Working Diagnosis:
Metastatic Ewing's Sarcoma

Treatment:
Athlete was enrolled in an open clinical trial with the Children's Oncology Group (national pediatric cancer consortium). The standard chemotherapy treatment for Ewing's sarcoma is six cycles of a five-drug regimen given every two weeks. Additionally, the patient is receiving an experimental new biologic agent, Ganitumab. Following six cycles of neoadjuvant therapy, the oncologist will obtain repeat imaging to assess the response.
The patient will then undergo eight more cycles of adjuvant/consolidation chemotherapy during his radiation treatment. Ganitumab will be given for an additional six months ("maintenance therapy") following the conclusion of radiation.

Outcome:
To be determined - patient currently in the midst of aforementioned treatment.

Author's Comments:
Ewing's sarcoma can develop in almost any bone or soft tissue but is most common in the pelvis, axial skeleton and femur. Patients typically present with localized pain and swelling. Overt metastatic disease is found in fewer than 25 percent of cases at the time of diagnosis.
No commonly used staging system exists for Ewing's sarcoma as they do for other solid tumors. Although there are tumor, node and metastasis staging systems for primary tumors of the bone and soft tissue available, they are not in widespread use for Ewing's. A deficiency of these staging systems is that they do not specify the primary site, which is one of the most important prognostic factors. Other prognostic factors (along with primary tumor site and size) include disease extent, histology, age and response to therapy. Considering this, the patient's oncologist declared that the overall survival prognosis in this case is poor.

Editor's Comments:
It is important to always consider as sports medicine physicians a comprehensive differential diagnosis for musculoskeletal pain. We can be easily trapped into common patterns of pain but need to be diligent and vigilant in recognizing red flags for alternate, more worrisome diagnoses. In this case, it is easy to assume standard causes of muscle pain in this field event athlete in the midst of a heavy weight training regimen. However, his progressive pain pattern that developed into a decreasing activity tolerance is a pattern that should not be ignored.

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