Laboratory study evaluation is also nonspecific; patients may have elevations of the erythrocyte sedimentation rate, lactate dehydrogenase levels, or white blood cell count. On plain radiographs, Ewing sarcoma appears as an ill-defined, mottled, moth-eaten, destructive bone lesion, with periosteal reaction resembling an onion skin, and an associated soft-tissue mass.5 All patients require thorough evaluation for additional tumor burden to guide appropriate intervention. Magnetic resonance imaging evaluation helps to assess tumor size. Computed tomography of the chest is the best method to evaluate for metastatic disease, while a full-body bone scan assists in detection of skin lesions near the primary lesion and distant bone metastases. Bone marrow biopsy is recommended to exclude widespread metastatic disease of the bone marrow.