key: cord-0967574-qe3hp7zv authors: Aghili, Mahdi; Jafari, Fatemeh; Vand Rajabpoor, Mojtaba title: Brachytherapy during the COVID-19– Lessons from Iran date: 2020-05-14 journal: Brachytherapy DOI: 10.1016/j.brachy.2020.05.003 sha: a6b785f40a5e20e6c1f0d2aa50039a76569e8a3f doc_id: 967574 cord_uid: qe3hp7zv nan Iran is in a dire situation as a result of the COVID19 outbreak and reported its first confirmed case of COVID19 infections on 19 February 2020(1), and it was one of the first countries to deal with the corona epidemic. We have been fighting with the novel coronavirus for more than 50 days in Iran. COVID 19 mortality rate is higher in cancer patients (2) , and COVID 19 pandemic poses severe challenges in the treatment of cancer patients. At the onset of the outbreak, discontinuation, or postponing, the non-emergent treatments were considered. However, as time passes, we realize that COVID 19 is not a short-term crisis. Estimates are suggesting a longlasting pandemic, perhaps for months. Therefore, it is not logical to deprive patients of lifesaving treatments. Besides, quarantine policy in our country and many parts of the world are different from China. People have different levels of exposure with the novel coronavirus, and some patients may have a higher chance of receiving necessary, timely, and effective treatments. Delaying radiotherapy in some patients will reduce the efficacy of this treatment and will affect the patient's survival. Additionally, it can cause a high mortality rate for patients and also place a higher financial burden on the health system after the COVID 19 pandemic is over. Therefore, canceling or too much delaying of the available treatment options does not seem logical. In this regard, we, in Iran Cancer Institute, have taken our policy to provide safe treatment options for cancer patients with the maximum level of patient and personnel protection. Brachytherapy is an efficacious modality in cancer treatment, combining optimal tumor-tonormal tissue gradients to save normal tissues. It can be delivered within a few days, compared to External Radiotherapy (ERT), to decrease the overall treatment time, so that it causes patients a lower risk of COVID 19 infection. These advantages make brachytherapy a viable treatment option in the novel coronavirus era. We have decided to limit the brachytherapy to patients in whom the validated guidelines or recommendations have proven its efficacy. We abstain from delaying patients' brachytherapy, and our rationale is that it is vague for everyone that the pandemic would be under control in the coming months or not. · The patients undergo a thorough physical examination(PE), with particular attention to the common symptoms and signs of COVID-19 infection like as sore throats, respiratory symptoms, myalgia, fever, or non-typical symptoms and signs ( anosmia, red eyes, diarrhea, etc.). Besides PE, we take a complete history of any exposure to the case of COVID-19 infection by the patient. A normal CXR is necessary to admit the patient for any procedure requiring anesthesia. Moreover, and in suspicious patients, we check the status of infection by the spiral chest CT scan and COVID-19 PCR test. For a patient with the symptoms of COVID -19 infection, we pause the treatment process meanwhile the patient undergoes infectious diseases consult. • In COVID 19 confirmed patient, we interrupt the treatment for at least two weeks after the patient becomes symptom-free or two negative COVID-19 PCR tests are required for re-starting the treatment. • We have given our priority to local or spinal anesthesia as far as possible; general anesthesia should be avoided whenever it is possible due to the risk of contamination of operating room staff or patients. • We have attempted to limit the patient's probable exposure to COVID 19 by escalating dose per fraction and reducing the number of fractions in case the dose homogeneity is kept well, and the Organ At Risks (OARs) are not compromised. Brachytherapy is a crucial part of locally advanced cervical cancer (LACC) (3) . The prolongation of the overall treatment time has resulted in more unfortunate outcomes in patients (4), Therefore delaying the treatment is not recommended in any case of LACC, except in the presence of confirmed or suspicious COVID-19 infection. In our center, we recommend delivering up to a total dose of 85-90 Gy to HR-CTV in 2 fractions by at least 9.5 Gy dose per fraction (5) . We consider dose constrains, and in case the OARs are compromised, we use more fraction numbers. Post-operation brachytherapy in endometrial cancer is performed under specific conditions. We use a cylinder for this purpose. We recommend the routine treatment of radiotherapy for this group of patients without any delay, while we prefer to deliver the dose in 3 instead of four or more fractions to limit the chance of exposure. In the case of early-stage breast cancer suitable or cautionary for accelerated partial breast irradiation (APBI), we recommend balloon or multi-catheter based brachytherapy instead of ERT for shortening the treatment duration (6) . Balloon or catheters based APBI is preferred to be inserted intraoperatively or by local anesthesia or sedation in the postoperative setting. Due to the need for intubation during catheters insertion, it is highly recommended to rule out patients infected by COVID-19 before brachytherapy, and screening should be done before anesthesia. According to our experience, we perform adjuvant brachytherapy for patients with pT1-T2, N0 oral tongue cancer who have a high risk for local recurrence (closed margin, perineural and lymphovascular invasion or high depth of invasion) by 39 Gy in 13 fractions in 7 days, two times daily instead 60 Gy in 30 fractions by ERT (7). In non-melanoma skin, cancer brachytherapy is a good option for treatment in inoperable patients or the sites that surgery could have unacceptable cosmetic results (8) . Fewer fractions of brachytherapy and similar effectiveness in non-melanoma skin cancers compared to ERT gave us a unique opportunity to treat our patients with lower exposure to COVID 19. The role of brachytherapy in prostate cancer treatment is inevitable. HDR brachytherapy is an attractive modality for prostate cancer treatment. Optimized dosage for CTV and OARs, coverage of seminal vesicles, and periprostatic tissue are among the advantages of this method. In the Corona outbreak, brachytherapy gave us the opportunity to treat patients with less exposure to the virus and less hospital stay compared to other costly modalities such as radical or robotic surgery and Intensity-Modulated Radiation Therapy (IMRT). When the intention of treatment is monotherapy in a low-risk prostate cancer patient, we recommend delaying the treatment for 3-6 months. In high-risk patients who require brachytherapy as a boost, our recommendation is avoiding any delay in patient's treatment; we prefer to deliver doses of 19 GY for brachytherapy alone (9) or 15 GY for booster dosages after ERT in one session (10) . Brachytherapy is a viable option amid the COVID-19 pandemic for soft tissue sarcoma in adjuvant settings. As the recommended adjuvant EBRT dose for sarcomas is 60-66 Gy with 1.8-2 dose per fraction, brachytherapy alone is a reasonable option in patients with known indications and especially in perioperative settings (11) . We recommend HDR rather than LDR with Iridium-192 wires for decreasing the patients' hospital stay duration. In some miscellaneous cases, the only option we have is brachytherapy, and we prefer to avoid delaying the treatment in such cases; uveal melanoma, palliation of symptoms in esophageal cancer, or cholangiocarcinoma. Considering the COVID-19 pandemic besides the necessity of cancer treatment for cancer patients, brachytherapy provides an opportunity for the patients and the physicians amid the COVID-19 outbreak; it can retain the patients' chance for treatment while limiting the chance of exposure and transmission of infection, but maximum personal protection is essential to avoid infection for patients and health care workers against the novel coronavirus. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China Differences in outcome for cervical cancer patients treated with or without brachytherapy Overall treatment time in advanced cervical carcinomas: a critical parameter in treatment outcome Compendium of fractionation choices for gynecologic HDR brachytherapy-An American Brachytherapy Society Task Group Report Accelerated Partial Breast Irradiation: A New Strategy for Early-Stage Breast Cancer. Archives of Breast Cancer Adjuvant high-dose-rate brachytherapy in the management of oral cavity cancers: 5 years of experience in Iran High-dose-rate brachytherapy in treatment of non-melanoma skin cancer of head and neck region: preliminary results of a prospective single institution study Five-Year Outcomes of a Single-Institution Prospective Trial of 19-Gy Single-Fraction High-Dose-Rate Brachytherapy for Low-and Intermediate-Risk Prostate Cancer Late toxicity after single dose HDR prostate brachytherapy and EBRT for localized prostate cancer: Clinical and dosimetric predictors in a prospective cohort study American Brachytherapy Society consensus statement for soft tissue sarcoma brachytherapy The authors declare no conflict of interests. This study was completely conducted in Radiation Oncology Ward, Iran Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences