Journal of Advanced Clinical & Research Insights (2015), 2, 164–168

REVIEW ARTICLE

Pathogenesis of Ewing sarcoma: A review

Keywords Abstract
Chimeric protein, Ewing sarcoma, EWS/E- Ewing sarcoma is a rare sarcoma of bone and soft tissue that uncommonly involve the
twenty six oncogenic fusions, EWS/FLI,
head and neck. It is the second most common malignant tumor seen in children and
oncogenesis
young adults. It is most common observed during the second or third decade, with a male
Correspondence
predilection. In the head and neck region, it involves skull, clavicle, maxilla, and mandible.
P. S. Vidya Rani, Department of Oral Pathology The reported incidence of this tumor is only 1-3 cases per million of population per year
and Microbiology, RajaRajeswari Dental and skull tumors constitute about 2% of it. The cell of origin is still unclear as there are
College and Hospital, Bengaluru - 560 074, several literature supporting both the neural crest mesenchymal progenitor/stem cells
Karnataka, India. hypothesis. Ewing sarcoma is believed to be derived from recurrent EWS/E-twenty six
E-mail: [email protected] (ETS) oncogenic fusions, which result in altered gene expression in the cell and other
mechanisms. This altered gene expression is followed by the abnormal regulation in the
Received 11 May 2015; expression of several genes and non-coding RNAs. In Ewing sarcoma, the translocation
Accepted 20 June 2015 of t(11;22)(q24;q12) is considered as the primary mechanism for tumorigenesis. The
tumor is characterized by the rearrangement of EWS gene on chromosome 22q12 and
doi: 10.15713/ins.jcri.70
the fusion partners from the ETS oncogene family, chimeric transcription factor, which
is responsible for the Ewing sarcoma oncogenic program. A hybrid gene is formed by
the fusion of EWSR1 in 22q12 with the FLI1 gene in 11q24. EWS/FLI is the common
chimeric protein that is expressed in Ewing’s sarcoma. The expression of this protein
results in the growth arrest and cell death, when they are expressed in primary cell lines.
The expression of these proteins in primitive cell or tumor cell causes differentiation
defects resulting in oncogenesis. In this review, we have made an attempt to have an
insight into the possible mechanism of pathogenesis and cell of origin of Ewing sarcoma.

Introduction the deeper regions and may measure about 5-10 cm in greatest
diameter. Superficially cases do occur, but are rare. In few cases,
Ewing sarcoma is a rare sarcoma of bone and soft tissue that pain can be observed. It may result in the disturbances of sensory
uncommonly involve the head and neck. It is the second most or motor nerves, when they involve spinal cord or peripheral
common malignant tumor seen in children and young adults,[1] nerves.[4] Ewing sarcoma belongs to the Ewing sarcoma family of
commonly seen in the second or third decade, with a male tumors, which are considered as morphologically heterogeneous
predilection. The principal sites of this tumor include long bones tumors[5] that are characterized by chromosomal translocations
of the extremities, paravertebral region, chest wall and vertebrae involving the EWS gene with a member of the E-twenty six
or the ribs. In head and neck region, it involves skull, clavicle, (ETS) family genes[3] which results in the major alterations in
maxilla and mandible. The mandible is the more common site the cell gene. The dysregulated signaling of receptor tyrosine
than maxilla. In the mandible, the posterior body, the angle and kinase involving insulin-like growth factor-1R, PIK3R3, PTEN
ramus regions are most common. Its presentation involves bone and PIK3R have a key role in Ewing’s sarcoma pathogenesis.
expansion, mobile teeth, and fever. The reported incidence of this Altered pathways of RB and p53 may also be responsible factors
tumor is only 1-3 cases per million of population per year. The for mutation in Ewing sarcoma.[6] However, the cell of origin
skull tumors constitute about 2% of tumors.[2] The recurrence and the particular mechanism of pathogenesis is still unclear, for
of this cancer has a survival rate of 10% with increased risk of this tumor.[7] In this review, we have made an attempt to have an
chronic health conditions.[3] The cell of origin is still unclear. In insight into its cell of origin and also the possible mechanism in
general, the tumor exhibits rapid growth. It is usually located in the pathogenesis of Ewing sarcoma.

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Rani, et al. Ewing sarcoma

History stem cells (MSCs) will also provide a suitable cellular context for
the expression of EWS/FL1. MSCs are also capable of retaining
In 1918, a case was reported by Arthur Purdy Stoui which was their propogation, even in the presence of the EWS/FL1 protein.
associated with the ulnar nerve. The tumor was composed These cells exhibit gene expression profiles which are similar to
of round cells, which were undifferentiated and arranged in that of Ewing’s sarcoma. However, they are distinct from the
the form of rosettes in a 42-year-old man. After 3 years James other tumors of bone and soft tissue[21,22] and these cells failed to
Ewing reported a round cell neoplasm was noticed in a girl of develop tumors they were injected into an immunocompromised
about 14 years. They named it as “diffuse endothelioma of bone”
mice[21] suggesting the necessity of EWS/FLI and may not
and proposed an endothelial derivation hypothesis. In 1975,
be sufficient for oncogenic transformation of human MSCs.
Angervall and Enzinger described the first Ewing sarcomas
Recently, it has been demonstrated the possibility of development
arising in soft tissue (extra-skeletal). This tumor bears the
of Ewing’s sarcoma either from a neural crest stem cells or from
name Ewing and is most common called as Ewing’s sarcoma.
MSCs [Table 1].[5,6,13-15,17] Several studies supported this theory.
However, during conversation as well as in literatures both the
The authors have also observed the expression of antigens
terms are used interchangeably. Both the terms have been used
on the cell surface, which are found to be associated with the
interchangeably in previous literature. Etiology Ewing sarcoma
neuroectodermal lineage. Their expression was found in Ewing
is believed to be derived from recurrent EWS/ETS oncogenic
sarcoma.[23-25] Recently, a study on gene expression profile found
fusions, which results in altered gene expression in the cell
that, the genes that were seen expressing in neural tissues as well
and other mechanisms may result in the altered regulation of
as during the differentiation of neurons were also expressed
several genes and non-coding RNAs.[6,8-10] Recently, Ewing
in Ewing sarcoma, in a large amount. They also observed that
sarcomas are also known to exhibit genetic alterations other
there was an upregulation of neural genes with the expression of
than EWS/ETS oncogenic fusion 1. The tumor is characterized
EWS/FLI.[26] Based on their latter observation, they suggested a
by the rearrangement of EWS gene on chromosome 22q12
different hypothesis. The expression of EWS/FL1 will result in
and the fusion partners from the ETS oncogene family. FLI1
the Ewing’s sarcoma neural phenotype, hence does not reflect
on or ERG on chromosome 21q22 (10%) are most frequent
the cell of origin.[27-29] Due to the lack of knowledge about the
involved.[11] This fusion results in chimeric transcription factor
definite cell of origin, the analysis of early stage precancerous
which is responsible for Ewing sarcoma oncogenic program.[11]
cells cannot be accomplished. In other sarcomas also, similar
approach has been effective in identifying the definite cell
The cell of origin
of origin as in the case of rhabdomyosarcoma,[30,31] synovial
The recognition of a more appropriate model system involved sarcoma,[32] and osteosarcoma.[33]
in the pathogenesis of this tumor still remains unclear due to the
lack of knowledge in identifying the cell of origin. The cellular Pathogenesis
environmental factors that influence the expression of EWS/
Aurias et al. and Turc-Carel in 1983, first described the
FLI are unclear. In many primary cells, the expression of EWS/
translocation of t(11;22)(q;24;12) in Ewing sarcoma.[34] This
FLI causes growth arrest or cell death. The differentiation
was thought to be the primary mechanism for tumorogenesis.
defects are resulted by the increased expression of these
However, the heterogeneous biology found in the tumors of
proteins, in the primitive cells.[12] The presentation of Ewing’s
patients with ES suggests the involvement of other molecular
sarcoma as an undifferentiated “small round blue cell tumor”
mechanisms.[6] Ewing sarcoma was the first sarcoma that
will present an idea about its original cell of origin.[12] In 1921,
was characterized by the translocation at the molecular level.
its endothelial origin was first proposed by James. Later, various
The translocation occurs in t(11;22)(q24;q12). A hybrid
authors have suggested different theories regarding its original
cell of origin. They consider that cell of origin of this tumor gene is formed by the fusion of EWSR1 in 22q12 with the
might be hematopoietic,[13] fibroblastic,[14] neural crest,[15] and FLI1 gene in 11q24. EWSR1 gene is a member of ten-eleven
mesenchymal progenitor/stem cells.[16,17] There is an increase in translocations (TET) and has multiple functions. TET family
the number of evidences supporting the theory of mesenchymal
progenitor/stem cells origin.[18] The expression of EWS-FLI1 Table 1: The various proposed cell of origin
is associated with activation of some genes and repression of Cell of origin Proposed by Year
other genes demonstrating the complexity of cellular response Endothelial origin James 1921
to this oncogenic transcription factor.[19] Later studies have Hematopoietic origin Kadsin and Bensch 1971
demonstrated the development of tumor with a small round cell Fibroblatic | Dickman et al. 1982
morphology by the transduced cells in an immunocompromised
Neural crest origin Cavazzana et al. 1988
mice following the introduction of EWS/FL1 protein into the
bone marrow cells mesenchymal progenitor cells.[17,20] Few Mesenchymal progenitor/stem cells Castillero‑trejo et al. 2005
studies have also demonstrated the expression of CD99 in Ewing’s Neural derived MSC or from a neural Elizabeth C. 2010
sarcoma, but the harboring of CD99 in the murine genome is Crest cell Toomey
still a controversy. It is observed that the human mesenchymal MSC: Mesenchymal stem cell

Journal of Advanced Clinical & Research Insights  ●  Vol. 2:4  ●  Jul-Aug 2015165
Ewing sarcoma Rani, et al.

proteins are involved in the processing and transportation of genetic diversities, the structure of these alternative fusions are
RNA, expression of genes and signaling of cells. FL1 belongs similar to EWS/FLI1. The retrospective study comparing these
to the family of ETS. These are the transcription factors and variants did not reveal any significant differences in their clinical
DNA sequences are targeted by them.[35] The 50th portion presentation and overall survival and event-free survival.[37]
of EWSR1 is joined to FLI1 by t(11;22)(q24;q12). Hence, The translocation in the chromosomes between EWSR1 and
the domain of transcription activation will be replaced by the transcription factors gene will result in the increase of chimeric
sequences of EWSR1. There will be variation of breakpoints proteins will increase in their number due to the and are known
in two genes. The fusion between EWSR1 exon 7 and FLI1 5 to involve in tumorigenesis through their function as an aberrant
or 6 are most common. The alterations in the translocation transcription factor.[34]
will result in the EWSR1 gene with other different ETS genes McKinsey et al. stated that precursor (pri-mr) transcription
like ETS-related gene, ETS-variant gene 1 or 4, or fifth Ewing was downregulated by the repression of EWS/FLI1 group. This
sarcoma variant. Among these fusions, EWSR1 and ERG was consistent with a transcriptional regulatory mechanism.[37]
fusion are most common [Figure 1].[28,36,37] In spite of having Nakatani et al. have analyzed and demonstrated five miRs. They

Figure 1: The sequence of molecular events reported during the pathogenesis of Ewing sarcoma

166 Journal of Advanced Clinical & Research Insights  ●  Vol. 2:4  ●  Jul-Aug 2015
Rani, et al. Ewing sarcoma

are, 34a, 23a, 92a, 490-3p, and 130b. The significant association 6. Randall L, Calvert G, Spraker H, Lessnick S. Ewing’s Sarcoma
of miR with event –free and overall survival was observed.[38] Family of Tumors (ESFT). ESUN. 2011;3-4.
They have also observed the low level of miR-34a which appears 7. Jedlicka P. Ewing Sarcoma, an enigmatic malignancy of likely
as a predictor of early relapse.[39] In other studies, the authors progenitor cell origin, driven by transcription factor oncogenic
have reported that the Ewing sarcoma cell line’s anchorage- fusions. Int J Clin Exp Pathol 2010;3:338-47.
8. Ordóñez JL, Osuna D, Herrero D, de Alava E, Madoz-Gúrpide J.
independent growth was inhibited by the expression of miR-
Advances in Ewing’s sarcoma research: Where are we now and
34a. The expression of miR will be regulated by p53 and its what lies ahead? Cancer Res 2009;69:7140-50.
role was consistent with miR-34a levels. The levels were low 9. Dylla L, Moore C, Jedlicka P. MicroRNAs in Ewing Sarcoma.
in Ewin sarcoma cell lines. Inactivation mutations of p53 were Front Oncol 2013;3:65.
also found.[9] The role of EWS in miR processing and whether 10. Kelleher FC, Thomas DM. Molecular pathogenesis and targeted
its haploinsufficiency, affects the miR biogenesis processing therapeutics in Ewing sarcoma/primitive neuroectodermal
function in case of Ewing sarcoma, is yet to be determined. tumours. Clin Sarcoma Res 2012;2:6.
The protein-protein interaction of EWS/Ets-EWS, causing 11. Kovar H, Bernard A. CD99-positive “Ewing’s sarcoma” from
the interference or gain to processing function is also yet to be mouse-bone marrow-derived mesenchymal progenitor cells?
determined.[9,40] Cancer Res 200;66:9786.
12. Triche TJ, Askin FB, Kissane JM. In: Feingold M, Benningtion JC,
editors. Major Problems in Pathology. Philadelphia: Saunders;
Conclusion 1987. p. 145-95.
13. Kadin ME, Bensch KG. On the origin of Ewing’s tumor. Cancer
Ewing sarcoma is a common and complex disease of bone and 1971;27:257-73.
soft tissues affecting children and young adults. The definite cell 14. Dickman PS, Liotta LA, Triche TJ. Ewing’s sarcoma.
of origin is yet to be determined. The cell of origin is known to Characterization in established cultures and evidence of its
play a significant role in the pathogenesis the disease by providing histogenesis. Lab Invest 1982;47:375-82.
a suitable environment for the transcriptional abnormal 15. Cavazzana AO, Magnani JL, Ross RA, Miser J, Triche TJ. Ewing’s
regulation, which is mediated by EWS/FL1. It also involves the sarcoma is an undifferentiated neuroectodermal tumor. Prog
other altered signaling pathways resulting in different genetic Clin Biol Res 1988;271:487-98.
16. Prieur A, Tirode F, Cohen P, Delattre O. EWS/FLI-1 silencing
diversities makes the research about this study a challenge. The
and gene profiling of Ewing cells reveal downstream oncogenic
treatment of this disease has still remained a challenge. The better
pathways and a crucial role for repression of insulin-like growth
definite knowledge about its cell of origin the potential of cancer factor binding protein 3. Mol Cell Biol 2004;24:7275-83.
stem cell in Ewing sarcoma will facilitate to study this malignancy 17. Riggi N, Cironi L, Provero P, Suvà ML, Kaloulis K,
which helps in the better understanding of the disease. This Garcia-Echeverria C, et al. Development of Ewing’s sarcoma
will allow the researchers to gain knowledge about the various from primary bone marrow-derived mesenchymal progenitor
proteins and their contributions in the tumorigenesis of Ewing’s cells. Cancer Res 2005;65:11459-68.
sarcoma. Finally, new technologies should be developed to 18. Torchia EC, Jaishankar S, Baker SJ. Ewing tumor fusion proteins
identify the mutations that cooperate with EWS/FL1 including block the differentiation of pluripotent marrow stromal cells.
its targets. New advanced studies should be performed for the Cancer Res 2003;63:3464-8.
identification of any alternate mechanisms that can prevent the 19. May WA, Gishizky ML, Lessnick SL, Lunsford LB, Lewis BC,
Delattre O, et al. Ewing sarcoma 11;22 translocation produces
extensive proliferation and other phenotypes of cancer. The
a chimeric transcription factor that requires the DNA-binding
enhanced molecular insight about this disease can facilitate a
domain encoded by FLI1 for transformation. Proc Natl Acad Sci
much better and targeted treatment in treating this disease. U S A 1993;90:5752-6.
20. Castillero-Trejo Y, Eliazer S, Xiang L, Richardson JA,
Ilaria RL Jr. Expression of the EWS/FLI-1 oncogene in murine
References
primary bone-derived cells Results in EWS/FLI-1-dependent,
1. Niemeyer BF, Parrish JK, Spoelstra NS, Joyal T, Richer JK, ewing sarcoma-like tumors. Cancer Res 2005;65:8698-705.
Jedlicka P. Variable expression of PIK3R3 and PTEN in 21. Riggi N, Suvà ML, Suvà D, Cironi L, Provero P, Tercier S, et al.
Ewing Sarcoma impacts oncogenic phenotypes. PLoS One EWS-FLI-1 expression triggers a Ewing’s sarcoma initiation
2015;10:e0116895. program in primary human mesenchymal stem cells. Cancer
2. Marx ER, Stern D. Oral and Maxillofacial Pathology; A Rationale Res 2008;68:2176-85.
for Diagnosis and Treatment. 2nd ed. New Delhi: Quintessence 22. Miyagawa Y, Okita H, Nakaijima H, Horiuchi Y, Sato B,
Publishing Co. Inc.; 2012. p. 859-61. Taguchi T, et al. Inducible expression of chimeric EWS/
3. Ross KA, Smyth NA, Murawski CD, Kennedy JG. The biology of ETS proteins confers Ewing’s family tumor-like phenotypes
ewing sarcoma. ISRN Oncol 2013;2013:759725. to human mesenchymal progenitor cells. Mol Cell Biol
4. Weiss WS, Goldblum JR. Enzinger and Weiss‘s Soft Tissue 2008;28:2125-37.
Tumors. 4th ed. Atlanta: Elsevier Saunders; 2001. p. 1289-308. 23. Lipinski M, Braham K, Philip I, Wiels J, Philip T, Dellagi K, et al.
5. Toomey EC, Schiffman JD, Lessnick SL. Recent advances in Phenotypic characterization of Ewing sarcoma cell lines with
the molecular pathogenesis of Ewing’s sarcoma. Oncogene monoclonal antibodies. J Cell Biochem 1986;31:289-96.
2010;29:4504-16. 24. Lipinski M, Braham K, Philip I, Wiels J, Philip T, Goridis C,

Journal of Advanced Clinical & Research Insights  ●  Vol. 2:4  ●  Jul-Aug 2015167
Ewing sarcoma Rani, et al.

et al. Neuroectoderm-associated antigens on Ewing’s sarcoma 33. Walkley CR, Qudsi R, Sankaran VG, Perry JA, Gostissa M,
cell lines. Cancer Res 1987;47:183-7. Roth SI, et al. Conditional mouse osteosarcoma, dependent
25. Lipinski M, Hirsch MR, Deagostini-Bazin H, Yamada O, Tursz T, on p53 loss and potentiated by loss of Rb, mimics the human
Goridis C. Characterization of neural cell adhesion molecules disease. Genes Dev 2008;22:1662-76.
(NCAM) expressed by Ewing and neuroblastoma cell lines. Int J 34. Blau O. Molecular investigation of Ewing sarcoma: About
Cancer 1987;40:81-6. detecting translocations. EMBO Mol Med 2012;4:449-50.
26. Staege MS, Hutter C, Neumann I, Foja S, Hattenhorst UE, 35. Riggi N, Cironi L, Suvà ML, Stamenkovic I. Sarcomas: Genetics,
Hansen G, et al. DNA microarrays reveal relationship of Ewing signalling, and cellular origins. Part  1: The fellowship of TET.
family tumors to both endothelial and fetal neural crest-derived J Pathol 2007;213:4-20.
cells and define novel targets. Cancer Res 2004;64:8213-21. 36. Sankar S, Lessnick SL. Promiscuous partnerships in Ewing’s
27. Hu-Lieskovan S, Zhang J, Wu L, Shimada H, Schofield DE, sarcoma. Cancer Genet 2011;204:351-65.
Triche TJ. EWS-FLI1 fusion protein up-regulates critical 37. Ginsberg JP, de Alava E, Ladanyi M, Wexler LH, Kovar H,
genes in neural crest development and is responsible for the Paulussen M, et al. EWS-FLI1 and EWS-ERG gene fusions are
observed phenotype of Ewing’s family of tumors. Cancer Res associated with similar clinical phenotypes in Ewing’s sarcoma.
2005;65:4633-44. J Clin Oncol 1999;17:1809-14.
28. Lessnick SL, Dacwag CS, Golub TR. The Ewing’s sarcoma
38. McKinsey EL, Parrish JK, Irwin AE, Niemeyer BF, Kern HB,
oncoprotein EWS/FLI induces a p53-dependent growth arrest
Birks DK, et al. A novel oncogenic mechanism in Ewing sarcoma
in primary human fibroblasts. Cancer Cell 2002;1:393-401.
involving IGF pathway targeting by EWS/Fli1-regulated
29. Rorie CJ, Thomas VD, Chen P, Pierce HH, O’Bryan JP, Weissman BE.
microRNAs. Oncogene 2011;30:4910-20.
The Ews/Fli-1 fusion gene switches the differentiation program
39. Nakatani F, Ferracin M, Manara MC, Ventura S, Del Monaco V,
of neuroblastomas to Ewing sarcoma/peripheral primitive
Ferrari S, et al. miR-34a predicts survival of Ewing’s sarcoma
neuroectodermal tumors. Cancer Res 2004;64:1266-77.
patients and directly influences cell chemo-sensitivity and
30. Keller C, Arenkiel BR, Coffin CM, El-Bardeesy N, DePinho RA,
Capecchi MR. Alveolar rhabdomyosarcomas in conditional malignancy. J Pathol 2012;226:796-805.
Pax3:Fkhr mice: Cooperativity of Ink4a/ARF and Trp53 loss of 40. Embree LJ, Azuma M, Hickstein DD. Ewing sarcoma fusion
function. Genes Dev 2004;18:2614-26. protein EWSR1/FLI1 interacts with EWSR1 leading to mitotic
31. Keller C, Hansen MS, Coffin CM, Capecchi MR. Pax3:Fkhr defects in zebrafish embryos and human cell lines. Cancer Res
interferes with embryonic Pax3 and Pax7 function: Implications 2009;69:4363-71.
for alveolar rhabdomyosarcoma cell of origin. Genes Dev
2004;18:2608-13. How to cite this article: Rani PS, Shyamala K, Girish HC,
32. Haldar M, Hancock JD, Coffin CM, Lessnick SL, Capecchi MR.
Murgod S. Pathogenesis of Ewing sarcoma: A review. J Adv
A conditional mouse model of synovial sarcoma: Insights into a
myogenic origin. Cancer Cell 2007;11:375-88.
Clin Res Insights 2015;2:164-168.

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