DISCUSSION
Chronic diseases are difficult to manage due to the coronavirus pandemic
affecting the whole world. Cancer patients constitute the most important
part of this group (3). Lung cancer cases, which have been shown to
increase frequency, are an important subgroup (4). Each country strives
to plan according to the adequacy and possibilities of its own
healthcare services for the management of patients receiving cancer
treatment. The main issue to focus in this study is symptoms that are
overlapping for both lung cancer and new coronavirus. The main symptoms
for COVID-19 are fever, cough, fatigue, slight dyspnoea that cause
confusion in patients with lung cancer (5). Because many other reasons
secondary to tumour or cancer treatments (surgery, chemotherapy,
radiotherapy, immunotherapy or targeted therapies) can cause these
symptoms to appear. In this pandemic process, it is important to
maintain follow-up and treatment process of lung cancer patients by
minimizing the risk of covid-19 transmission.
When compared clinical characteristics of our study population to
features of COVID-19 patients, it is noteworthy that both of them have
the 6th decade and male gender predominance (8). According to some
suggestions on diagnosis and treatment strategies of lung cancer
patients during outbreak of new coronavirus from China, which started to
fight first, for highly suspected or confirmed patient must be
transferred to specially prepared isolated department of hospital (5).
Five suspected patients of current study had admitted to our outpatient
clinic of chemotherapy unite and the differential diagnosis process took
place in the isolated service until the covid-19 was ruled out.
Each case should be handled separately, especially in terms of
treatments (chemotherapy, targeted therapies, immune-checkpoint
inhibitor, radiotherapy etc.) they receive at the time of admission,
history of suspected contact, visit to another country are important
issues (6). Totally, there were 11 (61.1%) patients (including
concurrent chemo-radiotherapy) receiving chemotherapy.
Even ground glass opacities are widely accepted radiological
presentation of new coronavirus pneumonia, it can be presented in
different manifestations in lung cancer patients (9). There are small
number of cases in literature. One of them is a case diagnosed lung
adenocarcinoma with simultaneous diagnosis of new coronavirus with
RT-PCR. Even she had no covid-19 specific symptoms she had contact with
an infected physician. There were no typical CTT findings (showed
diffuse, irregular, small, ground-glass opacities with partial
consolidation in bilateral lungs) even at the beginning (when she had no
symptoms) and after occurring symptoms. Finally, her complaints and
radiological findings were dedicated to obstructive pneumonia caused by
the tumour (10). Another reported case is a male with age of 73, who had
been operated for NSCLC in 2016. Even he had no COVID-19 suspected
symptoms, the patient was diagnosed with COVID-19 with positive PCR in
the PET-CT taken during re-staging. Bilateral diffuse, peripheral
predominant ground-glass opacities suggesting active inflammatory
processes on 18F-FDG PET/CT was the suspecting condition for new
coronavirus pneumonia (11). The most common radiological findings in our
cases were consolidation (44%) and GGOs (44%), even in 5 cases with
highly suspicious for covid-19 (Table 2).
There were 5 (27.8%) patients with pleural effusion. However, in none
of patients, pleural fluid was considered to be related to COVID. Thus
in highly suspected group (Table 2) there were no patients with pleural
fluid. Although cancer patients are not included, according to a
meta-analyse with 4121 patients, pleural effusion (5.3%) was reported
as rarest CTT imaging features in new coronavirus pneumonia (12).
Although complete clinical manifestation is not clear yet; fever,
lymphopenia, leukopenia, new pulmonary infiltrates on chest radiography,
and no response to antibiotics treatment are the most reliable clues for
COVID-19 diagnosis. The diagnosis of COVID-19 must be confirmed by the
reverse transcription polymerase chain reaction (RT-PCR) (13). But we
already know there is a discrepancy between PCR results and CTT
findings. According to data from China, while positive rates of RT-PCR
assay was 59% (601/1014), CTT imaging had 88% (888/1014) positivity in
suspected patients with COVID-19. Because there were, 308 patients with
negative PCR results but having COVİD-19 suggesting radiology. So when
evaluated together with clinical findings, CTT findings are quite
reliable for diagnosis (14). Considering that RT-PCR is not the gold
standard in diagnosis of new coronavirus, clinical and radiological
suspicion seems to be sufficient to start treatment early, especially in
patients with lung cancer. In our study population there were 2 patients
who had negative PCR results along with highly suspected clinical and
radiological findings (Table 1, case number 1 and 3). Both of them
responded well to COVID-19 specific therapies not requiring intensive
care unit (ICU) support (Figure 2).
Another case presentation is a stage IV lung adenocarcinoma patient from
Italy. While he was under nivolumab therapy within a multicentre
clinical trial almost for 6 months, also having partial response. He had
admitted with severe dyspnoea, hypoxia, lymphopenia, increased
C-reactive protein, transaminases and lactate deidrogenease. His chest
X-ray revealed reticular-interstitial addensative findings and his nasal
swab was positive for COVID-19. Due to the rapidly worsening clinical
condition, the patient died without receiving any of COVID-19 specific
treatment (15). Of course, it is not possible to predict the treatment
approach and prognosis in the presence of COVID in cancer cases
receiving immunotherapy nowadays. In this sense, we would like to
contribute by detailing a case in our study. There was a male receiving
immunotherapy following chemo-radiotherapy within the scope of
international, multi-centre clinical trial (Table 2, case number 2). On
his first admission to outpatient chemotherapy clinic he had severe
dyspnoea with oxygen saturation 83% in the room air. His laboratory
revealed increased LDH, C reactive protein and lymphopenia. There were
bilateral heterogeneous opacities on chest X-ray and bilateral ground
glass areas with right hemi thorax predominance on CTT. The patient was
quickly taken to isolated service. His nasal swab was negative for new
coronavirus for 3 times than transferred to general ward. He had been
administrated immunotherapy only for one cycle so it was too early to
expect immunotherapy related interstitial pneumonitis. But
chemo-radiotherapy was completed almost 4-6 months ago and his
radiological features were attempt to appear on radiotherapy side (right
hemi thorax). So he had been diagnosed with radiation pneumonia and
well-responded to metil-prednisolone therapy (Figure 1).