key: cord-312846-ef7m4875
authors: Nerina, Denaro; Anna Maria, Merlotti; Marco Carlo, Merlano; Russi, Elvio
title: Coronavirus Disease 19 (COVID-19) during chemoradiation for locally advanced oropharyngeal squamous cell carcinoma (LA-OPSCC)
date: 2020-05-14
journal: Oral Oncol
DOI: 10.1016/j.oraloncology.2020.104801
sha: 
doc_id: 312846
cord_uid: ef7m4875

nan

In the era of the pandemic the first goal is reducing COVID-19 risk for staff and patients and at the same time ensuring an optimal anti-cancer treatment avoiding delays.

Radiation therapy is a life-saving treatment and should be guaranteed to all patients with cancer for whom it is indicated.

Definitive chemo-radiotherapy (CRT) is the standard of care for locally advanced oropharyngeal squamous cell carcinoma (OPSCC). To continue curative CRT in patients affected by COVID-19 is subject of debate. Hereby we present a case report of OPSCC patient which was affected by COVID19 after the second Platinum cycle administration. In our multidisciplinary team after infectious disease assessment we decided to continue treatment because of curative intent and the young age of the patient. (1) Xy is a male 62 years old, heavy smokers, nothing in his medical history, who referred in From 25 th March 2020 the patient began to have fever (38.5°Celsius) and cough.

He performed a negative chest x-ray. For uncontrolled pain and inadequate oral intake it was agreed with the family doctor to increase pain therapy and start hydration at home On 27 March the fever was 38 °Celsius and a treatment with intravenous Ceftriaxone was started at home by the family doctor.

On 29th March, Xy accessed to the emergency room and was hospitalized for dysphagia (cancer and treatment -related) ,fever and cough.

Nasal and oropharyngeal swab revealed SARS-CoV-2 infection.

Blood examination were WBC 4.6K/mcl, Platelets144 K/mcl Haemoglobin 12.5 g/dL, D-Dimer 10ug/ml Reactive C protein 123mg/L pH =7.5; pCO2 35.1mmHg; pO2= 68.6mmHg. Given the stability of the patient, it was decided to resume radiation therapy on April 1st.

The treatment plan was modified by prescribing to the boost volume 6 fractions of 3 Gy instead of the planned 10 fractions of 2 Gy.

The aim was to achieve a radical dose for the patient but to reduce exposure to the staff of the Radiotherapy department. The patient was treated at the end of the working shift with appropriate protective devices for the staff. The bunker areas was sanitized at the end of the treatment session.

Xy received antibiotic treatment with piperacillin tazobactam for 10 days; low molecular weight heparin was administered prophylactically during the hospitalization.

Simultaneous supportive care was administered during the hospitalization; intravenous nutrition of about 1800 k-calories was administered from 29 th March to 20 th April with polyamine acids + glucose monohydrate + electrolytes + olive oil + medium chain triglycerides + fish oil with a high content of omega-3 acids + soybean oil for parenteral use, a reduced intravenous nutritional therapy of about 550 k-calories was administered to 23 rd April 2020.

Pain management consisted of continuous intravenous infusion of hydrochloride morphine 70 mg.

Pain therapy was turned to trans-dermal fentanyl to permit the patient to return home.

However pain control was insufficient therefore the patient was medicated with oral methadone with benefit.

Xy successfully completed radiotherapy on 7 th April, while the third Cis-platinum treatment was omitted. Total RT dose to gross tumor volume was 68 Gy, EQD2 69.5 Gy.

At the date of discharge (26 th April 2020) ENT examination revealed a clinical complete response.

The patient will perform a neck CT scan in July. Regarding these indications, we did not wait for the patient's recovery from the infection, while we respected the other recommendations.

The choice to continue RT treatment even during COVID 19 infection reflects the most recent indications of the ASTRO-ESTRO Consensus in which it emerged a strong agreement to continue RT in patients with SARS-CoV-2-related mild symptoms who had completed more than two weeks of treatment and an agreement to continue radiotherapy in patients with SARS-CoV-2-related mild symptoms, irrespective to the received treatment at that point. (4) We decided to omit the third cicle of concomitant chemotherapy because we considered it unsafe with the hypofractionated schedule choosed for RT.

Clinical assessment of patient's condition and rigid rules for radiotherapy staff and dedicated routes for this patient allowed to proceeding with treatment.

At this time, no clinical HNC-specific data on COVID-19 patients are available -but each choice requires an individualized risk/benefit assessment and a multidisciplinary agreement.

Head and neck oncology during the COVID-19 pandemic: Reconsidering traditional treatment paradigms in light of new surgical and other multilevel risks

Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China

MD §Letter from Italy: First practical indications for radiation therapy departments during COVID-19 outbreak

Yom SSPractice recommendations for risk-adapted head and neck cancer radiotherapy during the COVID-19 pandemic: an ASTRO-ESTRO consensus statement