This document discusses management strategies for thoracic and head and neck malignancies during the COVID-19 pandemic. It recommends prioritizing cancer treatments based on individual risk factors and balancing cancer treatment with risk of COVID-19 infection. Procedures generating aerosols like biopsies and endoscopy are discouraged. Surgery is recommended only for urgent or high-risk cases. Hypofractionated radiotherapy and chemotherapy without concurrent treatment are preferred options when possible to reduce treatment time and risk of immunosuppression. Treatment decisions should be made on a case-by-case basis accounting for cancer type, stage, patient factors, and available resources.

1. MANAGEMENT OF THORACIC MALIGNANCIES
DURING COVID 19 PANDEMIC
DR. R. RAJKUMAR D.M.
CONSULTANT MEDICAL ONCOLOGIST
VELAMMAL SPECIALITY HOSPITALS

2. DECISION FOR
PRIORITIZING
PATIENTS
SHOULD BE
TAKEN UNDER
MDT, ENSURING
EACH PATIENT IS
CONSIDERED
INDIVIDUALLY
AND SHALL TAKE
INTO ACCOUNT ..
Ueda et al; Natl Compr Canc Netw 2020;18(4):1–4, NICE guideline;
COVID-19 rapid guideline: delivery of systemic anticancer treatments; published: 20 March 2020
level of immunosuppression associated with
individual treatments and cancer types, and
any other patient-specific risk factors
capacity issues, such as limited resources
(workforce, facilities, intensive care,
equipment)
balancing the risk of cancer not being treated
optimally with the risk of the patient being
immunosuppressed and becoming seriously ill
from COVID-19

6. TERAVOLT STUDY- ASCO 2020 UPDATE

7. TERAVOLT STUDY- ASCO 2020 UPDATE

8. TERAVOLT STUDY- ASCO 2020 UPDATE

9. PRIORITIES FOR LUNG CANCER: MEDICAL
ONCOLOGY – EARLY STAGE LUNG CANCER
ESMO MANAGEMENT AND TREATMENT ADAPTED RECOMMENDATIONS IN THE COVID-19 ERA: LUNG
CANCER

10. PRIORITIES FOR LUNG CANCER: MEDICAL
ONCOLOGY – EARLY STAGE LUNG CANCER
ESMO MANAGEMENT AND TREATMENT ADAPTED RECOMMENDATIONS IN THE COVID-19 ERA: LUNG
CANCER

11. PRIORITIES FOR LUNG CANCER: MEDICAL
ONCOLOGY – EARLY STAGE LUNG CANCER
ESMO MANAGEMENT AND TREATMENT ADAPTED RECOMMENDATIONS IN THE COVID-19 ERA: LUNG
CANCER

12. PRIORITIES FOR LUNG CANCER: MEDICAL
ONCOLOGY – LOCALLY ADVANCED LUNG CANCER
ESMO MANAGEMENT AND TREATMENT ADAPTED RECOMMENDATIONS IN THE COVID-19 ERA: LUNG
CANCER

13. PRIORITIES FOR LUNG CANCER: MEDICAL
ONCOLOGY – LOCALLY ADVANCED LUNG CANCER
ESMO MANAGEMENT AND TREATMENT ADAPTED RECOMMENDATIONS IN THE COVID-19 ERA: LUNG
CANCER

14. PRIORITIES FOR LUNG CANCER: MEDICAL
ONCOLOGY – METASTATIC LUNG CANCER
ESMO MANAGEMENT AND TREATMENT ADAPTED RECOMMENDATIONS IN THE COVID-19 ERA: LUNG

15. PRIORITIES FOR LUNG CANCER: MEDICAL
ONCOLOGY – METASTATIC LUNG CANCER
ESMO MANAGEMENT AND TREATMENT ADAPTED RECOMMENDATIONS IN THE COVID-19 ERA: LUNG

16. PRIORITIES FOR LUNG CANCER: MEDICAL
ONCOLOGY – METASTATIC LUNG CANCER
ESMO MANAGEMENT AND TREATMENT ADAPTED RECOMMENDATIONS IN THE COVID-19 ERA: LUNG

17. ESMO Open 2020;4:e000765.

18. MANAGEMENT OF HEAD&NECK
MALIGNANCIES DURING COVID 19
PANDEMIC
DR. R. RAJKUMAR D.M.
CONSULTANT MEDICAL ONCOLOGIST
VELAMMAL SPECIALITY HOSPITALS

19. STRATIFICATIO
N OF COMMON
HEAD AND
NECK
SURGERY
CASES BY
URGENCY
• URGENT – PROCEED WITH SURGERY
• HPV-negative HNSCC (especially those with airway concerns)
• HPV-positive HNSCC with significant disease burden or delay
in diagnosis
• HNSCC patients with complications of cancer treatment
• Recurrent HNSCC
• - Large (> 4 cm) follicular lesions, neoplasms, or even
indeterminate nodules
• Salivary cancer
• - Salivary duct carcinoma
• - High-grade mucoepidermoid carcinoma
• - Adenoid cystic carcinoma
• - Carcinoma ex pleomorphic adenoma
• - Acinic cell carcinoma
• - Adenocarcinoma
• - Other aggressive, high-grade salivary histology
Head Neck. 2020 Apr 16. doi: 10.1002/hed.26184.

20. STRATIFICATION OF COMMON HEAD AND
NECK SURGERY CASES BY URGENCY
• LESS URGENT – CONSIDER POSTPONE > 30 DAYS
• Low-grade salivary carcinoma
• LESS URGENT – CONSIDER POSTPONE 30 – 90 DAYS; REASSESS AFTER
PANDEMIC APPEARS TO BE RESOLVING
• Benign salivary lesions
• CASE-BY-CASE BASIS
• Rare histology with uncertain rate of progression
• Diagnostic procedures, such as direct laryngoscopy with biopsy
Head Neck. 2020 Apr 16. doi: 10.1002/hed.26184.

21. • Despite the controversy surrounding its use independent of the
COVID-19 pandemic, neoadjuvant chemotherapy ± cetuximab
or neoadjuvant chemotherapy ± immunotherapy may be
considered, in certain settings, at this time
Oral Oncol. 2020 Apr 6 : 104684.

22. PRACTICE RECOMMENDATIONS FOR RISK-ADAPTED HEAD AND NECK CANCER
RADIOTHERAPY DURING THE COVID-19 PANDEMIC: AN ASTRO-ESTRO CONSENSUS
STATEMENT
Borderline
resectable tumors
Int J Radiat Oncol Biol Phys. 2020 Apr 14.

23. Nat Rev Clin Oncol (2020). https://doi.org/10.1038/s41571-020-0362-6
Clear evidence exists that,
for certain indications,
treatment postponement
can adversely affect
outcomes.
For example, a 16%
increased risk of death
exists for every month of
delay of radiotherapy for
patients with head and
neck cancer (risk ratio (RR)
1.16, 95% CI 1.02–1.32)

24. • In order to assist shared decision-making, multidisciplinary team
meetings should be promoted using web-platforms
• A reasonable treatment strategy between anticancer therapy and
epidemic prevention should be selected
• Considerations:
 omit systemic therapy for patients ≥ 70 years or younger with co-
morbidities, such as diabetes and cardiovascular diseases
 omit cisplatin-based induction chemotherapy
 short overall treatment time Definitive (C)RT should be limited to
simultaneous integrated boost (SIB) techniques in the standard (5 fractions
per week) or accelerated schedule (6 fractions per week), in order to
achieve a 1-week reduction compared to sequential technique. SIB
technique represents an optimum balance between tumor control and
prevention of late toxicity excess
 delay post-operative RT in patients with salivary gland tumors until 12
weeks after surgery. Time factor is not strictly linked to adverse effect in
these casesRadiotherapy and Oncology 147 (2020) 84–85

25. Foundation for Head and Neck Oncology (FHNO) Advisory for management of head
and neck cancers during COVID-19 epidemic period
Indian scenario and need for optimizing resources and treatment decisions
 Testing of COVID-19 is limited and cannot be performed in all patients.
 All HN procedures including simple clinical examination is aerosol generating and considered high risk.
 Protective supplies, such as N95 masks, PPE gowns, gloves and other protective materials are in short
supply or unavailable in many institutions.
 As the illness progresses our systems may be burdened with potential shortage of beds and health care
manpower.
 Difficulty and uncertainty in transport of patients due to the lockdown and quarantine.
 Availability of blood and blood products may become a challenge.
 ICU Bed/ ventilators may be at a premium and scarce.
 Cancer patients are likely to be more vulnerable to COVID-19.
 Risk benefit ratio should be considered during the epidemic period.

26. Fibreoptic Laryngoscopy (FOL) - As the nasal cavity and
nasopharynx have a high colonisation of COVID-19, even in
asymptomatic patients, it is recommended to avoid FOL
unless absolutely mandatory.
In case FOL is mandatory and cannot be avoided, the
following precautions should be taken:
 Use of adequate local anaesthetic in the form of nasal jelly,
lignocaine spray of the posterior pharyngeal wall (give
adequate time for action).
 Avoid looking through the lens of the scope and it would be
preferable to attach it to a monitor.
 Limit the number of staff in the room at the time of FOL.
No person should be within two metres of the patient.

27. Biopsy
 Avoid biopsies in benign lesions.
 Perform FNACs from neck nodes for obtaining diagnosis, in case of
laryngeal/hypopharyngeal primaries, where biopsies will entail some
form of endoscopy.
 Image guided (USG/CT guided) biopsies can be attempted.
Direct laryngoscopy:
 Not recommended in the current scenario.
 May use appropriate PPE in case of need to perform a direct
laryngoscopy.

28. Surgery:
Decisions regarding surgery on cancers of the head neck should take into consideration, the goals and
likely outcomes of surgery, the likelihood of curing the cancer, safety considerations and utilisation of
infrastructure which may be required for management of COVID-19 related emergencies. All patients
should be considered as asymptomatic carriers and adequate precautions to be taken prior to performing
any surgical procedure.
 Delay/postpone surgery in patients with low grade tumors (differentiated thyroid cancers, medullary
thyroid cancer, low grade parotid neoplasms, benign tumors etc).
 Avoid any form of surgery on a COVID-19 positive patient (unless in medical emergencies like stridor,
uncontrolled bleeding etc, with adequate precautions).
 Avoid extensive surgery in patients with advanced age (>65 years) with comorbidities like
uncontrolled hypertension, diabetes mellitus, COPD, immunocompromised/immunosuppressed.
 Avoid surgery with doubtful cancer outcomes.
 Avoid complex microvascular reconstructive surgery requiring long hours. Use of local and regional
flaps for reconstruction should be considered.
 Avoid performing surgeries that require elective tracheostomies.
 Avoid surgeries that require powered instrumentation (bone cutting instruments, saws, micromotors,
drills etc.).
 Check preoperative hemoglobin values and avoid surgeries on patients with low Hb to avoid the use of
blood and blood products.
 Day care surgery and surgery for early lesions is highly recommended as surgery of choice during this
period.

29. Curative treatment
RADIOTHERAPY
Consider hypofractionated radiotherapy regimens .
 65Gy in 30 fractions is preferable to 70Gy in 35 fractions. Prior
reported series from the UK demonstrate the efficacy and safety of
hypofractionated radiotherapy with 55Gy in 20 fractions over 4
weeks ,
It is still reasonable to offer concurrent chemotherapy where
indicated. However, this will increase overall risks of treatment. The
absolute benefit of concurrent chemotherapy reduces with age 4
and
older patients are at higher risk from developing a serious COVID- 19
infection. In this group the increased risks of infectious
complications may outweigh the benefit of chemotherapy.

30. CHEMOTHERAPY
Chemotherapy can still be considered for patients with good
performance status and rapidly progressing disease. These patients
with rapid progression are more likely to benefit from chemotherapy
than immunotherapy.
Pembrolizumab monotherapy is now an option in the first-line treatment
of metastatic or unresectable recurrent head and neck squamous cell
carcinoma (HNSCC) in adults whose tumours express PD-L1 with a
combined positive score (CPS) ≥ 1.