Paul Stalley

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

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Publications (38)96.09 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.
    No preview · Article · Jun 2015 · Orthopaedics and Trauma
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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.
    Full-text · Article · Jun 2015 · Annals of Surgical Oncology
  • Salman Ansari · Fiona Bonar · Paul Stalley · Wendy Brown
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    ABSTRACT: Paget's sarcoma is a rare complication of Paget's disease and isolated Paget's disease of the patella is extremely rare. We describe a unique case of Paget's sarcoma of the patella in a 69-year-old male farmer who had a remote history of a fracture in the same patella 40 years previously. In this case, imaging and pathogenesis of Paget's disease of bone is described and factors implicated in the development of Paget's disease in this patient are evaluated.
    No preview · Article · Apr 2015 · Skeletal Radiology
  • 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.
    No preview · Article · Feb 2015 · Annals of Surgical Oncology
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    ABSTRACT: Recurrent and advanced primary pelvic cancers present a complex clinical issue requiring multidisciplinary care and radical extended surgery. Sacral resection is necessary for tumors that invade posteriorly but is associated with increased morbidity and mortality.
    No preview · Article · Oct 2014 · Diseases of the Colon & Rectum
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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.
    Preview · Article · Jul 2013 · Annals of Oncology
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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.
    No preview · Article · Mar 2013 · Skeletal Radiology
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    ABSTRACT: OBJECTIVES:: To describe the experience of sacrectomy with extended radical resection in the treatment of locally recurrent rectal cancer. BACKGROUND:: Resections of the bony pelvis, especially the sacrum, are becoming more common as part of extended radical exenterations for patients with recurrent rectal cancer. However, sacrectomy has been shown to carry a significant decrease in survival. Morbidity rates have been associated with the level of the sacrectomy (ie, >S3 junction). METHODS:: An analysis was conducted using prospective data from patients with recurrent rectal cancer who underwent pelvic exenteration involving sacrectomy from July 1998 until June 2011. The impact of the proximal level of sacrectomy [low (≤S3) vs high (≥S2-S3 disc)] was compared. RESULTS:: Of 240 exenteration patients, 79 underwent sacrectomy, with 49 for recurrent rectal cancer. An R0 margin was achieved in 36 (74%) patients. Achievement of clear operative margins (R0) conferred a large and significant benefit for disease-free survival compared with R1 and R2 resections (median 45 months vs 19 and 8 months, respectively; P = 0.045). Complications were reported in 40 (82%) patients, with major and minor complications in 19 (39%) and 38 (78%) patients, respectively. The proximal level of the sacrectomy (high vs low) did not significantly impair the ability to achieve a clear margin and was not associated with an increase in major or minor complications. CONCLUSIONS:: This large, single-center series has demonstrated that extended pelvic exenteration involving sacrectomy has excellent R0 margins and survival rates for recurrent rectal cancer. A high sacrectomy has comparable results with a more distal abdominosacral resection.
    No preview · Article · Jan 2013 · Annals of surgery

  • No preview · Article · Nov 2012 · International Journal of Radiation OncologyBiologyPhysics
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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.
    No preview · Article · Jun 2012 · Orthopaedics and Trauma
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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.
    Full-text · Article · Apr 2012 · Asia-Pacific Journal of Clinical Oncology

  • No preview · Article · Feb 2012 · Clinical Oncology
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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.
    Full-text · Article · May 2011
  • 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.
    No preview · Article · Feb 2010 · European Journal of Orthopaedic Surgery & Traumatology
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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.
    No preview · Article · Jul 2009 · Hip international: the journal of clinical and experimental research on hip pathology and therapy
  • 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.
    No preview · Article · Apr 2009 · The Bone & Joint Journal
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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.
    Full-text · Article · Feb 2009 · Recent results in cancer research. Fortschritte der Krebsforschung. Progrès dans les recherches sur le cancer
  • L. Wen · S. Eberl · D. Feng · P. Stalley · G. Huang · M. Fulham
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    ABSTRACT: Kinetic modeling in functional imaging can derive quantitative rate constants and macroparameters, which can facilitate clinical evaluation. 18F-fluoride is a suitable tracer for quantifying bone metabolism. This study employed a three-compartment and four-parameter kinetic model for 18F-fluoride to analysis dynamic 18F-fluoride PET studies of eight patients with fibula bone grafts after limb salvage surgery. Kinetic parameters were estimated for bone graft, ilium, rib, femur and lumbar vertebra regions with non-linear least square fitting. Parametric images of the influx rate constant were constructed by the Patlak graphical analysis for comparison. Differences in net influx rate constant between bone graft and normal bone regions could be detected by the technique and the technique shows promise in providing quantitative assessment of the viability of bone grafts.
    No preview · Article · Jan 2009
  • 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.
    No preview · Article · Oct 2008 · Archives of Orthopaedic and Trauma Surgery
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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.
    Full-text · Article · Oct 2008 · Annals of Surgical Oncology

Publication Stats

636 Citations
96.09 Total Impact Points

Institutions

  • 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