key: cord-0854063-oj4rk88f authors: Pelcovits, Ari; Pandita, Aakriti; Farmakiotis, Dimitrios; Egan, Pamela title: Lymphocyte-Depleting Chemotherapy for Aggressive Hematologic Malignancies in Two Patients with Positive SARS-CoV-2 PCR date: 2020-11-13 journal: Leuk Res DOI: 10.1016/j.leukres.2020.106473 sha: 8040061d9ff7ca70536269a9e9c792b1617493dd doc_id: 854063 cord_uid: oj4rk88f nan Data regarding treatment of patients with hematologic malignancies (HM) and concomitant COVID-19 is very limited. 2 Some studies in patients with cancer found that HM was a risk factor for hospitalization 4 , severe disease 1,5 and mortality 1 . Separately, in large cohorts of patients with COVID-19, lymphopenia has been identified as a risk factor for poor outcomes. 3 These findings, although overall inconclusive, may raise concerns leading to delays in lymphocyte-depleting chemotherapy. Such delays can have detrimental consequences in cases of newly diagnosed, rapidly progressing HM, such as acute leukemia or aggressive lymphoma. In this correspondence, we describe two cases of patients diagnosed simultaneously with aggressive lymphoma and likely COVID-19, both of whom received uneventful early appropriate lymphocyte-depleting chemotherapy without incident. These cases may serve as a template for J o u r n a l P r e -p r o o f other hematologist on weighing the risks and benefits of early chemotherapy in patients simultaneously diagnosed with COVID-19 and aggressive hematologic malignancies. A 58-year-old previously healthy woman was diagnosed with T-lymphoblastic lymphoma A 43-year-old previously healthy man was diagnosed with high grade B-cell lymphoma after presentation for abdominal pain. Initial imaging showed extensive soft tissue thickening involving the gastric wall and extending into the retroperitoneum involving the pancreas, bilateral adrenal glands, and pararenal spaces as well as bilateral hypoattenuating renal mass (Fig. 2) . CT also showed bilateral airspace disease concerning for COVID-19 pneumonia (Fig. 2) . SARS-CoV-2 PCR was positive. He did not provide consent for participation in the remdesivir trial. The outcomes of patients with cancer and COVID-19 appear to be worse than those without underlying malignancies. 1,8 Patients with HM may experience even worse outcomes, although this concern is based on limited data. 2, [4] [5] [6] While several organizations have published COVID-19 management guides for patients with cancer during the COVID-19 pandemic, most do not specifically address treatment of patients with positive SARS-CoV-2 PCR. 9,10 Our two cases highlight the possibility of treating select, especially asymptomatic patients with aggressive HM and COVID-19 with standard-of-care chemotherapy, and a potential role for remdesivir in treatment algorithms. The FDA provided accelerated emergency use authorization of remdesivir for the treatment of hospitalized patients with severe COVID-19 patients on May 1 st , 2020 11 , based on early data from two randomized-controlled trials (RCT) 12, 13 and one open-label study of compassionate use 14 . The RCT included patients with cancer, however results were not stratified by comorbidity and type of cancer was not listed. In the largest RCT, remdesivir shortened the time to recovery among patients hospitalized with COVID-19 (P<0.001) 13 . In case 1, we felt comfortable starting chemotherapy after completion of 5 days of remdesivir, since another study showed that a 5-day course is probably as effective as a 10-day course in patients who are not receiving mechanical ventilation 15 . It should be noted that our patient tolerated remdesivir co-administered with hyper-CVAD with no significant side-effects from the antiviral. In the RCT, hepatotoxicity and nephrotoxicity were not more frequent, compared to placebo 12, 13 . Therefore, we believe that fear of toxicity and side-effects should not discourage providers from co-administration of remdesivir and potentially hepatotoxic or nephrotoxic chemotherapy. In conclusion, we report two cases of minimally symptomatic patients with newly diagnosed aggressive HM and concomitant positive SARS-CoV-2 PCR. One patient received remdesivir, and they both tolerated potentially life-saving lymphocyte-depleting chemotherapy, without worsening COVID-19. We hope this correspondence can serve as fodder for further discussion and analysis of best treatment practices for patients with aggressive HM and COVID-19. None. DF has received research support by Astellas and Viracor and consultation fee from Viracor, outside of the submitted work. J o u r n a l P r e -p r o o f Patients with Cancer Appear More Vulnerable to SARS-CoV-2: A Multicenter Study during the COVID-19 Outbreak COVID-19 in persons with haematological cancers Lymphopenia in severe coronavirus disease-2019 (COVID-19): systematic review and meta-analysis Determinants of COVID-19 disease severity in patients with cancer Clinical impact of COVID-19 on patients with cancer (CCC19): a cohort study Case Fatality Rate of Cancer Patients with COVID-19 in a New York Hospital System COVID-19 mortality in patients with cancer on chemotherapy or other anticancer treatments: a prospective cohort study Do patients with cancer have a poorer prognosis of COVID-19? An experience in Managing Cancer Care During the COVID-19 Pandemic: Agility and Collaboration Toward a Common Goal Considerations for Managing Patients With Hematologic Malignancy During the COVID-19 Pandemic: The Seattle Strategy Remdesivir Letter of Authorization. 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