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Background: Orthopedic oncology patients are particularly susceptible to increased readmission rates and poor surgical outcomes, yet little is known about readmission rates. The goal of this study is to identify factors independently associated with 90-day readmission for patients undergoing oncologic resection and subsequent prosthetic reconstruction for metastatic disease of the hip and knee.Methods: This is a retrospective comparative cohort study of all patients treated from 2013 to 2019 at a single tertiary care referral institution who underwent endoprosthetic reconstruction by an orthopedic oncologist for metastatic disease of the extremities. The primary outcome measure was unplanned 90-day readmission.Results: We identified 112 patients undergoing 127 endoprosthetic reconstruction surgeries. Metastatic disease was most commonly from renal (26.8%), lung (23.6%), and breast (13.4%) cancer. The most common type of skeletal reconstruction performed was simple arthroplasty (54%). There were 43 readmissions overall (33.9%). When controlling for confounding factors, body mass index >40, insurance status, peripheral vascular disease, and longer hospital length of stay were independently associated with risk of readmission (P ≤ .05).Conclusion: Readmission rates for endoprosthetic reconstructions for metastatic disease are high. Although predicting readmission remains challenging, risk stratification presents a viable option for helping minimize unplanned readmissions.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

In recent years, there has been growing interest in the use of reverse total shoulder arthroplasty (rTSA) for reconstruction of the proximal humerus after oncologic resection. However, the indications and outcomes of oncologic rTSA remain unclear. We conducted a systematic review to identify studies that reported outcomes of patients who underwent rTSA for oncologic reconstruction of the proximal humerus. Extracted data included demographic characteristics, indications, operative techniques, outcomes, and complications. Weighted means were calculated according to sample size. Twelve studies were included, containing 194 patients who underwent rTSA for oncologic reconstruction of the proximal humerus. The mean patient age was 48 years, and 52% of patients were male. Primary malignancies were present in 55% of patients; metastatic disease, 30%; and benign tumors, 9%. The mean humeral resection length was 12 cm. The mean postoperative Musculoskeletal Tumor Society score was 78%; Constant score, 60; and Toronto Extremity Salvage Score, 77%. The mean complication rate was 28%, with shoulder instability accounting for 63% of complications. Revisions were performed in 16% of patients, and the mean implant survival rate was 89% at a mean follow-up across studies of 53 months. Although the existing literature is of poor study quality, with a high level of heterogeneity and risk of bias, rTSA appears to be a suitable option in appropriately selected patients undergoing oncologic resection and reconstruction of the proximal humerus. The most common complication is instability. Higher-quality evidence is needed to help guide decision making on appropriate implant utilization for patients undergoing oncologic resection of the proximal humerus. [ABSTRACT FROM AUTHOR]

Background Context: Facility volume has been correlated with survival in many cancers. This relationship has not been established in primary malignant bone tumors of the vertebral column (BTVC).Purpose: To investigate whether facility patient volume is associated with overall survival in patients with primary malignant BTVCs.Study Design: Retrospective comparative cohort.Patient Sample: Adult patients with chordomas, chondrosarcomas, or osteosarcomas of the mobile spine.Outcome Measures: Five-year survival.Methods: We retrospectively analyzed 733 patients with primary malignant BTVCs in the national cancer database from 2004 through 2015. Univariate and multivariate analyses were used to correlate specific outcome measures with facility volume. Volume was stratified based on cumulative martingale residuals to determine the inflection point of negative to positive impact on survival based on the patient cohort. Long-term survival was compared between patients treated at high and low volume using the Kaplan-Meier method. Only patients with malignant primary tumors were considered eligible for inclusion; patients with incomplete treatment data or benign tumors were excluded.Results: Patients treated at high-volume centers (HVCs) were younger (p=.0003) and more likely to be insured (p<.0001). There were no significant differences in tumor characteristics. Patients treated at high-volume facilities had improved 5-year survival of 71% versus 58% at low-volume centers (p<.0001). Patients treated at HVCs were more likely to receive surgical treatment (91% vs. 80%, p<.0001); if surgery was performed, they were more likely to undergo an en bloc resection (48% vs. 30%, p<.0001). However, there were no differences in margin status or utilization of radiotherapy or chemotherapy between HVCs and low-volume centers. In a multivariate analysis, facility volume was independently associated with improved survival overall (HR 0.75 [0.58-0.97], p=.03).Conclusions: Primary malignant BTVCs are rare, even for HVCs. Despite this, patient survival was significantly improved when treatment was performed at HVCs. [ABSTRACT FROM AUTHOR]

Arthroscopic hip surgery is becoming increasingly popular for the treatment of femoroacetabular impingement and labral tears. Reports of outcomes of hip arthroscopy converted to total hip arthroplasty (THA) have been limited by small sample sizes. The purpose of this study was to investigate the impact of prior hip arthroscopy on THA complications. We queried our institutional database from January 2005 and December 2017 and identified 95 hip arthroscopy conversion THAs. A control cohort of 95 primary THA patients was matched by age, gender, and American Society of Anesthesiologists score. Patients were excluded if they had undergone open surgery on the ipsilateral hip. Intraoperative complications, estimated blood loss, operative time, postoperative complications, and need for revision were analyzed. Two separate analyses were performed. The first being intraoperative and immediate postoperative complications through 90-day follow-up and a second separate subanalysis of long-term outcomes on patients with minimum 2-year follow-up. Average time from hip arthroscopy to THA was 29 months (range 2-153). Compared with primary THA controls, conversion patients had longer OR times (122 vs 103 minutes, P =.003). Conversion patients had a higher risk of any intraoperative complication (P =.043) and any postoperative complication (P =.007), with a higher rate of wound complications seen in conversion patients. There was not an increased risk of transfusion (P =.360), infection (P = 1.000), or periprosthetic fracture between groups (P =.150). When comparing THA approaches independent of primary or conversion surgery, there was no difference in intraoperative or postoperative complications (P =.500 and P =.790, respectively). Conversion of prior hip arthroscopy to THA, compared with primary THA, resulted in increased surgical times and increased intraoperative and postoperative complications. Patients should be counseled about the potential increased risks associated with conversion THA after prior hip arthroscopy. [ABSTRACT FROM AUTHOR]

Background: Although predictive laboratory markers and cutoffs for immunocompetent patients are well-studied, similar reference ranges and decision thresholds for immunosuppressed patients are less understood. We investigated the utility of typical laboratory markers in immunosuppressed patients undergoing aspiration of a prosthetic hip or knee joint.Methods: A retrospective review of adult patients with an immunosuppressed state that underwent primary and revision total joint arthroplasty with a subsequent infection at our tertiary, academic institution was conducted. Infection was defined by Musculoskeletal Infection Society criteria. A multivariable analysis was used to identify independent factors associated with acute (<90 days) and chronic (>90 days) infection. Area under the receiver-operator curve (AUC) was used to determine the best supported laboratory cut points for identifying infection.Results: We identified 90 patients with immunosuppression states totaling 172 aspirations. Mean follow-up from aspiration was 33 months. In a multivariate analysis, only synovial fluid cell count and synovial percent neutrophils were found to be independently correlated with both acute and chronic infection. A synovial fluid cell count cutoff value of 5679 nucleated cells/mm3 maximized the AUC (0.839) for predicting acute infection, while a synovial fluid cell count cutoff value of 1293 nucleated cells/mm3 maximized the AUC (0.931) for predicting chronic infection.Conclusion: Physicians should be aware of lower levels of synovial nucleated cell count and percentage of neutrophils in prosthetic joint infections of the hip or knee in patients with immunosuppression. Further investigation is necessary to identify the best means of diagnosing periprosthetic joint infection in this patient population. [ABSTRACT FROM AUTHOR]

Purpose: To examine the clinical outcomes and biomechanical data supporting the use of the remplissage procedure.Methods: A query of the Embase, PubMed, Scopus, and Web of Science databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines from 2000 to 2017. Data were extracted from included studies for a qualitative review of both clinical and biomechanical outcomes.Results: After review, 18 clinical and 10 biomechanical studies were available for analysis; 10 of 18 clinical studies (55.6%) were Level IV evidence. Within the clinical studies, there were 567 patients (570 shoulders) evaluated with follow-up ranging from 6 to 180 months. Overall, 5.8% of shoulders (33 of 570) displayed recurrent instability after arthroscopic remplissage. Of the shoulders with recurrent instability, 42.4% of shoulders (14 of 33) underwent further surgical management. In all studies evaluating pre- and postoperative patient-reported outcomes, the arthroscopic remplissage procedure improved patient-reported outcomes a statistically significant amount postoperatively. Within individual clinical studies, external rotation with the arm in neutral was the most consistently limited range of motion (ROM) parameter, with deficits compared with the contralateral shoulder ranging from 9° to 14°. Biomechanical analysis appeared to corroborate the clinical results, although significant conclusions were limited by heterogeneity of reporting.Conclusions: Arthroscopic remplissage performed in conjunction with arthroscopic Bankart repair is a safe and effective procedure for patients with engaging Hill-Sachs lesions and subcritical glenoid bone loss. Although both the included clinical and biomechanical studies would suggest minimal changes in glenohumeral ROM following the remplissage procedure, strong conclusions are limited by the heterogeneity in reporting ROM data and lack of comparative studies.Level Of Evidence: IV, systematic review. [ABSTRACT FROM AUTHOR]

Background The purpose of this study was to conduct a systematic review of the literature to evaluate the characteristics of injury and treatment outcomes of rotator cuff tears in young patients. Methods A systematic electronic search was performed for clinical studies evaluating rotator cuff tears in patients younger than 40 years with special emphasis on reporting of injury characteristics and treatment outcomes with a minimum 1-year follow-up. Results Twelve studies (involving 336 patients) met inclusion criteria. The mean age of the patients was 28 years (range, 16-40 years), with a mean follow-up of 39 months. There were 2 distinct subgroups. The majority of studies (7 of 10) showed that patients typically had a full-thickness tear with an acute traumatic etiology. However, within the subgroup of elite throwers, 5 of 6 studies demonstrated a majority of tears that were partial thickness stemming from chronic overuse. Rotator cuff repair improved pain and strength in almost all studies reporting on these parameters. Eighty-seven percent of patients reported they were satisfied. However, all studies examining elite throwers showed significant difficulty in returning to play (25%-97%). Conclusions In young patients with rotator cuff tears, there are 2 primary groups. (1) A majority group with rotator cuff tears of traumatic origin responded well to both arthroscopic and open rotator cuff repair in terms of pain relief and self-reported outcomes postoperatively. These patients reported high levels of satisfaction and return to preinjury level of play. (2) A unique subpopulation composed of elite throwers had improved outcomes but suboptimal return to play. [ABSTRACT FROM AUTHOR]

Background: Metal-on-metal (MOM) total hip arthroplasty is associated with unacceptable failure rates secondary to metal ion reactions. Efforts to identify which patients will go on to failure have been limited; recently, there has been a suggestion for a potential genetic basis for the increased risk of revision in MOM hip replacements (MOMHRs). The purpose of this study is to determine whether certain immunologic genotypes are predictive of the need for revision in patients with MOM total hip implants.Methods: This is a case-control study of all patients undergoing primary MOMHR between September 2002 and January 2012 with a minimum of 5-year follow-up. Our investigational "case" cohort was comprised of patients who underwent revision for MOMHR for a reason other than infection. A single-nucleotide polymorphism (SNP) array analysis was performed to identify a potential genetic basis for failure.Results: Thirty-two patients (15 case and 17 control) were included in our analysis. All patients in the revision group had a chief complain of pain; revision patients were more likely to have a posterior approach (P = .01) and larger head size (P = .04) than nonrevision patients. No patient or implant characteristics were independently associated with revision in a multivariate analysis. Patients with SNP kgp9316441 were identified as having an increased odds of revision for MOM failure (P < .001).Conclusion: This study identified an SNP, kgp9316441, encoding proteins associated with inflammation and macrophage activation. This SNP was associated with significantly increased odds of revision for MOMHR. Future studies are warranted to validate this gene target both in vitro and in vivo.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Surgical resection is the primary mode of treatment for primary osseous neoplasms of the spine. While resection type and margin status have been well demonstrated in primary bone tumors of the extremity, the low prevalence of these tumors in the spine makes it difficult to determine the prognostic significance of these factors for spinal tumors. We investigated the largest registry of primary bone tumors, the national cancer database (NCDB). Our hypothesis was negative margin status and radical resection would correlate with increased length of survival (LOS). PURPOSE To determine if achieving a negative margin following resection of a malignant bone tumor of the spine improves 5-year survival. STUDY DESIGN/SETTING Retrospective. PATIENT SAMPLE A total of 759 patients. OUTCOME MEASURES A total of 5-year survival. METHODS We retrospectively analyzed patients in the NCDB from 2004 to 2015 with a histologic diagnosis of primary spinal chordoma, osteosarcoma, chondrosarcoma and Ewing's sarcoma. Only patients who underwent surgical resection were included. Patients were stratified by margin of resection (negative margin vs. positive margin) and type of surgical resection (radical resection vs. local excision). The Kaplan–Meier (KM) method with statistical comparisons based on the log-rank test was used to identify univariate factors associated with LOS. RESULTS A total of 759 patients with primary spinal tumors undergoing surgical resection were identified with diagnoses of chordoma (n=332), chondrosarcoma (n=217), Ewing's sarcoma (n=112) and osteosarcoma (n=98). Following resection, 36.1% had a negative margin (n=274), 20.2% had a positive margin (n=153) and 43.7% were unspecified (n=332). Improved 5-year survival was seen with a negative resection margin (72.5% vs. 58.3%, p=.0032). Patients undergoing radical resection were more likely to have negative margins (79.8%) than those undergoing local or partial excisions (51.1%) (p<.0001). No significant difference in 5-year survival was observed in patients undergoing radical excision compared to local and/or partial excision (p=.1275). For all spinal tumors, surgery improves 5-year survival as compared to no surgery; chordoma (72.6% vs. 59.9%, p=.015), chondrosarcoma (71% vs. 39.1%, p=.0002), Ewing's sarcoma (51.2% vs. 34.4%, p=.003) and osteosarcoma (36.6% vs. 21.5%, p=.0016). CONCLUSIONS Surgical resection is the primary mode of treatment for primary osseous neoplasms of the spine, and this study confirms improved 5-year survival rates with surgical resection. Achieving a negative margin following resection improves survival. The type of resection (radical vs. local or partial excision) was not associated with survival; however, a radical tumor excision was more likely to achieve a negative margin. This study confirms the role of tumor excision in bony neoplasms of the spine, and provides evidence towards the importance of achieving a negative margin. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Chemotherapy has dramatically improved survival in many primary bone tumors. Bone tumors of the vertebral column (BTVCs) are rarer and the impact of chemotherapy on these tumors is not well established. We investigated the largest registry of primary bone tumors, the National Cancer Database (NCDB). PURPOSE Our goal was to determine the impact of chemotherapy on outcomes in patients with primary BTVCs. STUDY DESIGN/SETTING Retrospective National Cancer Database review. PATIENT SAMPLE All patients identified in the National Cancer Database with primary bone tumors of the vertebral column. These were further stratified based on the use or nonuse of chemotherapy. OUTCOME MEASURES Patient survival was the primary outcome measure. METHODS We retrospectively analyzed patients in the NCDB from 2004 through 2015. Patients were stratified based on chemotherapy use for primary BTVCs; these were further stratified by histologic subtype. Univariate and multivariate analyzes were used to correlate specific outcome measures with these factors. Then, long-term survival between groups was evaluated using the Kaplan-Meier (KM) method with statistical comparisons based on the log-rank test. Multiple variables were analyzed between the two groups. RESULTS We identified 941 patients presenting with primary BTVCs. Thirty-seven patients were treated with chemotherapy alone, 293 were treated with surgery alone, and 72 were treated with both surgery and chemotherapy; 78/127 patients with osteosarcoma (61.4%) and 146/164 patients with Ewing's Sarcoma (89%) underwent chemotherapy as compared to 16/243 patients with chondrosarcoma (6.6%) and 14/407 patients with chordoma (3.4%). Across the entire cohort of patients, patients who received chemotherapy were on average, younger (38 vs. 56 years, p<.0001) and lived closer to the facility (52 vs. 110 miles, p=.0062). Patients with osteosarcoma and Ewing's sarcoma had significantly improved survival when treated with chemotherapy (p=.0156 and p=.0007, respectively); those patients with a chordoma demonstrated no significant difference in survival, and those with chondrosarcoma demonstrated decreased survival with chemotherapy treatment (p=.0009). In a pooled analysis, patients with osteosarcoma and Ewing's treated with the addition of chemotherapy had a lower risk of mortality overall than those treated without the addition of chemotherapy (49.4% five-year survival vs. 0% five-year survival, p=.0007). CONCLUSIONS This is the largest patient cohort to date examining the impact of chemotherapy on primary BTVCs. Chemotherapy use was far more likely for Ewing's sarcoma and osteosarcoma than chordoma and chondrosarcoma. Patients with either osteosarcoma or Ewing's sarcoma receiving surgery in addition to chemo had improved overall survival than those undergoing surgery alone. Further investigation is necessary to help improve the appropriate delivery of adjuvant therapies to patients with primary BVTCs. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Primary bone tumors of the vertebral column (BTVC) are rare and represent a challenge when considering management options. It stands to reason that these complicated tumors would be best treated at high volume centers. However, this has not been well established. We investigated the largest registry of primary bone tumors, the National Cancer Database (NCDB); our goal was to determine the impact of facility case volume on outcomes in patients with primary BTVCs. PURPOSE Our goal was to determine the impact of facility case volume on outcomes in patients with primary BTVCs. STUDY DESIGN/SETTING Retrospective National Cancer Database review. PATIENT SAMPLE Patients with primary osteosarcoma, chondrosarcoma, chondroma and Ewing's sarcoma of the vertebral column identified in the National Cancer Database. OUTCOME MEASURES Long-term survival by Kaplan-Meier method and univariate or multivariate analyses of factors associated with survival. METHODS We retrospectively analyzed 941 patients in the NCDB from 2004 through 2015. Patients were stratified based on per year facility volume for primary BTVCs. Univariate and multivariate analyses were used to correlate specific outcome measures with these factors. Then, long-term survival between groups was evaluated using the Kaplan-Meier (KM) method with statistical comparisons based on the log-rank test. Multiple variables were analyzed between the two groups. RESULTS We identified 941 patients presenting with primary BTVCs; histological diagnosis was chondrosarcoma (n=243), chordoma (n=407), Ewing's sarcoma (n=164) and osteosarcoma (n=127). A total of 199 patients were treated at HVCs (>1 case annually) and 742 were treated at low-volume centers (LVC). Patients treated at high-volume centers were, on average, younger (48 vs. 52 years, p=.0076), more likely to be insured (p<.0001), and more likely to travel farther to the treating facility (mean 278 vs. 47 miles, p<.0001). There were no significant differences between high- and low-volume facilities regarding tumor characteristics. In a KM survival analysis, patients treated at high-volume facilities had better outcomes, with five-year survival rate of 67.7% vs. 58.7% (p=.0262). Patients treated at HVCs were also more likely to receive surgical treatment (87% vs. 79%, p=.0191), and, if surgery was performed, they were more likely to receive a radical resection (52.5% vs. 32.7%, p<.0001) and a trend toward fewer positive margins (29% vs. 38%, p=.084). CONCLUSIONS This is the largest patient cohort to date examining the impact of facility volume on outcomes in patients with primary BTVCs. Primary BTVCs are rare, even for HVCs; despite this, patient survival was significantly improved when treatment was performed at HVCs. Patients receiving treatment at HVC were more likely to receive a radical resection. There was a trend toward fewer margin positive resections. Further investigation is necessary to help improve the referral of appropriate patients to the HVCs. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Background Context: Malignant primary spinal tumors are rare making it difficult to perform large studies comparing epidemiologic, survival, and treatment trends. We investigated the largest registry of primary bone tumors, the National Cancer Database (NCDB), to compare epidemiologic and survival trends among these tumors.Purpose: To use the NCDB to describe current epidemiologic trends, treatment modalities, and overall survival rates in patients with chordomas, osteosarcomas, chondrosarcomas, and Ewing sarcomas of the mobile spine. The secondary objective was to determine prognostic factors that impact overall survival rates.Study Design: Retrospective study.Patient Sample: A total of 1,011 patients with primary bone tumors of the spine (377 chordomas, 223 chondrosarcomas, 278 Ewing sarcomas, and 133 osteosarcomas).Outcome Measures: Five-year survival.Methods: We reviewed the records of 1,011 patients in the NCDB from 2004 through 2015 with histologically confirmed primary osteosarcoma, chondrosarcoma, Ewing sarcoma, or chordoma of the spine. Demographic, clinical, and outcomes data were compiled and compared using chi-squared tests and ANOVA. Long-term survival was compared using the Kaplan-Meier method with statistical comparisons based on the log-rank test. Multivariate analysis was performed to determine survival determinants.Results: Surgical resection was the primary mode of treatment for chondrosarcoma (90%), chordoma (84%), and osteosarcoma (80%). The treatment for Ewing sarcoma was multimodal involving chemotherapy, radiation therapy, and surgical resection. Five-year survival rates varied significantly with chordomas and chondrosarcomas having the greatest survival (70% and 69%), osteosarcomas having the worse survival (38%), and Ewing having intermediate 5-year survival at 62% (overall log-rank p<.0001). Multivariate analysis demonstrated significantly improved 5-year survival rates with younger age at diagnosis, private insurance status, lower comorbidity score, lower tumor grade, smaller tumor size, surgical resection, and negative surgical margin. Radiation therapy only improved survival for Ewing sarcoma.Conclusions: This study provides the most comprehensive description of the epidemiologic, treatment, and survival trends of primary bone tumors of the mobile spine. Second, patient and tumor characteristics associated with improved 5-year survival were identified using a multivariate model. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Primary malignant osseous spinal tumors (PMOST) are rare and difficult to manage tumors with poor outcomes despite multimodal treatment regimes. The rarity of these neoplasms makes it difficult to perform large studies comparing epidemiologic, survival, and treatment trends. We investigated the largest registry of primary bone tumors, the National Cancer Database (NCDB), to compare epidemiologic and survival trends between these tumors. PURPOSE To describe epidemiologic, survival, and treatment trends with primary malignant osseous spinal tumors. STUDY DESIGN/SETTING Retrospective. PATIENT SAMPLE N=941. OUTCOME MEASURES Length of survival. METHODS We retrospectively reviewed 941 patients in the NCDB from 2004 through 2015 with histologically confirmed primary osteosarcoma, chondrosarcoma, Ewing's sarcoma, or chordoma of the spine. Demographic, clinical, and outcomes data were compiled and compared using chi-squared tests and ANOVA. Long-term survival was compared using the Kaplan-Meier (KM) method with statistical comparisons based on the log-rank test. Multivariate analysis was performed to determine survival determinants. Study variables included age, sex, race, Hispanic ethnicity, insurance status, comorbidity score, year of diagnosis, grade of tumor, size of tumor, stage of tumor, surgical resection, chemotherapy, and radiation therapy. RESULTS The cohort included 941 patients; histological diagnosis was chordoma (n=407), chondrosarcoma (n=243), Ewing's sarcoma (n=164), and osteosarcoma (n=127). The average age at diagnosis was younger in Ewing's sarcoma (p<.0001), and there was no difference in gender, race, or comorbidity score between tumor types. Surgical resection was the primary mode of treatment for chondrosarcoma (89.3%), chordoma (81.6%), osteosarcoma (77.2%), and Ewing's sarcoma (68.3%). Ewing's sarcoma patients were more likely to be managed with radiation and chemotherapy (p<.0001). Five-year survival rates varied significantly between tumor types with chordomas having the greatest survival (70.5%) and osteosarcomas having the worst survival (32.9%) (p<.0001). Multivariate analysis demonstrated significantly improved 5-year survival rates with younger age at diagnosis, insurance status, lower comorbidity score, tumor type, tumor grade, tumor size, and surgical resection. Our analysis did not demonstrate improved survival with radiation therapy. CONCLUSIONS This study provides the most comprehensive comparison of epidemiologic, survival, and management trends in PMOST. Surgical resection is the most common form of treatment for all PMOST. Ewing's sarcoma was treated with adjuvant chemotherapy and radiation therapy more often than other tumor types. Osteosarcoma has the worst 5-year survival prognosis of 32.9%, which did not improve from 2004 to 2015. Radiation therapy did not provide a survival benefit when looking at all PMOST. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT The management of spinal metastasis has evolved with the development of improved radiation delivery methods and surgical techniques. The Spinal Instability Neoplastic Score (SINS) provides guidance on treatment for spinal instability. However, the best treatment modality for neurologically intact patients with indeterminate instability (SINS 7–12) remains unclear. PURPOSE The purpose of this study was to compare length of survival (LOS) and preservation of ambulatory status (PAS) in this patient population treated by three different techniques. STUDY DESIGN/SETTING Retrospective. PATIENT SAMPLE N=60 20 patients surgery + EBRT 20 patients XRT along 20 patients kyphoplasty +/− EBRT. OUTCOME MEASURES LOS - length of survival, PAS - preservation of ambulatory status. METHODS We queried our institution's database for neurologically intact patients treated for spinal metastatic disease with a SINS of 7-12. The cohort was stratified by treatment approach: external beam radiation (EBRT), surgery + EBRT (S+E), and kyphoplasty +/− EBRT (K). Demographic, clinical, and outcomes data were compared using Chi Squared tests and ANOVA. Kaplan-Meier analysis with the log-rank test was used to assess differences in LOS and PAS. Cox proportional hazard models were used to assess adjusted survival and time to loss of ambulation. RESULTS Sixty cases were included in our analysis (EBRT n=20; S+E n=20; Kn=20). There was no significant difference in gender, age or cancer type across the treatment groups. Tokuhashi scores were greater in the S+E group (p=.03). Kaplan Meier analysis revealed that there was no significant difference in LOS and PAS across the treatment arms (p=.10, p=.07). When adjusting these models for age, gender, SINS and Tokuhashi score; Toskuhashi score was associated with improved outcomes (LOS HR: 0.76 to 0.94, p=.002; PAS HR: 0.78 to 0.95, p=.005). CONCLUSIONS The choice of treatment for neurologically intact patients with indeterminate instability does not impact LOS or PAS. Patients with greater preoperative Tokuhashi scores had statistically longer LOS and PAS. When spinal instability and neurological status do not clearly guide treatment, the Tokuhashi score provides the best predictor in management decision-making. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

The role of radiation therapy (RT) for the treatment of axial chordomas remains controversial. Previous large database reviews have not found adjunct RT to improve overall survival, but these studies did not stratify based on high/low dose RT, the modality of RT, or the patient's surgical margin status. We investigated the National Cancer Database (NCDB) to determine if high dose RT improves survival in patients with positive vs negative surgical margins. Additionally, the study compares the 5-year survival between patient's treated with high vs low dose RT and advanced vs conventional delivery methods. Retrospective study. A total of 1,480 chordoma patients. Five-year overall survival. A total of 1,480 patients were identified in the NCDB between 2004 and 2015 with a histologically confirmed axial chordoma. Survival analysis was performed using the Kaplan Meier method. The 5-year survival was compared between surgical resection alone and surgical resection and adjunct therapeutic RT for the overall cohort, patients with positive surgical margins, and patients with negative surgical margins. Therapeutic RT was defined as a radiation dose greater than 65Gy. For patients treated with RT, the 5-year survival was compared between palliative dose (<40Gy), low dose (40-65Gy), and high dose (>65Gy) RT. Similarly, 5-year survival was compared between proton beam therapy (PBT), stereotactic radiosurgery (SRS), intensity-modulated radiation therapy (IMRT), and conventional external beam radiation therapy (EBRT). A multivariable analysis was performed to determine independent prognosticators associated with 5-year overall survival. The cohort included 1,480 chordoma patients; skull base (n=569), sacral (n=551), mobile spine (n=360). The 5-year survival for the entire cohort was 76%. The survival for patients treated with surgical resection and adjunct therapeutic RT was greater than surgery alone (85% vs 80%, p=0.04). Therapeutic adjunct RT improved survival compared to surgery alone in the setting of positive surgical margins (82% vs 71%, p=0.03). In the setting of negative surgical margins adjunct RT did not statistically improve survival (p=0.33). Radiation dose >65Gy improved survival when compared to radiation dose between 40-65Gy (85% vs 69%, p<0.001). Comparing the modality of RT, PBT had the greatest 5-year survival (85%), which was statistically greater than EBRT (85% vs 68%, p<0.001). In the multivariate analysis improved 5-year survival was associated with age <65, private health insurance, tumor size <5cm, surgical resection, negative surgical margins, and treatment at an academic facility. Adjunct RT (dose >65Gy) was associated with improved survival for patients with positive surgical margins; however, a survival benefit was not observed for patients with negative surgical margins. High dose RT and advanced radiation techniques, specifically PBT, were associated with improved 5-year survival. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]