Treating Patients With Primary Musculoskeletal Tumors in the Time of COVID-19 Pandemic, Alleviating the Pressure on CareProviders

Papavasiliou Kyriakos^1*, Prodoromos Hytiroglou², Christos Papandreou³ & Tsiridis Eleftherios¹

¹Department of Academic Orthopaedic, Papageorgiou General Hospital, Aristotle University Medical School, Thessaloniki Ring Road, 56403 Nea Efkarpia, Greece
²Laboratory of Pathology & Pathological Anatomy, Aristotle University Medical School, University Campus, 54124, Thessaloniki, Greece
³Department of Academic Oncology, Papageorgiou General Hospital, Aristotle University Medical School, Ring Road Thessaloniki, 56403, Greece

*Correspondence to: Dr. Papavasiliou Kyriakos, Department of Academic Orthopaedic, Papageorgiou General Hospital, Aristotle University Medical School, Thessaloniki Ring Road, 56403 Nea Efkarpia, Greece.

Copyright © 2020 Dr. Papavasiliou Kyriakos, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Overview
On March 11^th, 2020, the World Health Organization assessed and characterized the COVID-19 as a pandemic. Ever since, things are changing and evolving very rapidly [1]. Orthopaedic surgeons are not usually considered front-line staff in the fight against a viral pandemic [2]. Furthermore, the majority of elective orthopaedic operations, aim to improve the patients’ quality of life. As a result, most -if not all elective orthopaedic surgery has been temporarily postponed worldwide.

Patients with trauma and musculoskeletal tumors are generally excluded from this general rule. Nonetheless, during this COVID-19 outbreak, patients with cancer face the major risk of being unable to receive the necessary medical services both in terms of getting into the hospital and secondly enjoying regular medical care once there [3]. Concerning patients with musculoskeletal tumors, the existence of designated Musculoskeletal Tumors’ Treatment Centers [4-6] -being most of the times front-line departments of tertiary hospitals- may render the treatment of these patients in a timely and efficient manner, an even more difficult task. The scarcity of these centers of excellence in the treatment of musculoskeletal tumors, poses additional significant challenges during the COVID-19 era, especially if one considers the possibility to transfer patients to cancer centers which are not affected, or are moderately affected, by the COVID-19 [7]. As a result, there may be an immense pressure exerted on orthopaedic surgeons, who undoubtedly are at the front-line of identifying, diagnosing and treating patients with musculoskeletal tumors.

Facing the COVID-19 Challenges When Treating Patients With Primary Musculoskeletal Tumors
During these harsh and unprecedented times, even the Oncological Multidisciplinary Teams (MDTs) may need to take into account factors never considered before [4-6], when deciding on the optimal treatment of a patient with a musculoskeletal tumor. The necessity for immediate surgical intervention, or the possible postponement of the “operative window” period, need to be decided upon new criteria. The prognosis, the life-expectancy, the age and the existence of co-morbidities of the patient, should be thoroughly discussed under the light of recent pandemic developments. Following thorough consultation with all the members of our MDT, and based on our country’s current epidemiological status, we have reached an unanimous agreement to implement new rules during our Hospital’s MDT meetings, in order to decide whether a patient with a tumor should be operated on as an emergency or an urgent procedure, or whether the operation could or should be postponed for a later date (Figure 1). We propose these local guidelines on the basis of potential adaptation and further implementation by other MDT committees in Musculoskeletal Oncology Departments.

Further to medical and surgical considerations, there are also patient related issues that need to be taken into account before reaching a decision during an MDT meeting. The need for Intensive Care Unit (ICU) stay postoperatively, the increased need for blood transfusions perioperatively, the availability of absolute non COVID-19 wards and ICU units, the availability of all medical and surgical specialties potentially involved in the musculoskeletal oncological surgery, the possibility of an operation on an outpatient basis, should now be considered. As a result, our MDT board has been recently enhanced by an ICU internist, a senior Hospital Administrator and a member of the Infection Control Unit (Figure 2).

We present the adapted treatment algorithms for patients with bone (Figure 3) and soft-tissue (Figure 4) primary tumors in the COVID-19 era, which are currently employed in our Institution which is one of the largest tertiary hospitals of our country [4-6]. It has been decided by the MDT that these algorithms will be implemented during this strictest phase of the COVID-19 pandemic, they will be re-assessed and updated as needed on a monthly basis and they will be re-implemented should a similar emergency occur [8-10].

Conclusion
The COVID-19 pandemic will undoubtedly change the treatment management of our patients under emergency and long running scenarios for the years to come [11]. Oncological MDTs have always succeeded in alleviating the immense burden exerted on individual care-providers, let alone offering optimal treatment to patients with musculoskeletal tumors [4-6]. In the COVID-19 era, implementing precise guidelines, based on current international and local epidemiological data on virus spread, health-system capacity and human resources, will certainly lower patients’ iatrogenic morbidity, will identify optimal management and will relieve unnecessary pressure upon care-providers.

Conflict of Interest
The authors declare that there is no conflict of interest regarding the publication of this article.

Funding
This research didn’t receive grants from any funding agency in the public, commercial or not-for-profit sectors.

Ethics Committee Approval
This study did not require our Institute’s Ethics Committee approval.

Bibliography

1. Dyer, G. S. M. & Harris, M. B. (2020). What's Important: Facing Fear in the Time of COVID-19. J Bone Joint Surg Am., 102(11), 929-930.
2. Chang Liang, Z., Wang, W., Murphy, D. & Po Hui, J. H. (2020). Novel Coronavirus and Orthopaedic Surgery: Early Experiences from Singapore. J Bone Joint Surg Am.
3. Wang, H. & Zhang, L. (2020). Risk of COVID-19 for patients with cancer. Lancet Oncol., 21(4), e181.
4. Gerrand, G., Athanasou, N., Brennan, B., Grimer, R., Judson, I., Morland, B., Peake, D., Seddon, B. & Whelan, J. (2016). UK guidelines for the management of bone sarcomas. Clin Sarcoma Res., 6(7).
5. Casali, P. G., Bielack, S., Abecassis, N., et al. (2018). Bone sarcomas: ESMO-PaedCan-EURACAN Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol., 29(Suppl 4), iv79-iv95.
6. Biermann, J. S., Chow, W., Reed, D. R., et al. (2017). NCCN Guidelines Insights: Bone Cancer, Version 2. J Natl Compr Canc Netw., 15(2), 155-167.
7. Mussetti, A., Maluquer, C., Albasanz-Puig, A., Gudiol, C., Moreno-Gonzalez, G., Corradini, P. & Sureda, A. (2020). Handling the COVID-19 pandemic in the oncological setting. Lancet Haematol., 7(5), e365‐e366.
8. Guillou, L., Coindre, J. M., Bonichon, F., et al. (1997). Comparative study of the National Cancer Institute and French Federation of Cancer Centers Sarcoma Group grading systems in a population of 410 adult patients with soft tissue sarcoma. J Clin Oncol., 15(1), 350-362.
9. Edge, S. B. & Compton, C. C. (2010). The American Joint Committee on Cancer: the 7^th edition of the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol., 17(6), 1471-1474.
10. Mayhew, D., Mendonca, V. & Murthy, B. V. S. (2019). A review of ASA physical status - historical perspectives and modern developments. Anaesthesia, 74(3), 373-379.
11. Halawi, M. J., Wang, D. D. & Hunt, T. R. (2020). What's Important: Weathering the COVID-19 Crisis: Time for Leadership, Vigilance, and Unity. J Bone Joint Surg Am., 102(9), 759‐760.