James T. Evans

Pre‐ and postoperative uses of CEA

CEA plasma levels obtained prior to definitive surgery in patients with colorectal cancer in our hands have predictive ability. An elevated CEA > 2.5 ng/ml recorded by our laboratory means an increased risk of subsequent local recurrence or of later metastatic disease. The question as to whether or not this is additive as a prognostic variable when tested against careful histopathological staging remains. As a monitor, CEA will detect recurrence. Again, the problem as to how accurate this is remains. If we use two consecutive elevations of plasma CEA > 2.5 ng/ml as a criteria, we encounter about 15% false positives which must be weighed against finding disease significantly earlier in about one‐third of the patients followed. Our data for second‐look procedures indicate clearly that when used in patients with an elevated CEA laparotomy may be useful and further studies showed the presence of disease in 11 of 14 patients with an elevation following surgery for two consecutive tests were greater than 2.5 ng/ml. Two were operable. The significance of these findings is described.

Mithramycin in the Treatment of Paget's Disease of Bone

Ten patients with symptomatic Pagets disease of bone were treated with mithramycin. Subjective improvement, as demonstrated by complete pain relief and increased activity, was reported by seven patients and partial pain relief was reported by two. Pain persisted in one patient with a co-existing osteogenic sarcoma. No roentgenographic changes were noticed in the involved bones after therapy. Chemically, improvement was demonstrated by reduction of levels of serum alkaline phosphatase and urinary hydroxyproline. Five patients were in positive calcium balance before mithramycin therapy and showed an increase after therapy. Mithramycin administered in the dose of twenty-five micrograms per kilogram of body weight by slow intravenous drip method, once every two to three weeks, was well tolerated and showed suppressive effects on symptomatic Pagets disease of bone, and no hepatic, renal, or myelogenous evidence of toxicity was noticed in the immediate or long-term follow-up in these patients.

EEA stapler in low anterior anastomosis

Preservation of the anal sphincter is a goal of all surgeons treating colorectal malignancies. In the hands of many, transsacral and low anterior resections with end-to-end anastomosis have been associated with high morbidity and leakage. The EEA stapler represents an alternative in re-establishing bowel continuity. Fifty-eight patients with adenocarcinoma of the rectum were treated over a three-year period at Roswell Park Memorial Institute. Forty-nine procedures judged to be curative and nine, palliative. All patients had an EEA stapler introduced through the anus. No protective colostomies were needed. No case of clinically significant anastomotic leakage was seen. Minor spotting or bleeding was documented, but no patient required blood transfusions. Two patients developed constipation; 16 patients had temporary soiling, two had prolonged soiling. Frank incontinence was not observed. The EEA stapler is an evolutionary instrument derived from the Russian PKS model. It is safe, reliable, and simple to operate. With adequate training of the surgeon, precious time can be saved. Intraoperative sigmoidoscopies, as well as postoperative barium enema examinations, were not needed. Caps in the stapled anastomotic line (when present) were easily repaired. It is too early to tell whether anastomotic and local recurrence rates will increase, as more sphincter-saving procedures are performed. Five-year follow up is crucial to establish criteria for the use of the EEA stapler.