Randall Spotlights Surgical and Non-Surgical Advances in Musculoskeletal Oncology

R. Lor Randall, MD, FACS

Researchers in orthopedic oncology continue to develop innovative techniques for both the surgical and non-surgical management of benign and malignant tumors of bone and connective soft tissues. These solutions require a multidisciplinary approach, further emphasizing the importance of educating oncologists across all specialties on the current landscape of medical and surgical interventions, according to R. Lor Randall, MD, FACS.

Randall and his colleagues compiled a special issue on advancements in musculoskeletal oncology, which was published in the Journal of Surgical Oncology. The symposium covers an array of topics within musculoskeletal oncology, and consists of several commentary, research, and review articles from experts across disciplines. 

“We wanted to raise awareness, particularly about the non-surgical discussion points, for medical oncologists who want to know what’s going on in the world of sarcoma,” said Randall, who is the David Linn Endowed Chair for Orthopedic Surgery, the chair of the Department of Orthopedic Surgery, and a professor at UC Davis Comprehensive Cancer Center in Sacramento, California.

Other topics covered in the symposium include the current understanding of the dynamic microenvironment in metastatic bone disease, strategies for the management of tenosynovial giant cell tumors (TGCT), socioeconomic disparities and gaps in the treatment of musculoskeletal oncology, and ​​emerging techniques for minimally invasive stabilization in pelvic metastatic bone disease.

In an interview with OncLive®, Randall discusses the process of organizing the symposium, key surgical and non-surgical advancements as well as socioeconomic disparities identified in these papers, and the importance of this information for both surgical and medical oncologists.

OncLive: What was the rationale for compiling a symposium of key developments in orthopedic and musculoskeletal oncology for the JSO?

Randall: I wanted to highlight all the exciting things that are going on in orthopedic oncology and musculoskeletal oncology through innovations and advancements. Michael Monument, MD, who leads the [Integrated Sarcoma Research Program] at the University of Calgary, was my fellow more than several years ago at my prior institution. [He] has gone on to have an illustrious career, [and is] a thought leader in both wet lab science and clinical delivery of sarcoma care. He and I were solicited by the JSO to put together a symposium in one of their editions focusing on innovations and advancements in our field. This was a great opportunity to reach out to thought leaders around the world about what is going on in our discipline and relay it to our colleagues around the world.

What research areas were covered in this symposium?

We [divided] the special edition into several categories. One was outcomes, disparities, and quality of life [QOL]. Another was surgical management and technological developments. Lastly, we always want to emphasize non-surgical advancements because sarcoma care is multifaceted. It requires medical oncology, radiation therapy, pediatric oncology, surgical oncology, and a variety of other disciplines to move the needle in clinical care. It was exciting to have all these thought leaders from around the world contribute to these various topics.

How was feedback obtained from key opinion leaders, and what is the status of this publication?

Dr Monument and I came together and looked at who was contributing the most to the literature in the past 5 to 10 years. Then, we pinpointed people who we might know professionally or personally, and who we knew would be reliable and be able to produce some of these articles. [Lastly, we] looked at the various topics we wanted to highlight and cross referenced those to come up with this opinion leader list.

The symposium is published online, and the hard copy will be forthcoming. It took us about 4 to 5 months to put this all together. It was pretty labor intensive, working with Dr Monument and all the [other] authors, as well as the JSO.

What were some of the topline points from the symposium?

There are several articles [in the symposium], but I [want to] concentrate on the non-surgical advancements and [where] we have seen progress in this arena. We’ve looked at the use of bisphosphonates and denosumab [Prolia] to help manage skeletal-related events in [patients with] advanced cancer and metastatic bone disease. We’ve also looked at CSF1R inhibitors like pexidartinib [Turalio] in the management of TGCT.

[Excitingly, clinicians in] orthopedic and musculoskeletal oncology are doing a deep dive into socioeconomic disparities [experienced by] these patients afflicted with musculoskeletal cancers. [They are] looking at what we can do as a society and civilization to improve access to health care [in] these underserved patient populations.

Could you expand on some of the disparities identified in the articles?

One of the things we have hypothesized is that an actual fracture from metastatic carcinoma to bone is a signal that these patients are disadvantaged. There is a cohort of patients we see that can readily access health care, through clinic appointments and other resources. They’ll come in with an impending fracture and we’re able to do a relatively minimally invasive procedure.

Other patients, [however], come through the emergency room with a realized fracture, having had lots of pain and disability. For a variety of different reasons, [these patients] have not been able to get the care in a timely way to get a prophylactic stabilization, and they present with a realized fracture. That is a much worse outcome and is a signal of the disparity in access to orthopedic oncology care.

Where are the technologies spotlighted in surgical and non-surgical papers being used?

The surgical papers are about technologies that would be available in major sarcoma units. In some of the medical oncology papers, pexidartinib and [similar agents] are usually administered by providers at major sarcoma centers. With the non-surgical topics, there is more likely [to be] community providers using these new technologies.

What topics would you suggest for providers looking to obtain the latest information in orthopedic oncology?

It depends on your discipline and area of interest. If you’re a medical oncologist, we strongly encourage you to look at our non-surgical advancements. If you’re a surgical oncologist, we would recommend that you look at our new technologies in the surgical management of bone and soft tissue tumors. If you are an epidemiologist or a cancer population scientist, we have a variety of papers on outcomes and disparities and QOL in musculoskeletal oncology. It really is discipline driven.

What would you consider the most exciting research coming down the pike based on what was outlined in these papers?

The papers do [cover the research] that is emerging. Some of them also speculate about what is to come. I have my own professional biases in that I’m a surgical oncologist, and this is a surgical journal. Some of the exciting things are the navigation techniques, [which would enable us] to do more precise sarcoma resections. I’m also very excited about the idea of minimally invasive, image-guided techniques [that would allow us] to percutaneously stabilize the skeleton when it’s afflicted with secondary musculoskeletal neoplasms. That’s exciting to me as a surgical oncologist. As a global citizen wanting to help patients who have less resources, the disparities papers, [which] highlight the need for improved access to care, [identify] where we need to direct our efforts [in the sarcoma space].

Could you expand on how these papers relevant to medical oncologists? What information in the symposium is essential for them to know?

There is a new study coming along for intra-articular administration of CSFR1 inhibitors, [which could] obviate the need for any systemic treatment and [associated adverse] effects. This will be discussed in one of the papers. If you are a medical oncologist [who] sees a large [number of] TGCT papers, there will be information that will be very advantageous to you.

Any medical oncologist will invariably have patients with metastatic bone disease. Skeletal-related events make up about 20% of the cancer care economy. Learning about some of the latest medical and surgical treatments for this ubiquitous subpopulation of patients [with cancer], can afford medical oncologists to have more detailed conversations before they send patients off to the orthopedic oncologist for subspecialty consultation.

Reference

Randall RL, Theriault RV, Thorpe SW, et al. Emerging innovations and advancements in the field of musculoskeletal oncology. J Surg Oncol. 2023;128(3):415-417. doi:10.1002/jso.27409