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Coronavirus Disease 2019 or Lung Cancer: A Differential Diagnostic Experience and Management Model From Wuhan

  • Jian Zhu
    Affiliations
    Department of Thoracic Cardiovascular Surgery, General hospital of Central Theater Command of the People’s Liberation Army, Wuhan, People’s Republic of China
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  • Yu Zhang
    Affiliations
    Department of Thoracic Cardiovascular Surgery, General hospital of Central Theater Command of the People’s Liberation Army, Wuhan, People’s Republic of China
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  • Xu-Hui Gao
    Affiliations
    Department of Thoracic Cardiovascular Surgery, General hospital of Central Theater Command of the People’s Liberation Army, Wuhan, People’s Republic of China
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  • Er-Ping Xi
    Correspondence
    Address for correspondence: Er-Ping Xi, MD, PhD, Department of Thoracic Cardiovascular Surgery, General hospital of Central Theater Command of the People’s Liberation Army, 627#, Wuluo Road, Wuchang District, Wuhan, Hubei 430070, People’s Republic of China.
    Affiliations
    Department of Thoracic Cardiovascular Surgery, General hospital of Central Theater Command of the People’s Liberation Army, Wuhan, People’s Republic of China
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Open ArchivePublished:May 06, 2020DOI:https://doi.org/10.1016/j.jtho.2020.04.030
      To the Editor:
      In the Journal of Thoracic Oncology, Tian et al.
      • Tian S.
      • Hu W.
      • Niu L.
      • Liu H.
      • Xu H.
      • Xiao S.Y.
      Pulmonary pathology of early-phase 2019 novel coronavirus (COVID-19) pneumonia in two patients with lung cancer.
      reported one patient who died of coronavirus disease-2019 (COVID-19) after undergoing lung lobectomy for adenocarcinoma. Bonomi et al.

      Bonomi L, Ghilardi L, Arnoldi E, Tondini CA, Bettini AC. A rapid fatal evolution of coronavirus disease-19 (COVID-19) in an advanced lung cancer patient with a long time response to nivolumab [e-pub ahead of print]. J Thorac Oncol. https://doi.org/10.1016/j.jtho.2020.03.021, accessed March 31, 2020.

      presented a patient with metastatic lung cancer who died rapidly after contracting COVID-19. Russano et al.

      Russano M, Citarella F, Vincenzi B, Tonini G, Santini D. COVID-19 or lung cancer: what should we treat [e-pub ahead of print]? J Thorac Oncol. https://doi.org/10.1016/j.jtho.2020.04.001, accessed April 10, 2020.

      believed that patients with tumors had a higher risk of lethal COVID-19 complications. This news seems foreboding for patients with cancer who also acquire COVID-19. Therefore, because of the dramatic COVID-19 outbreak, extreme caution is required to ensure COVID-19 is not misdiagnosed as lung cancer and to consider that COVID-19 can coexist in patients with lung cancer.
      However, the high-resolution computed tomography (CT) findings of some patients with COVID-19 are dominated by ground-glass opacity–like changes, and these patients can even have only one localized lesion, with vacuoles, pleural traction, and invasion of pulmonary capillaries. These observations are also highly consistent with and are classic CT findings of lung cancer. Differentiating lung cancer from COVID-19 is a challenge in Wuhan, the epicenter of the outbreak currently on controlled levels of infection, and wherein the number of patients with early-stage lung cancer and those with asymptomatic COVID-19 is increasing.

      Ouyang W, Yu J, Zhang J, Xie C. Alert to potential contagiousness: a case of lung cancer with asymptomatic SARS-CoV-2 infection [e-pub ahead of print]. J Thorac Oncol. https://doi.org/10.1016/j.jtho.2020.04.005, accessed April 16, 2020.

      ,

      Meng H, Xiong R, He R, et al. CT imaging and clinical course of asymptomatic cases with COVID-19 pneumonia at admission in Wuhan, China [e-pub ahead of print]. J Infect. https://doi.org/10.1016/j.jinf.2020.04.004, accessed April 12, 2020.

      This adds to the problem of identifying those with asymptomatic COVID-19. The doctors’ concerns are twofold. First, patients with COVID-19 are being mistakenly treated for lung cancer, and these individuals could undergo an unnecessary operation. Second, patients with lung cancer with COVID-19 during the perioperative period can experience severe complications or nosocomial infection events.
      We took the following measures to distinguish them. First, the patients admitted to the hospital were asked about their detailed medical history, including any contact history with patients having COVID-19 and whether they had had fever, cough, diarrhea, sore throat, or other symptoms in the past 2 weeks. After stating their medical history, the patients signed a declaration form consenting to disclose their medical history without any concealment; otherwise, they would bear the legal responsibility. Second, chest CT examination, routine blood parameters, blood IgG and IgM analyses, and nucleic acid examination of pharyngeal swab specimens were performed on the patients and their companions on hospital admission. Third, only those patient companions whose tests revealed negative results were allowed to accompany the patient, and only a minimum number of people were allowed to accompany the patients. If the patients were diagnosed as having suspected COVID-19 in the above examination, they were admitted to the ward for patients with suspected COVID-19 for further investigation. If the diagnosis was confirmed, the patients were transferred to the infected area for treatment. Fourth, newly admitted patients were placed in protective isolation in single rooms. After repeated body temperature monitoring, if there were no abnormalities, and if none of the symptoms mentioned above were present after 24 hours, the patient underwent a second pharyngeal swab for nucleic acid examination. If the test result was negative, the patient was transferred to the general ward for 2 to 3 days. Patient indicator information of COVID-19 was announced in the department medical staffs’ WeChat group and was updated daily. Fifth, hospitalized patients wore masks at all times; visitors and discussions with other patients were strictly prohibited. Sixth, the department ward for suspected COVID-19 and the general ward were managed by different sets of staff, and the staff were strictly prohibited from changing wards. They also needed to follow strict protective measures among themselves, such as wearing a mask if two or more people slept in the same duty room. Seventh, patients going out for checks or eating were assigned a special route, and there was regular disinfection by professionals. Eighth, routine bronchoscopy was performed before lung surgery and nucleic acid examination was also performed along with an analysis of secretions from the lower respiratory tract. Ninth, after several days (generally 1–2 weeks) of examination and surgical preparation, patients with lung cancer and with no evidence of COVID-19 underwent a routine operation.

      References

        • Tian S.
        • Hu W.
        • Niu L.
        • Liu H.
        • Xu H.
        • Xiao S.Y.
        Pulmonary pathology of early-phase 2019 novel coronavirus (COVID-19) pneumonia in two patients with lung cancer.
        J Thorac Oncol. 2020; 15: 700-704
      1. Bonomi L, Ghilardi L, Arnoldi E, Tondini CA, Bettini AC. A rapid fatal evolution of coronavirus disease-19 (COVID-19) in an advanced lung cancer patient with a long time response to nivolumab [e-pub ahead of print]. J Thorac Oncol. https://doi.org/10.1016/j.jtho.2020.03.021, accessed March 31, 2020.

      2. Russano M, Citarella F, Vincenzi B, Tonini G, Santini D. COVID-19 or lung cancer: what should we treat [e-pub ahead of print]? J Thorac Oncol. https://doi.org/10.1016/j.jtho.2020.04.001, accessed April 10, 2020.

      3. Ouyang W, Yu J, Zhang J, Xie C. Alert to potential contagiousness: a case of lung cancer with asymptomatic SARS-CoV-2 infection [e-pub ahead of print]. J Thorac Oncol. https://doi.org/10.1016/j.jtho.2020.04.005, accessed April 16, 2020.

      4. Meng H, Xiong R, He R, et al. CT imaging and clinical course of asymptomatic cases with COVID-19 pneumonia at admission in Wuhan, China [e-pub ahead of print]. J Infect. https://doi.org/10.1016/j.jinf.2020.04.004, accessed April 12, 2020.

      Linked Article

      • A Rapid Fatal Evolution of Coronavirus Disease-19 in a Patient With Advanced Lung Cancer With a Long-Time Response to Nivolumab
        Journal of Thoracic OncologyVol. 15Issue 6
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          Coronavirus disease-19 (COVID-19) is now a pandemic disease. In Italy, the first set of cases were documented at the end of January 2020 reporting a dramatic spread. Liang et al.1 reported an increased risk of COVID-19 for patients with cancer, having poorer prognosis than those without cancer. We present a case of a rapid fatal evolution of COVID-19 in a patient with metastatic lung cancer in partial remission with immunotherapy since 2013.
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      • Pulmonary Pathology of Early Phase 2019 Novel Coronavirus Pneumonia
        Journal of Thoracic OncologyVol. 15Issue 5
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          We read the publication on “Pulmonary pathology of early phase 2019 novel coronavirus (COVID-19) pneumonia in two patients with lung cancer” with great interest.1 Tian et al.1 concluded that “the lungs of both patients exhibited edema, proteinaceous exudate, focal reactive hyperplasia of pneumocytes with patchy inflammatory cellular infiltration, and multinucleated giant cells” and noted that “these changes likely represent an early phase of the lung pathology of COVID-19 pneumonia.” Although this pathologic finding might be a lung abnormality in COVID-19, it should not be referred to as COVID-19 pneumonia because the patients did not have pneumonia.
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      • Alert to Potential Contagiousness: A Case of Lung Cancer With Asymptomatic Severe Acute Respiratory Syndrome Coronavirus 2 Infection
        Journal of Thoracic OncologyVol. 15Issue 6
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          The novel coronavirus disease 2019 (COVID-19) has become a global pandemic and affected more than 1 million people all over the world.1 This disease is notably linked to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Nowadays, asymptomatic SARS-CoV-2 carriers are causing concern.2 We previously reported that patients who had cancer were at an increased risk of COVID-19.3 Here, we report a case of an asymptomatic SARS-CoV-2 carrier with lung cancer who might be contagious.
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      • Coronavirus Disease 2019 or Lung Cancer: What Should We Treat?
        Journal of Thoracic OncologyVol. 15Issue 7
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          Management of patients with lung cancer in the era of coronavirus disease 2019 (COVID-19) has become a global concern. We read with great interest the article written by Zhang et al.,1 who first reported the treatment and outcome of a patient with lung cancer infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A 57-year-old Chinese man affected by advanced lung adenocarcinoma harboring EGFR L858R mutation continued targeted therapy with osimertinib despite development of COVID-19 pneumonia.
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