September18, Unitedkingdom  2021 

*WearMask,KeepSanitizeYourHands*

Abstract Volume: 1 Issue: 3 ISSN:

Skin Cancer Consultation and Surgery During the Spread of Coronavirus Disease 2019 -2020 (Covid-19) in a Public Hospital of Milan. A Plastic Surgeons Perspective

A. M. Capretti*, B.  Lombardi1, M. Brambilla2

 

1,2 Plastic Surgeon Consultant – Department of Gynecology   - Director Prof. P.  Vercellini,

Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan

*Corresponding Author: Dr. A. M. Capretti, Plastic Surgeon Consultant – Department of Gynecology   - Director Prof. P.  Vercellini, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan.


Received Date:  February 11, 2021

Publication Date: March 01, 2021

Skin Cancer Consultation and Surgery During the Spread of Coronavirus Disease 2019 -2020 (Covid-19) in a Public Hospital of Milan. A Plastic Surgeons Perspective

Introduction

In the autumn of 2019, a novel severe acute respiratory syndrome (SARS) coronavirus (CoV) named SARS –Co-V-2 or2019-nCoV has been identified as the microbial agent causing viral pneumonia in several epidemiologically linked to a seafood market in Wuhan (Hubei province, China). Since then, the spread of coronavirus disease 2019 has progressively involved countries outside China leading the World Health Organization (WHO) to declare pandemic Covid-19 disease (1-2).

Outside China, Italy has one of the largest Covid-19 outbreaks with 2.107.166 confirmed cases and 76.159 deaths according to the data of “Istituto Superiore di Sanità” on 31st December 2020 – “APP-Corriere” (3).

To limit viral spread the Italian Government has implemented extraordinary measures from 9 March 2020 started in a lockdown inhibiting people’s movements and social activities throughout the national territory. The Italian government recruits more than 20.000 new doctors, nurses and hospital employees to meet public demand (4-5).

A resident who has completed their medical degree and is in specialist training and Retired doctors has been called from Italian Authority to work in Emergency Hospital. Abroad Medical doctors volunteers come to Italy from many Countries: Albania, Cuba, the United State of America, etc.

Meanwhile, doctors who have come into contact with a patient affected by COVId-19 are encouraged to work unless having a positive test for Sars-CoV-2 or they show low symptoms of the infection.

A second Italian Pandemia Covid-19 started in October 2020: the Italian National Health System (SSN) is currently under pressure and extraordinary efforts are spent to provide an efficacious reaction to the emergency. Specific protocols with the Emergency Medical system are being implemented including the attempt to increase intensive care unit (ICU) capacity (6-7-8). Much operating room has been closed in Hospital: nurse, doctors Anesthesiologists work in ICUs, department s of infections and general internal medicine.

Hence, the current emergency is of particular concern to medical and surgical oncologists and their patients (9-10-11). Otherwise, multiple articles focusing that the risk of SARS-CoV-2 infection was higher in patients with advanced tumor states who deteriorated more rapidly in the clinic and had a higher risk of severe events including the necessity for admission in ICU (12-13-14).

Another factor is the older age with severe events from SarS-Co-V-2 infection among patients with cancer (15). The authors suggested three recommendations for reducing the charge of Covid-19 in oncology epidemic areas: postpone treatments or elective surgery for “stable “cancer in an endemic area, provide stronger personal protection supply in an endemic area and finally offer more surveillance or treatment for patients infected with SARS-Co-V2 (16).

The diagnosis is the most problem In skin cancer surveillance and surgery; use teleconsultation whenever possible: this is very important in patients at risk for serious COVID-19 infection ( old age other comorbidities and immunosuppressive ) (17-18-19). The second problem is the possibility for the hospital to have an operating room open and medical, nurse staff and COVID-19 swab test available.

However, early dermatologic consultation with dermoscopy is very important to diagnose malignant skin cancer (melanoma, BCC and SCC) but Teledermatoscopy is hardly ever used in SSR-Lombardy Health System.

 

We confirm recommendation for skin cancer consultation and surgery during the CoVID-19 pandemic in three categories:

Urgent care: no postponement (table 1), Semi-urgent care:  These indications can be postponed, but need to be replanned within -4-8 weeks (table 2), and low priority indications can be postponed beyond 8-12 weeks (table 3).

Table 1: Urgent care: no postponement

  • -Referral for possible melanoma or other skin cancer
  • -Confirmed new melanoma and its surgery
  • -Confirmed new SCC
  • -Confirmed new other skin cancer, e.g., Merkel cell CA, angiosarcoma
  • -Skin cancer with systemic treatment
  • -Excision suspicious nevus
  • -Excision dysplastic nevus in the personal history of melanoma
  • -Follow-up stage II and III melanoma within first 2 years of follow-up
  • -Follow?up SCC: moderate/poor differentiation or prior metastasis or transplant patient or history of multiple SCCs
  • -Follow-up multiple primary melanomas
  • -Confirmed new BCC in face surgery (eyelid and nose)
 

Table 2: Semi-urgent care: these indications can be postponed, but need to be replanned within 8–12 weeks

  • -Confirmed new BCC (for BCC in the face surgery should already be planned)
  • -Confirmed Morbus Bowen
  • -Follow-up multiple BCC
  • -Dysplastic nevus syndrome with family history of melanoma
  • -Follow-up stage II and III melanoma after 2 years of follow-up
  • -Follow-up stage I melanoma and in situ melanoma
  • -Follow-up low-risk SCC
 

Table 3: Low priority indications can be postponed beyond 12 weeks

  • -Follow-up BCC
  • -Follow-up dysplastic nevus syndrome with negative personal/family history of melanoma (annual check)
  • -Follow-up actinic keratosis


In the plastic surgery service at Fondazione IRCCS Ca Granda Hospital of Milan we have 150 skin cancer patients ( urgent care and semi-urgent care ) on the waiting list on 15th December ’20; many business and management  organizations have been exceeded during this year:

a great and close collaboration of doctors, nurses and administrative staff was necessary to continue Oncology surveillance, surgery and Complementary therapy. Also, measures for limiting viral transmission during consultation and surgery are described (table 4-5).


Table 4: Precautions during surgery

1. Outpatient intervention outside face mask area

Patient wears face mask

Doctor wears face mask and gloves and normal surgical clothing

When in the face outside the face mask area sterile field protects as much as possible mask area; normal protective clothing (mask, gloves, surgical clothing)

2. Outpatient intervention in mask area of the face

COVID testing (SWAB screening day before) negative

If testing is not available, treat the patients as potentially positive and increase doctor's protection: (FFP2) mask and extra protection (e.g. shield and extra surgical apron over surgical clothing)

3. Inpatient surgery

Consider COVID testing in all patients prior to hospitalization


Table 5: General precautions during the Plastic Surgery Consultation

  • -Patients should be spaced at least 1.5 m apart while waiting.
  • -Patient should clean their hands with soap and water for at least 20 s. Alternatively, they can be asked to use alcohol 70% disinfectant
  • -If patients have a face mask, they should be asked to wear it before entering the hospital
  • -Patients with fever- or cough- or flu-like symptoms in the past 4 weeks or patients who tested COVID19 positive should wear a face mask up to 30 days after the start of their first symptoms/ positive COVID?19 PCR testing.
  • -The plastic surgeon who performs a local and total body examination should wear a face mask and wash/disinfect hands and to wear gloves during examination.

 

173  skin cancer patients have been treated with ambulatory surgical therapy during the 2020 outbreak COVID-19: an inferior number of skin cancer patients’ have been surgical treatment compared to the same period in the 2019 year (296).

In conclusion, the Covid-19 Pandemia necessity significant challenges to medical and nurse staff to offer optimal and timely care (table 4-5). Low risk of Covid-19 infection patient’s is a prior object in the treatment of skin cancer pathology. Actually, In Lombardy Region Health System there is a low tele /video consultations application for the individual patient problems, whenever the evolution of Covid-19 outbreak is increasing.

These recommendations we need to take on a nation and Regional land wide similar approach for the different indication in dermato-oncology; tele /video consultations is a way to monitor skin oncology disease of postponed consultations since acceptable delay period for different indication in dermato-oncology (20-21- 22).

For the moment, the lockdown measures in Italy have been gradually increased and, we are waiting for the third outbreak next month and get the Covid-19 vaccine to all Italian population until December 2021; normal levels of hospital care will be returned in a medium-long period.

 

Figure 1: Clinical case: A 83-year-old woman with a vegetative-ulcerated skin lesion ( 4,5  cm diameter) of the right mandibular grew rapidly in a few a month after a dermatologic consultation and a negative ultrasound of the neck.

Figure 2: A large surgical excision and reconstructive with a local neck flap

Figure 3: Histology Photo Pilomatrical carcinoma

 

The excised specimen showed a nodular, well-circumscribed, dermal lesion with an asymmetrical profile  ulcerating the epidermis.

The neoplasm showed extension to the deep dermis with an infiltrative growth pattern and was surrounded by a moderate lymphocytic inflammatory infiltrate in a fibromyxoid stroma.

At higher magnification, the lesion was composed of islands and cords of basaloid cells with prominent nucleoli, frequent mitosis, and scant cytoplasm with tumor islands containing keratotic material and shadow cells (Figure 3, inset A).

Focally the neoplasm showed cystic spaces containing detritus material and keratin as a result of necrosis and masse (Figure 3, inset B).

 

To thank Francesca Boggio M.D.

Pathologist – Fondazione IRCCS Cà Granda  Maggiore Policlinico Hospital of Milan for histological  diagnosis and photos. 


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Volume 1 Issue 3 April 2021

©All rights reserved by Dr. A. M. Capretti

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