A group of Italian clinicians, led by Dr Massimo Iavarone of the Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico in Milan, described a dataset of 42 patients with hepatocellular carcinoma managed according modified algorithms to reduce the risk of patients’ exposure to infection with SARS-CoV-2. They published in the Annals of Oncology their data and considerations for altered management plans in patients with hepatocellular carcinoma, who are at high risk of poor outcome, if infected during COVID-19 pandemic.
During the COVID-19 outbreak, clinical activities are reduced and postponed in order to minimise the risk of infection among patients with cancer. In addition, healthcare staff is prioritised to dealing with clinical emergencies.
According to age, comorbidities and underlying cirrhosis, patients with hepatocellular carcinoma are at high risk of poor outcome when infected with SARS-CoV-2. Furthermore, interruption and delay in scheduled screenings, treatments, and follow-up contribute to worse outcome. Therefore, the authors urge for more intensive attention to cancer patients during the COVID-19 pandemic, not only in terms of reducing the risk for infection, but also to ensuring appropriate cancer management.
The authors described that in their hospital, all patients with hepatocellular carcinoma are managed based on discussion at multidisciplinary meetings. They follow the guidelines of the European Association for the Study of the Liver and the Barcelona clinic liver cancer staging system. However, they modified the management algorithms during the COVID-19 pandemic according following principles:
- Video-calls are preferred to face-to-face visits
- Weekly multidisciplinary meetings are operated through conference calls and sharing images online
- Imaging performed for diagnosis and staging is analyzed via the intranet, telemedicine or after courier delivery
- COVID-19 test is performed in all patients one day before admission
- Only COVID-19 negative patients are admitted to dedicated ward unit
- By optimising the ventilation systems, intra- and post-procedural workflow, the protocols are implemented to prepare the healthcare staff and angiographic suite
- Liver transplantation is reserved for patients with high risk of hepatocellular carcinoma progression
- Whenever possible, locoregional treatment is encouraged as bridge treatment to liver transplantation. Locoregional treatments are preferred to surgical resection to reduce the needs of post-operative stays in the intensive care unit and duration of time in hospital. Surgery is a salvage option only in cases who do not achieve complete radiological response or who are not appropriate for locoregional treatments
- Palliative treatments, such as transarterial chemo(radio)embolisation are maintained, but postponed in the elderly (>80 years) and in patients with comorbidities
- The management of patients with advanced hepatocellular carcinoma treated with systemic drugs has been modified. Home blood sampling and drug delivery were implemented together with video-calls to manage common adverse events. Intravenous anticancer therapies are administered in a dedicated section of outpatient service
- Radiological follow-up is postponed up to three months only in elderly patients and in those with comorbidities.
The authors compared 42 patients with hepatocellular carcinoma managed according above modifications between 24 February and 20 March 2020 with patients managed during the same period in 2019. They reported that the treatment for hepatocellular carcinoma was scheduled with a delay of at least 2 months in only one quarter of patients. In particular, delay was reported among 11 patients (26%) treated with thermal ablation (2 patients), transarterial chemoembolisation (4 patients), transarterial radioembolisation (3 patients) and systemic therapies (2 patients). Thermal ablations were performed instead of pre-planned surgical resection in 3 patients.
The authors reported that they may further update their approaches along the COVID-19 pandemic evolvement, but they believe that many of these changes may remain useful in terms of management of any future emergency.
Iavarone M, Sangiovanni A, Carrafiello G, et al. Management of hepatocellular carcinoma in the time of COVID-19. Annals of Oncology (2020). doi: https://doi.org/10.1016/j.annonc.2020.04.007.