Dr Randall on a Survey Outlining Surgical Trial Candidates With RCC and Proximal Femoral Metastases

"For the orthopedic oncologic management of patients with advanced renal cell carcinoma, mets to the upper femur, we are presented with a dilemma. Do we treat it aggressively, or should we carefully observe that patient?"

R. Lor Randall, MD, FACS, the David Linn Endowed Chair for Orthopedic Surgery, chair of the Department of Orthopedic Surgery, and professor at the University of California, Davis Health, discussed the ongoing clinical debate and forthcoming research efforts focused on surgical decision-making for patients with proximal femur metastases.

A global survey of 76 musculoskeletal oncology surgeons was distributed in an effort to determine enrollment criteria for the proposed PERFORM trial—which plans to evaluate post-surgical outcomes in patients with proximal femur metastases. In the survey, experts highlighted patient life expectancy, extent of bone loss, and risk for perioperative complications as key factors to consider.

Randall outlined a dilemma faced by orthopedic oncologists: whether to proceed with aggressive resection and reconstruction—such as proximal femoral replacement—or opt for less invasive stabilization procedures, like intramedullary nailing. Aggressive resection may provide local control but carries substantial morbidity and prolonged recovery; stabilization offers lower up-front risk but may be less durable in the face of tumor progression.

To address this question, Randall and colleagues from the Musculoskeletal Tumor Society (MSTS) developed a consensus initiative to evaluate global clinical equipoise. Led by Michelle Ghert, MD, FRCSC, of the University of Maryland, this effort included a Delphi-based methodology and a survey distributed to orthopedic oncologists worldwide. The survey aimed to assess willingness to participate in a randomized trial and to define the clinical parameters that would guide enrollment.

The proposed trial will aim to compare outcomes between aggressive resection and stabilization strategies, with the goal of informing evidence-based clinical guidelines. Randall highlighted the need for early engagement with orthopedic oncologists as part of multidisciplinary cancer care.