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   Table of Contents - Current issue
Coverpage
January-March 2022
Volume 5 | Issue 1
Page Nos. 1-197

Online since Thursday, March 31, 2022

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MUSINGS  

From Diamond Princess to Cordelia Cruises (Empress): Déjà vu in the New Year, lessons unlearned! p. 1
Nivedita Chakrabarty, Abhishek Mahajan
DOI:10.4103/crst.crst_20_22  
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Optimizing the bed distribution system in resource-constrained settings p. 5
Bal Krishna Mishra, Akhil Kapoor
DOI:10.4103/crst.crst_81_22  
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Impact of COVID-19 on global waste and the need for mitigation Highly accessed article p. 7
Nivedita Chakrabarty, Shreya Shukla, Abhishek Mahajan
DOI:10.4103/crst.crst_67_22  
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ORIGINAL ARTICLES Top

Outcome of COVID-19 on Indian patients with cancer: A multicenter, retrospective study Highly accessed article p. 11
Arun Seshachalam, SV Saju, Honey Susan Raju, Krishnakumar Rathnam, Murugesan Janarthinakani, Krishna Prasad, Channappa Patil, Parameswaran Anoop, Neelesh Reddy, Satish Kumar Anumula, Krishna Reddy Golamari, Sravan Kumar Bodepudi, Madhav Danthala, Basawantrao Malipatil, G Senthilkumar, Kesavan Niraimathi, SG Raman
DOI:10.4103/crst.crst_212_21  
Background: Managing patients with cancer during the coronavirus disease 2019 (COVID-19) pandemic has been challenging. Disruptions in cancer management have been observed due to cancellation of treatment, issues related to commuting, and dearth of health-care workers. Objectives: This study was conducted during the first wave of the COVID-19 pandemic and was aimed at evaluating the 30-day all-cause mortality among patients with cancer and COVID-19 infection and the factors affecting it. Materials and Methods: In this retrospective study, we collected secondary data from nine tertiary care centers in South India over a period of 10 months from March to Dec 2020. Patients across all age groups with histopathologically confirmed diagnosis of cancer who were affected by COVID-19 during their evaluation or treatment were included in the study. The primary outcome variables of the present study were 30-day all-cause mortality, cancer outcomes, and COVID-19 outcomes. Results: A total of 206 patients were included. Median age of the cohort was 55.5 years, and the male-to-female ratio was 1:1.03. The 30-day mortality rate was 12.6%. Twenty-two patients (10.7%) had severe COVID-19 infection at the initial presentation. Predictors for severe pneumonia at the initial presentation were incomplete remission at the time of COVID-19 diagnosis and palliative intent of treatment. Severe pneumonia at the initial presentation, diagnosis of COVID-19 on or before August 2020, and need for ventilator support were associated with increased mortality. Conclusion: Severity of infection at the initial presentation, cancer status, and the intent of cancer treatment impact COVID-19 outcomes in patients with cancer.
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Deep learning-based COVID-19 triage tool: An observational study on an X-ray dataset Highly accessed article p. 19
Abhishek Mahajan, Vivek Pawar, Vivek Punia, Aakash Vaswani, Piyush Gupta, KS S. Bharadwaj, Arvind Salunke, Sujit D Palande, Kalashree Banderkar, M L V. Apparao
DOI:10.4103/crst.crst_162_21  
Background: Easy availability, low cost, and low radiation exposure make chest radiography an ideal modality for coronavirus disease 2019 (COVID-19) detection. Objectives: In this study, we propose the use of an artificial intelligence (AI) algorithm to automatically detect abnormalities associated with COVID-19 on chest radiographs. We aimed to evaluate the performance of the algorithm against the interpretation of radiologists to assess its utility as a COVID-19 triage tool. Materials and Methods: The study was conducted in collaboration with Kaushalya Medical Trust Foundation Hospital, Thane, Maharashtra, between July and August 2020. We used a collection of public and private datasets to train our AI models. Specificity and sensitivity measures were used to assess the performance of the AI algorithm by comparing AI and radiology predictions using the result of the reverse transcriptase-polymerase chain reaction as reference. We also compared the existing open-source AI algorithms with our method using our private dataset to ascertain the reliability of our algorithm. Results: We evaluated 611 scans for semantic and non-semantic features. Our algorithm showed a sensitivity of 77.7% and a specificity of 75.4%. Our AI algorithm performed better than the radiologists who showed a sensitivity of 75.9% and specificity of 75.4%. The open-source model on the same dataset showed a large disparity in performance measures with a specificity of 46.5% and sensitivity of 91.8%, thus confirming the reliability of our approach. Conclusion: Our AI algorithm can aid radiologists in confirming the findings of COVID-19 pneumonia on chest radiography and identifying additional abnormalities and can be used as an assistive and complementary first-line COVID-19 triage tool.
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Preference and Satisfaction with Cancer Institute quality of life questionnaire, (CI - QoL) V. II and EORTC QLQ-C30 Tamil version: An observational study Highly accessed article p. 26
Sasikala Athikesavan, Vidhubala Elangovan, Sundaramoorthy Chidambaram, Surendran Veeraiah
DOI:10.4103/crst.crst_218_21  
Background: Quality of life (QoL) is an important clinical outcome in oncology and various tools are available for its assessment. The Cancer Institute QoL Questionnaire, Version II (CI-QoL II) is a questionnaire standardized for use in the Indian setting. Objectives: This study was aimed at evaluating the preference for and satisfaction with CI-QoL II and the European Organization for Research and Treatment of Cancer QoL Questionnaire Core 30 (EORTC QLQ-C30) (Tamil version) among patients with cancer. Materials and Methods: This study was conducted in the Department of Psycho-Oncology of the Cancer Institute (WIA), Chennai, India, in patients with cancer between September and October 2017. Participants were administered the CI-QoL II and EORTC QLQ-C30, questionnaires 15 min apart, and a debriefing interview was conducted to explore relevant, confusing, or upsetting items. Results: A total of 60 participants were included in the study. The mean age was 38 years (range, 18–60). CI-QoL II was preferred by 43% of the patients and EORTC QLQ-C30 by 20%. Around 85% of patients reported satisfaction with both questionnaires, 12% with CI-QoL II, and 3% with EORTC QLQ-C30. In EORTC QLQ-C30, items on daily activities (10%) and leisure activities (10%) were reported as confusing; impact on family (1.7%), social life (1.7%), and financial life (1.7%) were reported as upsetting; need for rest (5%), irritability (5%), daily activities (13.3%), and leisure activities (18.3%) were reported as irrelevant. In CI-QoL, items on dependency on medication (5%) were reported as confusing, spousal support (6.7%), and sex life (5%) were reported as upsetting, and dependency on medication (23.3%), sex life (31.7%), and spousal support (16.7%) were reported as irrelevant. Conclusion: Over twice the number of patients prefer the CI-QoL II questionnaire to EORTC QLQ-C30; more patients are satisfied with CI-QOL II. The CI-QoL II obtains more information on the QoL of patients to facilitate psychological counseling in the clinical setting, whereas EORTC QLQ-C30 is more appropriate in eliciting responses without bias.
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Construction and validation of palliative care nursing theory guidelines for patients with advanced cancer p. 35
C Vasantha Kalyani, Kusum K Rohilla, Amit Gupta, Sweety Gupta, Manoj Gupta, Nirmal Matella
DOI:10.4103/crst.crst_307_21  
Background: Globally, there are many patients suffering from advanced cancers. There is a limited structured theoretical framework available for providing palliative care to these patients. Objectives: We aimed to construct and validate palliative care nursing theory guidelines to provide better palliative services to patients with advanced cancer. Materials and Methods: This study was conducted in Departments of Surgery and Radiation Oncology at the All India Institute of Medical Sciences, Rishikesh. In the present study, we used mixed-method design in which both qualitative and quantitative methods were used. In the qualitative study, exploratory surveys were used to derive themes using directed content analysis. We used the prospective cohort methods in the quantitative study. We tested the palliative care nursing theory on 80 patients with advanced gallbladder cancer and their caregivers for 6 months using the European Organization for Research and Treatment of Cancer Quality of Life (EORTC QOL) scale and assessed the survival outcomes. Results: Between July 2019 and Dec 2019, we enrolled 25 patients in the qualitative study. Four concepts of palliative care nursing theory were derived, that is, symptomatic management, problem-solving counseling, yoga and meditation, and family or caregiver involvement. Out of these, we developed a conceptual framework and palliative care nursing theory. In the subsequent quantitative study, we then tested this palliative care nursing theory on 80 patients (40 in the interventional group and 40 in the control group) with advanced cancer who were receiving palliative treatment. We provided care according to the palliative care nursing theory guidelines to the patients in the interventional group and found that this resulted in a significant benefit for both overall survival and quality of life (P = 0.0001; 95% confidence interval [CI], 5.97–87.82). Conclusion: Our validated palliative care nursing theory is a structured and well-designed tool to provide comprehensive palliative care to patients with cancer. This can guide palliative care teams to provide better palliative care to patients and their families.
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Impact of demographic factors on delayed presentation of oral cancers: A questionnaire-based cross-sectional study from a rural cancer center p. 45
Anshul Singla, Alok K Goel, Simmi Oberoi, Shivani Jain, Deepak Singh, Rakesh Kapoor
DOI:10.4103/crst.crst_318_21  
Background: Oral cancer is a major health issue in India. The majority of patients with oral cancer present at an advanced stage. Objectives: We aimed to understand the factors responsible for delay in presentation of patients with oral cancer in rural areas. Materials and Methods: This questionnaire-based, cross-sectional study on patients with oral cancer was conducted in the head and neck surgical outpatient department of our tertiary care center at Homi Bhabha Cancer Hospital, Sangrur, between June and September 2021. A questionnaire consisting of 31 multiple choice questions was administered to consenting patients. The demographic and socio-economic profile of the patients, their knowledge of risk factors, and their symptomatology, attitude towards cancer management, access to cancer care, and knowledge about cancer treatment and its outcomes were assessed. Results: A total of 200 patients were included; 70% were men. About 60% of the participants had to travel more than 100 km to reach our center. About 50% of the patients were addicted to tobacco in some form. Only 30% of the participants were aware of the risk factors for oral cancer. The median time between symptom onset and seeking any medical consultation was 120 days, whereas the median time between symptom onset and cancer diagnosis was 165 days. About 75% of patients initially consulted an alternative medicine practitioner, and 90% took some form of alternative treatment before consulting a cancer specialist. Around 80% considered alternative medicines to be an effective form of cancer treatment. Conclusion: Our study shows a gross lack of awareness and multiple misconceptions that prevail in the rural population. Increasing public awareness, training primary healthcare workers to pick up on early signs of oral cancer, promoting tobacco cessation activities, and teaching oral self-examination and its importance to people can help tackle the problem of delayed presentation of oral cancers.
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Diagnostic accuracy of mammography in characterizing breast masses using the 5th edition of BI-RADS: A retrospective study p. 52
Suvendu Kumar Mohapatra, Prafulla Kumar Das, Rashmita Binod Nayak, Abhisek Mishra, Bhagyalaxmi Nayak
DOI:10.4103/crst.crst_224_21  
Background: Breast imaging-reporting and data system (BI-RADS) is intended for standardizing mammography reporting. Objectives: We aimed to evaluate the diagnostic precision of the BI-RADS assessment scoring system using histopathological findings as the reference standard. We also aimed to assess the positive predictive value (PPV) of different morphological descriptors for malignancy. Materials and Methods: This retrospective record-based analytical study was conducted in the Department of Radiodiagnosis of Acharya Harihar Post Graduate Institute of Cancer, Cuttack, Odisha, a tertiary cancer center in eastern India. We included patients attending the breast cancer unit with various breast complaints who were subjected to mammographic imaging and histopathological examination. The primary outcomes were the sensitivity, PPV, negative predictive value (NPV), and diagnostic accuracy (DA) of the BI-RADS scores for the pathological reports; secondary objective was the evaluation of the mammographic morphological characteristics. Mammography was interpreted using the BI-RADS 5th edition guidelines, without prior knowledge of the biopsy report. A BI-RADS final assessment score between 1 and 5 was assigned, where 1 indicated a normal study, 2 benign, 3 possibly benign requiring follow up, 4 suspicious requiring biopsy, and 5 indicating likely malignant requiring biopsy and further actions. Results: Between February 2020 and December 2020, we included 247 patients. All the category 5 lesions were malignant, while 76.5% of category 4 lesions were malignant. PPVs of BI-RADS categories 4a, 4b, and 4c were 38%, 90%, and 94%, respectively. Mammography had a sensitivity, specificity, PPV, NPV, and DA of 98.7%, 47.6%, 87.5%, 90.9%, and 87.9%, respectively. Morphological features that were significantly associated with malignancy were spiculated margins (P = 0.003, PPV = 100%), microlobulated margins (P = 0.005, PPV = 96.5%), irregular shape (P = 0.002, PPV = 89.6%), microcalcification (P = 0.005, PPV = 92.8%), skin thickening (P < 0.0001, PPV = 100%), and architectural distortion (P = 0.003, PPV = 96.7%). Conclusion: Digital mammography is a sensitive tool for the evaluation of breast lumps, but BI-RADS final assessment score is subjective as it depends on the interpreter's expertise.
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Significance of too-small-to-characterize (TSTC) pulmonary nodules in known extrapulmonary solid tumors: A retrospective observational study Highly accessed article p. 59
Abhishek Mahajan, Matthew Monachen, Shreya Shukla, Ujjwal Agarwal, Nilesh Sable, Kumar Prabhash, Swapnil Rane, Meenakshi Thakur
DOI:10.4103/crst.crst_228_21  
Background: Increased use of chest computed tomography (CT) scanning and greater awareness among general radiologists has led to a rise in lung nodule identification. Nodules less than 1 cm in diameter are considered small, and the morphology of such nodules is difficult to characterize. Objectives: The aim of our study was to determine the significance of pulmonary nodules that are too-small-to-characterize on CT scan in patients with extrapulmonary solid tumors and to determine the characteristics that help in distinguishing malignant from benign pulmonary nodules. Materials and Methods: We conducted a retrospective observational study in the Department of Radiodiagnosis of the Tata Memorial Hospital, Mumbai, India, and included patients with non-pulmonary solid malignancies who had obtained baseline CT/positron emission tomography (PET) scans between January 2010 and December 2014. Demographic information, site of the primary tumor, and histological diagnosis were recorded. Baseline and follow-up CT images were read by two radiologists. The significance of associated risk factors was analyzed using Pearson's Chi-square test. A multivariable logistic regression model was used. Results: Our study included 200 patients and 334 nodules, of which 148 (44.3%) nodules were found to be benign and 127 (38%) were malignant. The remaining 59 (17.7%) nodules in 32 patients were indeterminate. Most nodules located at a distance of less than 10 mm from the pleura were benign, whereas more than 2/3rd of the nodules more than 10 mm away from the pleura were malignant (n = 60/94, 63.8% P = 0.0001). The mean size of the 148 benign nodules (5.3 mm) was smaller than that of the 127 malignant nodules (9.2 mm). Nearly 93% of malignant nodules were solid (P = 0.0001). About 83% of malignant nodules were round, while 7 of 10 linear-shaped nodules were either benign or indeterminate (P = 0.006). Among the nodules associated with poorly differentiated primary neoplasms, 63.6% were malignant, 25% were benign, and 11.4% were indeterminate (P = 0.005). Conclusions: Too-small-to-characterize pulmonary nodules detected on CT are a common clinical problem and are more likely to be benign or indeterminate even in patients with known extrapulmonary neoplasms. Using nodule size, distance from the pleura, and morphological pointers, radiologists can help clinicians decide whether there is a need for biopsy or a short-interval follow-up. We have proposed a Pulmonary Metastases Cancer Imaging and Reporting Data System (PM-CI-RADS).
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ORIGINAL ARTICLE - REAL WORLD DATA Top

Clinicopathologic features and outcomes of diffuse large B-cell lymphoma with extranodal involvement: A retrospective analysis p. 67
Sukesh C Nair, Ajay Gogia, Shalabh Arora, Lalit Kumar, Atul Sharma, Ahitagni Biswas, Ritu Gupta, Saumyaranjan Mallick
DOI:10.4103/crst.crst_204_21  
Background: Extranodal involvement is seen in about 40%–50% of the cases of diffuse large B-cell lymphoma (DLBCL). However, data on the clinicopathological features and outcomes of DLBCL with extranodal involvement, especially in the rituximab era, are scarce from India. Objectives: In this study, we aimed to assess the clinicopathological features and outcomes of DLBCL with extranodal involvement among Indian patients. Materials and Methods: This retrospective study was conducted on patients with DLBCL, registered in the Department of Medical Oncology of the All India Institute of Medical Sciences, Delhi, India, between January 2014 and December 2018. Patients with nodal DLBCL aged more than 18 years, with concomitant extranodal disease in any anatomical site were included. All patients were treated with multiagent chemotherapy with or without rituximab. Results: Median age of the cohort was 50 years (range, 18–86), a male-to-female ratio of 2:1. B-symptoms and bulky disease were seen in 48% and 39% patients, respectively. Bone was the most common site of extranodal involvement observed in 32% patients. Bone marrow involvement was present in 13% patients. Low-risk International Prognostic Index (IPI) was seen in 32% patients and intermediate risk IPI in 38% patients. Cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP)-based treatment was used in 80% of the patients and rituximab (R) was used in 73% of the patients. The objective response rate was 76%, with a complete response rate of 65.5%. After a median follow-up of 26 months, the 3-year progression free survival and overall survival (OS) were 65% and 82.7%, respectively. Involvement of the kidney/adrenal gland and central nervous system, high IPI score, and use of non- R-CHOP regimens were associated with a poor OS on the multivariate analysis. Conclusions: The bone is the most common site of extranodal involvement in Indian patients with DLBCL. The outcome of extranodal DLBCL depends on the primary site of disease involvement.
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ORIGINAL ARTICLE: GERIATRIC ONCOLOGY SECTION Top

Timed Up and Go as a predictor of mortality in older Indian patients with cancer: An observational study Highly accessed article p. 75
Abhijith Rajaram Rao, Sharath Kumar, Ratan Dhekale, Jyoti Krishnamurthy, Sarika Mahajan, Anuradha Daptardar, Anant Ramaswamy, Vanita Noronha, Vikram Gota, Shripad Banavali, Kumar Prabhash
DOI:10.4103/crst.crst_79_22  
Background: Therapeutic decision-making in older patients with cancer is challenging, and there is a need for a clinical parameter that can guide these decisions. The Timed Up and Go (TUG) test is an easy-to-administer tool that measures physical performance and may help to identify vulnerable patients. Objectives: We aimed to study the association between the TUG and overall survival in older Indian patients with cancer. We also aimed to evaluate the factors that were associated with a poor TUG score, to define the optimal cut-off score for older patients with cancer, along with the sensitivity and specificity. Materials and Methods: This prospective observational study was conducted in the geriatric oncology clinic at the Tata Memorial Hospital, a tertiary care center in Mumbai, India, between June 2018 and January 2022. We included adults aged 60 years and above, who had a diagnosis of malignancy, and had undergone a multidimensional geriatric assessment. Patients without a TUG score and for whom survival information was not available were excluded. Using the Short Physical Performance Battery (SPPB) as the gold standard, Receiver Operating Characteristic (ROC) curves with Area Under the Curve (AUC) were used, and the cut-off score with optimum sensitivity and specificity was derived. Mean values between two and more groups were compared using t test and analysis of variance, respectively. Categorical variables were compared using Fisher's exact and Pearson's Chi-squared test. The Kaplan–Meier survival estimate, and the unadjusted and adjusted Cox proportional-hazards model were used for survival analysis. Results: We enrolled 851 patients in the study. The median age was 69 (IQR, 65 to 73) years; 544 patients (76%) were men. We found that the TUG in women (median TUG, 11 seconds; IQR, 9.5 - 13.7) was longer than in men (median TUG, 9.6 seconds; IQR, 8.2 -11.6); P < 0.01. The TUG score increased significantly with increasing age in both sexes. Presence of comorbidities impaired cognition, poor nutritional status, depression, and anxiety were significantly associated with higher TUG scores. TUG was a significant predictor of mortality on both the univariate (HR, 1.056; 95% CI, 1.037–1.075) and multivariate models (HR, 1.058; 95% CI, 1.039–1.078). The median survival of patients with TUG <12 seconds was 13.9 months (95% CI, 11.2 to 16.5), compared to 8.5 months (95% CI, 6.6 to 10.3) in those with a TUG ≥ 12 seconds (P = 0.002). The TUG cut-off score of 10 seconds had an AUC-ROC, sensitivity of 62.32% and specificity of 80.58%. Conclusion: TUG can be a reliable tool in a busy outpatient setting to identify vulnerable patients who require a detailed geriatric assessment. A TUG score of ≥ 10 seconds is a good predictor of impaired mobility. Further 0.78 interventional studies are required to identify the benefits of physical therapy in older patients with cancer.
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POETRY IN ONCOLOGY Top

The emancipation p. 83
Nivedita Chakrabarty
DOI:10.4103/crst.crst_3_22  
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Superhero p. 84
Archi Rungta
DOI:10.4103/crst.crst_16_22  
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PATIENT/CAREGIVER CORNER Top

You can (cer) do it! p. 85
Ananya Pendekanti
DOI:10.4103/crst.crst_321_21  
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Caregiving: A journey unacknowledged p. 88
Vandana Mahajan
DOI:10.4103/crst.crst_29_22  
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REVIEW ARTICLE Top

Body image disturbances among breast cancer survivors: A narrative review of prevalence and correlates p. 90
Monika Thakur, Roopali Sharma, Anand Kumar Mishra, Bandna Gupta
DOI:10.4103/crst.crst_170_21  
Body image is an essential aspect of femininity. Body image disturbances occurring due to breast cancer pose a difficult challenge, which can impact the quality of life of breast cancer survivors. Various treatment modalities used to cure cancer may result in major alterations of body image. The purpose of this review is to describe the magnitude of body image disturbances and the associated factors which influence the quality of life. A thorough literature search was performed to identify articles related to body image disturbances in patients with breast cancer. Google Scholar, PubMed, Scopus, and Web of Science databases were searched using key terms such as “body image disturbances,” “sexuality,” “women,” and “breast cancer.” Original research articles, systematic reviews, and meta-analyses published in English from 2000 to 2020 that reported on body image as the main variable using standardized tools and had a sample size of at least 100 were considered eligible for inclusion in the review. A total of 40 articles matched the inclusion criteria, out of 100 that were identified from the database search. Our review suggests that in patients with breast cancer, the type of treatment, primarily modified radical mastectomy, and age have a significant association with disturbed body image, resulting in physical or psychological distress, eventually leading to difficulty in partnered relationships and sexual intimacy. Body image disturbance is an indispensable part of female health, and due care must be taken along with treatment to avoid psychological and physical distress.
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REVIEW ARTICLE-BIOMARKER SERIES Top

A narrative review of ERBB2 in non-small cell lung carcinoma p. 97
Mansi Sharma, Abhinav Dewan, Himanshi Diwan, Shrinidhi Nathany, Ullas Batra
DOI:10.4103/crst.crst_323_21  
The plethora of biomarkers and the availability of targeted treatment have revolutionized the therapeutic profile of non-small cell lung cancer (NSCLC). Erythroblastic oncogene B (ERBB2) has been reported in 1%–4% cases of lung adenocarcinoma and recognized as a prognostic marker in a myriad of cancers like pancreatic, gastric, and breast carcinomas. It is more commonly recognized as human epidermal growth factor receptor 2 (HER2). Molecular characterization of NSCLC based on the mechanism of HER2 activation, including mutation, amplification, and overexpression, has recently been widely adopted owing to the differences in prognosis and predictive outcomes. This narrative review of ERBB2 is intended to describe the molecular biology, historical perspective, clinical profile, and therapeutic options for HER2-activated NSCLC. For the purpose of this review, we performed a comprehensive and detailed search in PubMed, Scopus, and My Cancer Genome databases using the keywords “HER2/neu,” “HER2,” “NSCLC,” “pertuzumab,” “trastuzumab,” and “T-DM1.” A total of 59 articles were included in the review.
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DRUG REVIEW Top

Romiplostim – A narrative drug review p. 105
Anuj Gupta, Akhil Kapoor, Amit Choudhary, Sujeet Kumar, Bal Krishna Mishra
DOI:10.4103/crst.crst_17_22  
Chemotherapy-induced thrombocytopenia (CIT) is a challenging condition that is routinely encountered in oncology practice. Currently, the sole therapeutic modality for CIT is the transfusion of platelets, especially when the platelet count is less than 20,000 per microliter. Chemotherapy dose reductions and dose delays result, which may lead to compromised outcomes. Drugs like oprelvekin and avatrombopag have been tried for CIT, but are not in routine use due to severe adverse effects. Romiplostim and eltrombopag are thrombopoietin receptor agonists that have been successfully used in benign conditions like idiopathic thrombocytopenic purpura (ITP), but are not approved for use in CIT. We searched PubMed for studies published in the last 5 years (2017–2021), using the key words “romiplostim,” “cancer,” and “malignancy”. We excluded articles that were related to benign causes of thrombocytopenia, articles for which the full text was not available, non-human studies, and articles in a language other than English. A total of 34 articles were included. In this narrative drug review, we have focused on romiplostim and the evidence supporting its use in both solid and hematologic malignancies.
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RESIDENT CORNER Top

My experience with medical oncology fellowship training at the Tata Memorial Hospital p. 111
Mahamat Saleh Baldass
DOI:10.4103/crst.crst_77_21  
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EDITORIALS Top

Perceptions and realities about early mortality rates from COVID-19 in Indian patients with cancer p. 113
Vinayak V Maka, Santhosh K Devadas
DOI:10.4103/crst.crst_90_22  
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Use of artificial intelligence on chest skiagrams in patients with COVID-19: Time to widen the horizon p. 116
Atul Kapoor
DOI:10.4103/crst.crst_39_22  
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Extranodal diffuse large B-cell lymphoma: Real-world experience from an Indian tertiary cancer center p. 119
MC Suresh Babu, A Sreevalli
DOI:10.4103/crst.crst_93_22  
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MOLECULAR TUMOR BOARD Top

EGFR exon 20 insertion in non-small cell lung cancer p. 122
Goutam Santosh Panda, Vanita Noronha, Omshree Shetty, Subhash Yadav, Rajiv Kumar, Vijay Patil, Pratik Chandrani, Amit Janu, Abhishek Mahajan, Anuradha Chougule, Kumar Prabhash
DOI:10.4103/crst.crst_77_22  
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IMAGE CHALLENGES Top

Diagnostic quandary over a cheek(y) neoplasm p. 131
Shreya Shukla, Ujjwal Agarwal, Vasundhara Patil, Swapnil Rane, Nandini Menon, Vanita Noronha, Vijay Patil, Kumar Prabhash, Abhishek Mahajan
DOI:10.4103/crst.crst_274_21  
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What's that in the infratemporal fossa? p. 136
Abhishek Mahajan, Renuka Ashtekar, Ujjwal Agarwal, Shreya Shukla
DOI:10.4103/crst.crst_251_21  
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STATISTICAL RESOURCE Top

Are you confident about your confidence in confidence intervals? p. 139
HS Darling
DOI:10.4103/crst.crst_75_22  
Confidence interval (CI) is a commonly used parameter in the statistical analysis of various clinical studies. Despite being highly informative, and easily interpretable, the CI is associated with certain oversimplifications, leading to occasionally distorted conclusions of the results. This review is an overview of the characteristics, uses, shortcomings, and recommendations to help guide the best use of the CI. We searched in the PubMed and Cochrane databases using the search terms, “clinical importance,” “confidence interval,” “confidence level,” “point estimate,” and “statistical significance,” and the articles directly relevant to this review were chosen. The purpose of the review is to familiarize clinicians with the concept of the CI and to equip them with a basic understanding of the results of scientific publications.
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LETTERS TO EDITOR Top

Problems associated with inadequate surgery in patients with cervical cancer: Can they be avoided? p. 145
Mrinalini Verma, Kirti Srivastava, Sanjay Singhal, M L B Bhatt
DOI:10.4103/crst.crst_52_22  
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P values need to be correctly understood and read along with 95% confidence intervals p. 147
Chittaranjan Andrade
DOI:10.4103/crst.crst_54_22  
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Author's reply to Andrade p. 148
HS Darling
DOI:10.4103/crst.crst_87_22  
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Changing the paradigm of treatment in locally advanced breast cancers: Can we impact outcomes in resource-limited settings by improving pathological complete response? p. 149
Priya Iyer
DOI:10.4103/crst.crst_32_22  
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Pathological complete response in locally advanced breast cancer after neoadjuvant chemotherapy: Hope or hype p. 150
Reshu Agarwal, Vijaykumar Dehannathparambil Kottarathil
DOI:10.4103/crst.crst_24_22  
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Authors' reply to Agarwal et al. and Iyer p. 152
Ajeet Kumar Gandhi, Ajay Gogia
DOI:10.4103/crst.crst_61_22  
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Day 14 bone marrow response assessment in acute myeloid leukemia: Should we discontinue? p. 153
Shilpi Chaudhary, Shuvadeep Ganguly, Sameer Bakhshi
DOI:10.4103/crst.crst_44_22  
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The day 14 conundrum still remains unresolved! p. 155
Priyanka Soni, Naveen Gupta, Hemant Malhotra
DOI:10.4103/crst.crst_49_22  
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Authors' reply to Chaudhary et al. and Soni et al. p. 156
Avaronnan Manuprasad, Vineetha Raghavan, Praveen K Shenoy, Aswathi Krishnan, Chandran K Nair
DOI:10.4103/crst.crst_76_22  
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Profile and outcome of advanced malignant melanoma in India: Need for cost-effective innovations p. 157
Shuvadeep Ganguly, Sameer Bakhshi
DOI:10.4103/crst.crst_30_22  
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Indian real-world data on melanoma p. 158
HN Arun
DOI:10.4103/crst.crst_40_22  
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Malignant melanoma in India: Is it time to set the wheels in motion? p. 159
Bivas Biswas, Somnath Roy, Sandip Ganguly
DOI:10.4103/crst.crst_37_22  
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Authors' reply to Arun, Biswas et al., and Ganguly et al. p. 161
Sameer Rastogi, Sorun Shishak, Abhenil Mittal
DOI:10.4103/crst.crst_91_22  
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Improving access to technology among older adults with cancer: Current perspectives and future priorities p. 162
Andrea de-la-O-Murillo, Enrique Soto-Perez-de-Celis
DOI:10.4103/crst.crst_33_22  
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Making the seniors tech savvy: The way forward to bringing cancer care to the doorstep p. 163
Naganath Narasimhan Prem, Anupa Pillai, Joyita Banerjee
DOI:10.4103/crst.crst_43_22  
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Authors' reply to de-la-O-Murillo and Soto-Perez-de-Celis, and Prem et al. p. 164
Abhijith Rajaram Rao, Vanita Noronha, Anant Ramaswamy, Kumar Prabhash
DOI:10.4103/crst.crst_63_22  
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Is CROSS the right approach for locally advanced esophageal cancer in India? p. 165
HN Arun
DOI:10.4103/crst.crst_47_22  
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Neoadjuvant chemoradiation followed by surgery in operable carcinoma esophagus: Is the real-world scenario too far from clinical trial settings? p. 166
Tapesh Bhattacharyya, Indranil Mallick, Moses Arun Singh
DOI:10.4103/crst.crst_48_22  
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Does the radiation dose in neoadjuvant chemoradiation in resectable esophageal carcinoma matter in the Indian scenario? p. 167
Subramanyeshwar Rao Thammineedi, Sujith Chyau Patnaik, Syed Nusrath
DOI:10.4103/crst.crst_58_22  
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Authors' reply to Bhattacharyya et al., Thammineedi et al., and Arun p. 169
Tapas Kumar Dora, Tushar Aeron, Abhishek Chatterjee, Jayashree Deshmukh
DOI:10.4103/crst.crst_65_22  
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Is there a place today for augmented and virtual reality in cigarette smoking cessation? p. 172
Pankaj Chaturvedi, Arjun Singh
DOI:10.4103/crst.crst_12_22  
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Future scope of virtual reality and augmented reality in tobacco control p. 173
Harsh Priya, Bharathi M Purohit, Priyanka Ravi
DOI:10.4103/crst.crst_22_22  
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Authors' reply to Singh and Chaturvedi, and Priya et al. p. 174
S Canty Sandra, Anusha Raghavan, PD Madan Kumar
DOI:10.4103/crst.crst_50_22  
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Are we there RET? p. 175
Ashutosh Jaiswal, Raajit Chanana
DOI:10.4103/crst.crst_28_22  
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Authors' reply to Jaiswal and Chanana p. 176
Ullas Batra, Shrinidhi Nathany, Himanshi Diwan
DOI:10.4103/crst.crst_62_22  
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Lenvatinib: With more power comes more toxicity p. 177
Shikhar Kumar
DOI:10.4103/crst.crst_18_22  
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Lenvatinib: A potent oral tyrosine kinase inhibitor across multiple histologies with differing dosages p. 178
Bipinesh Sansar, Neha Singh, Arpita Singh
DOI:10.4103/crst.crst_31_22  
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iT may improve prognostication but is not meant for staging in its current form p. 179
MP Sreeram, Narayana Subramaniam
DOI:10.4103/crst.crst_34_22  
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Authors' reply to Sreeram and Subramaniam p. 181
Abhishek Mahajan, Richa Vaish, Shreya Shukla, Ujjwa Agarwal
DOI:10.4103/crst.crst_83_22  
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Immunotherapy for triple-negative breast cancer: Time to pause? p. 182
Vamshi Krishna Muddu, Nanditha Boindala
DOI:10.4103/crst.crst_42_22  
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Authors' reply to Muddu and Boindala p. 183
Rakesh Sharma, Ajay Gogia
DOI:10.4103/crst.crst_66_22  
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M. masseter pars coronoidea: Gateway between the masticator space and infratemporal fossa p. 185
Abhishek Mahajan, Vasundhara Smriti
DOI:10.4103/crst.crst_9_22  
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Transplantation and maintenance in multiple myeloma appear to overcome differences in induction regimens p. 186
Jagdeep Singh, Kaveri Joshi, Suvir Singh
DOI:10.4103/crst.crst_291_21  
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Vemurafenib plus rituximab in relapsed or refractory hairy cell leukemia p. 188
Annie Kanchan Baa, Ajay Gogia
DOI:10.4103/crst.crst_8_22  
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Organizational aspects of critical care in patients with hematologic malignancies and those undergoing stem cell transplantation p. 189
Suvir Singh, Vivek K Gupta, Gurkirat Kaur
DOI:10.4103/crst.crst_5_22  
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Adjuvant pembrolizumab in renal cell carcinoma p. 191
Raghav Raodha, Ajay Gogia, Annie Baa
DOI:10.4103/crst.crst_10_22  
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Microbiota as a predictor of mortality in allogeneic hematopoietic cell transplantation p. 191
Rakesh Sharma, Ajay Gogia, Annie Kanchan Baa
DOI:10.4103/crst.crst_11_22  
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Secondary cytoreductive surgery in recurrent ovarian carcinoma p. 192
Shuvadeep Ganguly, Ajay Gogia
DOI:10.4103/crst.crst_14_22  
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Preparation is key: Prehabilitation for patients receiving high-dose chemotherapy and autologous stem cell transplant p. 193
Suvir Singh, Gurkirat Kaur
DOI:10.4103/crst.crst_35_22  
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Is cabozantinib the common answer to all radioiodine-refractory differentiated thyroid cancers? p. 194
Akhil Kapoor, Vijay M Patil, Kumar Prabhash
DOI:10.4103/crst.crst_15_22  
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Trastuzumab deruxtecan in HER2-mutant non-small-cell lung cancer p. 195
Shuvadeep Ganguly, Ajay Gogia
DOI:10.4103/crst.crst_84_22  
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Relatlimab and nivolumab in untreated advanced melanoma p. 196
Shuvadeep Ganguly, Ajay Gogia
DOI:10.4103/crst.crst_71_22  
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