key: cord-1007633-ki2x47nx authors: Lapolla, Pierfrancesco; Familiari, Pietro; Bruzzaniti, Placido; Arcese, Roberto; Matassa, Roberto; Frati, Alessandro; D’Andrea, Giancarlo; Santoro, Antonio title: First-in-Man Craniectomy and Asportation of Solitary Cerebellar Metastasis in COVID-19 Patient: A Case Report date: 2020-11-21 journal: Int J Surg Case Rep DOI: 10.1016/j.ijscr.2020.11.102 sha: 805703316db34e536f9478badca6f765b69f9405 doc_id: 1007633 cord_uid: ki2x47nx INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak has an impact on the delivery of neurosurgical care, and it is changing the perioperative practice worldwide. We present the first case in the literature of craniectomy procedure and asportation of a solitary cerebellar metastasis of the oesophagus squamous carcinoma in a 77 years old woman COVID-19 positive. In these particular circumstances, we show that adequate healthcare resources and risk assessments are essential in the management of COVID-19 patients referred to emergency surgery. PRESENTATION OF CASE: The case here presented was treated in 2019 for squamous carcinoma of the oesophagus. In April 2020, she presented a deterioration of her clinical picture consisting of dysphagia, abdominal pain, hyposthenia and ataxia. A Head CT scan was performed, which showed the presence of a solitary cerebellar metastasis. Her associated SARS-CoV-2 positivity status represented the principal clinical concern throughout her hospitalisation. DISCUSSION: The patient underwent a suboccipital craniectomy procedure with metastasis asportation. She tested positive for SARS-CoV-2 in the pre- and post-operative phases, but she was not admitted to the intensive care unit because she did not present any respiratory complications. Her vital parameters and inflammation indexes fell within the reference ranges, and she was kept in isolation for 16 days in our neurosurgical unit following strict COVID-19 measures. She was asymptomatic and not treated for any of the specific and non-specific symptoms of COVID-19. CONCLUSION: This is the first case reported of solitary cerebellar metastasis of oesophagus carcinoma operated on a COVID-19 positive patient. It shows that asymptomatic COVID-19 positive patients can undergo major emergency surgeries without the risk of infecting the operating team if adequate Personal Protection Equipment (PPE) is used. The patient remained asymptomatic and did not develop the disease’s active phase despite undergoing a stressful event such as a major emergency neurosurgical procedure. In the current crisis, a prophylactic COVID-19 screening test can identify asymptomatic patients undergoing major emergency surgery and adequate resource planning and Personal Protective Equipment (PPE) for healthcare workers can minimise the effect of the COVID-19 pandemic. Background. Oesophageal carcinoma frequently metastasises in the lungs, pleura, liver, stomach, peritoneum, kidney, adrenal gland, and bones [1] . Brain metastasis in primary oesophageal cancer patients are considered very rare, incidence estimated at between 1.4% and 6.6% according to retrospective reviews of patients treated for oesophageal and oesophagogastric junction cancers [2, 3] . Surgical treatment and favourable Karnofsky Performance Status (KPS) are associated with longer survivals for selected patients with brain metastasis from oesophageal carcinoma [4] . The Chemoradiotherapy for Esophageal Cancer Followed by Surgery Study (CROSS) trial established tri-modality therapy with 49.4 months median survival in the combined treatment group [5] . During the SARS-CoV-2 pandemic, when cases often suffer severe acute respiratory syndrome, surgery should be offered only to patients with extensive lesions causing symptoms related to mass effect and vasogenic oedema, whose survival is expected to be greater than three months [6] . In the public health emergency for the COVID-19 outbreak, surgery has been reduced for urgencies and cerebral J o u r n a l P r e -p r o o f and spinal oncological cases; some of the neurosurgical unit personnel have been assigned to the COVID-19 units [7] . We report a case of a 77 years old woman, previously treated for oesophageal carcinoma in our centre, arriving at our unit with chief neurological complaints. The clinical examination revealed ataxia, nausea, vomiting and headache, which prompted us to perform urgent craniectomy and metastasis removal. During her hospitalisation, she resulted positive for COVID-19, and she has been tested for SARS-CoV-2 in the pre-and post-operative phases. The operation took place in April in -----Name of centre blinded-----in a dedicated operating theatre. This report describes for the first time in the literature a case solitary cerebellar metastasis removal of oesophageal carcinoma in a COVID-19 positive patient. This case report demonstrates that major neurological surgeries such as craniectomy and asportation of cerebellar metastasis can be performed in asymptomatic COVID-19 patients and that adequate resource planning and Personal Protective Equipment (PPE) are essential to reduce the healthcare-associated infections (HCAIs) risk in the current COVID-19 pandemic. The presented work has been reported in line with the SCARE criteria [8] , and it reports the first-inman case intervention of a solitary cerebellar metastasis of oesophagus origin on a COVID-19 positive patient. Therefore it has been registered at the Research Registry and it has been assigned the following Research Registry unique identifying number (UIN) researchregistry6241. Patient history and examination. The patient was treated (September 2019) for oesophageal squamous carcinoma with radiotherapy and chemotherapy in our General Surgical and Oncology Department. On a routine CT Total Body scan performed in January 2020 for tumour follow-up, no metastasis was found (Figure 1 ), and the cancer staging was T3-N0-M0. Table 1 . We report the case of a 77 years old woman with oesophagus carcinoma diagnosed in September 2019 and treated at our centre with chemotherapy and radiotherapy. In January 2020, she underwent a Total Body CT scan to assess the staging, grading and spread of the tumour resulting in the absence of metastatic disease. Later she underwent KPS evaluation resulting in 80 and Recursive Partitioning Analysis (RPA) Class II. In April, she presented symptoms associated with hypertension in the posterior fossa (dysphagia, headache, ataxia, and progressive sensorium deterioration). An urgent enhanced head-CT scan was performed which showed a solitary cerebellar metastasis in the paramedian aspect of the right cerebellum hemisphere causing compression of the 4 th ventricle. The patient was found positive for COVID-19 infection at molecular screening without respiratory symptoms. Therefore she has not been treated for any specific and non-specific symptoms of COVID-19. We hypothesise that the metastatic lesion's mass effect would have resulted in acute obstructive hydrocephalus with rapid coma and death if we did not promptly proceed with emergency surgery [10] . Patients with esophageal carcinoma and brain metastasis have an overall survival (OS) of 2 weeks J o u r n a l P r e -p r o o f after metastasis diagnosis to 25 months after treatment [11] . On the other hand, patients with oesophageal cancer and solitary solid and stable organ metastases have an OS of 54 months after surgery, which was superior compared to chemotherapy only [12] . A case series of surgeries for posterior fossa metastases demonstrates a median OS of 6 months for all posterior fossa brain metastasis [11] . According to the priority criteria defined for neurological surgeries during the COVID-29 pandemic, the case under discussion was evaluated as a Class A ++ grade, indicating cases requiring immediate treatment. This class of priority comprises patients with intracranial or spinal tumours requiring urgent treatment such as rapidly evolving intracranial hypertension with deteriorating state of consciousness, spinal cord compression, hydrocephalus. [13] . Our hospital is one of the largest designated COVID-19 centres with theatres dedicated to COVID-19 positive patients, with appropriately trained staff on COVID-19 emergency and specific protocols. Our team joined an international research to study the disruption of elective cancer surgeries and the outcomes of COVID-19 patients undergoing surgery (COVIDSurg of the NIHR Global Surgery Group) which suggested that, for patients undergoing surgery with perioperative SARS-CoV-2 infection, postponing non-urgent procedures and promoting non-operative treatment (to delay or avoid the need for surgery) should be taken in consideration to avoid mortality and pulmonary complications [14] . For major elective cancer procedures, recent evidence indicates that delaying surgery following a positive SARS-CoV-2 swab test by at least four weeks will minimise post-operative complications in infected asymptomatic patients [15] . Regarding the importance of COVID-19 pre-operative testing, in a recent international cohort study of patients undergoing elective cancer surgery for ten different types of cancer. There were 87484 patients included in the analysis, run in 432 hospitals over 53 countries worldwide; the overall pulmonary complication rate was 3.9%. This was higher in patients with no test (4.2%) or CT only (4.8%, Adjusted OR 1.27) compared to those who underwent a swab test (2.8%, AOR 0.68, 95 percent c.i. 0.47 to 0.98, P = 0.040) or swab test and CT (2.5%, AOR 0.57). Overall it has been found that pre-operative nasopharyngeal swab testing in asymptomatic patients was associated with a reduced rate of post-J o u r n a l P r e -p r o o f operative pulmonary complication and the main benefit was seen in patients undergoing major surgeries in high incidence areas [16] . Other Italian centres have reported a total of 15 cases of COVID-19 positive patients who have undergone neurosurgery treatments; 9 of these had a regular course and did not present any COVID-19 associated complications during their hospitalisation [17] . This shows that symptomatic COVID-19 patients can undergo major surgery. Interventions must be carried out with dedicated routes and appropriate individual protection equipment for healthcare workers [18] . In the pre-and post-operative management, specific planning and control measures were adopted for healthcare personnel involved in managing the patient undergoing surgery (Table 4 ). In the postoperative phase, the patient was not admitted into the intensive care unit (ICU) because, according to COVID-19 local protocol the, ICU is currently reserved for critical patients with acute respiratory. Sixteen days after surgery, on clinical and laboratory examination, the patient recovered quickly and in good condition; the inflammatory markers were within the reference ranges and the post-operative head CT showed no abnormalities and the normalisation of the 4 th ventricle spaces. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. 1. Name of the registry: Research Registry 2. 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