The COVID-19 outbreak in dermatologic surgery: resetting clinical priorities

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The COVID-19 outbreak in

dermatologic surgery: resetting

clinical priorities

Editor

Emilia-Romagna was one of the Italian regions mostly affected by the COVID-19 pandemic, and lockdown measures were taken to slow the COVID-19 outbreak.1,2,3_{All routine activities}

in Modena hospitals were suspended; however, urgent dures were still to be performed. Setting the priority of proce-dures in oncological dermatology in the COVID-19 era is challenging.4,5,6

We share our experience as a dermatological surgical unit at the Policlinico of Modena, highlighting the resetting of priorities and procedures, and the safety measures applied.

In 2019, 5483 surgical procedures were performed in our department: 482 inpatient, 836 day surgeries, and 4165

Neoplastic or inflam m a tory lesion? Neoplastic Melanocytic lesion Histologically confirmed Thick melanoma Narrow excision performed

pre-COVID-19

Wide excision + SLB* performed following

giudelines Thin melanoma

Narrow excision performed pre-COVID-19

Wide excision postponed Thin melanoma

Incisional biopsy performed pre-COVID-19

Wide excision performed In situ melanoma

Narrow excision performed pre-COVID-19

Wide excision postponed

Not histologically confirmed

Melanocytic lesion palpable or strongly suspicious for thick

melanoma

Narrow excision or punch biopsy performed

Flat atypical or dysplastic nevus

Narrow excision or punch biopsy postponed NMSC Histologically confirmed Infiltrating SCC of H area, rapidly growing/ulcerated or ≥2 cm any locations

Wide excision performed

In situ SCC Wide excision postponed

Any BCC Wide excision postponed

Other diagnoses According to the diagnosis, treated or postponed

Not histologically confirmed

Palpable lesions strongly suspicious for infiltrating

tumor

Narrow excision if possible or incisional biopsy

Flat lesion Excision postponed

Unknown diagnosis Not histologically confirmed

Palpable lesions strongly suspicious for infiltrating

tumor

Narrow excision or incisional biopsy

Flat lesion Excision or incisional biopsy postponed

Inflammatory

Suspicious blistering disease Punch biopsy for histology and direct immunofluorescence

Erythroderma Punch biopsy

All non-severe and not

life-threatening skin conditions Punch biopsy postponed

Figure 1 Reset of clinical priorities after the COVID-19 pandemic for dermatologic surgery planning. *SLB: sentinel node biopsy.

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Saf

e

ty Pr

ocedur

es

Inpaent Phone triage

by RN Preadmission (7–10 days before surgery) Blood test SARS-CoV-2 IgG and IgM

Posive Immediate oro-naso-pharygeal swab Posive Evaluaon case by case risk/benefit balance If possible, postpone Negave Evaluaon case by case risk/benefit balance If possible, postpone Proceed aer 2 negave swabs Negave Proceed to oro-naso-pharyngeal swab 24 hours before Chest x-ray Between preadmission and admission Self-isolaon at home Daily registraon of: – Temperature – Cough (yes/no) 24 hours before surgery Molecular test or oro-naso-pharyngeal swab Posive Evaluaon case by case risk/benefit balance If possible, postpone Negave Proceed

During surgery PPE

Day surgery Phone triage _{by RN}

Preadmission According to the anatomical locaon of cancer If paent can wear mask during procedure Nothing If paent cannot wear mask during procedure: lesion located of nose, lip, cheek,ear, chin Oro-naso-pharingeal swab Posive If possible, postpone Negave Proceed During surgery When possible, only one paent/day who cannot wear the mask

PPE

Outpaent

Phone triage by RN

If temperature, cough or any respiratory

symptoms in 14 days Postponed

If any contact with COVID-19-posve or

suspicious for COVID-19-posve subject Postponed

If no symptoms and no suspicion or no

contact with COVID-19-posve subjects Proceed

During surgery

1 paent every 45 minutes

PPE

Figure 2 Preoperative and operative procedures for hospital admission (inpatient and outpatient). PPE: personal protection equipment.

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outpatients. Weekly, our surgical activity consists of (i) four ses-sions of major surgery for inpatient with anaesthesiologic sup-port, 3 three patients/session; (ii) four day-surgery sessions, four patients/session; (iii) 13 sessions of outpatient surgeries.

After lockdown (9 March 2020), dermatology departments were challenged to a sudden reorganization of surgical activity within 48 h. We had to perform only undelayable urgent inter-ventions, leading to a new definition of priorities (Fig. 1). We limited our activity to potentially life-threatening or severe can-cer types, such as melanocytic lesions suspicious of thick mela-noma, histologically confirmed thick melamela-noma, histologically confirmed infiltrating high-risk squamous cell carcinoma (SCC) according to NCCN guidelines7 and rapidly growing nodular lesions. All clinical charts were reviewed to assign these new pri-orities. We treated thick melanoma by performing both wide excision and sentinel node biopsy, while wide excision for already confirmed thin and in situ melanoma was deferred. Recently, different approaches were proposed regarding the pos-sibility to postpone the node biopsy.6,8,9

Regarding SCC, the excision was performed in line with cur-rent guidelines while simple techniques, such as dermo-epider-mal grafts, were selected for immediate reconstruction in order to shorten the hospitalization period. For in situ SCC and basal cell carcinoma (BCC), surgical treatment was postponed. Diag-nostic incisional biopsies were restricted to severe diseases, such as suspicious blistering diseases or erythroderma.

Moreover, we set a new weekly plan of surgical sessions, con-sisting of (i) one session of major surgeries; (ii) two sessions of day surgeries; (iii) two sessions for outpatient surgeries; (iv) everyday, two urgent biopsies for in/outpatients.

All activities were performed wearing appropriate individual protective devices, such as FFP2 or FFP3 masks covered with a disposable surgical mask, protective eye-goggles or helmets, and overshoes in addition to the standard surgical equipment. Sur-geons were requested to wear surgical equipment in a clean and safe area, different from the area they took off the equipment.

A strict triage procedure was applied before the admission of patients (Fig. 2). Consecutive surgical activities for outpatients were planned with a 45-min interval, to allow thorough cleaning of the operation room.

Dermatological surgery is considered a low-/medium-risk surgery. This also remains true in the current COVID-19 era, but only when the patient can safely wear a mask. For proce-dures on the face, we think that dermatological surgery should be considered as a high-risk procedure. Therefore, we suggest that independently from the type of anaesthesia used, it should be mandatory to wear high protection mask (FFP3) during sur-gery on the facial area. For body areas other than face, we suggest that FFP2 can be considered as an appropriate protection device. We also believe that standardized consent forms should be prepared to inform patients of the inherent risk of getting infected from SARS-CoV-2 while they are in the hospital, in an

effort to ensure transparency. Moreover, patients with dermato-logical conditions may feel abandoned, given the relocation of resources to address the pandemic emergency. It is therefore crucial to maintain proper communication with patients, ensur-ing that all urgent treatments continue to be delivered.

Conﬂicts of interest

None.

Acknowledgements

Editorial assistance was provided by Aashni Shah (Polistudium SRL, Milan, Italy) and was supported by internal funds.

E. Rossi,1,* M. Trakatelli,2L. Giacomelli,3,4B. Ferrari,1 M. Francomano,1G. Pellacani,1C. Magnoni1

1

Department of Dermatology, Head and Neck Skin Cancer Service, Modena and Reggio Emilia University, Modena, Italy,2_Second

Department of Dermatology, Aristotle University Medical School, Papageorgiou General Hospital, Thessaloniki, Greece,3_{Polistudium SRL,}

Milan, Italy,4_{Department of Surgical Sciences and Integrated Diagnostics,}

University of Genoa, Genoa, Italy *Correspondence: E. Rossi. E-mail: dr.elenarossi@gmail.com

References

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7 NCCN Clinical Practice Guidelines in Oncology (NCCN Guideli-nesâ) Squamous Cell Skin Cancer Version 1. https://www.nccn. org/professionals/physician_gls/pdf/squamous.pdf (accessed 1 May 2020). 8 Melanoma Institute Australia. Important notice regarding the

manage-ment of clinically suspected primary melanoma during the COVID-19 cri-sis. https://mcusercontent.com/88a3bd528a963791abea7c880/files/ b853272a-052d-4eeb-b62a-ea0bd2cbce60/Melanoma_Management__ Covid_FINAL.pdf (accessed 1 May 2020).

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DOI: 10.1111/jdv.16672

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