Guidelines and Evidence Based Medicine

The Guidelines and Evidence Based Medicine (GEBM) committee is charged with producing evidence-based practice guidelines and position statements on behalf of MSTS, independently and in collaboration with other medical organizations. The committee will help the MSTS accomplish its vision as a recognized authority on all aspects of orthopaedic oncology, an influential participant in policy-making for orthopaedic oncology services, and responsive to the needs of orthopaedic oncologists and their patients.

The current committee members are:

Nicholas Tedesco, MD (Chair) (2022-2025)
Yee-Cheen Doung, MD (2021-2024)
Alexander L. Lazarides, MD (2023-2026)

Pietro Ruggieri, MD (2022-2025)
Dipak B. Ramkumar, MD (2023-2026)

Henock Wolde-Semait, MD (2022-2025)
Matthew W. Colman, MD (2020-2023)

The GEBM committee serves the MSTS membership. If you have ideas for guidelines or other quality improvement projects, please do not hesitate to reach out to the current GEBM Chair or any GEBM committee members.

MSTS CPG Methodology

Committee Work

The GEBM committee produces three types of practice guidelines, as described below. In all cases the document is shared with MSTS membership for public review and comment, before adoption by the society.

Clinical Practice Guidelines (CPG) begin with a workgroup drafting series of structured clinical ("PICOT") questions. Using these questions, a rigorous systematic review of the literature is performed. Articles with low evidence level (e.g. uncontrolled case series) are excluded. Results from the included articles are aggregated and abstracted, from which the workgroup writes the guideline recommendations. The process is labor intensive and requires statistical expertise.

Appropriate Use Criteria (AUC) are a type of consensus-based guideline that combine literature review with expert opinion. They are more appropriate when there is a relative paucity of level 1 and level 2 evidence. AUCs start with a writing panel drafting a series of clinical scenarios with options for intervention. A literature search is then performed. In contrast to CPGs, articles with lower levels evidence are allowed. The findings from the literature search are abstracted. The clinical scenarios, interventions and the abstracted literature, are presented to separate a voting panel. This panel ranks the appropriateness of each intervention for each clinical scenario.

Information or Position Statements are crafted by one or several authors reflecting on an issue of relevance to MSTS members. There is no fixed methodology. The document is edited and modified by GEBM committee members. Once complete, the document is submitted to the MSTS Executive Committee for approval.

In addition to the above, the GEBM committee leads MSTS collaboration with other medical societies. GEBM committee members serve on other societies guideline workgroups. In some instances other societies guidelines were initiated following proposals by GEBM committee members.

Clinical Practice Guidelines (CPGs)

1. Management of Metastatic Humeral Disease

  • Adopted and Approved: April 12, 2023

From the document:

       This clinical practice guideline for thesurgical management of metastatic humeraldisease is based on a systematic review ofpublished studies surrounding the management of metastatic disease, multiplemyeloma, and lymphoma limited to thehumerus. In addition to providing practicerecommendations, this guideline also highlights both limitations in the literatureand consequent areas that should be the focus of future research collaborations.

Read CPG Metastatic Humerus Document


2. Use of Imaging Prior to Referral to a Musculoskeletal Oncologist

  • Adopted and Approved February 2018

From the document:

The intention of this effort was to produce a vetted and thoughtful document that would provide guidance regarding imaging options and delivery in musculoskeletal tumors of unknown biological significance. The goal is not to diminish the use of advanced imaging techniques and modalities, but rather to propose a clinically meaningful approach to ensure that the correct studies are done for appropriate indications. Although diminishing the use of costly and unnecessary imaging is an intended consequence of this project, these guidelines will also provide support for the expeditious use of advanced imaging modalities when clinically indicated.

Read CPG document

 Accompanying Publication

CPG recommendations on

 Treatment of Metastatic Carcinoma and Myeloma of the Femur

  • Principal Authors: Felasfa Wodajo and Patrick Getty
  • Approval: June 2020

This MSTS-led guideline was produced in collaboration with ASCO and ASTRO. From the document:

Previous guidelines that address the potential benefits of bone targeted agents (e.g. bisphosphonates) refer to reductions in skeletal related events (SREs). This is a broad term that encompasses pathologic fractures of any bone, need for surgery or radiation, and hypercalcemia. Guidelines around the use of palliative radiotherapy have been primarily focused on short-term pain control and long-term radiation-induced side effects, without significant consideration to modifying the risk of pathologic fracture or the need for subsequent surgical intervention ... The purpose of this clinical practice guideline is to provide medical, radiation, and surgical providers with a practical and vetted set of recommendations regarding the management of patients with metastatic or myelomatous lesions of the femur

Read CPG document

   Read the Peer Review Responses

Appropriate Use Criteria (AUC)

Surveillance of Local Recurrence and Distant Metastasis after Surgical Treatment of Bone and Soft Tissue Sarcomas

  • Principal Author: Rajiv Rajani
  • Approved June 2018

From the document:

The Musculoskeletal Tumor Society (MSTS) has developed this Appropriate Use Criteria (AUC) to determine the appropriateness of various imaging modalities and the timing of surveillance for Surveillance of Local Recurrence and Distant Metastasis after Surgical Treatment of Bone and Soft Tissue Sarcomas. This AUC is intended for use with patients with bone or soft tissue sarcomas following surgical resection with intent to cure. Palliative patients or patients with low functional status who are not candidates for additional chemotherapy, radiation therapy, and/or surgery are not included within the scope of this AUC. The scope of these appropriate use criteria includes the surveillance for local recurrence, regional lymphatic and distant metastatic disease in individuals that have had surgical removal of a primary sarcoma.

Read the AUC

AUC Recommendations on



Information Statements

Inappropriate Excision of Unrecognized Sarcoma

  • Principal author: Felasfa Wodajo
  • Approved Jan 2017

From the document:

Despite ample evidence advising against inappropriate excision, this problem has persisted in clinical practice accounting for an estimated 30% of sarcoma referrals, with reported rates ranging from 18-53%. In part, we believe this may be due to knowledge gaps or barriers to information dissemination. In some cases, surgeons may be working outside the normal scope of their training.

In the past, much of the of the literature on this subject has referred to these events as “inadvertent excisions.” However, because many of these procedures were likely elective, scheduled surgeries, and to emphasize the risk of additional morbidity to the patient, we suggest a more apt description would be “inappropriate excisions of an unrecognized sarcoma.”

Read the Information Statement

 Current Distribution of MSTS Members In The United States

  • Principal Author: Ben Miller
  • Approved January 2018

From the document:

In the 40 years since the establishment of the Musculoskeletal Tumor Society (MSTS), the membership has grown from the 17 founders in 1977, to over 100 orthopaedic oncologists in 2000, to over 200 in 2017. Each year, an average of 12-13 musculoskeletal oncology fellows are trained and enter practice, outnumbering the number of physicians retiring. This information statement is a snapshot of the current distribution of MSTS members in the United States.

Read the Information Statement

Guidelines for Specialist Referral for Newly Identified Bone Lesions

  • Principal author: Eric Henderson
  • Approved February 2019

From the document:

Although the detection of abnormal skeletal findings on plain radiographs is common, the subsequent management can be a source of concern and uncertainty for medical providers. This information statement is directed toward “front line” medical personnel, such as primary care physicians, pediatricians, advanced practice providers, and orthopaedic generalists and specialists without training in oncology, who often are the first to evaluate radiographs and recognize an underlying skeletal abnormality. Our goal is to provide a simple, algorithmic framework for managing patients with newly identified bone lesions.

Endorsed by the American College of Radiology March 2019

Read the Information Statement

 Collaborations with Other Societies
The information below is current as of May 2020.

American Academy of Orthopedic Surgery (AAOS)
MSTS and GEBM Committee members are serving on two AAOS guideline workgroups - 1) Performing a Transtibial Amputation- Targeted Muscle Reintegration and Prevention and 2) Treatment of Surgical Site Infections.

American College of Radiology (ACR)
GEBM committee members proposed to ACR the development of a structured reporting template for potentially neoplastic lesions on bone radiographs. This would be analogous to other ACR developed structured reports, such as those for lung, prostate and breast imaging (“lung RADS”, “PI RADS” and “BI RADS”, RADS stands for Reporting and Data Systems). These tools promote more detailed reporting and appropriate risk stratification of imaging findings. The ACR “Bone RADS” workgroup, which includes MSTS and GEBM members, was convened in May 2019.

The ACR has now expanded Bone RADS to include a template for MRI reporting. This workgroup, which also includes GEBM committee members, was assembled in March 2020.

GEBM committee members proposed to ACR in January 2020 the development of structured reporting for soft tissue lesions (Soft RADS).

American Society of Clinical Oncology (ASCO)
GEBM committee members have proposed a collaborative CPG for the use of chemotherapy for non-metastatic high grade soft tissue sarcomas. The project currently is expected to begin Winter 2020.

American Society for Therapeutic Radiology (ASTRO)
ASTRO has invited MSTS to collaborate on a guideline for Radiation Therapy in the Treatment of Soft Tissue Sarcoma. GEBM committee member Steve Thorpe is representing MSTS on the ASTRO led multidisciplinary workgroup which was seated in September 2019.

American College of Surgeons (ACS) 
GEBM committee members have proposed producing a collaborative guideline for appropriate workup of soft tissue lesions. One goal of the project is reduce the incidence of inappropriate excisions of soft tissue sarcomas.