Background Ewing tumor treatment involves high cumulative doses of alkylating agents and topoisomerase inhibitors, drugs capable of inducing second cancers We analyzed the second cancer risk in a large cohort of consistently treated patients Patients and methods Six hundred ninety Ewing tumor patients were treated between 1992 and 1999 with local therapy and vincristine, doxorubicin, ifosfamide and/or cyclophosphamide, and antinomycin D, with or without etoposide as a randomized question Second cancer incidences were estimated by competing risk analyses, standardized incidence ratios (SIR) in comparison to registry data were compiled Results After a median observation time of 56 months (32 months for survivors), 6 of 690 patients had developed second cancers MDS/AML, two, ALL/NHL, two, squamous cell carcinoma, one, liposarcoma, one SIR were increased 20–30 fold in comparison to the general population The cumulative second cancer risk five years after diagnosis of the Ewing tumor was 0 0093 for the total group, zero for patients without etoposide, and 0.0118 with etoposide. Additional phase II high-dose therapy increased the risk to 0 0398 after five years Conclusions The second cancder risk observed was in the range to be expected in cancer survivors High-dose therapy, and less markedly, etoposide, may contribute to the overall second cancer risk