Paul Stalley

Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia

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Publications (33)79.77 Total impact

  • P.D. Gikas · S. Keller · R. Boyle · P.D. Stalley ·
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    ABSTRACT: Bone tumours are rare and should be assessed and treated in specialized centres. Clinical staging uses various imaging techniques; pathological grading requires tumour biopsy following clinical staging. Surgery remains the mainstay of treatment for musculoskeletal tumours.The surgical margin describes the extent of the procedure, with marginal excision referring to a procedure that removes the tumour alone. Radical margins may require removal of the entire bone/compartment.Open incisional biopsy is the gold standard method for obtaining a representative specimen of tumour. Careful planning and good collaboration is crucial between surgeons, radiologists, and pathologists in order to prevent unnecessary morbidity.The aims of the bone tumour surgeon are to improve survival and maintain optimal function of the patient. This can potentially be achieved by amputation or limb salvage. Currently, limb salvage provides no greater risk to the survival of the patient compared to amputation. Reconstruction after excision of the tumour can be achieved by using endoprosthetic replacements, autografts, or massive allografts. Major complications of limb salvage include infection and difficulties associated with soft tissue re-attachment and coverage of the prosthesis.
    Orthopaedics and Trauma 06/2015; 29(3). DOI:10.1016/j.mporth.2015.05.001
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    ABSTRACT: Surgical resection with curative intent for giant cell tumor of bone (GCTB) may be associated with severe morbidity. This interim analysis evaluated reduction in surgical invasiveness after denosumab treatment in patients with resectable GCTB. Patients with primary or recurrent GCTB, for whom the initially planned surgery was associated with functional compromise or morbidity, received denosumab 120 mg subcutaneously every 4 weeks (additional doses on days 8 and 15 of the first cycle). Planned and actual GCTB-related surgical procedures before and after denosumab treatment were reported. Patients were followed for surgical outcome, adverse events, and recurrence following resection. Overall, 222 patients were evaluable for surgical downstaging (54 % were women; median age 34 years). Lesions (67 % primary and 33 % recurrent) were located in the axial (15 %) and appendicular skeleton (85 %). At the data cutoff date, most patients had not yet undergone surgery (n = 106; 48 %) or had a less morbid procedure (n = 84; 38 %) than originally planned. Median (interquartile range) time on denosumab was 19.5 (12.4-28.6) months for the 106 patients who had not undergone surgery and were continuing on monthly denosumab. Native joint preservation was 96 % (n = 24/25) for patients with planned joint/prosthesis replacement and 86 % (n = 30/35) for patients with planned joint resection/fusion. Of the 116 patients who had surgery (median postsurgical follow-up 13.0 [8.5-17.9] months), local recurrence occurred in 17 (15 %) patients. For patients with resectable GCTB, neoadjuvant denosumab therapy resulted in beneficial surgical downstaging, including either no surgery or a less morbid surgical procedure.
    Annals of Surgical Oncology 06/2015; 22(9). DOI:10.1245/s10434-015-4634-9 · 3.93 Impact Factor
  • Rebecca L Read · Paul Stalley · John F Thompson ·
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    ABSTRACT: Major amputations are rarely performed for melanoma, with limb-preserving techniques used whenever possible. This article reviews the indications for major amputation in patients with melanoma and reports outcomes with the aim of better classifying progressive and potentially curable disease patterns. At a single institution in Australia, 55 major amputations were performed for melanoma in 51 patients treated between 1984 and 2012. Clinicopathologic characteristics, treatments before amputation, and outcomes were analyzed. The 55 cases included 17 upper limb (9 forequarter) and 38 lower limb (3 hindquarter) amputations. The most common reasons for amputation were progressive in-transit metastases (ITM, 67 %), troublesome limb metastases from distant sites (14 %), pain or ulceration after regional chemotherapy (14 %) and otherwise inoperable regional recurrence (6 %). Regional chemotherapy was used before amputation for 58 % of the patients, and for those with ITM, it was associated with an increased interval between ITM diagnosis and amputation. The overall 5-year survival rate (5YS) from the time of amputation was 22.8 %. For stage 3 patients with either ITM or regional recurrence, who had all known disease resected at the time of amputation, the 5YS was 38.4 %. Major amputation may be indicated for advanced limb melanoma when limb-preserving strategies have been exhausted. Although they have advanced locoregional disease, some patients undergoing potentially curative amputation can achieve long-term survival.
    Annals of Surgical Oncology 02/2015; 22(12). DOI:10.1245/s10434-015-4416-4 · 3.93 Impact Factor
  • A M Hong · S Millington · V Ahern · G McCowage · R Boyle · M Tattersall · L Haydu · P D Stalley ·
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    ABSTRACT: En bloc resection, extracorporeal irradiation (ECI) and reimplantation have been used selectively at our centers as part of limb preservation surgery of malignant bone tumors since 1996. We report the long-term oncological outcomes. One hundred one patients were treated with ECI at two Australian centers between 1996 and 2011. A single dose of 50 Gy was delivered to the resected bone segments. The irradiated bones were reimplanted immediately as a biological graft. Patients were treated with chemotherapy as per standard protocol. The three main histological diagnoses were Ewing's sarcoma (35), osteosarcoma (37) and chondrosarcoma (20). There were nine patients with a range of different histologies. There was one local recurrence (2.86%) in Ewing's sarcoma and the 5-year cumulative overall survival was 81.9%. There was no local recurrence in osteosarcoma and five distant recurrences. The 5-year cumulative overall survival was 85.7%. The local recurrence rate was 20% (4 of 20) in chondrosarcoma, and the 5-year cumulative overall survival was 80.8%. Limb preservation was achieved in 97 patients. For the 64 patients with disease in the pelvis or lower limb, 53 (82.3%) could walk without aids at the time of last follow-up. This large series of ECI shows an excellent long-term local control. It is a good alternative reconstruction method in selected patients. The overall survival is comparable to other published series.
    Annals of Oncology 07/2013; 10(10). DOI:10.1093/annonc/mdt252 · 7.04 Impact Factor
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    ABSTRACT: The retention of foreign bodies after surgery is rare, but carries significant morbidity and mortality as well as financial and legal implications. Such retained items cause a foreign-body reaction, which in the case of cotton-based materials are called gossypibomas. We present the case of an 84-year-old woman with a pseudotumor secondary to a retained dressing gauze roll, presenting 5 months after resection of a gluteal sarcoma, which had raised concerns of local recurrence. We also outline the imaging modalities that may assist in diagnosis of a retained foreign body, and suggest the MRI "row of dots" sign as a useful radiological feature associated with gossypiboma. Awareness of the imaging appearances of retained foreign bodies allows the inclusion of this possibility in differential diagnosis of a mass in patients with a surgical history.
    Skeletal Radiology 03/2013; 42(7). DOI:10.1007/s00256-013-1596-5 · 1.51 Impact Factor

  • International Journal of Radiation OncologyBiologyPhysics 11/2012; 84(3):S169. DOI:10.1016/j.ijrobp.2012.07.439 · 4.26 Impact Factor
  • Robert U. Ashford · Linus Benjamin · Susan Pendlebury · Paul D. Stalley ·
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    ABSTRACT: Bone is the third most common site of metastatic disease. The management of skeletal metastases has continued to evolve over recent years. There have been developments particularly in the oncologic field. This, in conjunction with a multi-disciplinary approach, has resulted in prolonged survival. Disease prognosis is an important consideration in the management of all patients with appendicular skeletal metastases. This review article covers both surgical and non-surgical management of skeletal metastases.
    Orthopaedics and Trauma 06/2012; 26(3):184–199. DOI:10.1016/j.mporth.2012.02.002
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    ABSTRACT: The aim of this study is to analyze the prognostic factors for overall and relapse-free survival that may help select patients for pulmonary metastasectomy and inform their prognosis. From 1978 to 2008 130 patients underwent pulmonary metastasectomy for bone (osteosarcoma, chondrosarcoma and Ewing's sarcoma) and soft tissue sarcomas. Outcome measures analyzed were time to death and relapse and Cox regression models analyzed the association of prognostic factors. In total 114 patients were analyzed. The 5-year post-metastasectomy overall survival rate was 43%. The 5-year relapse-free survival rate was 19%. In the multivariate analysis, an incomplete surgical resection (P = 0.02) was associated with an increased risk of death. There was weak evidence that a diameter of the largest resected metastasis ≥ 1.8 cm (P = 0.07) and a disease-free interval of ≤ 18 months (P = 0.08) were associated with an increased risk of death. Poor prognostic factors for overall survival after a pulmonary metastasectomy are an incomplete surgical resection, a large diameter of the biggest resected metastasis and a short disease-free interval. The role of perioperative chemotherapy is uncertain.
    Asia-Pacific Journal of Clinical Oncology 04/2012; 8(3):292-302. DOI:10.1111/j.1743-7563.2012.01521.x · 1.54 Impact Factor

  • Clinical Oncology 02/2012; 24(1):77-9. DOI:10.1016/j.clon.2011.09.015 · 3.40 Impact Factor
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    ABSTRACT: The early identification of graft failure would improve patient management. (18)F-fluoride is a suitable tracer for quantifying bone metabolism. Performance of parametric images constructed by Patlak graphical analysis (PGA) with various time periods was evaluated in the analysis of dynamic (18)F-fluoride PET studies of eight patients with fibula bone grafts after limb salvage surgery. The PGA parametric image approach tended to underestimate influx rate. The linear portion of PGA analysis was found to be from 10 to 50 min. It shows promise in providing a quantitative assessment of the viability of bone grafts.
  • Robert U. Ashford · Judy Soper · Paul D. Stalley ·
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    ABSTRACT: The third most common site that giant cell tumours occur is the distal radius, with approximately 10% of cases occurring at that site. We report three cases where the imaging raised the possibility of giant cell tumours but biopsy has revealed an altogether more aggressive pathology. We believe biopsy is mandatory in presumed giant cell tumours, particularly those affecting the distal radius.
    European Journal of Orthopaedic Surgery & Traumatology 02/2010; 20(2):109-111. DOI:10.1007/s00590-009-0502-2 · 0.18 Impact Factor
  • AH Krieg · M Mani · B M Speth · P D Stalley ·
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    ABSTRACT: We review the treatment of pelvic Ewing's sarcoma by the implantation of extracorporeally-irradiated (ECI) autografts and compare the outcome with that of other reported methods. We treated 13 patients with ECI autografts between 1994 and 2004. There were seven males and six females with a median age of 15.7 years (interquartile range (IQR) 12.2 to 21.7). At a median follow-up of five years (IQR 1.8 to 7.4), the disease-free survival was 69% overall, and 75% if one patient with local recurrence after initial treatment elsewhere was excluded. Four patients died from distant metastases at a mean of 17 months (13 to 23). There were three complications which required operative intervention; one was a deep infection which required removal of the graft. The functional results gave a mean Musculoskeletal Tumor Society score of 85% (60% to 97%), a mean Toronto extremity salvage score of 86% (69% to 100%) and a mean Harris hip score of 92 (67 to 100). We conclude that ECI grafting is a suitable form of treatment for localised and resectable pelvic Ewing's sarcoma.
    The Bone & Joint Journal 04/2009; 91(3):395-400. DOI:10.1302/0301-620X.91B3.21164 · 3.31 Impact Factor
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    ABSTRACT: A tissue biopsy is usually a critical aspect in guiding appropriate initial management in patients with musculoskeletal tumours. We have previously outlined the role of intra-operative frozen section in both the determination of adequacy of a biopsy and for its diagnostic utility. In this article, the options and techniques for intra-operative pathological evaluation, namely frozen section, fine needle aspiration cytology and touch imprint cytology are reviewed. Frozen section examination may be applicable in the following Sections, including (1) at core biopsy, (2) at surgical margins, (3) at confirming diagnosis prior to definitive treatment or to evaluate tumour spread, and (4) at establishing a diagnosis of a metastasis prior to intramedullary nailing. There are also situations in which frozen section is inappropriate. Pitfalls associated with frozen sections are also highlighted. There are also cost implications, which we have quantified, of performing frozen sections. In our experience that the use of intra-operative pathological evaluation reduces the non-diagnostic rate of bone and soft tissue sarcoma biopsies, eliminates the need for re-biopsy hence alleviating stress, and is a useful addition to the armamentarium in evaluating musculoskeletal tumours.
    Recent results in cancer research. Fortschritte der Krebsforschung. Progrès dans les recherches sur le cancer 02/2009; 179:11-24. DOI:10.1007/978-3-540-77960-5_2
  • Matthew Moran · Andreas H Krieg · Richard A Boyle · Paul D Stalley ·
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    ABSTRACT: Staged bilateral hip arthroplasties were carried out in two patients with osteoarthritis of the hip secondary to the development of hip dysplasia in Hereditary Multiple Exostosis (HME).Both patients had near ankylosis of their hips with pain and difficulty in performing activities of daily living. A proximal femur replacing prosthesis was implanted through an extended trochanteric osteotomy, with preservation of as much proximal bone stock as possible. At latest followup (two to five years), there was a sustained improvement in range of motion and symptoms. The Harris Hip Scores improved from 25 and 31 to 83 and 78. The Toronto Extremity Salvage Scores improved from 49% and 55% to 88% and 75%. Radiographs show bony ingrowth and healing of the trochanteric fragments. In severe HME, hip arthroplasty with replacement of the proximal femur provides good symptomatic relief and return of hip joint movement.
    Hip international: the journal of clinical and experimental research on hip pathology and therapy 01/2009; 19(3):279-82. · 0.76 Impact Factor
  • Matthew Moran · Paul D Stalley ·
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    ABSTRACT: Functional reconstruction of the shoulder joint following excision of a malignant proximal humeral tumour is a difficult proposition. Eleven patients with primary osteosarcoma or Ewing's sarcoma underwent reconstruction with a composite of extra-corporeally irradiated autograft with the addition of a long stemmed hemiarthroplasty. At a mean follow-up of 5.8 years two patients had died from disseminated disease and one patient had undergone amputation for local recurrence. The eight patients with a surviving limb were examined clinically and radiographically. The mean Toronto Extremity Salvage Score was 74 and Musculo-Skeletal Tumour Society score 66. Rotation was well preserved but abduction (mean 32 degrees ) and flexion (40 degrees ) were poor. There was a high rate of secondary surgery, with five out of eleven patients requiring re-operation for complications of reconstruction surgery. Radiographic estimate of graft remaining at follow up was 71%. There were no infections, revisions or radiographic failures. Whilst the reconstructions were durable in the medium term, the functional outcome was no better than with other reported reconstructive methods. The composite technique was especially useful in subtotal humeral resections, allowing preservation of the elbow joint even with very distal osteotomy. Bone stock is restored, which may be useful for future revision surgery in this young group of patients.
    Archives of Orthopaedic and Trauma Surgery 10/2008; 129(10):1339-45. DOI:10.1007/s00402-008-0752-1 · 1.60 Impact Factor
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    ABSTRACT: Isolated limb infusion (ILI) is a minimally invasive technique for delivering high-dose regional chemotherapy. We report our experience with ILI for the treatment of soft tissue sarcoma (STS). From our prospective database, 21 patients with STS of the limb treated with ILI between 1994 and 2007 were identified. In all patients, a high-dose cytotoxic drug combination was used. There were 14 men, and the median age was 60 years (range, 18-85 years). Eighteen patients (86%) had lower limb tumors. All patients had advanced local disease. The procedure was well tolerated. Fourteen patients (67%) received ILI before definitive surgery. The overall response rate was 90% (complete response [CR] rate 57%, partial response rate 33%). The disease-specific overall survival was 61.9% (median follow-up, 28 months). Only American Joint Committee on Cancer stage was associated with overall survival. The local recurrence rate was 42%. CR and malignant fibrous histiocytoma tumor subtype were associated with a lower local recurrence rate. A lower initial skin temperature (median 35.8 degrees C) was associated with a CR (P = .033). Patients who had a steep increase in intramuscular temperature during the procedure were more likely to have a CR (P = .055). Classification tree analysis identified patients with an initial PaO(2) of >/=194 mmHg as being more likely to have a CR. Ultimately, the overall limb salvage rate was 76%. The outcomes after ILI are comparable to those achieved by conventional isolated limb perfusion. ILI is a minimally invasive alternative to isolated limb perfusion for patients with advanced STS of the extremity.
    Annals of Surgical Oncology 10/2008; 15(10):2749-56. DOI:10.1245/s10434-008-0045-5 · 3.93 Impact Factor
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    ABSTRACT: A case of epithelioid and spindle cell haemangioma of bone occurring in the proximal femur is presented. The tumour had typical microscopic features with a striking lobular pattern comprising spindled and epithelioid areas with admixed inflammatory cells. The case represents only the eighth reported example of this rare tumour, which appears to fit in the spectrum of epithelioid haemangioma. This is the first case to involve the proximal portion of a long bone. A review of the classification and features of similar vascular tumours of bone is presented.
    Skeletal Radiology 07/2007; 36 Suppl 1(S1):S50-7. DOI:10.1007/s00256-006-0135-z · 1.51 Impact Factor
  • R. A. Boyle · P. D. Stalley · D. Loxton · M. Windolf ·
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    ABSTRACT: This paper presents an audit of 22 years of bone banking at Royal Prince Alfred Hospital, along with a review of the current literature regarding the use of allograft bone.Comparisons both locally and internationally are made, and we are confident that standards in Australia are equivalent to those internationally. The requirement for bone graft material in Australia is likely to rise, as more reconstructive and revision surgery is undertaken, along with increases in primary arthroplasty procedures.
    ANZ Journal of Surgery 05/2007; 77(s1). DOI:10.1111/j.1445-2197.2007.04132_6.x · 1.12 Impact Factor
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    A H Krieg · A W Davidson · P D Stalley ·
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    ABSTRACT: Between 1996 and 2003, 16 patients (nine female, seven male) were treated for a primary bone sarcoma of the femur by wide local excision of the tumour, extracorporeal irradiation and re-implantation. An additional vascularised fibular graft was used in 13 patients (81%). All patients were free from disease when reviewed at a minimum of two years postoperatively (mean 49.7 months (24 to 96). There were no cases of infection. Primary union was achieved after a median of nine months (interquartile range 7 to 11). Five host-donor junctions (16%) united only after a second procedure. Primary union recurred faster at metaphyseal junctions (94% (15) at a median of 7.5 months (interquartile range 4 to 12)) than at diaphyseal junctions (75% (12) at a median of 11.1 months (interquartile range 5 to 18)). Post-operatively, the median Musculoskeletal Tumour Society score was 85% (interquartile range 75 to 96) and the median Toronto Extremity Salvage score 94% (interquartile range 82 to 99). The Mankin score gave a good or excellent result in 14 patients (88%). The range of movement of the knee was significantly worse when the extracorporeally irradiated autografts were fixed by plates rather than by nails (p = 0.035). A total of 16 (62%) of the junctions of the vascularised fibular grafts underwent hypertrophy, indicating union and loading. Extracorporeal irradiation autografting with supplementary vascularised fibular grafting is a promising biological alternative for intercalary reconstruction after wide resection of malignant bone tumours of the femur.
    The Bone & Joint Journal 04/2007; 89(3):366-71. DOI:10.1302/0301-620X.89B3.18508 · 3.31 Impact Factor
  • R U Ashford · S W McCarthy · R A Scolyer · S F Bonar · R Z Karim · P D Stalley ·
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    ABSTRACT: The most appropriate protocol for the biopsy of musculoskeletal tumours is controversial, with some authors advocating CT-guided core biopsy. At our hospital the initial biopsies of most musculoskeletal tumours has been by operative core biopsy with evaluation by frozen section which determines whether diagnostic tissue has been obtained and, if possible, gives the definitive diagnosis. In order to determine the accuracy and cost-effectiveness of this protocol we have undertaken a retrospective audit of biopsies of musculoskeletal tumours performed over a period of two years. A total of 104 patients had biopsies according to this regime. All gave the diagnosis apart from one minor error which did not alter the management of the patient. There was no requirement for re-biopsy. This protocol was more labour-intensive and 38% more costly than CT-guided core biopsy (AU$1804 vs AU$1308). However, the accuracy and avoidance of the anxiety associated with repeat biopsy outweighed these disadvantages.
    The Bone & Joint Journal 10/2006; 88(9):1207-11. DOI:10.1302/0301-620X.88B9.17680 · 3.31 Impact Factor

Publication Stats

563 Citations
79.77 Total Impact Points


  • 1997-2015
    • Royal Prince Alfred Hospital
      • • Department of Pet & Nuclear Medicine
      • • Department of Surgery
      • • Department of Orthopaedics
      • • Department of Radiation Oncology
      • • Division of Anatomical Pathology
      • • Department of Medical Oncology
      Camperdown, New South Wales, Australia
  • 2009
    • Alfred Hospital
      Melbourne, Victoria, Australia