Effect of Insurance Status on Mortality in Adults With Sarcoma of the Extremities and Pelvis: A SEER-Medicare Study.

INTRODUCTION: Previous studies have highlighted the association between insurance status and poor outcomes after surgical treatment of sarcomas in the United States.1-3 It is unclear how much of this disparity is mediated by confounding factors such as medical comorbidities and socioeconomic status and how much can be explained by barriers to care caused by insurance status. METHODS: Surveillance, Epidemiology, and End Results-Medicare linkage data were procured for 7,056 patients undergoing treatment for bone and soft-tissue sarcomas in the extremities diagnosed between 2006 and 2013. A Cox proportional hazards model was used to assess the relative contributions of insurance status, medical comorbidities, tumor factors, treatment characteristics, and other demographic factors (race, household income, education level, and urban/rural status) to overall survival. RESULTS: Patients with Medicaid insurance had a 28% higher mortality rate over the period studied, compared with patients with private insurance (hazard ratio, 1.28; 95% confidence interval, 1.03 to 1.60, P = 0.026), even when accounting for all other confounding variables. The 28% higher mortality rate associated with having Medicaid insurance was equivalent to being approximately 10 years older at the time of diagnosis or having a Charlson comorbidity index of 4 rather than zero (hazard ratio, 1.27). DISCUSSION: Insurance status is an independent predictor of mortality from sarcoma, with 28% higher mortality in those with pre-expansion Medicaid.4,5 This association between insurance status and higher mortality held true even when accounting for numerous other confounding factors. Additional study is necessary into the mechanism for this healthcare disparity for the uninsured and underinsured, as well as strategies to resolve this inequality.

Modern Therapy for Chest Wall Ewing Sarcoma: An Update of the University of Florida Experience.

PURPOSE: Owing to adjacent critical organs, the aggressive multimodality local therapy necessary for Ewing sarcoma of the chest wall is a challenge. Our previous review of historical outcomes at our institution revealed suboptimal disease control and a high incidence of grade ≥3 toxic effects in patients treated before 2006. The purpose of this study was to evaluate changes during the past decade since the introduction of proton therapy. METHODS AND MATERIALS: Thirty-nine consecutive pediatric patients with a chest wall Ewing sarcoma treated between 2006 and 2020 at the University of Florida were identified. The median maximum tumor diameter was 10 cm (range, 4-28 cm). At diagnosis, 19 patients had local disease and the others had a pleural effusion (11), pleural nodules (5), or pulmonary metastases (4). Patients were treated with chemotherapy regimens according to contemporary North American and European protocols: 7 were treated with preoperative, 18 with postoperative, and 14 with definitive radiation. Preceding primary site treatment, 15 patients required hemithorax radiation and 4 patients underwent whole-lung irradiation using photon techniques. The total median radiation dose to the primary tumor was 52.8 GyRBE [relative biological effectiveness] (range, 44.4-55.8 GyRBE). RESULTS: With a median follow-up of 4 years (range, 0.7-14.7 years), the 5-year local control, progression-free survival, and overall survival rates were 97.2%, 74.4%, and 81.6%, respectively, for the whole cohort. For the 19 patients with nonmetastatic disease, the 5-year local control, progression-free survival, and overall survival rates were 100%, 78.9%, and 78.9%, respectively. No patients developed grade ≥4 toxic effects. Two patients (5%) experienced grade 3 toxic effects related to multimodality treatment; both were patients who required surgery to correct scoliosis. Two patients (5%) developed grade 2 pneumonitis. CONCLUSIONS: Compared with our prior published institutional experience, our data suggest improvements in disease control and multimodality toxic effects since the introduction of proton therapy. This should be confirmed with a larger sample size and longer follow-up.

Why Rotationplasty? A Qualitative Study of Decision-Making by Families of Patients With Primary Bone Sarcoma.

Rotationplasty is an established technique that is indicated as part of the surgical reconstruction for certain patients with primary bone tumors around the knee who undergo tumor resection. There is considerable variation in the application of rotationplasty by surgeons as well as acceptance of the procedure by patients who may be candidates for this procedure. We qualitatively studied the decision-making process of families of patients who had undergone rotationplasty by interviewing 4 patients and their families using semi-structured interviews. Thematic analysis identified the following themes that were important in the decision-making process: (1) the desire for good information sources, (2) finding value in meeting with other patients who had been faced with a similar decision, (3) prioritizing function over cosmesis, (4) a desire to limit the need for revision surgeries, and (5) accepting that a return to normalcy is not an option with a surgery. Physicians and patients faced with a similar decision can benefit from a better understanding of the process, and by the normalization of anxieties and concerns that they may experience.

Effect of Resident and Fellow Involvement on Outcomes of Sarcoma Surgery: A NSQIP Database Cross-Sectional Study.

BACKGROUND: The complexity of sarcoma surgery often justifies surgical assistants of higher levels of academic training: senior residents, fellows, or co-surgeons. The association between the level of training of assistants and outcomes of these procedures has yet to be studied. METHODS: The Current Procedural Terminology (CPT) codes comprising the "core" procedures for musculoskeletal oncology fellowships were gathered. After CPTs primarily capturing nononcologic procedures were excluded, the National Surgical Quality Improvement Program (NSQIP) database was used to find procedures with these CPTs. The severity of complications was assessed using the Severity Weighting of Postoperative Adverse Events in Orthopedic Surgery (SWORD) score. Resident/fellow presence was analyzed both as a binary variable and stratified by level of training. RESULTS: In 159 cases meeting inclusion criteria, higher-level assistants were associated with increased rate of any complication (p=0.006) and greater need for transfusion (p=0.001) but also tended to be used in cases of longer duration (p=0.001) and with higher total work relative value units (wRVUs) (p=0.001). Multivariate analysis showed that while higher-wRVU procedures persisted as an independent predictor of increased complications (OR 1.028 per RVU unit, p=0.002), neither the presence nor level of training of assistants had an independent effect on complication rates. Other independent predictors of 30-day complications were treatment comorbidity (OR 3.433, p=0.010) and lower extremity location of the tumor (OR 4.393, p=0.006). Severity of complications did not differ between any of the groups on either univariate or multivariate analysis. CONCLUSIONS: Trainees of higher levels of academic training tend to be present for longer, higher-complexity musculoskeletal oncology cases, but the overall severity of complications from these do not significantly differ from lower-risk cases without trainees. Orthopedic oncologists may reassure patients that the presence of trainees and co-surgeons is not only safe but it may also help reduce the severity of complications in more complex procedures.

Brain metastases from Truncal and extremity bone and soft tissue sarcoma: Single institution study of oncologic outcomes.

Brain metastases are a rare occurrence in patients with sarcoma. The prognosis for patients is poor, and treatment can contribute to considerable morbidity. We sought to examine the experience of our institution in managing these patients over a period of 17 years. We performed a retrospective cohort study of patients managed for sarcoma of the extremity or trunk who developed brain metastases from 2000 to 2017. Clinical data were analyzed and we assessed survival outcomes. 14 patients presenting at a mean age of 46.7 years were included. All patients were treated with radiotherapy for their brain metastases. 3 patients underwent surgical excision of their intracranial metastases. Two patients were treated with radium-223 dichloride. Kaplan-Meier survival analysis and the log rank test were used to calculate the survival probability, and to compare patient subgroups. All patients in this study developed lung or bone metastases at a mean interval of 13.3 months prior to the development of brain metastasis. The median interval from diagnosis of a brain metastasis to death was 3.6 months. The Kaplan-Meier survival probability at 6 months was 28.6%, and 14.3% at 1 year. Surgery was not found to be associated with increased survival. Patients with cerebellar metastasis had increased survival probability as compared to those with cerebral metastasis. Patients with extremity or trunk sarcoma who develop brain metastases frequently develop lung or bone metastases in the year preceding their diagnosis of brain metastasis. Patients with cerebellar metastasis may have better survival than those with cerebral metastasis, and an aggressive treatment approach should be considered. Despite aggressive treatment, the prognosis is grim.

Pediatric Sarcoma Patients with Worse Physical Function but Better Peer Relationships and Depressive Symptoms than U.S. Pediatric Population as Measured by PROMIS®.

Background Pediatric patients with sarcomas are at risk of poor quality of life outcomes. The National Institutes of Health (NIH)-funded Patient-reported Outcomes Measurement Information System (PROMIS®) improves our ability to capture patient-reported outcomes. Do physical function, social, and mental health PROMIS outcomes for pediatric patients with non-metastatic malignant sarcomas differ from the U.S. pediatric population? Methods Six pediatric PROMIS short forms were collected for patient visits to orthopedic oncology at a tertiary referral center from September 1, 2016, to March 31, 2017. Mean T-scores differed from the reference population by a one-sample t-test. Results Of the 30 eligible patients, five had soft-tissue sarcomas and 25 (83%) had bone sarcomas. The mean age of the cohort was 13 years (5-17). The study cohort had a mean physical function T-score of 39.8 (SD 9.8), which was worse than the reference population. In contrast, the mean peer relationship T-score of 54.3 (SD 8.8) and mean depression T-score of 42.0 (SD 9.1) were better than the reference population. Conclusions Pediatric patients with non-metastatic sarcomas had a worse physical function but a better peer relationship and depression scores than the U.S. PROMIS reference population. Ceiling and flooring effects were reported. The level of evidence was III.

Evaluation of Planned versus Unplanned Soft-Tissue Sarcoma Resection Using PROMIS Measures.

BACKGROUND: The Patient Reported Outcomes Measurement Information System (PROMIS) is a tool developed by the National Institutes of Health that allows comparisons across conditions or even the United States (U.S.) general population. OBJECTIVES: Our purpose was to compare PROMIS outcomes between patients who underwent a planned resection to those who underwent an initial unplanned excision of their sarcoma followed by a definitive oncologic resection. We then compared these groups to the U.S. general population. METHODS: Eighty-five patients were included and were divided into those who underwent an initial planned resection (67) and unplanned excision (18). These patients were then further categorized based on the length of follow-up since their last surgery, either early (<12 months) or late (>12 months). RESULTS: We evaluated seven PROMIS domains and found no differences between patients who underwent planned resection versus those who underwent an initial unplanned excision followed by a wide resection of the previous wound bed. When compared to the U.S. population, both cohorts demonstrated significantly improved scores in several emotional health domains. CONCLUSIONS: Patients who undergo an unplanned excision followed by a definitive oncologic procedure have similar PROMIS scores compared to patients who undergo an initial planned resection.

An Evaluation of PROMIS Health Domains in Sarcoma Patients Compared to the United States Population.

BACKGROUND: The Patient Reported Outcomes Measurement Information System (PROMIS) is a patient-directed system that allows comparisons across medical conditions. With this tool, comparisons can now be made between rare conditions, such as sarcomas, and more common ailments, of the United States general population. This allows comparisons between rare conditions, such as sarcomas, to more common ailments, or even the United States (US) general population. OBJECTIVES: Our purpose was to use PROMIS to compare outcomes in patients that had undergone resection of a nonmetastatic sarcoma to the US population. METHODS: One hundred thirty-eight patients were included in the analysis. These patients were divided into early (<2 years) and late follow-up (>2 years). RESULTS: We evaluated results from seven health domains and found significantly lower scores in the physical function and depression domains. These differences were present in both the early and late cohorts when compared to the US population. CONCLUSION: While physical function was found to be worse in the sarcoma cohorts, we observed significantly improved levels of depression in these patients when compared to the US population. This finding was maintained over time and is an important reminder that a patient's goals and desires change following a cancer diagnosis and must be taken into consideration when planning treatment and determining a successful outcome.

Periosteal Osteosarcoma: A Single-Institutional Study of Factors Related to Oncologic Outcomes.

BACKGROUND: Periosteal osteosarcoma is a rare surface-based variant with a lower propensity to metastasis and better prognosis than conventional osteosarcoma. The literature supporting survival benefit with adjuvant chemotherapy is lacking. Our institutional practice is for chemotherapy to be offered to patients with high-grade disease. METHODS: We conducted a retrospective cohort study of patients managed for periosteal osteosarcoma from 1970 to 2015 analyzing the survival outcomes and assessing for any relationship of survival to patient- or treatment-related factors. 18 patients were included. The study population presented at a mean of 20.8 years and was followed for a mean of 10.7 years. Factors assessed for an association with survival included age, size of tumor, use of chemotherapy, presence of medullary involvement, presence of high-grade disease, local recurrence, and site of disease. Kaplan-Meier survival analysis and Cox proportional hazard regression were performed to calculate the survival rates and to assess for the effect of any factor on survival. RESULTS: 10-year overall survival rate was 77.1%, and 10-year event-free survival rate was 66.4%. No factor was found to have an association with overall or event-free survival. CONCLUSION: These findings add to the available evidence which has failed to find any survival benefit from chemotherapy; patients with this rare disease and their families should be counselled regarding the unclear role of chemotherapy in this rare subtype of osteosarcoma.

Long-Term Functional Outcomes of Distal Femoral Replacements Compared to Geographic Resections for Parosteal Osteosarcomas of the Distal Femur.

Background: Parosteal osteosarcoma is a rare tumor with increased survival compared to conventional high-grade osteosarcoma. Due to this increased survival comes the need for reconstructive options that provide good long-term functional results. Current treatment methods include geographic resection with allograft reconstruction versus resection and reconstruction with a distal femoral replacement. Purpose: Our purpose was to compare the long-term functional outcomes of distal femoral replacements to allograft reconstructions, using the musculoskeletal tumor society (MSTS) scoring system. Methods: After querying our database, 12 patients were identified and completed a MSTS questionnaire. Results: There was no difference in functional outcomes between the cohorts at an average of 14 years follow up for the endoprosthetic group and 25 years of follow up for the geographic resection group. Conclusion: At long-term follow-up, patients who undergo a distal femoral replacement for a parosteal osteosarcoma have no difference in functional outcomes compared to those who undergo an allograft reconstruction.Level of Evidence: IV.

Reverse-reamed Intercalary Allograft: A Surgical Technique.

Allograft reconstruction of large segmental intercalary bone defects after tumor resection is a well-accepted surgical technique. Although results generally have been satisfactory, nonunion at the allograft-host bone junction site remains a notable concern. Various reports have described attempts to enhance junctional healing with a variety of complex osteotomies, often complicating an already complex procedure. The use of an innovative reverse reaming technique can decrease the level of intraoperative difficulty mating the allograft-host junction and theoretically may improve junctional healing by enhancing stability and increasing the contact surface area.

Radiation Therapy for Aggressive Fibromatosis: The Association Between Local Control and Age.

PURPOSE: Radiation therapy (RT) is often used in the treatment of unresectable or recurrent aggressive fibromatosis (also known as desmoid tumor) typically with excellent local control. Prior reports have suggested that local control in pediatric patients with aggressive fibromatosis is poor. We aimed to report a long-term single-institution experience with the radiotherapeutic treatment of these tumors with a focus on age-dependent outcomes. METHODS AND MATERIALS: A total of 101 patients treated with RT for aggressive fibromatosis between 1975 and 2015 at a single institution were identified. A variety of demographic and treatment-related variables were abstracted from patients' medical records. Kaplan-Meier analyses were performed to investigate the relationship between these variables and local control. RESULTS: Overall survival was excellent (98% and 95% at 5 and 10 years, respectively); local control was likewise excellent (82% and 78% at 5 and 10 years, respectively). Patients aged <20 years at diagnosis had significantly worse 5-year local control than those aged >40 years at diagnosis (72% vs 97%; hazard ratio, 9.0; P = .009). Patients treated with once-daily fractionation had significantly improved 5-year local control compared with those treated with twice-daily fractionation (90% vs 73%; hazard ratio, 0.3; P = .008). Neither the presence of gross versus microscopic residual disease, initial versus recurrent presentation, number of prior surgical procedures, nor tumor size had any effect on 5-year local control. In a total of 36.6% of patients, Common Terminology Criteria for Adverse Events grade 3 or 4 toxicity developed following treatment; the frequency of toxicities was reduced in patients treated during or after 1995 (24.5%) relative to those treated prior to 1995 (51.9%, P = .02). CONCLUSIONS: RT for aggressive fibromatosis offers excellent local control and should remain the standard of care for patients with unresectable or recurrent disease. Younger patients have diminished local control relative to older patients, suggesting possible biological differences contributing to radioresistance in the pediatric and young adult population.

Diffuse Pigmented Villonodular Synovitis as a Rare Cause of Graft Failure Following Anterior Cruciate Ligament Reconstruction.

This case report describes a 42-year-old woman who was diagnosed with pigmented villonodular synovitis (PVNS) in the knee. The patient had received a bone-patella tendon-bone autograft reconstruction of her anterior cruciate ligament (ACL) 22 years prior to her diagnosis of PVNS. After a traumatic event that tore her ACL graft, she underwent a second surgery to repair the initial reconstruction. However, her pain and joint instability remained unresolved. When radiolucent lesions in her tibia and femur were identified through a radiographic image, the patient was referred to the authors' orthopedic oncology clinic. Additional imaging, including magnetic resonance imaging, revealed PVNS, and she was scheduled for debridement and a complete synovectomy of the knee. After surgery, the patient's pain decreased dramatically. She continues to maintain an active lifestyle despite a relatively minor decrease in range of motion. In this case, PVNS proved to be an unlikely complication after ACL reconstruction. The patient remains at risk for the development of degenerative arthritis. [Orthopedics. 2018; 41(1):e142-e144.].

Evidence-based Practice Intentions and Long-term Behaviours of Physiotherapy Graduates Following an Intensive Education Programme.

BACKGROUND: Assisting physiotherapists to implement research evidence into clinical practice is essential to ensure the quality of practice and encourage lifelong learning and professional progression. However, many physiotherapists report barriers to implementing research, and there is little evidence regarding the sustainability of intended evidence-based practice (EBP) behaviours following EBP education programmes. This paper reports on intended and actual long-term EBP behaviours of physiotherapy students who completed an intensive EBP training programme embedded within a post-graduate coursework programme. METHODS: An intensive 3-week course in quantitative health research methods and EBP was delivered annually from 2007 to 2014 as part of the programme to national and international students. Following the course, students were asked about their intention of using evidence to inform their future clinical practice. An online survey was used to evaluate EBP behaviours of graduates. RESULTS: Of a possible total of 202 students, contact details for 193 students were sourced, and 65 students responded to the survey (34% response rate). At course completion, 174 students (86%) indicated that they intended to use research to guide their clinical decisions at least once a week. At follow-up, most graduates reported frequently using research to inform their clinical practice; indicated by a mean score of 6.5 (±1.9) from a possible range of 0 (not at all) to 10 (all the time). On average, students reported spending 2.2 (±2.2) hours accessing and reading research evidence per week. The most common barriers to implementing evidence were lack of time, limited access to evidence sources and a perceived lack of generalizability of research findings to specific patient groups. CONCLUSION: Graduates of an intensive EBP training programme embedded within an existing post-graduate physiotherapy programme regularly implemented EBP in clinical practice. Barriers to evidence implementation were time, access to research and perceived lack of generalizability of research findings. Copyright © 2016 John Wiley & Sons, Ltd.

Embedding Evidence-based Practice Education into a Post-graduate Physiotherapy Program: Eight Years of pre-Post Course Evaluations.

BACKGROUND AND PURPOSE: Little has been published about the effectiveness of training postgraduate physiotherapy coursework students in research methods and evidence-based practice (EBP) theory. Graduate qualities in most universities include lifelong learning. Inclusion of EBP in post-graduate coursework students' training is one way for students to develop the knowledge and skills needed to implement current best evidence in their clinical practice after graduation, thereby facilitating lifelong learning. This paper reports on change in confidence and anxiety in knowledge of statistical terminology and concepts related to research design and EBP in eight consecutive years of post-graduate physiotherapy students at one Australian university. METHODS: Pre-survey/post-survey instruments were administered to students in an intensive 3-week post-graduate course, which taught health research methods, biostatistics and EBP. This course was embedded into a post-graduate physiotherapy programme from 2007 to 2014. The organization and delivery of the course was based on best pedagogical evidence for effectively teaching adult physiotherapists. The course was first delivered each year in the programme, and no other course was delivered concurrently. RESULTS: There were significant improvements in confidence, significantly decreased anxiety and improvements in knowledge of statistical terminology and concepts related to research design and EBP, at course completion. Age, gender and country of origin were not confounders on learning outcomes, although there was a (non-significant) trend that years of practice negatively impacted on learning outcomes (p = 0.09). There was a greater improvement in confidence in statistical terminology than in concepts related to research design and EBP. CONCLUSION: An intensive teaching programme in health research methods and biostatistics and EBP, based on best practice adult physiotherapy learning principles, is effective immediately post-course, in decreasing anxiety and increasing confidence in the terminology used in research methods and EBP. Copyright © 2016 John Wiley & Sons, Ltd.

The Treatment and Outcomes of Extraskeletal Osteosarcoma: Institutional Experience and Review of The Literature.

BACKGROUND: Extraskeletal osteosarcoma is a rare tumor with a poor prognosis. The purpose of this study is to examine the oncologic outcomes of this disease as they relate to surgical treatment and use of adjuvant therapies. METHODS: We retrospectively analyzed all patients treated at our institution for high-grade extraskeletal osteosarcoma of the limb or chest wall. We recorded demographic data, presenting stage, surgical margin, use of adjuvant chemotherapy or radiation, incidence of local recurrence, metastases, and death. Overall and event-free survival were calculated using Kaplan-Meier survival methods. RESULTS: There were 12 patients treated with primary wide resection or re-excision of a previously operated tumor bed. Four patients presented with metastases. Seven patients received chemotherapy and four patients received radiation therapy. There were two local recurrences, six patients developed new metastases, and nine patients died. There was no difference in overall survival in patients who received chemotherapy. There was, however, a trend towards increased length of survival in patients who received chemotherapy compared to those who did not (16.4 months vs. 9.3 months, p=0.16). CONCLUSIONS: Despite no difference in overall survival, patients treated with adjuvant chemotherapy have a trend towards increased length of survival. We suggest that extraskeletal osteosarcoma be treated with standard osteosarcoma chemotherapy regimens in addition to wide resection.

Pulmonary Surveillance Strategies Following Sarcoma Excision Vary Among Orthopedic Oncologists: A Survey of the Musculoskeletal Tumor Society.

BACKGROUND: Pulmonary surveillance protocols following sarcoma excision based on clinical evidence and outcomes are limited in current literature. The purpose of this study was to determine the method, frequency, and reasoning behind pulmonary surveillance strategies in patients treated for sarcoma among members of the Musculoskeletal Tumor Society (MSTS). METHODS: SurveyMonkey, an online survey tool, was used to create and distribute a questionnaire to 211 members of the MSTS in 2011. The 16 questions focused on current pulmonary surveillance algorithms and their reasoning. RESULTS: Of the surveyed members of the MSTS, 65% follow high-grade sarcoma with routine chest CT scans. Most disagreement involved low-grade sarcomas, where radiographs (34%), routine CT (33%), or selective CT scans (31%) were evenly distributed. Selective CT scans in low-grade lesions were warranted with an indeterminate nodule on prior CT (81%), local recurrence (40%), or large/ deep tumor characteristics (31%). Most protocols were based on continuation of training protocols (46%), clinician's interpretation of the current literature (23%), or personal experience (14%). CONCLUSIONS: Significant clinician variability exists in terms of pulmonary surveillance of sarcomas, most notably in low-grade lesions. The results of this study represent an area in need of further study to develop an evidence-based protocol for sarcoma pulmonary surveillance.

A Prospective Outcomes Study of Proton Therapy for Chordomas and Chondrosarcomas of the Spine.

PURPOSE: To evaluate the effectiveness of definitive or adjuvant external beam proton therapy on survival in patients with chordomas and chondrosarcomas of the spine. METHODS AND MATERIALS: Between March 2007 and May 2013, 51 patients with a median age of 58 years (range, 22-83 years) with chordoma (n=34) or chondrosarcomas (n=17) of the sacrum (n=21), the cervical spine (n=20), and the thoracolumbar spine (n=10) were treated with external beam proton therapy to a median dose of 70.2 Gy(RBE) [range, 64.2-75.6 Gy(RBE)] at our institution. Distant metastases, overall survival, cause-specific survival, local control, and disease-free survival were calculated. RESULTS: The mean follow-up time was 3.7 years (range, 0.3-7.7 years). Across all time points, 25 patients experienced disease recurrence: 18 local recurrences, 6 local and distant recurrences, and 1 distant metastasis. The 4-year rates of overall survival and cause-specific survival were 72%; disease-free survival was 57%, local control was 58%, and freedom from distant metastases was 86%. The median time to local progression was 1.7 years (range, 0.2-6.0 years), and the median time to distant progression was 1.6 years (range, 0.2-6.0 years). The risk factors for local recurrence were age ≤58 years (62% vs 26%; P=.04) and recurrence after prior surgery (29% vs 81%; P=.01). Secondary cancers developed in 2 patients: B-cell lymphoma 5.5 years after treatment and bladder cancer 2 years after treatment. We observed the following toxicities: sacral soft tissue necrosis requiring surgery (n=2), T1 vertebral fracture requiring fusion surgery (n=1), chronic urinary tract infections (n=1), surgery for necrotic bone cyst (n=1), and grade 2 bilateral radiation nephritis (n=1). CONCLUSION: High-dose proton therapy controls more than half of spinal chordomas and chondrosarcomas and compares favorably with historic photon data. Local progression is the dominant mode of treatment failure and may be reduced by treating patients at the time of initial diagnosis. The impact of age is a novel finding of this study.

Allograft-prosthetic composite reverse total shoulder arthroplasty for reconstruction of proximal humerus tumor resections.

BACKGROUND: Proximal humerus reconstructions after resection of tumors are challenging. Early success of the reverse shoulder arthroplasty for reconstructions has recently been reported. The reverse allograft-prosthetic composite offers the advantage of improved glenohumeral stability compared with hemiarthroplasty for proximal humeral reconstructions as it uses the deltoid for stability. METHODS: This article describes the technique for treating proximal humeral tumors, including preoperative planning, biopsy principles, resection pearls, soft tissue tensioning, and specifics about reconstruction using the reverse allograft-prosthetic composite. Two cases are presented along with the functional outcomes with use of this technique. Biomechanical considerations during reconstruction are reviewed, including techniques to improve the deltoid compression force. RESULTS: Reported instability rates are less with reverse shoulder arthroplasty reconstruction as opposed to hemiarthroplasty or total shoulder arthroplasty reconstructions of tumor resections. Reported functional outcomes are promising for the reverse allograft-prosthetic composite reconstructions, although complications are reported. CONCLUSION: Reverse allograft-prosthetic composites are a promising option for proximal humeral reconstructions, although nonunion of the allograft-host bone junction continues to be a challenge for this technique.