Orthopedic Oncology Experts Shape Global Consensus on Chondrosarcoma Management

R. Lor Randall, MD, FACS

Most global chondrosarcoma management practices align with standards agreed upon by a range of experts; however, uncertainties remain regarding the optimal surgical strategy for the treatment of patients with low-grade chondrosarcoma, according to R. Lor Randall, MD, FACS. 

In January 2024, orthopedic oncologists from around the world convened in Birmingham, United Kingdom (UK), for the inaugural Birmingham Orthopaedic Oncology Meeting.1 A total of 309 delegates from 53 countries discussed 21 consensus statements about optimal chondrosarcoma management. Discussion topics ranged from the roles of radiology, surveillance, and chemotherapy to the management of locally recurrent, low-grade, and dedifferentiated chondrosarcoma.

During the meeting, presentations and debates surrounded 21 consensus statements, which delegates subsequently voted on. Strong consensus (with strengths ranging from 85% to 99%) was reached on 19 statements. No consensus was reached regarding the optimal treatment of intraosseous atypical chondroid tumor (ACT)/chondrosarcoma (52%), and only a moderate consensus was reached regarding the definition of a wide margin in chondrosarcoma (77%).

“There was great consensus—greater than 80%—around most aspects of managing chondrosarcoma, but how we surgically manage low-grade chondrosarcoma is still contentious, with wide variance across the world,” Randall summarized in an interview with OncLive®. “It is important that [orthopedic surgeons and oncologists] are coming together every other year to answer some profound and quintessential questions. I want to [thank Lee Jeys, MB ChB, MSc, DSc, of the Royal Orthopaedic Hospital NHS Trust in Birmingham] and his team for initiating this meeting.”

In the interview, Randall highlighted the importance of holding orthopedic oncology consensus meetings, key discussion points that the meeting delegates reached consensus about, and his insights on research developments that may drive greater consensus regarding the surgical management of low-grade chondrosarcoma.

Randall is the David Linn Endowed Chair for Orthopaedic Surgery, chair of the Department of Orthopaedic Surgery, and a professor in the Department of Orthopaedic Surgery at the University of California, Davis Comprehensive Cancer Center in Sacramento.

OncLive: What was the purpose behind the 2024 Birmingham Orthopaedic Oncology Meeting?

Randall: Dr Jeys [organized this meeting] with a group of other like-minded, fervent orthopedic oncologists to bring consensus around some points of contention in orthopedic oncology. This was the inaugural meeting, [which took place] in Birmingham, UK. This meeting will happen every other year, and next year’s meeting is going to be in Cape Town, South Africa. This exciting [meeting brought together] world experts. It occurred in January 2024, and there were 309 delegates from 53 countries [in attendance].

The goal was to discuss and refine 21 statements on the optimal management of chondrosarcoma. Chondrosarcoma is a relatively common form of primary bone cancer, and [most patients are] treated with surgery. Chemotherapy and radiation [are not routinely used in this population]. In this consensus group, there was representation from Europe [n = 133 delegates; 43%], North America [n = 53; 17%], South America [n = 49; 16%], Asia [n = 40; 13%], Australasia [n = 16; 5%], the Middle East [n = 12; 4%], and Africa, [n = 6; 2%]. I hope that moving forward, we’ll get more participants from [regions with] emerging economies, because those were a bit underrepresented [at this meeting]. However, this was a great turnout for the first meeting.

Importantly, these delegates are experienced orthopedic oncologists. Dr Jeys calculated that the conglomerate of expertise from all the participants for the 2 days [of the meeting] reflected [the management of approximately] 30,000 cases annually and 66 years of experience in the UK alone. [In total, all the participants at this meeting] probably [had approximately] 100 years of experience [combined]. This was an informed group that made these consensus statements.

I can’t express [enough] gratitude to Dr Jeys for how he has brought the world together around this [topic]. There are other orthopedic oncology questions that we’re going to be asking in South Africa. There are discussions about how we can interface with the Connective Tissue Oncology Society and the International Society Of Limb Salvage to make multidisciplinary decisions where appropriate in some of this orthopedic oncologic decision-making.

What were some of the topics discussed at this meeting? Was consensus reached in all areas?

It was nice to see that there was strong consensus around 19 of the 21 statements. However, there were a couple areas with real points of contention. There was consensus around the role of radiology in diagnosis and surveillance, the management of locally recurrent disease, and the treatment of dedifferentiated chondrosarcoma. There was also consensus that routine chemotherapy is not indicated for conventional chondrosarcoma, and that, importantly, radiographic surveillance is safe for [patients with] potential low-grade chondrosarcoma contained within the bone. [Therefore], following those patients to watch for radiographic evidence of progression is within the global standard of care.

One area that was contentious [revolved around the question]: How do we best [surgically] manage ACTs, or low-grade chondrosarcomas? [Do we resect them] with an intralesional approach or en bloc resection? We also talked a little about margins and their importance in chondrosarcoma.

What are your views on these areas of contention?

I have strong opinions about how best to manage low-grade chondrosarcoma. It’s important for medical oncologists and any oncologists evaluating a patient who may undergo surgery for chondrosarcoma [to know] that for lower-grade lesions, defined as lesions contained within the bone, more conservative surgery—meaning going into the lesion, scraping out [the disease], then reinforcing the bone—has been proven in much of the literature to be adequate for local and systemic control of the disease. Yet some [surgeons] are a little uncomfortable with that and still perform en bloc resections.

My opinion is that en bloc resections are not indicated [in these cases]. If medical oncologists and nonsurgical [providers] are reading a radiology report for a patient that [shows suspected] low-grade chondrosarcoma, and the patient is evaluated by an orthopedic oncologist in that group who wants to perform an en bloc resection, I think it is fair to say that there is room for another opinion in that situation. [Some other surgeons] might treat [that patient] more conservatively. [Regarding] functional outcome for the patient, a less aggressive resection can afford a much better quality of life over the years, and, in my opinion, can provide adequate local control.

How might the landscape of low-grade chondrosarcoma clinical research evolve to address questions regarding the optimal surgical management of this disease?

Approximately 20 years ago, I tried to initiate a clinical trial investigating [the clinical relevance of] wide resection of low-grade chondrosarcoma. The problem was that orthopedic surgeons are opinionated, and they weren’t willing to randomly assign patients [to undergo wide resection or more conservative resection]. It is important to reconsider that question 20 years later, to ask [surgeons whether] they would be willing to [conduct a randomized trial to answer this question]. Despite my strong preferences, because there’s another [group of surgeons] that feels that wide resection is indicated, that would be a great [question to evaluate in] a prospective, randomized control trial.

Short of that, I also think we could perform a prospective trial that is not randomized. That is probably the compromise that would afford an actual trial. [In that case, we would not] have to randomly assign the patients, but they would be enrolled in the trial [to participate] prospectively and observationally. Some patients would undergo the less aggressive surgery, and their local control and systemic relapses would be followed and compared with those [in patients who undergo] wide resection. [There would be confounding factors to consider, like] patient selection bias. However, with a nonrandomized trial, we [would have] surgical buy-in to give us a better level of data than we have now in the literature, which is mostly retrospective.

Reference

Jeys LM, Morris GV, Kurisunkal VJ, et al. Identifying consensus and areas for future research in chondrosarcoma : a report from the Birmingham Orthopaedic Oncology Meeting. Bone Joint J. 2025;107-B(2):246-252. doi:10.1302/0301-620X.107B2.BJJ-2024-0643.R1