key: cord-352382-mazwgsbc authors: Vavassori, Andrea; Tagliaferri, Luca; Vicenzi, Lisa; D'Aviero, Andrea; Ciabattoni, Antonella; Gribaudo, Sergio; Lapadula, Loredana; Carlo Mattiucci, Gian; Vinante, Lorenzo; De Sanctis, Vitaliana; Vidali, Cristiana; Murri, Rita; Antonietta Gambacorta, Maria; Mignogna, Marcello; Jereczek-Fossa, Barbara A.; Donato, Vittorio title: Practical indications for management of patients candidate to Interventional and Intraoperative Radiotherapy (Brachytherapy, IORT) during COVID-19 pandemic – A document endorsed by AIRO (Italian Association of Radiotherapy and Clinical Oncology) Interventional Radiotherapy Working Group date: 2020-05-08 journal: Radiother Oncol DOI: 10.1016/j.radonc.2020.04.040 sha: doc_id: 352382 cord_uid: mazwgsbc nan In the contest of COVID-19 rapid spread in Italy, the Italian Government in March 2020 released an official recommendation statement indicating . 1 Regarding oncological patients, the statement indicates to regional health authorities to identify and implement as quickly as possible the arrangements necessary to ensure oncological treatments, in order not to influence disease prognosis. The Italian Association of Radiotherapy and Clinical Oncology (AIRO) released an orientation paper in order to assure homogeneous working procedures during the COVID-19 pandemic emergency. 2 Interventional Radiation Therapy (IRT, Brachytherapy, BT) and IntraOperative Radiotherapy (IORT) represent potentially life-saving treatment options in different oncological clinical settings with indications shared in multidisciplinary contexts following international guidelines or trial protocols. 3 Delaying radiation treatments could worsen the overall prognosis of the disease, so that it seems to be essential to ensure radiation treatments delivery even at the time of COVID-19 emergency, fully guaranteeing health professionals, patients, and caregivers safety. 4, 5 Current evidences review on "COVID-19 disease" and "Radiation Oncology" was performed, then a multicenter team composed by all members of current AIRO-IRT/IORT-Working Group (WG), an infectious disease expert working in a COVID-19 Hospital, the past chair and deputy chair of AIRO-IRT/IORT-WG, members of AIRO committee, the chair of the Scientific Committee and the president of AIRO wrote this document. To enable the regular conduct of clinical activity and the reduction of the risk of COVID-19 diffusion in the radiation oncology departments, it is essential to identify patients and operators with suspected or proven infection performing triage at the hospital and/or departments entrance (Table 1) . It is strongly recommended the identification of dedicated team members to manage COVID-19 cases. As a general rule, the RADS (Remote visits, Avoidance of treatment if little to no benefit or if an alternative treatment is available, Deferment of treatment if clinically appropriate, and Shortening of radiotherapy if treatment is unavoidable) principle is recommended to plan each individual patient treatment. 6 For new outpatients' appointments it is recommended, if possible, to contact patients the day before the start of treatment (or any fraction if once weekly) whereas any new patient who has to undergo inpatient therapy should be contacted the day before hospitalization or any preoperative anesthesiologic assessment. According to national, regional or institutional recommendation, consider nasopharyngeal swab for SARS-CoV-2 in people who has to undergo inpatient therapy. In case of suspected or positive patients, starting or continuing treatments should be allowed by local health authorities and carried out under condition of maximum safety for health professionals, with dedicated routes and facilities, dedicated treatment schedules and appropriate sanitization of treatment areas and equipment. 7 It is also recommended to limit access to patients and their relatives or accompanying persons: -offering IRT or IORT, if available and whenever possible, -encouraging high hypofractionation, where indicated, -postponing treatments of certain oncological diseases according to clinical judgement, -in palliative setting it might be useful to optimize medical symptomatic treatments, if judged to be of similar efficacy, -postponing treatment for benign diseases, -considering hormonal or cytotoxic therapy in selected cases for further deferral of radiotherapy, -allowing only one accompanying person per patient, whenever possible, -considering dedicated "COVID+ interventional radiotherapy pathway". Follow-up evaluations should be: -postponed until proven healing in COVID-19 positive patients, -postponed and/or converted to telephone contact in case of negative COVID-19 patients without referred post-treatment symptoms, -planned according to the clinical case presentation verified by telephone contact, in COVID-19 negative patients but with referred symptoms related to radiation treatments. According to institutional recommendations, the use of specific Personal Protective Equipment is indicated during treatments with an aerosol generating procedure such as intubation, open suctioning of the respiratory tract, endoluminal IRT with bronchoscopy or upper gastrointestinal endoscopy and IRT for some intrabuccal lesions. 1, 8 In these cases, it is suggested to wear disposable gloves, FFP2/FFP3 mask and fluid resistant surgical mask, eye/face protection, disposable fluid repellent gown, disposable caps and shoe covers. The surgical room for IORT and the IRT dedicated room should have an area for donning and doffing of personal protective equipment and exchange of material and medications for the procedure. In case of endocavitary and/or interstitial IRT requiring major anesthesia the definitive indication should be made considering the expected need for intensive therapy unit and its availability. As long as IORT is concerned, cases should be prioritized by the Operating team and coordinated centrally. 9 We suggest to shortening the case duration of surgery, discussing in advance every potential scenarios with the referring surgeons (e.g. treatment volume and doses according to site, histology and resection margins) and assigning the docking procedure to an expert team. Optionally discuss treatment options in multidisciplinary boards with consultants from Anesthesia and Intensive Care and Infectious Diseases. Patients should be adequately informed. There are few evidences on the management of radiation treatments' long-term interruptions, due to large-scale emergencies. 10, 11 It is indicated to avoid or in any case limit delaying treatments that could negatively affect the disease control and/or the related symptoms, evaluating comorbidities and balancing the cost/benefit ratio related to infection or contamination risk and the risk of cancer not being treated optimally. 3,12-20 Whenever possible and clinically indicated, providing radiotherapy and/or systemic therapy and/or targeted treatments would potentially reduce the impact on need for level 2/3 hospital beds for elective surgery. Patients over 70, especially with co-morbidities, are at highest risk of death from coronavirus and ideally, they should be seen once the pandemic is over, unless clinically urgent. 9 Table 2 summarizes relevant clinical suggestions for COVID-19 negative or positive patients eligible for IRT treatments in relation to oncological disease. By adopting these practical suggestions we will protect ourselves and the patients from the risk of infection, respecting oncological outcomes and reducing the workload in any Radiotherapy Service. The indications reported in this orientation paper cannot leave aside the careful evaluation of the proposed treatment setting, the clinical case and the life expectancy of each patient also taking into account any concomitant or alternative valid therapy. curative-intent radiotherapy during the COVID-19 pandemic The Christie NHS Foundation Trust. https://www.nice.org.uk/guidance/ng162/resources/covid19-rapid-guideline-delivery-of-(accessed April 7, 2020 COVID-19, raccomandazioni per i pazienti oncologici Can brachytherapy be properly considered in the clinical practice? Trilogy project: The vision of the AIRO (Italian Association of Radiotherapy and Clinical Oncology) Interventional Radiotherapy study group Journal Pre-proofs COVID-19: Global Radiation Oncology's Targeted Response for Pandemic Preparedness COVID-19: Global Radiation Oncology's Targeted Response for Pandemic Preparedness Prostate Cancer Radiotherapy Recommendations in Response to COVID-19 Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents Advice on the use of masks in the community, during home care and in healthcare settings in the context of the novel coronavirus (2019-nCoV) outbreak Lessons Learned From Hurricane Maria in Puerto Rico: Practical Measures to Mitigate the Impact of a Catastrophic Natural Disaster on Radiation Oncology Patients The timely delivery of radical radiotherapy: guidelines for the management of unscheduled treatment interruptions Fourth edition Renzo Corvò Letter from Italy: First practical indications for radiation therapy departments during COVID-19 outbreak Journal Pre-proof Running a Radiation Oncology Department at the time of coronavirus: an Italian experience How should we implement radiotherapy for cancer patients in China during the endemic period of COVID-19? Journal Pre-proof Radiotherapy care during a major outbreak of COVID-19 in Wuhan Journal Pre-proof Managing COVID-19 in the oncology clinic and avoiding the distraction effect Overview | COVID-19 rapid guideline: delivery of systemic anticancer treatments | Guidance | NICE Overview | COVID-19 rapid guideline: delivery of radiotherapy | Guidance | NICE Overview | COVID-19 rapid guideline: critical care in adults | Guidance | NICE COVID-19): cancer treatment documents | The Royal College of Radiologists International Guidelines on Radiation Therapy for Breast Cancer During the COVID-19 Pandemic Radiation therapy for the whole breast: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based guideline Proposed guidance for radiotherapy for gynaecological cancer and COVID-19. www.rcr.ac.uk/cancer-treatment-documents Reduced fractionation in lung cancer patients treated with The Authors thank the Scientific Committee of the AIRO for the critical revision of the paper.