Surgical Treatment
Principles Concerning Operating Room Availability
- If there is a temporary inability to access operating rooms due to the
COVID-19 pandemic, defer surgical treatment until a point in time when
the operating rooms are re-opened.
- If treatment is delayed because of operating room capacity issues due
to the pandemic, perform monthly CT or MRI scans to monitor growth of
the tumor and consider primary radiation or chemoradiation for tumors
with continued growth.
Masses and Lesions of Uncertain Behavior
- Needle biopsy for masses or biopsy of mucosal or skin lesions to rule
out cancer can be done in the outpatient setting.
- If excision is thought to be the best way to determine the nature of
the lesion, then perform incisional or excisional biopsy. We suggest
the biopsy be done in the operating room with a justification of
“rule out cancer”.
Definitively Benign Tumors and Masses Based on Biopsy
Results.
Defer treatment until after the COVID-19 pandemic.
Salivary Malignancy
- Resect all high and intermediate grade cancers.5
- Defer treatment of low-grade carcinomas (e.g., low grade
mucoepidermoid carcinoma, acinic cell carcinoma or polymorphous
low-grade adenocarcinoma) until after the COVID-19 pandemic, per
clinical judgement of the surgeon. In the interim, perform serial MRI
or CT scans with contrast every two months to monitor growth of the
tumor.
Asymptomatic Leukoplakia
- If this is the first patient visit for leukoplakia with no history of
prior biopsy and no histologic diagnosis, we recommend the patient
send pictures of the suspicious area(s) via our secure patient portal
followed by a telehealth video visit6 To avoid
missing cancer, perform either incisional or excisional biopsy within
1 -6 weeks depending on the surgeon’s index of suspicion based on the
pictures. The biopsy can be done in the outpatient setting or in the
operating room depending on the preference of the clinician.
- If this is a long-standing patient with history of leukoplakia or a
recent biopsy that shows premalignancy then have the patient submit a
photo to your team and perform a telehealth video visit. If the lesion
on the photo does not have high-risk features, then defer treatment
until after the COVID-19 pandemic. If the lesion has high-risk
features in the photo, then to avoid missing a cancer perform either
incisional or excisional biopsy within 1 - 6 weeks depending on the
surgeon’s index of suspicion based on the picture. The biopsy can be
done in the outpatient setting or in the operating room depending on
the preference of the clinician.
Mucosal Squamous Cell Carcinoma: p16 + and p16 -
- Perform surgery on all surgically resectable squamous cell carcinomas
as soon as possible.
- The rationale is based on the following:
- Studies from Italy indicate delays in care may lead to increased
cost of care and loss of life during the
pandemic.7
- The literature indicates that treatment delays in the 19-46 day
range increase the risk of mortality.8,9
- Treatment delays can result in upstaging of
cancers.10
- Choice of reconstructive approach should be based upon the defect as
well as the preference of the reconstructive surgeon. We recommend the
surgeon factor in time in the operating room and minimization of
complications.11
- Prior to all transoral approaches, it is recommended that the nose and
pharynx be irrigated with 1:4 solution of povidone iodine which has
been shown to be virucidal for coronaviruses.12
Skull Base Malignancy
- Due to the potentially high COVID-19 viral load in the nasal mucosa,
we suggest the guidelines in the section below for Office Procedures
“Fiberoptic Laryngoscopy, Nasal Endoscopy, Transoral and Transnasal
biopsies.”
- Unlike mucosal squamous cell carcinoma in which the recommendation is
to perform surgery in all resectable cases as soon as possible, given
the diverse biology of skull base tumors we recommend following the
ICAR-Skull Base Tumors guideline to determine therapy after definitive
biopsy is performed.13
- If a transnasal endoscopic surgery is needed, it is highly recommended
that high speed drills be avoided and that the entire surgical,
perioperative and anesthesia teams wear N95 masks, goggles and face
shields for these cases for the duration of the COVID-19
pandemic.14,15