Leveraging Large Language Models to Extract Prognostic Pathology Features in Ewing Sarcoma

<b>Evidence before this study:</b> We searched PubMed and Google Scholar for articles published up to December 2025, using terms such as "Ewing sarcoma", "prognosis", "risk stratification", "large language models", "natural language processing", and "pathology report extraction". Current risk stratification for Ewing sarcoma relies predominantly on clinical variables, specifically the presence of metastatic disease and tumor size. While histologic heterogeneity is well-documented, it is rarely incorporated into risk models because extracting structured data from narrative pathology reports is labor-intensive. Small, single-institution studies have suggested potential prognostic roles for markers like Neuron-Specific Enolase (NSE) or S100, but results have been inconsistent and limited by small sample sizes. Furthermore, while Large Language Models (LLMs) have demonstrated potential for extracting clinical data, their application to "rescue" data from legacy, multi-institutional clinical trial documents (scanned PDF images) for rare disease biomarker discovery has not been validated at scale.<b>Added value of this study:</b> To our knowledge, this is the largest study to utilize AI to extract histologic data from Ewing sarcoma pathology reports, aggregating 931 patients from six distinct Children's Oncology Group (COG) clinical trials spanning over 21 years. We validated an LLM-based pipeline that converted noisy, optically character-recognized text from diverse institutions into structured data with 98.1% accuracy, outperforming human annotators. This scalable approach revealed that NSE positivity is a significant independent risk factor for mortality (HR=2.15), particularly in patients with non-metastatic disease where it confers a more than 5-fold increased risk of death. Conversely, we identified S100 positivity as a protective factor associated with improved survival (HR=0.58).<b>Implications of all the available evidence:</b> This study demonstrates that LLMs can reliably unlock "dark data" from historical clinical trials, rendering vast archives of unstructured medical documents accessible for retrospective analysis. The identification of NSE and S100 as robust prognostic biomarkers suggests that these widely available immunohistochemical stains provide valuable information beyond standard diagnostic information. These findings support the integration of automated data extraction tools in research workflows and suggest that NSE and S100 status should be considered in the design of future risk-stratified clinical trials for Ewing sarcoma.