Treatment protocol to allow reconstructive breast surgery during COVID-19 pandemic

Editor

The COVID-19 pandemic determined a significant reduction in elective surgery¹.

Regarding breast cancer, recommendations were to defer immediate reconstruction following mastectomy^2,3.

In our University hospital, a tertiary care facility, more than 1.800 COVID-19 positive patients were assisted during Pandemic “Phase 1” (37% of all patients hospitalized in the Roman metropolitan area between February 1st and April 30st 2020)⁴.

According to the guidelines issued by COVID 19 Pandemic Breast Cancer Consortium our facility was in a semi-urgent setting². Nevertheless, with the use of a strict safety protocol for surgical candidates, we managed to grant reconstruction to all patients undergoing mastectomy, without increased risks (Fig. 1).

Fig. 1.

COVID-19 safety protocol

Multidisciplinary meetings (MDM), were regularly held limiting live attendance to two breast surgeons, one plastic surgeon, one radiologist, one oncologist and one radiotherapist. All other MDM members participated via web-conference. Decisions on surgical planning were made on a case by case statement.

Prior to hospitalization surgical candidates were contacted by phone to assess if they had experienced any symptom related to a COVID-19 infection or had contacts with anyone known or suspected to have COVID-19 in the last 14 days.

If the phone interview did not reveal contraindications, hospitalization was scheduled on the day prior to surgery.

Upon arrival to the hospital, patients underwent SARS-COV2 blood quick testing (lateral flow immunoassay). Patients with a negative test received a nasopharyngeal swab (real-time RT-PCR assay). If the swab resulted negative, patients were admitted to the ward to complete preoperative routine assessments.

If SARS-COV2 quick testing was positive, patients were confined in a dedicated unit. An initial swab was performed and if SARS-COV2 disease was confirmed, surgical treatment for breast cancer was temporarily suspended and the patient treated according to the COVID-19 protocols.

If the initial swab was negative, the patient remained in observation for at least 4 days, repeating swabs every 48 hours. If two consecutive swabs resulted negative with the patient asymptomatic, surgical treatment was delivered.

Risks and benefits of immediate reconstruction in the COVID-19 scenario were discussed with each patient scheduled for mastectomy and a specific “informed consent” signed.

Nipple sparing mastectomy (NSM) or skin sparing mastectomy (SSM) were performed according to the usual protocols. Vital blue dye, injected sub-dermally in the operating room, was used for sentinel lymph node detection.

Reconstruction was preferentially performed with a prepectoral implant or a tissue expander, to reduce the operative time and postoperative hospital stay⁵.

Contralateral symmetrization procedures were deferred, in order to reduce surgical timing and facilitate early discharge.

Patients were discharged with drainages still in place, properly instructed on how to manage them at home. They were also instructed to limit contacts with relatives at home, wear surgical face masks, wash hands frequently and measure body temperature daily. Post-operative visits were scheduled in a special area of the hospital with direct external access, to limit risk of COVID exposure. An emergency helpline was established that patients could promptly access for any postoperative need.

With the adoption of this COVID-19 protection protocol, between February 1^st and July 1^st, mastectomy and immediate reconstruction for invasive breast cancers was safely offered to 74 patients. Patients received 62 NSM and 12 SSM, with prepectoral reconstruction in 41 cases and subpectoral in 33 cases.

We did not observe any case of COVID-19 infection (in-hospital or after discharge), with a mean follow-up of 61 days.

This preliminary experience seems to suggest that immediate breast reconstruction can be safely offered even in a semi-urgent setting, with the adoption of an appropriate COVID-19 protection protocol.

Conflict of Interest

All the authors declare no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. The authors declare that they have no conflict of interest.