100%, respectively [49].…”

“…Cesari et al noted 5 patients had lung metastases detected with imaging assessment in the 12 patients with known bone marrow involvement, 11 of which had bone metastases on imaging [42]. In the systematic review by Campbell et al, from 6 relevant studies they reported 8.8% (20/225) of ES patients with lung metastases also had bone marrow metastases without bone metastases [49]. However, there is a caveat that not all of these studies from earlier years had imaging techniques available as standard for the modern days, including FDG-PET/CT or WB-MRI, additional distant metastatic sites could have remained undiagnosed and underestimated.…”

Current Approaches to Management of Bone Sarcoma in Adolescent and Young Adult (AYA) Patients

“…With the advent and familiarity of functional imaging in solid tumors, excellent correlation rates have been demonstrated between bone marrow biopsy and FDG-PET/CT in patients with ES. [95][96][97][98][99] WB-MRI appears comparable to FDG-PET/CT and superior to bone scintigraphy, without requiring ionising radiation. 88,100 In centers with access to these imaging modalities, it is possible to avoid an invasive bone marrow biopsy.…”