Diagnosis of COVID-19
2020 coronavirus disease (COIID-19) technical guidance: laboratory testing for 2019-now in humans.
2020 testing for COVID-19.
Global surveillance for COVID-19 caused by human infection with COVID-19 virus: interim guidance, 20 March 2020.
|Type||Symptom or Sign|
|Common symptoms or signs (2–14 d after exposure): >30%|
|Other symptoms: 5%–15%|
|Rare symptoms or signs <5%|
Diagnostic Strategies for Patients With Lung Cancer
2020 AABIP Statement on COVID-19 Infections; March 19th Updates.
- •Elective Bronchoscopy for lung mass, bronchial mass, mediastinal, or hilar lymphadenopathy, lung infiltrates, and mild-to-moderate airway stenosis should be postponed until after full recovery from COVID-19;
- •Bronchoscopy for urgent or emergent reasons should be considered with all precautionary measures only if it is a lifesaving intervention, e.g., massive hemoptysis, benign or malignant severe airway stenosis or suspicion of an alternative or secondary infectious cause or malignant condition with a resultant substantial endobronchial obstruction or rapidly progressing malignancy.
A COVID−19 Toolkit for Interventional Radiologists.
Imaging Features of SARS-CoV-2 Infection (COVID-19) and Implications for Patients With Lung Cancer
- (1)Early stage: 0 to 4 days after onset of flulike symptoms; normal CT scans in up to 50% of patients or scans with small subpleural GGO (Fig. 2A), mainly in the lower lobes. Typical CT findings are infrequently observed.
- (2)Progressive stage: 5 to 8 days after onset of symptoms; peripheral focal or multifocal GGO affecting both lungs in approximately 50% to 75% of patients, which then rapidly develop into crazy paving pattern and areas of consolidation, typically affecting both lungs (Fig. 2B).
- (3)Peak stage: 9 to 13 days after onset of symptoms; as the disease progresses, crazy paving and consolidation with air bronchograms become the dominant findings (Fig. 3A and B).
ACR recommendations for the use of chest radiography and computed tomography (CT) for suspected COVID-19 infection.
What Does All of This Mean for Patients With Lung Cancer?
Management of COVID-19
|Class||Agent||Mechanism of Actions||Developer||Original Use||Ongoing Trials|
|Treatment Of COVID-19|
|Antiviral||Remdesivir||inhibit RNA-dependent RNA polymerase||Gilead sciences||Ebola and Marburg virus infections||NCT04252664|
|Lopinavir-ritonavir||HIV reverse transcriptase inhibitors||AbbVie||HIV-1 infection||NCT04255017|
|Favipiravir (fapilavir)||inhibit RNA-dependent RNA polymerase||Avigan||influenza||NCT04346628|
|Others||Hydroxychloroquine||DMARD||Multiple||Malaria, RA, SLE, Q fever,||NCT04332991|
|ACE inhibitors||ACE-2 inhibitor||Multiple||Hypertension, cardiac failure||NCT04330300|
|Chloroquine sulfate||glycosylation of viral ACE-2/inhibition of quinone reductase 2||Multiple||Malaria||NCT04321616|
|Azithromycin||inhibit mRNA translation||Pfizer||Respiratory tract infections||NCT04341870|
|Convalescent plasma||passive immunotherapy||Multiple||NA||NCT04355767|
|Treatment of COVID-19–induced Cytokine Storm|
|Monoclonal Ab||Tocilizumab||IL-6 receptor antagonist||Roche||RA, GCA, CRS, JIA||NCT04306705|
|Sarilumab||IL-6 receptor antagonist||Regeneron, Sanofi||RA||NCT04315298|
|Lenzilumab||Antihuman GM-CSF monoclonal Ab||Humanigen||CRS||NCT04351152|
|Leronlimab||Anti-CCR5 receptor Ab||CytoDyn||HIV-1 infection||NCT04343651|
|Eculizumab||anti-C5 antibody||Alexion||PNH, atypical HUS||NCT04288713|
- Wang Y.
- Zhang D.
- Du G.
- et al.
2020 NIH clinical trial shows Remdesivir accelerates recovery from advanced COVID-19.
Overall Treatment of Patients With Lung Cancer
|Clinical Scenario||Treatment Recommendation||Initial Delay, wk||Workup||Comments|
|Stage I, II, and resectable IIIA|
|Stage I and II, untreated||Surgery SBRT for selected stage I||2–8||Repeat CT scan if baseline CT >8 wk|
|Stage I and II, resected||Observation (adjuvant therapy for a subset of stage II disease)||>8||Expand interval for CT scans up to 4– 6 mo if asymptomatic with 4 y, then annually after y 5||Consider CT scan but perform remote follow-up|
|Stage IIIa resectable single station||Surgery followed by chemo +/- radiation||<2||CT scan every 4 mo|
|Stage III untreated||Concurrent chemotherapy and radiotherapy but may start with chemotherapy for two cycles||<2||Same||Consider cisplatin/ pemetrexed|
Consider G-CSF if administering chemotherapy alone
|Stage III completed chemoradiotherapy Immune therapy||<2||Usual workup for immune checkpoint therapy||May delay up to 7 wk per the study, but the sooner the better|
|Stage II completed treatment||Observation||>8||Ct scan every 4 mo||Consider CT scan but perform remote follow-up|
|Stage IV with actionable targets|
|Untreated||Targeted therapy||<2||Start on time, perform safety assessments as laboratory or ECG, but do phone clinic instead of in-person visit. Consider performing response assessment after 2 mo|
|On treatment with disease control targeted therapy||<2||May expand the disease assessment for 3 mo if clinically stable or longer if on treatment for a long period of time||Do virtual clinics for toxicity notation, management, and any sign of disease progression|
|Stage IV wild-type|
|Untreated||Chemotherapy alone||<2||Standard||Consider less immune suppressive agents and use of growth factors or dose reduction as appropriate|
|Chemotherapy and immune therapy combination||<2||Standard||Need to be very selective|
|Immune therapy single agent||<2||Standard||Preferred if PD-L1 score >50% consider the approved longer interval of dosing|
|On treatment first line||Chemotherapy|
|Chemotherapy and immunotherapy||<2||May do imaging every 3 cycles, if stable||Consider growth factor, aim for a lesser number of cycles (4, if disease stable), and switch to maintenance|
|Immune therapy||<2||May do imaging every 3 mo, if stable||Consider switching to maintenance as early as indicated, use a longer interval of administration. Skip cycles if appropriate|
|<2||May do imaging every 3 cycles, if stable.||Use approved longer dosing intervals and stop at 2 y.|
|On treatment beyond first-line||Chemotherapy||<2 or 2–8||Extend CT scan to 3 or 4 cycles, if clinically stable||Consider chemotherapy holidays for 2–3 cycles interval.|
|Immunotherapy||<2 or 2–8||Extend disease assessment interval||Use approved longer dosing intervals|
|No evidence of disease||Observation||>8||Extend interval of workup||refer to survival clinics|
|Presence of disease||Observation||2–8||Extend the interval of workup||per phone clinic|
|Clinical Scenario||Treatment Recommendation||Initial Delay, wk||Workup||Comments|
|Untreated||Concurrent chemotherapy and radiotherapy||<2||standard||if radiation therapy is not available start with chemotherapy and add XRT as early as possible|
|On treatment||Concurrent chemotherapy and radiotherapy followed by chemotherapy||<2||standard||continue with CCRT, keep cycles of chemotherapy to 4, use growth factors away from XRT|
|Observation||>8||may delay imaging for a mo||Flow up by teleclinic|
|Untreated||Chemotherapy||<2||standard||should start on time. Consider growth factors or dose reduction, consider oral etoposide for d 2 and 3|
|Chemotherapy and immunotherapy||<2||standard||Be selective|
|On treatment||chemotherapy||<2||may extend assessment for 3 cycles if stable|
|Chemotherapy and immunotherapy||<2|
|Completed treatment||Observation||2–8||May extend up to 2 mo||if asymptomatic by teleclinic|
|Lung cancer screening||All activities should be halted for the screening of asymptomatic patients.|
|Suspected cancer cases||To be reviewed by virtual multidisciplinary team and decide case by case.|
|Smoking cessation||Impact of coronavirus disease 2019 on lung should energize tobacco control efforts.|
Early Stage Lung Cancer
Interim guidance for healthcare facilities: preparing for community transmission of COVID-19 in the United States.
COVID-19 Patient Care information.
ESMO management and treatment adapted recommendations in the COVID-19 era: lung cancer.
2020 COVID-19 guidelines for triage of thoracic patients.
Locally Advanced Lung Cancer
- Rubinstein S.
- Steinharter J.A.
- Warner J.
- Rini B.I.
- Peters S.
- Choueiri T.K.
COVID-19 and Immunotherapy
Advanced Stage NSCLC
Patients on Treatment With Single-Agent Immunotherapy
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Disclosure: Dr. Dingemans reports receiving personal fees from Roche, Pharma Mar, Boehringer Ingelheim, Eli Lilly, and Merck Sharp and Dohme; and grants from Bristol-Myers Squibb outside of the submitted work. Dr. Soo reports receiving grants and personal fees from AstraZeneca and Boehringer Ingelheim; and personal fees from Bristol-Myers Squibb, Eli Lilly, Merck, Novartis, Pfizer, Roch0065, Taiho, Takeda, Yuhan, and Amgen outside of the submitted work. Dr. Jazieh reports receiving grants from Merck Sharp and Dohme and other fees from Bristol-Myers Squibb outside of the submitted work. Dr. Aerts reports receiving personal fees and nonfinancial support from Merck Sharp and Dohme; received personal fees from Bristol-Myers Squibb, Boehringer Ingelheim, Amphera, Eli Lilly, Takeda, Bayer, Roche, and AstraZeneca outside of the submitted work; has a patent allogenic tumor cell lysate licensed to Amphera; has a patent combination immunotherapy in cancer pending; and has a patent biomarker for immunotherapy pending. Dr. Yoon reports receiving research grants from GE Healthcare outside of the submitted work. Dr. Veronesi reports receiving grants from Associazione Italiana per la Ricerca sul Cancro, the Ministry of Health, and Istituto Nazionale Assicurazione Infortuni sul Lavoro outside of the submitted work; and received honoraria from Ab Medica SpA, Medtronic, and Verb Medical. Dr. Ramalingam reports receiving grants and other fees from Amgen, AstraZeneca, and Bristol-Myers Squibb; received other fees from Abbvie, Genentech, and Roche; and received grants from Merck, Takeda, Tesaro, and Advaxis outside of the submitted work. Dr. Garassino reports receiving personal fees from Bayer Incyte, Sanofi-Aventis, Inivata Takeda, Boehringer Ingelheim, Otsuka Pharma, Seattle Genetics, and Daiichi Sankyo; personal fees and other fees from AstraZeneca, Eli Lilly, Novartis, Bristol-Myers Squibb, Roche, Pfizer, and Celgene; and other fees from Tiziana Sciences, Clovis GlaxoSmithKline, Spectrum Pharmaceuticals, Blueprint Medicine, Bayer Healthcare Pharmaceuticals, Janssen, and GlaxoSmithKline outside of the submitted work. Dr. Haanen reports receiving grants from Bristol-Myers Squibb, Merck, Sharp and Dohme, Novartis, and Neon Therapeutics outside of the submitted work; and advisory roles for AIMM, Amgen, Achilles Tx, AstraZeneca, Bristol-Myers Squibb, Bayer, Celsius Tx, GSK, Gadeta, Immunocore, MSD, Merck Serono, Neon Tx, Neogene Tx, Novartis, Pfizer, Roche/Genentech, Sanofi, Seattle Genetics, Third Rock Ventures, and Vaximm. Dr. Peters reports receiving personal fees from Abbvie, Amgen, AstraZeneca, Bayer, Biocartis, Boehringer Ingelheim, and Bristol-Myers Squibb; personal fees from Clovis, Daiichi Sankyo, Debiopharm, Eli Lilly, F. Hoffmann-La Roche, Foundation Medicine, Illumina, Janssen, Merck Sharp, and Dohme, Merck Serono, Merrimack, Novartis, Pharma Mar, Pfizer, Regeneron, Sanofi, Seattle Genetics, Takeda, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, and Eli Lilly; nonfinancial support from Amgen, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Clovis, F. Hoffmann-La Roche, Illumina, Merck Sharp, and Dohme, Merck Serono, Novartis, Pfizer, and Sanofi; and fees for the institution from Bioinvent outside of the submitted work. Dr. Scagliotti reports receiving personal fees from AstraZeneca, Roche, Merck Sharp, and Dohme, Takeda, and Eli Lilly outside of the submitted work. Dr. Belani reports receiving personal fees from Genentech outside of the submitted work. The remaining authors declare no conflict of interest.
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