Over the past two months, COVID-19 has infected nearly 3,000,000
individuals globally.1 After early bewilderment, the
scientific community has rallied and put an impressive effort into
addressing the needs of the crisis. As a result of these tremendous
endeavors, at present, appropriate personal protective equipment (PPE)
is more widely available, developments in testing for COVID-19 allow for
SARS-CoV-2 detection with RT-PCR within 15 minutes and the sensitivity
and specificity of the test is increasing daily thanks to refinements in
performing the swabs procedure.2 Furthermore, recent
studies provide better understanding of the aerosolization risks for
different diagnostic and surgical procedures and an evolving body of
knowledge is currently available to optimize treatment strategies for
COVID-19 patients.3
However, those now suffering greatly from the COVID-19 pandemic are
patients with severe disease such as cancers, who are not only at
greater risk of infection from SARS-CoV-2, suffering more severe
symptoms given their immunosuppressed status, but may also experience
delays in oncological treatments resulting from reallocation of health
resources.4 This in turn may lead to cancer
progression and result in worse survival outcomes.
In this unprecedented scenario, patients affected by sinonasal and
anterior skull base cancers are extremely critical and vulnerable for
various reasons: their tumor is growing in a deep region in close
contact with vital neurovascular structures such as brain, dura, carotid
artery, orbit, and optic nerve; if not treated quickly, it may rapidly
evolve to encroach into these vital areas, leading to severe symptoms
such as visual impairment and neurological sequelae. These patients
usually present at an advanced stage of disease due to the insidious
growth of the tumor with late alarming symptoms, therefore even a short
delay in treatment delivery might be fatal, as the patients may became
incurable. Such patients are often elderly and multiple comorbidities
are generally observed along with an impaired immune status related to
the cancer.
It is therefore paramount that criteria are defined to stratify the
urgency of cancer care based on patient-tailored and cancer-specific
factors, while at the same time protecting both patients and healthcare
workers from the spread of the pandemic.
The first recommendation is to avoid delay in diagnosis, even in this
situation of infectious emergency: contrast-enhanced radiological exams
of the head and neck (CT, MRI) as well as systemic assessment of the
patient (total body PET-CT scan, neck ultrasounds) should be performed
to properly define the extension of the sinonasal cancer;
endoscopic-assisted nasal biopsy is essential for histological typing
and grading of the tumor. Both these preoperative assessments are
mandatory to estimate the patient’s prognosis, which is crucial in
understanding the intensity of care needed to properly manage any given
patient and to balance the risks of potential SARS-CoV-2 infection
(immunosuppressive oncological care, frequent hospital attendance) with
the negative impact on survival rates of each specific histotype of
sinonasal cancers. To perform diagnostic investigations safely, it is
mandatory, before any procedures, to define the COVID-19 status of
patients, even if they are asymptomatic: nasopharyngeal swabs
complemented with chest imaging,5 immunological
antibodies determination,6 and saliva viral load
quantification 7 are used to this purpose.
Secondly, our advice is to undertake regular multidisciplinary tumor
board consultations using teleconference systems. Otolaryngologists,
neurosurgeons, ophthalmologists, plastic surgeons, radiologists,
pathologists, oncologists and radiation therapists can thus coordinate
to identify the best level of care for each patient, considering
patient-specific and tumor-related factors. Interactions between
clinicians involved in the management of sinonasal cancers are necessary
for analysis of patients, case by case, to determine a best practice
consensus in relation to the local situation (level of the pandemic in
region, transport mobility, healthcare resources available). Likewise,
multidisciplinary tumor board discussion is paramount in managing care
for patients currently receiving treatment (radiotherapy, chemotherapy,
immunotherapy) and for those who have recently undergone surgery in
order to define the protocol of adjuvant treatments needed.
Third, and most challenging, is to identify patients for whom it would
be advisable to defer cancer treatment until after the pandemic. When
dealing with early-staged and low-grade sinonasal cancers (e.g. salivary
gland tumors, haemangiopericytoma, low-grade sarcoma, low-grade
adenocarcinoma), showing an indolent slow-growing pattern, the delay of
oncological treatment (e.g. surgery) has a moderate clinically important
adverse impact on quality of life and survival rates. Postponement of
cancer care is also advisable for patients with multiple high-risk
comorbidities, for whom intensified oncological treatments such as major
surgery, radiochemotherapy or immunotherapy might severely impact on
their immune competence, increasing the risk of COVID-19 related death
should they contract the infection.4 Patients with
sinonasal cancers and active COVID-19 disease should be managed giving
the highest priority to treatment of the viral manifestations and
deferring the oncological treatments until after complete resolution of
the infection. At present, it remains uncertain when the SARS-CoV-2
infection can be considered completely resolved, since negativization of
swab specimens and normalization of chest imaging are probably
correlated more to the resolution of the acute phase of the disease than
to the complete viral clearance from mucosal surfaces and biological
fluids such as saliva, urine and stool.8-9 In the
absence of sound evidence, patients who have recovered from the COVID-19
acute phase should be managed in both outpatient and surgical settings
with extra-care in terms of PPE for healthcare
workers.10
Fourth, and easily understandable, is to provide prompt cancer care to
those patients for whom treatments have the potential to cure and which
cannot safely be delayed.11 Non-surgical treatment
with chemo-radiation therapy should be suggested for patients affected
by poorly-differentiated sinonasal cancers such as sinonasal
undifferentiated carcinoma, neuroendocrine carcinoma,
poorly-differentiated squamous cell carcinoma, high-grade sarcoma,
regardless of the stage of disease at presentation. Patients should be
encouraged to receive such treatment in the hospital nearest to their
home, in order to avoid long and frequent journeys and to reduce
exposure to crowds. Surgery should be proposed for patients presenting
in suitable clinical conditions and affected by locally-advanced
well-differentiated cancers, or as a salvage treatment after the failure
of radiochemotherapy. In patients with close proximity of disease to
critical neurovascular structures (dura, periorbit, optic nerve), a
delay in surgical treatment would definitively impair the possibility of
a cure and result in deterioration of survival outcomes. Surgery should
be performed using endoscopic endonasal or combined
transcranial/transfacial approaches (orbital exenteration, nasectomy,
maxillectomy), based on the local extension of disease and with the goal
of free-margins resection, which significantly impacts on the patient
prognosis. Healthcare resources should be fully allocated for patients
requiring oncological surgery for curative purposes, including
intraoperative frozen sections analysis, reconstructive surgery with
free-flaps and COVID-free ICU access whenever needed, exactly as before
the pandemic. Despite resource constraints, well-selected cases of
critical sinonasal cancers should receive appropriate life-saving
surgical treatment. Evidence that transcranial surgery might be safer
than endonasal approaches, because of the elevated concentration of the
SARS-CoV-2 in nose and nasopharynx, is, so far,
limited.12 Moreover, it has been postulated that small
viral particle aerosolization might also be generated from the use of
power instruments in contact with blood or bone, not just respiratory
mucosa, since, as demonstrated by a recent Chinese series, several
biological fluids may contain detectable viral RNA.8However, at present, a more cautious stance should be adopted for
endoscopic endonasal approaches as there is a potentially high viral
load exposure, given the direct contact with upper respiratory tract
mucosa and secretions and the use of power tools which aggressively
disrupt potentially virus-containing mucosa.13Therefore, in this setting, it is imperative to maximize the use of PPE
for healthcare providers. Another open issue with skull base surgery
during the COVID-19 pandemic is related to the potential neurotropism of
SARS‐CoV‐2. New evidence has suggested the possible transcribriform
route of the SARS‐CoV‐2 to the brain, as was reported during the
epidemic of SARS-CoV and MERS-CoV which occurred several years
ago.14 Isolation of SARS‐CoV‐2 RNA in the
cerebrospinal fluid would be conclusive evidence to document the
neurovirulence of SARS‐CoV‐2. Therefore, dura handling during skull base
surgery should be performed with particular caution, especially in
endoscopic endonasal approaches. Extradural surgery should be advised
whenever feasible, with transdural approaches reserved only for selected
cases of unavoidable necessity. Other precautionary practices to be
adopted in anterior skull base surgery in order to limit the spread of
the SARS-CoV-2 infection have been previously described and include:
using negative-pressure operating rooms; wearing appropriate PPE, not
only during the surgical procedure but also in the pre-operative period
(intubation) and during the post-operative care; monitoring the body
temperature of patients during the hospitalization period; prohibiting
visitors from going to see patients and keeping relatives informed about
the patient’s medical condition using telephone or video chatting.
The fifth and final recommendation is to promote the use of telemedicine
in providing care for sinonasal cancer patients. In this period of
pandemic which is threatening the world, many oncology patients are
concerned that their needs may be overlooked or marginalized. This is
also true for some critical sinonasal cancer patients involved in
long-term follow-up, which is generally continued for at least 10 years
and, whenever possible, for an individual’s lifetime. Video visits
represent a valid alternative to in-office evaluations for
post-operative surveillance, especially for patients treated many years
ago, who are currently under routine yearly or six-monthly follow-up
visits, but also for patients treated more recently, who don’t strictly
need in-person physical evaluation. In all instances, patients should be
questioned via telephone or video chat about pending functional issues
(nasal breathing, visual ability, lacrimal function, pain) or any new or
concerning signs or symptoms that may suggest disease recurrence.
Patients requiring post-operative medications, as well as patients with
alarming clinical symptoms or radiological signs of cancer recurrence
should be visited in person. Adequate preventative measures, in terms of
appropriate PPE for healthcare workers, social distancing and body
temperature screening for patients and attendants are imperative,
especially when performing nasal endoscopy at the outpatient
service.15
In conclusion, even as we hope to overcome this pandemic, we cannot
predict how and when it will end and must also be prepared for the
likelihood that COVID-19 spread will continue or reappear in different
forms. Therefore, the measures proposed here may evolve over time,
should be proportional to the degree of risk and take into consideration
country-specific resource constraints. It may be that some of the
changes forced by this outbreak will permanently transform how we treat
cancer in the future. Until then, we will continue to work towards
stratifying sinonasal cancers according to urgency, so as to balance
prompt oncological treatments with the safety needs of all patients.