Patrick J Boland

Stony Brook University, Stony Brook, NY, United States

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Publications (94)312.45 Total impact

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    ABSTRACT: QUALITY OF LIFE POST SACRAL RESECTION USING PATIENT REPORTED OUTCOMES – A RETROSPECTIVE ANALYSIS OF PROSPECTIVELY COLLECTED DATA David McKeown MD, Polina Osler, Matthew Houdek MD, Peter Rose MD, Nicola Fabbri MD, Joseph H. Schwab MD, Patrick J. Boland MD Objective: At present there is paucity of data regarding the long term morbidity of patients who undergo a sacral resection. There is an increasing application of sacral resection for malignant tumors of the pelvis and primary lesions of the sacrum. By collecting patient reported outcomes on the impact of this procedure we can then aim to better educate and inform future patients on the life changing aftermath of this procedure. Methods: All patients who had previously undergone a sacral resection at Memorial Sloan Kettering, Massachusetts General Hospital or the Mayo Clinic from the years 1990-2012 were eligible for inclusion. A questionnaire was created using the NIH’s Patient Reported Outcomes Measurement Information System (PROMIS). The questionnaire included instruments designed to measure global quality of life, physical function, pain interference, urinary function and bowel function. Patients were either mailed the questionnaire in paper form or asked to complete the questionnaire electronically when they returned for their annual clinical review at each institution. A total of 81 (50 male, 31 female) patients were recruited between the three institutions. The patients were then stratified into 5 different groups depending on the extent of their procedure; 1) Total sacrectomy (n=9), 2) Coronal transection of the sacrum at S1 (n=23), 3) Coronal transection of the sacrum at S2 (n=19), 4) Coronal transection of the sacrum at S3 (n=17), 5) sagittal hemi-sacrectomy (n=11). Results: With regards to physical function we identified a definite trend of improved physical function with a low sacral resection vs a high sacral resection. Global quality of life was similar across all levels of resection. In patients with bowel and bladder dysfunction, patients using self catheterization reported a higher global quality of life than those who were incontinent or suffered from urinary constipation. Likewise, patients who had undergone a stoma formation reported a greater global quality of life than patients who suffered from bowel incontinence or chronic constipation. Conclusions: These results demonstrate that the ability to retain as much of the sacrum as possible while still attaining good surgical margins allows for improved physical function and overall quality of life in patients who undergo a sacral resection for a malignant cause. Furthermore, these results may allow patients to make a better informed choice regarding the formation of a stoma or urinary diversion as patients in these groups have reported better outcomes than those who have lost neurological control of their bowel and bladder.
    ISOLS 2013; 09/2013
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    ABSTRACT: En bloc wide-margin excision significantly decreases the risk of chordoma recurrence. However, a wide surgical margin cannot be obtained in many chordomas, as they arise primarily in the sacrum, clivus and mobile spine. Furthermore, these tumors have shown resistance to fractionated photon radiation at conventional doses and numerous chemotherapies. To analyze the outcomes of single-fraction SRS in the treatment of chordomas of the mobile spine and sacrum. Twenty-four patients with chordoma of the sacrum and mobile spine were treated with high-dose single-fraction SRS (median dose 2400 cGy). Twenty-one primary and three metastatic tumors were treated. Seven patients were treated for post-operative tumor recurrence. In seven patients, SRS was administered as planned adjuvant therapy and in thirteen patients SRS was administered as neo-adjuvant therapy. All patients had serial MRI follow-up. The overall median follow-up was 24 months. Of the 24 patients, 23 (95%) demonstrated stable or reduced tumor burden based on serial MR imaging. One patient had radiographic progression of tumor eleven months after SRS. Only 6 of 13 patients who underwent neo-adjuvant SRS proceeded to surgery. This decision was based on the lack of radiographic progression and the patient's preference. Complications were limited to one patient who developed sciatic neuropathy and one with vocal cord paralysis. High-dose single-fraction SRS provides good tumor control with low treatment-related morbidity. Additional follow-up will be required in order to determine the long-term recurrence risk.
    Neurosurgery 07/2013; · 2.53 Impact Factor
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    ABSTRACT: BACKGROUND:: Notochord-related lesions of the spinal column include benign notochordal cell tumors (BNCT), ecchordosis physaliphora, both generally considered benign lesions, and chordomas, which represent malignant tumors. The histologic similarity of these lesions to the notochord and each other, in addition to their strong predilection to the axial skeleton, haveledto the hypothesis that these lesions represent a continuum of malignant transformation from notochordal remnants, BNCTs, and finally, chordomas. OBJECTIVE:: We present a cohort of biopsy-proven BNCTs, with description of radiographic features, histology, and follow-up to help elucidate the optimal management of these lesions. METHODS:: A retrospective chart review identified 13 patients with notochordal rest lesions confirmed by histology. Histologic inclusion criteria included notochordal features without evidence of septation, myxoid matrix, nuclear atypia, or mitotic figures. Tumors exhibiting evidence of cortical expansion or destruction were excluded. The natural history and histologic and radiographic features were examined. RESULTS:: 16 spinal lesions from 8 patients met the diagnostic criteria for BNCTs, identified on imaging following presentation with back pain. Radiographically, all lesions were hypointense on T1-weighted MRI sequences, and hyperintense on T2-weighted and STIR. The median radiographic follow-up was 21.6 months (range 8.5-71.2). None of the lesions exhibited radiographic or symptomatic progression. CONCLUSION:: Although limited by short follow-up, our series confirms that these lesions may be safely observed without evidence of malignant transformation, which emphasizes the importance of distinction of BNCT from chordoma at diagnosis and the possibility of close follow-up for these lesions instead of aggressive treatment indicated in patients with chordomas.
    Neurosurgery 05/2013; · 2.53 Impact Factor
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    ABSTRACT: BACKGROUND: Manual techniques of reproducing a preoperative plan for primary bone tumor resection using rudimentary devices and imprecise localization techniques can result in compromised margins or unnecessary removal of unaffected tissue. We examined whether a novel technique using computer-generated custom jigs more accurately reproduces a preoperative resection plan than a standard manual technique. DESCRIPTION OF TECHNIQUE: Using CT images and advanced imaging, reverse engineering, and computer-assisted design software, custom jigs were designed to precisely conform to a specific location on the surface of partially skeletonized cadaveric femurs. The jigs were used to perform a hemimetaphyseal resection. METHODS: We performed CT scans on six matched pairs of cadaveric femurs. Based on a primary bone sarcoma model, a joint-sparing, hemimetaphyseal wide resection was precisely outlined on each femur. For each pair, the resection was performed using the standard manual technique on one specimen and the custom jig-assisted technique on the other. Superimposition of preoperative and postresection images enabled quantitative analysis of resection accuracy. RESULTS: The mean maximum deviation from the preoperative plan was 9.0 mm for the manual group and 2.0 mm for the custom-jig group. The percentages of times the maximum deviation was greater than 3 mm and greater than 4 mm was 100% and 72% for the manual group and 5.6% and 0.0% for the custom-jig group, respectively. CONCLUSIONS: Our findings suggest that custom-jig technology substantially improves the accuracy of primary bone tumor resection, enabling a surgeon to reproduce a given preoperative plan reliably and consistently.
    Clinical Orthopaedics and Related Research 01/2013; · 2.79 Impact Factor
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    ABSTRACT: Allograft-prosthesis composite (APC) can restore capsular and ligamentous tissues of the knee sacrificed in a tumor extirpation. We asked if performing APC would restore knee stability and allow the use of nonconstrained arthroplasty while preventing aseptic loosening. We retrospectively compared 50 knee APCs performed with non-constrained revision knee prosthesis (Group 1) with 36 matched APCs performed with a constrained prosthesis (Group 2). In Group 1, the survival rate was 69% at five and 62% at ten years. Sixteen reconstructions were removed due to complications: eight deep infections, three fractures, two instabilities, one aseptic loosening, one local recurrence, and one nonunion. In Group 2, the survival rate was 80% at five and 53% at ten years. Nine reconstructions were removed: 3 due to deep infections, 3 to fractures, and 3 to aseptic loosening. In both groups, we observed more allograft fractures when the prosthetic stem does not bypass the host-donor osteotomy ( > 0.05). Both groups had mainly good or excellent MSTS functional results. Survival rate and functional scores and aseptic loosening were similar in both groups. A rotating-hinge APC is recommended when host-donor soft tissue reconstruction fails to restore knee instability. The use of a short prosthetic stem has a statistical relationship with APC fractures.
    Sarcoma 01/2013; 2013:489652.
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    ABSTRACT: BACKGROUND: We recently developed two Bayesian networks, referred to as the Bayesian-Estimated Tools for Survival (BETS) models, capable of estimating the likelihood of survival at 3 and 12 months following surgery for patients with operable skeletal metastases (BETS-3 and BETS-12, respectively). In this study, we attempted to externally validate the BETS-3 and BETS-12 models using an independent, international dataset. METHODS: Data were collected from the Scandinavian Skeletal Metastasis Registry for patients with extremity skeletal metastases surgically treated at eight major Scandinavian referral centers between 1999 and 2009. These data were applied to the BETS-3 and BETS-12 models, which generated a probability of survival at 3 and 12 months for each patient. Model robustness was assessed using the area under the receiver-operating characteristic curve (AUC). An analysis of incorrect predictions was also performed. RESULTS: Our dataset contained 815 records with adequate follow-up information to establish survival at 12 months. All records were missing data including the surgeon's estimate of survival, which was previously shown to be a first-degree predictor of survival in both models. The AUCs for the BETS-3 and BETS-12 models were 0.79 and 0.76, respectively. Incorrect estimations by both models were more commonly optimistic than pessimistic. CONCLUSIONS: The BETS-3 and BETS-12 models were successfully validated using an independent dataset containing missing data. These models are the first validated tools for accurately estimating postoperative survival in patients with operable skeletal metastases of the extremities and can provide the surgeon with valuable information to support clinical decisions in this patient population.
    BMC Cancer 10/2012; 12(1):493. · 3.33 Impact Factor
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    ABSTRACT: BACKGROUND: Compliant, self-adjusting compression technology is a novel approach for durable prosthetic fixation of the knee. However, the long-term survival of these constructs is unknown. QUESTIONS/PURPOSES: We therefore determined the survival of the Compress(®) prosthesis (Biomet Inc, Warsaw, IN, USA) at 5 and 10 actuarial years and identified the failure modes for this form of prosthetic fixation. METHODS: We retrospectively reviewed clinical and radiographic records for all 82 patients who underwent Compress(®) knee arthroplasty from 1998 to 2008, as well as one patient who received the device elsewhere but was followed at our institution. Prosthesis survivorship and modes of failure were determined. Followup was for a minimum of 12 months or until implant removal (median, 43 months; range, 6-131 months); 28 patients were followed for more than 5 years. RESULTS: We found a survivorship of 85% at 5 years and 80% at 10 years. Eight patients required prosthetic revision after interface failure due to aseptic loosening alone (n = 3) or aseptic loosening with periprosthetic fracture (n = 5). Additionally, five periprosthetic bone failures occurred that did not require revision: three patients had periprosthetic bone failure without fixation compromise and two exhibited irregular prosthetic osteointegration patterns with concomitant fracture due to mechanical insufficiency. CONCLUSIONS: Compress(®) prosthetic fixation after distal femoral tumor resection exhibits long-term survivorship. Implant failure was associated with patient nonadherence to the recommended weightbearing proscription or with bone necrosis and fracture. We conclude this is the most durable FDA-approved fixation method for distal femoral megaprostheses. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
    Clinical Orthopaedics and Related Research 10/2012; · 2.79 Impact Factor
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    ABSTRACT: In the pediatric population, malignant osseous tumors of the spine include osteosarcoma, Ewing sarcoma, lymphoma, and metastatic neuroblastoma. Although these tumors are rare, prompt diagnosis and recognition are critical to the overall prognosis. Improved understanding of the natural history of spine deformity, combined with advances in imaging, surgical technology, radiation therapy, and chemotherapeutic regimens, has improved survival rates and decreased rates of local recurrence-especially recurrence of low-grade lesions. Prognosis for patients with high-grade lesions with distant metastasis on presentation remains exceedingly poor. Recognition of these spine tumors and prompt referral to a tertiary care center that specializes in oncology can optimize patient outcomes.
    The Journal of the American Academy of Orthopaedic Surgeons 10/2012; 20(10):646-56. · 2.46 Impact Factor
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    ABSTRACT: In the pediatric population, malignant osseous tumors of the spine include osteosarcoma, Ewing sarcoma, lymphoma, and metastatic neuroblastoma. Although these tumors are rare, prompt diagnosis and recognition are critical to the overall prognosis. Improved understanding of the natural history of spine deformity, combined with advances in imaging, surgical technology, radiation therapy, and chemotherapeutic regimens, has improved survival rates and decreased rates of local recurrence—especially recurrence of low-grade lesions. Prognosis for patients with high-grade lesions with distant metastasis on presentation remains exceedingly poor. Recognition of these spine tumors and prompt referral to a tertiary care center that specializes in oncology can optimize patient outcomes.
    The Journal of the American Academy of Orthopaedic Surgeons 10/2012; · 2.46 Impact Factor
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    ABSTRACT: BACKGROUND: Accurate reproduction of the preoperative plan at the time of surgery is critical for wide resection of primary bone tumors. Robotic technology can potentially help the surgeon reproduce a given preoperative plan, but yielding control of cutting instruments to a robot introduces potentially serious complications. We developed a novel passive ("haptics") robot-assisted resection technique for primary bone sarcomas that takes advantage of robotic accuracy while still leaving control of the cutting instrument in the hands of the surgeon. QUESTIONS/PURPOSES: We asked whether this technique would enable a preoperative resection plan to be reproduced more accurately than a standard manual technique. METHODS: A joint-sparing hemimetaphyseal resection was precisely outlined on the three-dimensionally reconstructed image of a representative Sawbones femur. The indicated resection was performed on 12 Sawbones specimens using the standard manual technique on six specimens and the haptic robotic technique on six specimens. Postresection images were quantitatively analyzed to determine the accuracy of the resections compared to the preoperative plan, which included measuring the maximum linear deviation of the cuts from the preoperative plan and the angular deviation of the resection planes from the target planes. RESULTS: Compared with the manual technique, the robotic technique resulted in a mean improvement of 7.8 mm of maximum linear deviation from the preoperative plan and 7.9° improvement in pitch and 4.6° improvement in roll for the angular deviation from the target planes. CONCLUSIONS: The haptic robot-assisted technique improved the accuracy of simulated wide resections of bone tumors compared with manual techniques. CLINICAL RELEVANCE: Haptic robot-assisted technology has the potential to enhance primary bone tumor resection. Further bench and clinical studies, including comparisons with recently introduced computer navigation technology, are warranted.
    Clinical Orthopaedics and Related Research 08/2012; · 2.79 Impact Factor
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    ABSTRACT: : Treatment of spinal and intracranial tumors with dural involvement is complicated by radiation tolerance of sensitive structures, especially in the setting of previous treatment. : To evaluate whether intraoperative brachytherapy with short-range sources allows therapeutic dose delivery without damaging sensitive structures. : The median doses of previous treatment were 3000 cGy (range, 1800-7200 cGy) for 8 patients with primary/recurrent and 17 patients with metastatic spinal tumors and 5040 cGy (range, 1300-6040 cGy) for 5 patients with locally recurrent and 2 patients with metastatic intracranial tumors. Patients underwent gross total or maximal resection of the tumor and were then treated with an intraoperative brachytherapy plaque consisting of a flexible silicone film incorporating P. A dose of 1000 cGy was delivered to a depth of 1 mm; the percent depth dose was less than 1% at 4 mm from the prescription depth. Median postoperative radiation doses of 2700 cGy (range, 1800-3000 cGy) were delivered to 15 spinal tumor patients and 3000 cGy (range, 1800-3000 cGy) to 3 intracranial tumor patients. The median follow-up was 4.4 months (range, 2.6-23.3 months) for spinal tumor patients and 5.3 months (range, 0.7-16.2) for intracranial tumor patients. : At 6-month follow-up, for all spinal tumor patients, local progression-free survival and overall survival rates were both 83.3% (95% confidence interval [CI]: 62.3%-94.3%); for all intracranial tumor patients, the local progression-free survival rate was 62.5% (95% CI: 23.8%-90.9%) and the overall survival rate was 66.7% (95% CI: 26.7%-92.9%). There were no intraoperative or postoperative complications secondary to radiotherapy. : Use of the P brachytherapy plaque is technically simple and not associated with increased risk of complications, even after multiple radiation courses. Local control rates were more than 80% in patients with proven radiation-resistant spinal disease. : CI, confidence intervalSRS, stereotactic radiosurgery.
    Neurosurgery 08/2012; 71(5):1003-11. · 2.53 Impact Factor
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    ABSTRACT: Sacral insufficiency fractures after adjuvant radiation for rectal carcinoma can present similarly to recurrent disease. As a complication associated with pelvic radiation, it is important to be aware of the incidence and risk factors associated with sacral fractures in the clinical assessment of these patients. Between 1998 and 2007, a total of 582 patients with locally advanced rectal carcinoma received adjuvant chemoradiation and surgical excision. Of these, 492 patients had imaging studies available for review. Hospital records and imaging studies from all 492 patients were retrospectively evaluated to identify risk factors associated with developing a sacral insufficiency fracture. With a median follow-up time of 3.5 years, the incidence of sacral fractures was 7.1% (35/492). The 4-year sacral fracture free rate was 0.91. Univariate analysis showed that increasing age (≥60 vs. <60 years), female sex, and history of osteoporosis were significantly associated with shorter time to sacral fracture (P=.01, P=.004, P=.001, respectively). There was no significant difference in the time to sacral fracture for patients based on stage, radiotherapy dose, or chemotherapy regimen. Multivariate analysis showed increasing age (≥60 vs. <60 years, hazard ratio [HR] = 2.50, 95% confidence interval [CI] = 1.22-5.13, P=.01), female sex (HR = 2.64, CI = 1.29-5.38, P=.008), and history of osteoporosis (HR = 3.23, CI = 1.23-8.50, P=.02) were independent risk factors associated with sacral fracture. Sacral insufficiency fractures after pelvic radiation for rectal carcinoma occur more commonly than previously described. Independent risk factors associated with fracture were osteoporosis, female sex, and age greater than 60 years.
    International journal of radiation oncology, biology, physics 08/2012; 84(3):694-9. · 4.59 Impact Factor
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    ABSTRACT: To update our report on the outcome of patients who underwent extended pelvic resection (EPR) for recurrent or persistent uterine and cervical malignancies. We reviewed the records of all patients who underwent EPR between 6/2000 and 07/2011. EPR was defined as an en-bloc resection of a pelvic tumor with sidewall muscle, bone, major nerve, and/or major vascular structure. Complications up to 180 days post surgery were analyzed. Survivals were estimated using the Kaplan-Meier method. We identified 22 patients. Median age at the time of EPR was 58 years (range, 36-74). Median tumor diameter was 5.4 cm (range, 1.5-11.2). Primary tumor sites included: uterus, 13; cervix, 7; synchronous uterus/cervix, 1; and synchronous uterus/ovary, 1. The EPR structures were: muscle, 13; nerve, 10; bone, 8; vessel, 5. Complete gross resection with microscopically negative margins (R0 resection) was achieved in 17 patients (77%). There were no perioperative mortalities. Major postoperative complications occurred in 14 patients (64%). The two most common morbidities were pelvic abscesses and peripheral neuropathies. Median follow-up time was 28 months (range, 6-99). The 5-year overall survival (OS) for the entire cohort was 34% (95% CI, 13-57). For the 17 patients who had an R0 resection, the 5-year OS was 48% (95% CI, 19-73). In patients with positive pathologic margins (n=5), the 5-year OS was 0%. EPR was associated with prolonged survival when an R0 resection was achieved. The high rate of postoperative complications remains a hallmark of these procedures and properly selected patients should be extensively counseled preoperatively.
    Gynecologic Oncology 01/2012; 125(2):404-8. · 3.93 Impact Factor
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    ABSTRACT: Pathologic proximal femur fractures result in substantial morbidity for patients with skeletal metastases. Surgical treatment is widely regarded as effective; however, failure rates associated with the most commonly used operative treatments are not well defined. We therefore compared surgical treatment failure rates among intramedullary nailing, endoprosthetic reconstruction, and open reduction-internal fixation when applied to impending or displaced pathologic proximal femur fractures. We retrospectively compared the clinical course of 298 patients who underwent intramedullary nailing (n = 82), endoprosthetic reconstruction (n = 197), or open reduction-internal fixation (n = 19) from 1993 to 2008. Primary outcome was treatment failure, which was defined as reoperation for any reason. Treatment groups were compared for differences in demographic and clinical parameters. The number of treatment failures in the endoprosthetic reconstruction group (3.1%) was significantly lower than in the intramedullary nailing (6.1%) and open reduction-internal fixation (42.1%) groups. The number of revisions requiring implant exchange also was significantly lower for endoprosthetic reconstruction (0.5%), compared with intramedullary nailing (6.1%) and open reduction-internal fixation (42.1%). Endoprosthetic reconstruction is associated with fewer treatment failures and greater implant durability. Prospective studies are needed to determine the impact of operative strategy on function and quality of life. Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
    Clinical Orthopaedics and Related Research 08/2011; 470(3):920-6. · 2.79 Impact Factor
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    ABSTRACT: Atypical subtrochanteric femoral fractures have been identified as a potential complication of long-term bisphosphonate therapy for the treatment of osteoporosis. Patients with skeletal malignant involvement, who receive much higher cumulative doses of bisphosphonates than do patients with osteoporosis, may be at higher risk for the development of these fractures. A retrospective review of the imaging studies and case notes was done for patients with skeletal malignant involvement who received a minimum of twenty-four doses of intravenous bisphosphonates between 2004 and 2007 and were followed until death or the time of the latest review. Patients were classified as having an atypical subtrochanteric femoral fracture if they had a transverse subtrochanteric fracture following low-energy trauma or an impending fracture, together with radiographic findings of diffuse diaphyseal cortical thickening and cortical beaking at the subtrochanteric area. In the study cohort of 327 patients, we identified four patients who developed an atypical subtrochanteric femoral fracture. All four patients were female, three had breast cancer, and one had myeloma. There was no significant difference between patients who developed an atypical subtrochanteric femoral fracture and those who did not with regard to the doses of intravenous bisphosphonates or the duration of treatment. The prevalence of atypical subtrochanteric femoral fractures in patients with skeletal malignant involvement who are managed with high doses of intravenous bisphosphonates is low. All patients in our study who had development of these fractures had prodromal symptoms of thigh pain.
    The Journal of Bone and Joint Surgery 07/2011; 93(13):1235-42. · 3.23 Impact Factor
  • Fuel and Energy Abstracts 01/2011; 81(2).
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    ABSTRACT: Accurate estimations of life expectancy are important in the management of patients with metastatic cancer affecting the extremities, and help set patient, family, and physician expectations. Clinically, the decision whether to operate on patients with skeletal metastases, as well as the choice of surgical procedure, are predicated on an individual patient's estimated survival. Currently, there are no reliable methods for estimating survival in this patient population. Bayesian classification, which includes bayesian belief network (BBN) modeling, is a statistical method that explores conditional, probabilistic relationships between variables to estimate the likelihood of an outcome using observed data. Thus, BBN models are being used with increasing frequency in a variety of diagnoses to codify complex clinical data into prognostic models. The purpose of this study was to determine the feasibility of developing bayesian classifiers to estimate survival in patients undergoing surgery for metastases of the axial and appendicular skeleton. We searched an institution-owned patient management database for all patients who underwent surgery for skeletal metastases between 1999 and 2003. We then developed and trained a machine-learned BBN model to estimate survival in months using candidate features based on historical data. Ten-fold cross-validation and receiver operating characteristic (ROC) curve analysis were performed to evaluate the BNN model's accuracy and robustness. A total of 189 consecutive patients were included. First-degree predictors of survival differed between the 3-month and 12-month models. Following cross validation, the area under the ROC curve was 0.85 (95% CI: 0.80-0.93) for 3-month probability of survival and 0.83 (95% CI: 0.77-0.90) for 12-month probability of survival. A robust, accurate, probabilistic naïve BBN model was successfully developed using observed clinical data to estimate individualized survival in patients with operable skeletal metastases. This method warrants further development and must be externally validated in other patient populations.
    PLoS ONE 01/2011; 6(5):e19956. · 3.53 Impact Factor
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    ABSTRACT: High-dose radiation retards bone healing, compromising the surgical results of radiation-induced fractures. Prosthetic replacement has traditionally been reserved as a salvage option but may best achieve the clinical goals of eliminating pain, restoring function and avoiding complications. We asked whether patients undergoing prosthetic replacement at index surgery for radiation-related subtrochanteric or diaphyseal fractures of the femur had fewer complications than those undergoing open reduction internal fixation at index operation. We retrospectively reviewed records from 1045 patients with soft tissue sarcomas treated with surgical resection and high-dose radiation therapy between 1982 and 2009 and identified 37 patients with 39 fractures. We recorded patient demographics, diagnosis, type of surgical resection, total radiation dose, fracture location and pattern, years after radiation the fracture occurred, type of surgical fixation, and associated complications. Patients undergoing prosthetic replacement at index surgery had a lower number of major complications and revision surgeries than those undergoing index open reduction internal fixation. Patients undergoing open reduction internal fixation at index surgery had a nonunion rate of 63% (19 of 30). Fractures located in the metaphysis were more likely to heal than those located in the subtrochanteric or diaphyseal regions. Radiation-induced fractures have poor healing potential. Our data suggest an aggressive approach to fracture treatment with a prosthetic replacement can minimize complications and the need for revision surgery.
    Clinical Orthopaedics and Related Research 11/2010; 468(11):3035-40. · 2.79 Impact Factor
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    ABSTRACT: Retrospective review plus 2 representative case reports. To evaluate the prevalence of scoliosis after extended hemipelvectomy (EH) and illustrate the problem's severity. No published series has analyzed this problem. Data are needed to decide the potential need for and timing of spine fusion in these patients. We treated 14 patients with EH over 10 years. Mean age was 47 years. Diagnoses included osteosarcoma (6); chondrosarcoma (4); metastatic cancer (2); and MFH and undifferentiated sarcoma (1 each). Operating time ranged from 7 to 15 hours, and mean estimated blood loss was 8 L. Patients were observed for scoliosis, functional results, and for oncological outcome (survival, disease progression). Two patients who became scoliotic after EH illustrate the problem: a 31-year-old man underwent EH for pelvic osteosarcoma and progressively developed a painful 44° scoliotic curve; and a 27-year-old woman who developed a 60° painful scoliotic curve and radiculopathy years after EH including L5-S1 disc disruption. Of 12 patients, 8 died within 7 months of EH. Only 2 of 12 patients are long-term survivors free of disease (3 and 6 years after surgery), and 2 are alive with disease more than 1 year after surgery. In patients >1 year survival, 3 of 4 patients had curves greater than 20°. Of 10 evaluable patients, 2 developed a curve greater than 30° that warranted fusion. Four others had curves between 20° and 30°. Of these 6, 5 developed a sharp-angled lumbar curve with the concavity away from the operated side. Risk factors for symptomatic scoliosis after EH include disc disruption, paraspinal muscle/ligament resection, or facetectomies in ambulatory patients with a lengthy survival. Primary spinal fixation should be avoided because of the high morbidity and early mortality of EH. Selected high-risk patients can be stabilized later if they develop painful instability.
    Spine 11/2010; 35(23):E1328-33. · 2.16 Impact Factor
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    ABSTRACT: The goal of this study was to identify radiographic and anatomic features of Campanacci grade 3 distal radius giant cell tumors that are associated with an acceptable rate of local recurrence after intralesional treatment. We retrospectively reviewed 15 grade 3 distal radius giant cell tumors treated with intralesional curettage, cryosurgery, and cementation (CCC) (n = 9) or with wide en bloc excision and reconstruction (WEE) (n = 6). Success was defined as local control after CCC without conversion to wide excision, and as a recurrence rate comparable with rates in the scientific literature. Preoperative radiographic evaluation and intraoperative determination of tumor extension guided the choice of treatment. Tumor width on x-rays and tumor volume on magnetic resonance imaging were measured. Outcome was assessed with postoperative motion and grip strength, and the Disabilities of the Shoulder, Arm and Hand, the visual analog pain score, and a satisfaction questionnaire. Local recurrence occurred in 2 of 9 patients after primary CCC, in none with repeat CCC, and in none of the 6 with WEE. No patient treated with secondary CCC had unresectable recurrence requiring conversion to WEE. Patients with a single site of cortical perforation who received CCC treatment achieved local control with intralesional treatment alone. Average tumor volume was 12 cm(3) (range, 9-17 cm(3)) with CCC and 43 cm(3) (range, 29-57 cm(3)) with WEE. Postoperative motion and strength, Disabilities of the Shoulder, Arm and Hand score, and visual analog pain scale score were acceptable in all and superior with CCC. All patients were highly satisfied. Tumor volume measured with magnetic resonance imaging and anatomically defined limits of soft tissue extension may help identify grade 3 lesions that can be treated with with CCC with an acceptable rate of local recurrence. We propose subclassification of Campanacci grade 3 lesions. Under this classification, tumors with extension assessed by preoperative imaging and confirmed by intraoperatively to be limited to a single site of palmar cortical perforation are classified as grade 3(p), where (p) denotes a single site bound by the pronator quadratus. Therapeutic IV.
    The Journal of hand surgery 10/2010; 35(11):1850-7. · 1.33 Impact Factor

Publication Stats

2k Citations
312.45 Total Impact Points

Institutions

  • 2013
    • Stony Brook University
      • Department of Orthopaedics
      Stony Brook, NY, United States
  • 1997–2013
    • Memorial Sloan-Kettering Cancer Center
      • Department of Surgery
      New York City, New York, United States
  • 2010–2012
    • Weill Cornell Medical College
      • Department of Surgery
      New York City, NY, United States
    • Hospital for Special Surgery
      • Department of Orthopaedic Surgery
      New York City, NY, United States
  • 2009
    • National University of Singapore
      Tumasik, Singapore
  • 1999
    • National Cancer Center Korea
      Kōyō, Gyeonggi Province, South Korea