Endoscopic management of chronic pancreatitis

Chronic pancreatitis (CP) is a common gastrointestinal illness, which affects the quality of life with substantial morbidity and mortality. The management includes medical, endoscopic and surgical approaches with the need for interaction between various specialties, calling for a concerted multidisciplinary approach. However, at the time of this publication, guidelines to establish care of these patients are lacking. This review provides the reader with a comprehensive overview of the studies summarizing the various treatment options available, including medical, surgical and endoscopic options. In addition, technological advances such as endoscopic retrograde cholangiopancreatogrophy, endoscopic shock wave lithotripsy and endoscopic ultrasound can now be offered with reasonable success for pancreatic decompression, stricture dilatation with stent placement, stone fragmentation, pseudocyst drainage, and other endoscopic interventions such as celiac plexus block for pain relief. We emphasize the endoscopic op-tions in this review, and attempt to extract the most up to date information from the current literature. The treatment of CP and its complications are discussed extensively. Complications such as biliary strictures. pancreatic pseudocysts, and chronic pain are common issues that arise as long-term complications of CP. These often require endoscopic or surgical management and possibly a combination of approaches, however choosing amongst the various therapeutic and palliative modalities while weighing the risks and benefits, makes the management of CP challenging. Treatment goals should be not just to control symptoms but also to prevent disease progression. Our aim in this paper is to advocate and emphasize an evidence based approach for the management of CP and associated long term complications.     

Delaying surgery for clinical T1b-T2bN0M0 renal cell carcinoma: Oncologic implications in the COVID-19 era and beyond

PurposeDuring COVID-19, many operating rooms were reserved exclusively for emergent cases. As a result, many elective surgeries for renal cell carcinoma (RCC) were deferred, with an unknown impact on outcomes. Since surveillance is commonplace for small renal masses, we focused on larger, organ-confined RCCs. Our primary endpoint was pT3a upstaging and our secondary endpoint was overall survival.Materials and methodsWe retrospectively abstracted cT1b-T2bN0M0 RCC patients from the National Cancer Database, stratifying them by clinical stage and time from diagnosis to surgery. We selected only those patients who underwent surgery. Patients were grouped by having surgery within 1 month, 1–3 months, or >3 months after diagnosis. Logistic regression models measured pT3a upstaging risk. Kaplan Meier curves and Cox proportional hazards models assessed overall survival.ResultsA total of 29,746 patients underwent partial or radical nephrectomy. Delaying surgery >3 months after diagnosis did not confer pT3a upstaging risk among cT1b (OR = 0.90; 95% CI: 0.77–1.05, P = 0.170), cT2a (OR = 0.90; 95% CI: 0.69–1.19, P = 0.454), or cT2b (OR = 0.96; 95% CI: 0.62–1.51, P = 0.873). In all clinical stage strata, nonclear cell RCCs were significantly less likely to be upstaged (P <0.001). A sensitivity analysis, performed for delays of <1, 1–3, 3–6, and >6 months, also showed no increase in upstaging risk.ConclusionDelaying surgery up to, and even beyond, 3 months does not significantly increase risk of tumor progression in clinically localized RCC. However, if deciding to delay surgery due to COVID-19, tumor histology, growth kinetics, patient comorbidities, and hospital capacity/resources, should be considered.     

Self-reported Papanicolaou smears and hysterectomies among women in the United States

OBJECTIVE: To evaluate the potential overuse of Papanicolaou smears among women who have had a hysterectomy. METHODS: We analyzed two surveys of US women aged 18 years or older, the Behavioral Risk Factor Surveillance System (1992-1997) and the National Health Interview Survey (1993-1994), and one survey of US hospitals (National Hospital Discharge Survey, 1980-1997). We examined the number of women who have had a hysterectomy who had a recent (within 3 years) Papanicolaou smear. We also examined trends in the proportions and rates of hysterectomies by diagnoses and type of procedure that potentially could require a Papanicolaou smear. RESULTS: From the Behavioral Risk Factor Surveillance System, an estimated 21.2% of US women have had a hysterectomy. Among women who have had a hysterectomy, 78.3% had a recent Papanicolaou smear. Among those reporting no hysterectomy, 82.1% had a recent Papanicolaou smear. Estimates from the National Health Interview Survey were similar. From the National Hospital Discharge Survey, an estimated 6.7% to 15.4% of women with a history of hysterectomy would require a subsequent Papanicolaou smear because they had a diagnosis related to cervical neoplasia or because they had undergone a supracervical hysterectomy. For an estimated 10.6-11.6 million of the 12.5 million women who had a hysterectomy and a recent Papanicolaou smear, that test could be considered unnecessary. CONCLUSION: Continued Papanicolaou screening of women without an intact uteri may result in excessive use of resources in time and money with minimal impact on decreasing cervical cancer.     

Study of estrogen activity in 1300 menopausal women

Over the 1969-1974 period a cytohormonal study was undertaken in 1200 menopausal women seen at the Cama Hospital, Bombay, India. Results are categorized under the following headings: postmenopausal endometrium - 104 cases; routine cytology in 1200 women; women with postmenopausal bleeding - 120 cases; women after hysterectomy and oophorectomy - 159 cases; and estrogen estimations in urine and correlation with cytology - 125 cases. Over 1961-1963, endometrium from 104 uteri removed for genital prolapse were studied and classified according to Parks et al. (1959). 9.6% were atrophic, 17.3% were inactive cystic glands, 2.8% were hyperplasia, 66.3% were proliferative, 2.8% were secretory, and 0.96% were polyps. There were only 297 normal smears in which cytohormonal evaluation could be done. Out of 215 cases in the 1st decade of menopause, 1/2 show some degree of estrogen activity and the other 1/2 show an atrophic pattern. Out of 76 cases in the 2nd decade only 24 show some degree of estrogen activity. Whereas 52 showed an atrophic pattern after 20 years of menopause only an occasional smear will show an estrogenic smear. Cytology has a definite place in the management of cases with menopausal bleeding and if used routinely will diagnose a few more cases which may be missed on biopsy, but routine cervico-vaginal smears should be supplemented with endocervical and endometrial aspiration smears. Vault smears from 159 hysterectomized women were studied. 71 had normal smears, 77 had inflammatory smears, 10 showed abnormal cells, and 1 smear was unsatisfactory. Cytohormonal evaluation was possible in 71 cases. 43 showed some degree of estrogen activity, whereas 28 smears were atrophic. When chemical estimation of urinary estrogen was done, it was found that the mean average value in the series was 7.6/mcgms.     

Low or absent SPARC expression in acute myeloid leukemia with MLL rearrangements is associated with sensitivity to growth inhibition by exogenous SPARC protein.

Secreted protein, acidic and rich in cysteine (SPARC), is a matricellular glycoprotein with growth-inhibitory and antiangiogenic functions. Although SPARC has been implicated as a tumor suppressor in humans, its function in normal or malignant hematopoiesis has not previously been studied. We found that the leukemic cells of AML patients with MLL gene rearrangements express low to undetectable amounts of SPARC whereas normal hematopoietic progenitors and most AML patients express this gene. SPARC RNA and protein levels were also low or undetectable in AML cell lines with MLL translocations. Consistent with its tumor suppressive effects in various solid tumor models, exogenous SPARC protein selectively reduced the growth of cell lines with MLL rearrangements by inhibiting cell cycle progression from G1 to S phase. The lack of SPARC expression in MLL-rearranged cell lines was associated with dense promoter methylation. However, we found no evidence of methylation-based silencing of SPARC in primary patient samples. Our results suggest that low or absent SPARC expression is a consistent feature of AML cells with MLL rearrangements and that SPARC may function as a tumor suppressor in this subset of patients. A potential role of exogenous SPARC in the therapy of MLL-rearranged AML warrants further investigation.