Coronavirus Disease (COVID-19) and Peritoneal Malignancies

Cancer shared this article with you from Inoreader Message: Advertisement SpringerLink Search Log in Coronavirus Disease (COVID-19) and Peritoneal Malignancies Download PDF Letter to the Editor Published: 16 January 2021 Coronavirus Disease (COVID-19) and Peritoneal Malignancies Sohan Lal Solanki, Mrida AK Jhingan & Avanish P Saklani Indian Journal of Surgical Oncology (2021)Cite this article 46 Accesses 2 Altmetric Metricsdetails To the Editor, As the number of coronavirus disease 2019 (COVID-19) cases are rapidly increasing, hospitals are finding it progressively difficult to accommodate an increased patient load and provide services, both emergent and elective in nature. During this pandemic, it has become essential to ensure adequate allocation of resources for the management of both COVID-19 patients and non-COVID-19 patients, and in particular, patients with cancer. Delayed cancer treatment may lead to an increased risk of disease progression and subsequent, worsening prognosis [1]. The Lancet reported an estimated 59.7% cancer surgeries being postponed in India during the peak 12 weeks of disruption due to the COVID-19 pandemic and lockdown, translating to about 51,100 cancer patients being denied of treatment. This delay in treatment could have led to disastrous consequences, such as increase in the tumor load leading to increased morbidity, inoperability, and eventual palliative intent of treatment [2]. Early studies have demonstrated that cancer patients are more likely to develop a severe form of COVID-19 [3, 4] with a fatality rate up to eight times as high as compared to non-cancer patients [3]. Peri-operative infection with SARS-CoV2 has been associated with high mortality with more than half patients developing post-operative pulmonary complications in the form of pneumonia, requirement of post-operative mechanical ventilation, and acute respiratory distress syndrome [5]. However, no association has been found between chemotherapy and mortality related to COVID-19 [4]. Peritoneal malignancies, both of primary and metastatic origin, benefit greatly from cytoreductive surgeries (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) [6]. The performance of these potential life-saving surgeries in the current health crisis poses a significant dilemma to treating physicians. Another treatment offered for these malignancies is pressurized intraperitoneal aerosolized chemotherapy (PIPAC). Though its efficacy has not yet been proven, it is hypothesized to increase patient lifespan [3, 7]. Benefits of CRS-HIPEC are well established in peritoneal malignancies with a median disease-free survival of 98 months being achieved in high volume centers for pseudomyxoma peritonei and median survival of more than 50 months after CRS-HIPEC for peritoneal mesotheliomas. On the other hand, median survival of 1 year has been achieved with isolated systemic chemotherapy in peritoneal mesotheliomas [3]. Thus, despite higher complication risks, improved survival benefits with surgery can justify the need to target curative intent with surgical procedures and thus improve the overall outcome of the patients. These procedures can, however, lead to exhaustion of resources, such as intensive care unit (ICU) beds and ventilators in the post-operative period along with the increased need for blood and blood products in the peri-operative period besides being labor exhaustive with requirement of large teams for peri-operative management [8]. This puts both the healthcare professionals and the patients, at an increased risk of infection with the SARS-CoV2 virus. The decision to proceed with surgery must be made keeping in mind both risks and benefits associated with a major definitive surgery versus the risks of a lesser aggressive treatment modality with a higher chance of recurrence and progression. Also, the risk of death due to cancer itself must be weighed against the risk of death due to the infection. Shrikhande et al. reported a post-operative morbidity rate of 5.65% with no mortality in patients posted for elective oncosurgeries during the pandemic, with only 6 out of 494 patients testing positive in the post-operative period, none of whom required intensive care [9]. It is recommended that treatment decision for peritoneal malignancies should be made on a case-to-case basis. The patient's disease status, alternative treatment strategies, and institutional policies play important factors in making this decision. Studies early in the course of the pandemic recommended neoadjuvant systemic chemotherapy in cases of peritoneal metastasis from high-grade appendiceal, gastric, and colorectal cancers, along with high-grade mesotheliomas, ovarian cancers, and desmoplastic small round cell tumors [8, 10]. It was also recommended to continue systemic chemotherapy in patients who were completing neoadjuvant chemotherapy and were responding well in an attempt to delay surgery. The RENAPE and BIG-RENAPE groups [3], however, in their recent treatment proposals, make no recommendations of preferring chemotherapy over surgery in view of the COVID-19 pandemic. In cases where CRS with or without HIPEC would be the gold standard of treatment, such as pseudomyxoma peritonei; resectable, malignant peritoneal mesotheliomas; resectable peritoneal metastasis of colorectal origin not responding to chemotherapy; and limited peritoneal metastasis from ovarian carcinomas, surgery has been recommended, albeit with better patient selection criteria. Chemotherapy has been proposed for these indications only when scheduling of surgeries would prove difficult in the current scenario. Enhanced recovery pathways would serve as an essential component when opting for surgical management and would help reduce hospital stay, complication rates, and thus expedite patient turnover [11]. The decision to proceed for surgery must be made keeping two factors in mind, the possibility of achieving complete cytoreduction and a low to moderate peritoneal carcinomatosis index (PCI) [3]. In cases with low tumor burden, surgical resection involved would be comparatively less, with lesser chances of post-operative complications and hence morbidity and mortality. Besides, efforts for better patient selection must take into account the fact that younger patients having few or no comorbidities with lesser disease burden serve as better candidates for these procedures. Besides routine pre-operative assessment before the procedure, additional screening for COVID-19 infection and any chance of inoperability should be ruled out [3]. In conclusion, for resectable peritoneal malignancies, CRS with or without HIPEC can be carried out, with strict patient selection criteria, adequate availability of resources, and sufficient workforce comprising of adequately trained health personnel while adhering to all safety measures. Decision to delay surgery must be considered carefully, keeping in mind the possibility of disease progression in high-grade tumors and an inadequate response to chemotherapy. References 1. Solanki SL, Thota RS, Garg R, Pingle AA, Goswami J, Ranganath N et al (2020) Society of Onco-Anesthesia and Perioperative Care (SOAPC) advisory regarding perioperative management of onco-surgeries during COVID-19 pandemic. Indian J Anaesth 64:S97–S102 2. Sharma DC (2020) Lockdown poses new challenges for cancer care in India. Lancet Oncol 21:884 CAS Article Google Scholar 3. Glehen O, Kepenekian V, Bouché O, Gladieff L, Honore C, RENAPE-BIG-RENAPE (2020) Treatment of primary and metastatic peritoneal tumors in the Covid-19 pandemic. Proposals for prioritization from the RENAPE and BIG-RENAPE groups. J Visc Surg 157(3S1):S25–S31 Article Google Scholar 4. LYW L, Cazier JB, Starkey T, Turnbull CD, UK Coronavirus Cancer Monitoring Project Team, Kerr R, Middleton G (2020) COVID-19 mortality in patients with cancer on chemotherapy or other anticancer treatments: a prospective cohort study. Lancet 395(10241):1919–1926 Article Google Scholar 5. COVIDSurg Collaborative (2020) Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study [published online ahead of print, 2020 May 29] [published correction appears in Lancet. 2020 Jun 9]. Lancet S0140–6736(20):31182-X Google Scholar 6. Solanki SL, Mukherjee S, Agarwal V, Thota RS, Balakrishnan K, Shah SB, Desai N, Garg R, Ambulkar RP, Bhorkar NM, Patro V, Sinukumar S, Venketeswaran MV, Joshi MP, Chikkalingegowda RH, Gottumukkala V, Owusu-Agyemang P, Saklani AP, Mehta SS, Seshadri RA, Bell JC, Bhatnagar S, Divatia JV (2019) Society of Onco- Anaesthesia and Perioperative Care consensus guidelines for perioperative management of patients for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). Indian J Anaesth 63:972–987 CAS Article Google Scholar 7. Solanki SL, Kumar PP, DeSouza A, Saklani AP (2018) Perioperative concerns and management of pressurised intraperitoneal aerosolised chemotherapy: report of two cases. Indian J Anaesth 62:225–228 Article Google Scholar 8. Bartlett DL, Howe JR, Chang G, Crago A, Hogg M, Karakousis G et al (2020) Management of cancer surgery cases during the COVID-19 pandemic: considerations. Ann Surg Oncol 27:1717–1720 Article Google Scholar 9. Shrikhande SV, Pai PS, Bhandare MS, Bakshi G, Chaukar DA, Chaturvedi P, Goel M, Gulia A, Qureshi SS, Maheshwari A, Moiyadi A, Nair S, Nair NS, Karimundackal G, Saklani AP, Shankhadhar VK, Parmar V, Divatia JV, CS P, Puri A, Badwe RA (2020) Outcomes of elective major cancer surgery during COVID-19 at Tata Memorial Centre. Ann Surg 272:e249–e252 Article Google Scholar 10. Akladios C, Azais H, Ballester M, Bendifallah S, Bolze PA, Bourdel N, Bricou A, Canlorbe G, Carcopino X, Chauvet P, Collinet P, Coutant C, Dabi Y, Dion L, Gauthier T, Graesslin O, Huchon C, Koskas M, Kridelka F, Lavoue V, Lecointre L, Mezzadri M, Mimoun C, Ouldamer L, Raimond E, Touboul C (2020) Recommendations for the surgical management of gynecological cancers during the COVID-19 pandemic - FRANCOGYN group for the CNGOF. J Gynecol Obstet Hum Reprod 49:101729 Article Google Scholar 11. Uwins C, Bhandoria GP, Shylasree TS, Butler-Manuel S, Ellis P, Chatterjee J, Tailor A, Stewart A, Michael A (2020) COVID-19 and gynecological cancer: a review of the published guidelines. Int J Gynecol Cancer 30:1424–1433 Article Google Scholar Download references Author information Affiliations Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India Sohan Lal Solanki & Mrida AK Jhingan Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India Avanish P Saklani Corresponding author Correspondence to Sohan Lal Solanki. Ethics declarations Conflict of Interest The authors declare that they do not have conflict of interest. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. The manuscript has been read and approved by all the authors, that the requirements for authorship as stated earlier in this document have been met, and that each author believes that the manuscript represents honest work. Rights and permissions Reprints and Permissions About this article Verify currency and authenticity via CrossMark Cite this article Solanki, S.L., Jhingan, M.A. & Saklani, A.P. Coronavirus Disease (COVID-19) and Peritoneal Malignancies. Indian J Surg Oncol (2021). https://doi.org/10.1007/s13193-020-01270-9 Download citation Received 28 June 2020 Accepted 06 December 2020 Published 16 January 2021 DOI https://doi.org/10.1007/s13193-020-01270-9 Share this article Anyone you share the following link with will be able to read this content: Get shareable link Provided by the Springer Nature SharedIt content-sharing initiative Keywords Cancer COVID-19 Cytoreductive surgery Hyperthermic chemotherapy Pandemic Peritoneal malignancies Download PDF Sections References References Author information Ethics declarations Additional information Rights and permissions About this article Advertisement Over 10 million scientific documents at your fingertipsSwitch Edition Academic Edition Corporate Edition Home Impressum Legal information Privacy statement California Privacy Statement How we use cookies Manage cookies/Do not sell my data Accessibility Contact us Not logged in - 79.167.123.139 Not affiliated Springer Nature © 2021 Springer Nature Switzerland AG. Part of Springer Nature. Coronavirus Disease (COVID-19) and Peritoneal Malignancies Via Latest Results for Indian Journal of Surgical Oncology View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.