Patrick J Boland

Memorial Sloan-Kettering Cancer Center, New York, New York, United States

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Publications (100)350.76 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: OBJECT There is no consensus regarding the appropriate treatment of sacral giant cell tumor (GCT). There are 3 main management problems: tumor control, neurological loss, and pelvic instability. The objective of this study was to examine oncological, neurological, and structural outcomes of sacral GCT after intralesional excision and local intraoperative adjunctive treatment. METHODS The authors retrospectively reviewed the records of 24 patients with sacral GCT who underwent conservative surgery (intralesional resection/curettage) at Memorial Sloan Kettering Cancer Center from 1973 through 2012. They analyzed patient demographic data, tumor characteristics, and operative techniques, and examined possible correlations with postoperative functional outcomes, complications, recurrence, and mortality. RESULTS There were 7 local recurrences (30%) and 3 distant recurrences (13%). Three of 24 patients (12.5%) had significant neurological loss after treatment-specifically, severe bowel and/or bladder dysfunction, but all regained function within 1-4 years. Larger tumor size (> 320 cm(3)) was associated with greater postoperative neurological loss. Radiation therapy and preoperative embolization were associated with prolonged disease-free survival. There were no local recurrences among the 11 patients who were treated with both modalities. Based on radiographic and clinical assessment, spinopelvic stability was present in 23 of 24 patients at final follow-up. CONCLUSIONS High local and distant recurrence rates associated with sacral GCT suggest the need for careful local and systemic follow-up in managing these patients. Intraoperative preservation of sacral roots was associated with better pain relief, improvement in ambulatory function, and retention of bowel/bladder function in most patients. Fusion and instrumentation of the sacroiliac joint successfully achieved spinopelvic stability in cases deemed clinically unstable. Despite improvement in the management of sacral GCT over 35 years, a need for novel therapies remains. The strategy of combining radiotherapy and embolization merits further study.
    Journal of neurosurgery. Spine 10/2015; DOI:10.3171/2015.4.SPINE13215 · 2.38 Impact Factor
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    ABSTRACT: Background: Patients with failed distal femoral megaprostheses often have bone loss that limits reconstructive options and contributes to the high failure rate of revision surgery. The Compress(®) Compliant Pre-stress (CPS) implant can reconstruct the femur even when there is little remaining bone. It differs from traditional stemmed prostheses because it requires only 4 to 8 cm of residual bone for fixation. Given the poor long-term results of stemmed revision constructs, we sought to determine the failure rate and functional outcomes of the CPS implant in revision surgery. Questions/purposes: (1) What is the cumulative incidence of mechanical and other types of implant failure when used to revise failed distal femoral arthroplasties placed after oncologic resection? (2) What complications are characteristic of this prosthesis? (3) What function do patients achieve after receiving this prosthesis? Methods: We retrospectively reviewed 27 patients who experienced failure of a distal femoral prosthesis and were revised to a CPS implant from April 2000 to February 2013. Indications for use included a minimum 2.5 mm cortical thickness of the remaining proximal femur, no prior radiation, life expectancy > 10 years, and compliance with protected weightbearing for 3 months. The cumulative incidence of failure was calculated for both mechanical (loss of compression between the implant anchor plug and spindle) and other failure modes using a competing risk analysis. Failure was defined as removal of the CPS implant. Followup was a minimum of 2 years or until implant removal. Median followup for patients with successful revision arthroplasty was 90 months (range, 24-181 months). Functional outcomes were measured with the Musculoskeletal Tumor Society (MSTS) functional assessment score. Results: The cumulative incidence of mechanical failure was 11% (95% confidence interval [CI], 4%-33%) at both 5 and 10 years. These failures occurred early at a median of 5 months. The cumulative incidence of other failures was 18% (95% CI, 7%-45%) at 5 and 10 years, all of which were deep infection. Three patients required secondary operations for cortical insufficiency proximal to the anchor plug in bone not spanned by the CPS implant and unrelated to the prosthesis. Median MSTS score was 27 (range, 24-30). Conclusions: Revision distal femoral replacement arthroplasty after a failed megaprosthesis is often difficult as a result of a lack of adequate bone. Reconstruction with the CPS implant has an 11% failure rate at 10 years. Our results are promising and demonstrate the durable fixation provided by the CPS implant. Further studies to compare the CPS prosthesis and other reconstruction options with respect to survival and functional outcomes are warranted. Level of evidence: Level IV, therapeutic study.
    Clinical Orthopaedics and Related Research 09/2015; DOI:10.1007/s11999-015-4552-y · 2.77 Impact Factor
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    ABSTRACT: En bloc resection for treatment of sacral tumors is the approach of choice for patients with resectable tumors who are well enough to undergo surgery, and studies describe patient survival, postoperative complications, and recurrence rates associated with this treatment. However, most of these studies do not provide patient-reported functional outcomes other than binary metrics for bowel and bladder function postresection. The purpose of this study was to use validated patient-reported outcomes tools to compare quality of life based on level of sacral resection in terms of (1) physical and mental health; (2) pain; (3) mobility; and (4) incontinence and sexual function. Our analysis included 33 patients (19 men, 14 women) who had a mean age of 53 years (range, 22-72 years) with a quality-of-life survey administered at a mean postoperative followup of 41 months (range, 6-123 months). The majority of patient-reported quality-of-life outcome surveys for this study were taken from the National Institute of Health's Patient Reported Outcome Measurement Information System (PROMIS) system. To assess physical and mental health, the PROMIS Global Items Survey with physical and mental subscores, Anxiety, and Depression scores were used. Pain outcomes were assessed using PROMIS Pain Intensity and Pain Interference surveys. Patient-reported lower extremity function was assessed using the PROMIS Mobility Survey. Patient-reported quality of life for sexual function was assessed using the PROMIS Sex Interest and Orgasm survey, whereas incontinence was measured using the International Continence Society Voiding and Incontinence scores and the Modified Obstruction and Defecation Score. Surveys were collected prospectively during clinic visits in the postoperative period. Patients were grouped by the level of osteotomy as determined by review of postoperative MRI or CT and half levels were grouped with the more cephalad level. This resulted in the inclusion of total sacrectomy (N = 6), S1 (N = 8), S2 (N = 10), S3 (N = 5), and S4 (N = 4). One-way analysis of variance tests on means or ranks were used to conduct statistical analysis between levels. Patients with more caudal resections had higher physical health (95% confidence interval [CI] total sacrectomy 36-42 versus S4 50-64, p < 0.001), less intense pain (95% CI total sacrectomy 47-60 versus S4 28-37, p < 0.001), less interference resulting from pain (95% CI total sacrectomy 58-69 versus S4 36-51, p = 0.004), higher mobility (95% CI total sacrectomy 24-46 versus S4 59-59, p = 0.002), and were more functionally able to achieve orgasm (95% CI S1 1-1 versus S4 2.2-5.3, p = 0.043). No difference was found for PROMIS Global Item Mental Health Subscore, Sex Interest, Sex Satisfaction, modified obstruction and defecation score, and International Continence Society Voiding and Incontinence although this could be the result of an inadequate sample size. Our analysis on patient-reported quality of life based on the level of bony resection in patients who underwent resection for primary sacral tumor indicates that patients with higher resections have more pain and loss of physical function in comparison to patients with lower resections. Additionally, use of the PROMIS outcomes allows for comparisons to normative data. Level III, therapeutic study.
    Clinical Orthopaedics and Related Research 05/2015; DOI:10.1007/s11999-015-4361-3 · 2.77 Impact Factor
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    ABSTRACT: Tumor-associated sacral insufficiency fractures (SIF) present a significant clinical challenge. As survival increases for many malignancies, sacral fractures associated with metastases, sacral or extended pelvic radiation, and paraneoplastic osteoporosis are increasingly common and yet remain difficult to treat in the setting of the potentially significant morbidity of open sacral surgery. To describe our prospective experience with sacroplasty for tumor-associated lesions, including the largest series to date of radiation-induced SIF. Twenty-five patients with symptomatic SIF underwent 31 percutaneous fluoroscopy-guided sacroplasties with a median 5.8 mL of polymethyl methacrylate or a ceramic-resin composite under fluoroscopic guidance and with concurrent biopsy acquisition. Eighteen patients had fractures related to previous sacral or pelvic radiation; 4 had viable lytic lesions; and 2 had oncology-related osteoporosis. Postoperative pain reduction, procedural morbidity, and functional outcomes were recorded. Twenty of 25 patients (80%) had reduction in their visual analog pain score at a median follow-up of 6.5 months; no patients worsened. The mean visual analog scale score decreased from 8.8 to 4.7 postprocedurally (P < .001), with significant reductions regardless of the underlying pathology (P < .001 to P < .05). Six of 13 patients with pretreatment ambulatory impairment required fewer ambulatory aids and 3 were newly ambulatory. Extravertebral cement migration was noted in 18 procedures; however, no instance was clinically relevant. Six repeat or contralateral procedures were performed. No morbidity was encountered. Sacroplasty is a safe and effective option for the palliation of sacral fractures in the oncologic population. PPRS, posterior pelvic ring stabilizationSIF, sacral insufficiency fractureVAS, visual analog scale.
    Neurosurgery 01/2015; 76(4). DOI:10.1227/NEU.0000000000000658 · 3.62 Impact Factor
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    ABSTRACT: To evaluate local control and survival outcomes in adults with Ewing sarcoma (ES) treated with radiotherapy (RT). Retrospective review of all 109 patients age ⩾18 treated for ES with RT to the primary site at Memorial Sloan Kettering Cancer Center between 1990 and 2011. RT was used as the definitive local control modality in 44% of patients, preoperatively for 6%, and postoperatively for 50%. Median age at diagnosis was 27years (range, 18-67). The 5-year local failure (LF) was 18%. Differences in LF were not identified when evaluated by modality of local control (RT versus combined surgery and RT), RT dose, fractionation, and RT technique. However, margin status at time of resection significantly predicted LF. The 5-year event-free survival and overall survival rates were 44% and 66% for patients with localized disease, compared with 16% and 26% for metastatic disease (p=0.0005 and 0.0002). Tumor size, histopathologic response to chemotherapy, and treatment on or according to a protocol were also significantly associated with survival. This series of adults treated with modern chemotherapy and RT had prognostic factors and outcomes similar to adolescents with ES. All adults with ES should be treated with an aggressive, multidisciplinary approach. Copyright © 2014. Published by Elsevier Ireland Ltd.
    Radiotherapy and Oncology 11/2014; 113(2):248-53. DOI:10.1016/j.radonc.2014.11.023 · 4.36 Impact Factor
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    ABSTRACT: Voiding dysfunction after radical non-genitourinary pelvic surgery is a common but poorly understood entity. It is thought to be multifactorial, likely related to the type of surgery, degree of injury to nerves, degree of injury to urinary tract and vasculature, and (neo)adjuvant therapy. Management is focused on ensuring that the bladder is an adequate storage reservoir with ability to empty volitionally. We review voiding dysfunction caused by radical gynecological, rectal, and sacral surgeries. Voiding dysfunction, although common after radical gynecological, rectal, and sacral surgeries, has been declining due to the recognition of the nerves involved in voiding function and the techniques designed to preserve them. The most common types of voiding dysfunction after radical pelvic surgery are impaired detrusor contractility, detrusor overactivity, reduced bladder compliance, and stress urinary incontinence. Urodynamics testing and upper tract imaging studies are the diagnostic mainstays. Various treatments are available and reviewed in this manuscript. Non-genitourinary radical pelvic surgery often results in voiding dysfunction ranging from urinary retention to urinary incontinence. Treatment is guided by two main principles—ensuring that the bladder is an adequate storage reservoir and preserving the ability to empty volitionally. This can be accomplished by pharmacologic means, intermittent catheterization, and multiple anti-incontinence procedures.
    Current Bladder Dysfunction Reports 09/2014; 9(3):234-241. DOI:10.1007/s11884-014-0253-8
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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; 73(4). DOI:10.1227/NEU.0000000000000083 · 3.62 Impact Factor
  • D G McKeown · P J Boland ·
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    ABSTRACT: We present a case of chronic lymphoedema that progressed to Stewart-Treves syndrome in a 63-year-old woman with a previous modified radical mastectomy, associated lymph node dissection, chemotherapy and radiotherapy. While producing stabilisation of most cutaneous lesions initially, chemotherapeutic treatment of the angiosarcoma did not prevent subsequent metastasis and patient death. We urge vigilance and regular follow-up appointments for patients following a mastectomy with chronic lymphoedema to facilitate prevention or early treatment of this devastating syndrome.
    Annals of The Royal College of Surgeons of England 07/2013; 95(5):80-2. DOI:10.1308/003588413X13629960046110 · 1.27 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; 73(3). DOI:10.1227/01.neu.0000431476.94783.c6 · 3.62 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 02/2013; 2013(373):489652. DOI:10.1155/2013/489652
  • Fazel A Khan · Joseph D Lipman · Andrew D Pearle · Patrick J Boland · John H Healey ·
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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; 471(6). DOI:10.1007/s11999-012-2769-6 · 2.77 Impact Factor
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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 estimations 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 associate 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. DOI:10.1186/1471-2407-12-493 · 3.36 Impact Factor
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    John H Healey · Carol D Morris · Edward A Athanasian · Patrick J Boland ·
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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; 471(3). DOI:10.1007/s11999-012-2635-6 · 2.77 Impact Factor
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    Kim HJ · McLawhorn AS · Goldstein MJ · Boland PJ ·
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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; DOI:10.5435/JAAOS-20-10-646. · 2.53 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. DOI:10.5435/JAAOS-20-10-646 · 2.53 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; 471(3). DOI:10.1007/s11999-012-2529-7 · 2.77 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. DOI:10.1227/NEU.0b013e31826d5ac1 · 3.62 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. DOI:10.1016/j.ijrobp.2012.01.021 · 4.26 Impact Factor

  • Radiotherapy and Oncology 05/2012; 103:S19–S20. DOI:10.1016/S0167-8140(12)72013-3 · 4.36 Impact Factor

Publication Stats

3k Citations
350.76 Total Impact Points


  • 1995-2015
    • Memorial Sloan-Kettering Cancer Center
      • • Department of Surgery
      • • Orthopaedic Service
      • • Department of Pediatrics
      New York, New York, United States
  • 2005-2012
    • Cornell University
      • Department of Surgery
      Итак, New York, United States
  • 2002-2008
    • Weill Cornell Medical College
      • Department of Surgery
      New York City, New York, United States
  • 1999
    • National Cancer Center Korea
      Kōyō, Gyeonggi Province, South Korea