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ORIGINAL ARTICLE
Year : 2020  |  Volume : 16  |  Issue : 2  |  Page : 350-355

CSCO ablation expert workshop report: Recommendations for the management of tumor ablation during the coronavirus disease 2019 epidemic


1 Minimally Invasive Therapy Center, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
2 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Interventional Therapy, Peking University Cancer Hospital & Institute, Beijing, China
3 Department of Thoracic Surgery, Shaanxi Provincial Tumor Hospital, Xi'an, China
4 Department of Medical Oncology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
5 Department of Minimal-Invasive Intervention, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
6 Department of Minimally Invasive Interventional Center, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
7 Department of Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
8 Institute of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
9 Department of Center of Minimally Invasive Therapies for Tumors, Beijing Hospital, National Center of Gerontology, Beijing, China
10 Department of Interventional Radiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
11 Department of Interventional Therapy, Jiangsu Cancer Hospital, Nanjing, China
12 Department of Oncology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
13 Department of Interventional Oncology, Renji Hospital, School of Medicine, Jiaotong University, Shanghai, China
14 Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
15 Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Ultrasound Research and Education Institute, Tongji University, Cancer Center, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Tongji University School of Medicine, Shanghai, China
16 Department of Ultrasound, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
17 Department of General Surgery, Guangdong Provincial Peoplefs Hospital, Guangdong Academy of Medical Sciences, Guangdong, The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
18 Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, China
19 Department of Ultrasound, Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Hangzhou, China
20 Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

Date of Submission17-Apr-2020
Date of Decision20-Apr-2020
Date of Acceptance24-Apr-2020
Date of Web Publication28-May-2020

Correspondence Address:
Weijun Fan
651 Dongfeng East Road, Guangzhou, Guangdong 510060
China
Xin Ye
16766 Jingshi Road, Jinan, Shandong 250014
China
Zhiqiang Meng
270 Dong'An Road, Shanghai 200032
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_480_20

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 > Abstract 


The coronavirus disease 2019 (COVID-19) has become a global pandemic since its outbreak in December 2019, which posed a threat to the safety and well-being of people on a global scale. Cancer patients are at high risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and their critical morbidity and case fatality rates are high. The ablation expert committee of the Chinese Society of Clinical Oncology compiled corresponding expert recommendations. These recommendations summarize the preventive measures and management of tumor ablation treatment in medical institutions, including outpatient clinics, oncology wards, ablation operation room, and postablation follow-ups in accordance with the guidelines and protocols imposed by the National Health Commission of the People's Republic of China and the experience in management and prevention according to various hospitals. This consensus aims to reduce and prevent the spread of SARS-CoV-2 and its cross-infection between cancer patients in hospitals and provide regulatory advice and guidelines for medical personnel.

Keywords: Ablation therapy, coronavirus disease 2019, tumor


How to cite this article:
Shen Y, Cheng Cs, Wang P, Zhu X, Lei G, Fang Y, Li H, Fan W, Pan H, Tang Z, Ma K, Li X, Lin Z, Zhuang Y, Ye X, Zhai B, Han Y, Huang J, Xu H, Zheng R, Chen R, Yu J, Xu D, Wang Z, Meng Z. CSCO ablation expert workshop report: Recommendations for the management of tumor ablation during the coronavirus disease 2019 epidemic. J Can Res Ther 2020;16:350-5

How to cite this URL:
Shen Y, Cheng Cs, Wang P, Zhu X, Lei G, Fang Y, Li H, Fan W, Pan H, Tang Z, Ma K, Li X, Lin Z, Zhuang Y, Ye X, Zhai B, Han Y, Huang J, Xu H, Zheng R, Chen R, Yu J, Xu D, Wang Z, Meng Z. CSCO ablation expert workshop report: Recommendations for the management of tumor ablation during the coronavirus disease 2019 epidemic. J Can Res Ther [serial online] 2020 [cited 2020 Jul 16];16:350-5. Available from: http://www.cancerjournal.net/text.asp?2020/16/2/350/285188




 > Introduction Top


Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 wasfirst reported as a highly contagious disease in December 2019 and eventually spread worldwide.[1],[2] On March 11, 2020, the World Health Organization (WHO) declared COVID-2019 as a global pandemic.[3] As of April 14, 2020, >1.84 million cases have been reported worldwide, resulting in >117,000 deaths.[4] According to the national statistics of COVID-19 in China, most patients suffer from the mild syndrome. The elderly patients with risk factors and comorbidities showed an increase in severe morbidity and fatality rates.[5] In all confirmed cases, patients with a history of malignant tumors accounted for approximately 1.3% and showed a higher rate of severe acute morbidity.[6]

Malignant tumors, unlike other chronic diseases, tend to progress relatively fast, and therefore, delayed treatment during the period of COVID-19 epidemic is life-threatening for cancer patients. Therefore, ensuring the safety of continuous treatment of patients with malignant disease is particularly important during this time. Ablation therapy is one of the essential methods of tumor treatment. Ablation therapy is characterized by the minimally invasive nature of the procedure and its proven effectiveness. It is widely performed on the liver, lung, and other malignant tumors.[7],[8] As the epidemic continues, many cancer patients sought hospitalization for tumor treatment and ablation therapy. In the past 3 months, numerous efforts have been made to fight against the COVID-19 outbreak. Although the COVID-19 epidemic appears to be constrained in mainland China, COVID-19 spread throughout the hospital and causes crossover infections.[9] Symptoms of COVID-19 can be relatively nonspecific, with an incubation period for several days, and the infected person may be asymptomatic. Current reports indicate that asymptomatic cases may contribute to the spread of the disease. Potential asymptomatic, recurrent, and foreign-imported cases increase the risk of cluster infection in medical facilities, leading to further fatalities in patients and medical personnel. Therefore, it is of great importance to imposing prevention and control measures for ablation treatment to avoid nosocomial infections.

To enhance the awareness and capabilities of self-protection among medical personnel and avoid hospital infection while performing ablation therapy during the prevention and control of the COVID-19 epidemic, the Ablation Expert Committee of the Chinese Society of Clinical Oncology organized experts in related fields to formulate the “Chinese Expert Recommendations for the Management of Tumor Ablation during the Prevention of COVID-19.” This recommendation highlights the features of tumor ablation therapy in reference to the seventh edition of the Chinese Clinical Guideline for COVID-19 Pneumonia Diagnosis and Treatment issued by the National Health Commission of China,[5] thefirst edition of the technical guidelines for the prevention and control of new coronavirus infections in medical institutions,[10] COVID-19 series guide issued by the Chinese Center for Disease Control and Prevention (CDC),[11] and the WHO technical guidance for COVID-19,[12] as well as the working experience of ablation experts in China during the epidemic. This expert recommendations are intended to provide guidance for tumor ablation therapy during the COVID-19 epidemic and provide a reference for medical personnel of related fields in China and other countries and regions.


 > General Principles of Medical Institutional Management Top


The unified management of the hospital is particularly important. Preventive control systems and emergency measures must be developed to ensure the safety of medical staff and patients in noncommunicable disease medical institutions.

Formulate emergency plans and workflows

According to the transmission characteristics of SARS-CoV-2, emergency plan and workflow are formulated to determine the source of infection, transmission route, and susceptible population,[10] for example, develop treatment guidelines for fever patients, construct protection standards for employees in various positions and establish a COVID-19 prevention and control team in a medical institution to be responsible for leading the prevention, control, training, management, consultation, and reporting of infectious diseases.

Training for all staffs

Provide training for the prevention and control of COVID-19 through the distribution of electronic teaching materials and online video lectures to all the employees. Training should include knowledge on etiology, hand hygiene, use of protective equipment, etc. Tailor-made training should be conducted according to different positions, especially for high-risk departments, such as outpatient, emergency, intensive care unit, computed tomography (CT) room, and operating room, and hence that medical personnel in high-risk departments are familiar with COVID-19 detection, diagnosis, reporting, isolation, prevention, and control processes.

Implement medical personnel protection measures and health reporting system

Reserve and distribute sufficient qualified personal protective equipment to ensure that medical personnel meets personal protection standards in different medical settings. Standardized disinfection procedures can reduce the chance of contact and droplet transmission. It is recommended that medical personnel's health be actively monitored, including the daily recording of body temperature and any respiratory symptoms. People with abnormal conditions must be quarantined as required. Employees with symptoms of COVID-19 should not work. During vacations, staff are encouraged to stay at home and those who traveled to high-risk areas or have contact history with suspected or confirmed COVID-19 cases should be isolated and observed as required.

Strengthen the management of patient visits

Implement a comprehensive appointment system and divided appointments into time intervals to minimize the risk of congestion and hospital infection. Conduct epidemiological investigations and temperature checks on all patients and entourage entering the hospital.[13] Travel history from high-risk areas or a history of contact with confirmed cases must be reported. The definition of high-risk areas shall be adjusted in time according to changes in the prevailing situation. Patients and their families must wear medical masks, wash their hands, and practice cough etiquette within medical institutions.


 > Management of Ablation Clinic Top


Patient appointment requirement

Patients need to visit the medical institution according to schedule. Before entering the outpatient clinic area, patients should present their identifications and provide a contact number. In addition to verifying the health code and the signed commitments, temperature check, epidemiological survey, and symptom questionnaire related to COVID-19 should also be completed.[13] The health code is an electronic QR code that collects data from the national public administration agencies and calculates on the basis of a big data platform. The red code indicates people who did not or have not completed medical quarantine measures, have not recovered from COVID-19 or did not rule out the suspect. The yellow code indicates people who have traveled from areas with a high incidence of COVID-19 within the past 14 days. The green code specifies individuals without any abnormalities or has completed medical quarantine measures. If the body temperature of the person holding a green code does not exceed 37.3°C, the person may enter the clinic.

Medical personnel protection requirements

Outpatient medical staff should conduct environmental ventilation, surface cleaning and disinfection, and medical waste management according to standards. They should strictly abide with the principle of “one person, one inspection room” to minimize the density in the clinic. Outpatient medical staff should be protected in accordance with thefirst-level protection standards. They should wear medical masks, work clothes, disposable work caps, and disposable latex gloves.[14] Hand hygiene measures should be strictly implemented before and after touching each patient.[15] It is recommended to choose an effective skin disinfectant, such as povidone-iodine, chlorine-containing disinfectant, hydrogen peroxide disinfectant, or quick-drying hand disinfectant. After using a diagnostic equipment, disinfect the equipment with 75% alcohol or 1000 g/L chlorine.[16]

Management of suspicious patients

Before entering the ablation clinic, people with elevated body temperature but no history of exposure in a high-risk area or a contact history with a confirmed COVID-19 case should complete fever registration, sign a notification, and consult with a fever clinic designated by the local health administration to exclude COVID-19. If a person with a highly suspicious infection from SARS-CoV-2 is identified (e.g., fever, exposure history in an infected area, or a confirmed case), the patient shall be escorted by a person with standard protective measures to a specially designed isolation room. Cases shall be reported to the epidemiological prevention and control expert group of the medical institution, and then, the medical management office or the CDC of the Health Commission will carry out further necessary inspections.[17] The venue shall be disinfected, and people in close contact shall receive medical observation and other preventive measures.[18] Institutions shall refer patients to medical institutions with treatment capabilities promptly.[19]


 > Management of Ablation Treatment Ward Top


New admission screening

During the epidemic, the admission criteria and procedures for inpatients must be strictly enforced. Ablation therapy is usually targeted at patients with nonemergency tumors. Hospitalization of COVID-19 patients should be avoided to reduce the risk of nosocomial infections. Furthermore, when patients recover from COVID-19, they can already be admitted to the hospital for treatment. Patients should be screened prior to admission, including their travel history in the past 14 days, history of close contact with a confirmed COVID-19 case, and presence of suspicious symptoms, such as fever and cough.[13] It is recommended to perform routine chest CT scans and routine blood tests as well as SARS-CoV-2 nucleic acid tests whenever possible. After excluding COVID-19 and signing a legal and effective commitment, the attending doctor will decide on admission based on the patient's condition and body temperature on the day.

Inpatient management

A 24-h access control is situated at the entrance of the ward. Medical personnel access through assigned access cards, and inpatients enter after checking their identities at the entrance. People with the following conditions are forbidden to enter the ward: (1) Body temperature ≥37.3°C or other suspicious symptoms, such as cough and fatigue, but not excluded within the scope of COVID-19; (2) Residence or travel history to areas with a high incidence of COVID-19 in the past 14 days; (3) History of contact with COVID-19 patients or suspected cases within the past 14 days; (4) Engaging with two or more people at home or at work who have experienced fever or respiratory symptoms in the past 14 days; and (5) Inpatients who are not hospitalized in this ward or family members without permission to accompany inpatients.

It is strictly forbidden for inpatients to leave the hospital without permission. To reduce the density in the ward, keep one patient per room if possible, or at least maintain a sufficient distance between each bed. Curtains shall be set up to reduce the chance of cross-infection. During hospitalization, patients should wear disposable medical masks. After treatment, no new patients shall be admitted on the day of the previous discharge. After strict disinfection, new patients will be accommodated the next day.


 > Management of Family Member Accompaniments Top


Strictly restrain family accompaniment. In the case of medically requiring family members to accompany the patient, a family member should obtain a valid accompanying guest certificate, which shall not be passed between family members. The entourage should undergo epidemiological investigations and have his or her body temperature checked at the entrance of the ward. Individuals with body temperature over 37.3°C or have suspicious symptoms, such as cough and fatigue, as well as those with a history of exposure to high-risk areas or confirmed COVID-19 cases are not allowed to enter the ward. The accompanying personnel is required to wear medical masks and cooperate with daily temperature monitoring.

Management of medical personnel in daily clinical work

In the daily management of inpatients, including routine diagnosis and treatment of ordinary patients, the protection standards of medical staff should be the same as the requirements of the abovementioned outpatient clinics. In cases of potential blood or body fluid overflow, wear goggles or face shields.[14] Routine medical operations, such as inquiries, physical examinations, consent documents, blood draws, and other operations, shall be performed on the patient's bed to avoid the flocking of patients and family members. Hand hygiene is strictly enforced before and after contact with each patient. Patients and their families are prohibited from entering nurses' stations, doctors' offices, or other patients' rooms.

Principles of ward disinfection

Maintain the indoor air circulation in each ward and ventilate two to three times a day for >30 min. Ultraviolet light can disinfect air under unattended conditions.[20] Wipe the surface and floor of the ward twice with chlorine disinfectant every day for 30 min. If contamination is suspected, disinfect immediately. Hand disinfectants and alcohol hand rub shall be provided outside each room.[16]

Detection and management of suspicious patient

Prepare at least one fixed spare room in each ward for isolation when a suspicious patient is found. Daily temperature shall be measured and recorded for all inpatients. Patients with suspicious respiratory symptoms or body temperature >37.3°C shall be suspended from ablation operations. Suspicious cases shall be promptly reported to the doctor in charge or doctor on duty. After reexamining the patient's medical history (especially the patient's epidemiological history, including the places he has been to, the transportation he has used, the people he has visited, etc.), medical judgment shall be made to clarify the cause of fever. In cases where COVID-19 cannot be excluded, instruct the patient to wear medical surgical masks and gloves, transfer the patient to the standby ward for isolation, and implement dedicated diagnosis and treatment. At the same time, notify the medical affairs department and hospital infection department and contact the hospital prevention and control expert group to start the hospital consultation process. Perform a complete blood count, C-reactive protein (CRP), procalcitonin, and chest CT examination (contact CT room preparation before the examination; use a dedicated channel to transport patients to avoid contact with other patients) and perform SARS-CoV-2 nucleic acid testing if possible.[17] Medical personnel in contact with patients, including CT laboratory technicians, must meet the secondary level protection standards (wear protective clothing and wear medical protective masks, hats, goggles, gloves, and shoe covers).[14] After complete evaluation by the radiology department and the expert team and COVID-19 is excluded, the patient can be transferred to the original ward for routine treatment. If COVID-19 cannot be excluded, the patient should be taken directly to a negative-pressure isolation ward. The medical management office or CDC of the Health Commission shall be immediately notified for further necessary inspections. The hospital shall refer patients to medical institutions with treatment capabilities promptly.[19] The venue shall be disinfected, and people in close contact shall receive medical observations and other preventive measures.[18]


 > Management of Ablation Operation Room Top


Preparation before ablation

Personal protection shall be fulfilled in accordance with standard protection requirements.[14] Surgical nurses and anesthesiologists should wear disposable working caps, disposable latex gloves, medical protective masks, and isolation gowns. Anesthesiologists can also wear protective masks and goggles. Before and after the operation, the operators shall use the “seven-step handwashing method” to wash hands with running water and use rapid hand sanitizer for disinfection. In addition to the wear required for routine aseptic surgery, goggles shall be worn. Before the ablation procedure, the patient's medical history shall be obtained again, and vital signs shall be measured. In principle, patients with suspected or confirmed COVID-19 infection cannot undergo ablation. Prepare disposable surgical kits, surgical instruments, accessories, and consumables. The operating bed shall be covered with disposable sheets to avoid contamination by the patient's blood and body fluids.

Precautions during ablation

Reduce the number of medical staff during surgery. Except for doctors, nurses, and anesthesiologists, other personnel is prohibited from entering the operating room. Without affecting the surgical outcome, reduce high-risk anesthesia, such as tracheal intubation. Choose a simple and effective ablation method to reduce surgical trauma and shorten operation time. Operators and assistants should pay special attention to the aseptic operation. To prevent splashing of body fluids, prevent sharp instruments from piercing surgical gowns and gloves and other occupational contacts. The movements should be gentle and standardized. Promptly clean up body fluid and blood promptly.

Cleanup after ablation

Postoperative medical waste shall be disposed of according to classifications and the surrounding environment shall be disinfected. After using disposable surgical instruments and consumables, use a yellow garbage bag to seal the waste and dispose of through the dirt delivery channel. Reusable instruments shall be soaked in a 2000 mg/L of effective chlorine-containing disinfectant for 30 min and then sent to the supply center for disinfection. The floor of the operating room shall be disinfected with chlorine-containing preparations, and the surfaces of ablation instruments, anesthesia instruments, electrocardiogram monitors, etc., shall be wiped with chlorine-containing solutions.[16] After each operation, the air can be sterilized using a UV light for 15–20 min under unattended conditions, and then, the next operation can be performed.[20]


 > Follow-Up Management After Ablation Surgery Top


Postoperative outpatient clinic follow-up

Usually, thefirst follow-up is required about 1 month following tumor ablation. The patient may experience symptoms such as fever, pain, and even ablation-related complications. Therefore, the doctor needs to make further judgment and treatment promptly. For patients in other provinces, appointments, examinations, and efficacy evaluations will lead to repeated visits to medical institutions, which increase the risk of SARS-CoV-2 infection. Therefore, patients without obvious symptoms or complications and patients undergoing routine examination after ablation should communicate with the attending physician before going to the medical institution for follow-up and should carefully assess the risk of infection during the COVID-19 epidemic.

Online platform follow-up

With the continuous development and improvement of online medical platforms, online consultation platforms have been established. Routine postoperative examination and adjuvant treatment can be performed at home or at a local hospital or community medical facilities through online consultation under the guidance of an ablation doctor. Online models and local medical management methods can reduce the risk of COVID-19 introduction and cluster infection, while ensuring the continuity of tumor treatment.


 > Conclusion Top


The COVID-19 outbreak is challenging in the treatment of patients with malignant tumors. Although the current COVID-19 epidemic in China has been controlled, the international epidemic continues. This article aims to provide a reference for domestic and international medical personnel in the field of tumor ablation therapy to broaden their understanding of COVID-19 prevention and control. Medical staff should always be vigilant to avoid cross-infections during ablation surgery, to control the tumor progression of patients with malignant tumors who are a high-risk group of COVID-19. In addition, medical institutions should develop preventive measures specific to tumor ablation therapy to prevent outbreaks in hospitals and combat COVID-19 epidemics and malignant tumors at the same time.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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