Digestive and breast cancer patients managed during the first wave of COVID-19 pandemic: Short and middle term outcomes

Table 1 Patient demographics and number of comorbidities by cancer type, n (%)

		Colorectal	HBP	OG	Breast
Total number		53 (100)	13 (100)	9 (100)	20 (100)
Age (yr)	40-49	3 (5.7)	2 (15.4)		5 (25.0)
	50-59	3 (5.7)	2 (15.4)		8 (40.0)
	60-69	13 (24.5)	5 (38.5)	5 (55.6)	3 (15.0)
	70-79	22 (41.5)	3 (23.1)	3 (33.3)	4 (20.0)
	80-89	11 (20.8)	1 (7.7)	1 (11.1)
	90-99	1 (1.9)
Sex	Female	18 (34)	7 (53.8)	2 (22.2)	19 (95.0)
	Male	35 (66)	6 (46.2)	7 (77.8)	1 (5.0)
ECOG perfor-mance score	0	13 (24.5)	5 (38.5)	3 (33.3)	19 (95.0)
	1	21 (39.6)	6 (46.2)	4 (44.4)	1 (5.0)
	2	17 (32.1)	2 (15.4)	2 (22.2)
	3	2 (3.8)
ASA	I	7 (13.2)	1 (7.7)	0	4 (20.0)
	II	25 (47.2)	6 (46.2)	6 (66.7)	13 (65.0)
	III	17 (32.1)	5 (38.5)	2 (22.2)	3 (15.0)
	IV	4 /7.5)	1 (7.7)	1 (11.1)
BMI	< 18.5	0	1 (7.7)
	18.5-24.9	10 (18.9)	4 (30.8)	3 (33.3)	7 (35.0)
	25-29.9	24 (45.3)	5 (38.5)	5 (55.6)	8 (40.0)
	30-34.9	15 (28.3)	1 (7.7)	1 (11.1)	1 (5.0)
	35-39.9	4 (28.3)	1 (7.7)		3 (15.0)
	≥ 40	0	1 (7.7)		1 (5.0)
Number of comorbidities	Mean (SD), range	3.13 (1.34) 1-6	2.85 (1.4), 1-5	3 (1.22) 1-5	1.85 (1.14) 0-4

ECOG: Eastern cooperative oncology group; ASA: American society of anesthesiology; BMI: Body mass index; HBP: Hepato-Bilio-Pancreatic; OG: Oesophago-Gastric.

Table 2 Patient comorbidities ordered by cancer type group

n (%)	CR, n = 53	HBP, n = 13	OG, n = 9	Breast, n = 16
Smoker	5 (9.4)	2 (15.4)	2 (22.2)	3 (18.8)
Chronic kidney disease (moderate/severe)	7 (13.2)	1 (7.7)	2 (22.2)	1 (6.3)
Chronic obstructive pulmonary disease	1 (1.9)	1 (7.7)	0	0
Asthma	1 (1.9)	1 (7.7)	1 (11.1)	0
Congenital abnormality - cardiac	1 (1.9)	0	0	0
Hypertension	29 (54.7)	5 (38.5)	6 (66.7)	7 (43.8)
Congestive heart failure	6 (11.3)	1 (7.7)	0	0
Ischemic heart disease	4 (7.5)	1 (7.7)	0	0
Peripheral vascular disease	2 (3.8)	0	0	0
Stroke/TIA	4 (7.5)	1 (7.7)	0	1 (6.3)
Dementia	1 (1.9)	0	0
Diabetes mellitus	15 (28.3)	3 (23.1)	2 (22.2)	1 (6.3)
HIV infection	0	0	0	0
Others	39 (73.6)1	8 (61.5)2	6 (66.7)3	11 (68.8)4

¹Atrial fibrilation (6 patients), Previous cancer (6), Cardiac valvular disease (4), Obstructive sleep apnea (3), Pulmonary hypertension (2), Pulmonary fibrosis (1), Liver cirrhosis with portal hypertension (1).

²Previous cancer (3), Pulmonary hypertension (1).

³Mitral insufficiency (1).

⁴Previous breast cancer (1), Previous colorectal and thyroid cancer (1).

CR: Colorectal; HBP: Hepato-Bilio-Pancreatic; OG: Oesophago-Gastric.

Table 3 Characteristics of colorectal cancer and of the performed surgery

		Colon, n (%)	Rectal, n (%)
Total n (%)		32/28 operated	21 (1 positive)3
Final disease stage	0	1 (3.1)	1 (4.8)
	I	4 (12.5) + 2 (6.2)1	3 (14.3)
	IIA	6 (18.8) + 1 (3.1)1	7 (33.3)
	IIB	6 (18.8)	0
	IIIA	1 (3.1)	4 (19.0)
	IIIB	7 (21.7) + 1 (3.1)2	4 (19.0)
	IIIC	3 (9.4)	0
	IVA	0	2 (9.5)
Resection	R0	28 (100)	18 (90.0)
	R1	0	2 (10.0)
	R2	0	0
CRITCON level	0	13 (46.4)	9 (45.0)
	1	4 (14.3)	4 (20.0)
	2	8 (28.6)	4 (20.0)
	3	3 (10.7)	3 (15.0)
Urgency	Urgent/Expedited	4 (14.3)	0
	Elective	24 (85.7)	20 (100)
Operative approach	Open	10 (35.7)	1 (5.0)
	MIS	15 (53.6)	18 (90)
	MIS-open	3 (10.7)	1 (5.0)
Anastomosis	Yes, with protective stoma	0	5 (25.0)
	Yes	25 (89.3)	3 (15.0)
	No, end stoma only	3 (10.7)	12 (60.0)
Changes in anastomosis practice	No, typical practice	27 (96.4)	18 (90.0)
	Change unrelated to COVID	0	1 (5.0)
	Change due to pandemic	1 (3.6)	1 (5.0)

¹Non operated patient.

²Non operated patient that became operated at August 2020.

³SARS-Cov-2 positive case only considered for staging.

MIS: Minimally invasive surgery; R0: No microscopic disease; R1: Microscopic disease; R2: Macroscopic disease at margin.

Table 4 Colorectal cancer patients’ postoperative outcomes and stay

Colorectal cancer, n (%)		Right colon	Left colon	Rectal
Total, n		15	13	20
Mortality		0	1 (7.7)	0
Discharged rehabilitation center		0	1 (7.7)	0
Reoperation (CD III)		0	1 (7.7)	4 (20.0)
Unplanned critical care admission (CD IV)		0	0	1 (5.0) from theatre
Any complication		6 (40.0)	9 (69.2)	13 (65.0)
Anastomotic leak		0	0	1 (5.0)
Bleeding requiring transfusion		1 (6.7)	2 (15.4)	2 (10.0)
Ileus		3 (20.0)	0	5 (25.0)
Superficial/deep SSI		1 (6.7)	3 (23.1)	3 (15.0)
Organ/space SSI		0	1 (7.7)	2 (10.0)
Wound dehiscence		0	0	0
Acute kidney injury		4 (26.7)	3 (23.1)	5 (25.0)
Pneumonia		0	1 (7.7)	0
Other organ injury		0	0	1 (5.0)
Other		0	4 (30.8)	7 (35.0)
Length of stay (d)	mean (SD)	6.27 (2.76)	6.36 (1.91)	8.8 (7.36)

CD: Clavien Dindo classification; SSI: Surgical site infection.

Table 5 Colorectal cancer patients’ adjuvant therapies and oncological outcomes ordered by postoperative tumor-node-metastasis staging

Colorectal		Colon			Rectal
		Chemo	Relapse	Death	Chemo	RT	Relapse	Death
I	No	4	3	2	2		2	3
	Yes	0	0	2 (PO/?)	1		1 (S)
	Unknown	0	1
IIA	No	5	6	5	3		4	6
	Yes	1	0	1 (COVID)	4		2 (L+R/L)	1 (Infection)
	Unknown						1
IIB	No	3	5	5
	Yes	3	1 (R)	1 (CA)
IIIA	No	0	1	1	0		4	3
	Yes	1	0	0	4	1	0	1 (RAD)
IIIB	No	3	5	6	0		0	2
	Yes	4	2 (R+S/S)	1 (CA)	4		4 (S)	2 (CA/PO)
IIIC	No	1	1	2
	Yes	2	2 (S)	1 (?)
IVA	No	0	0	0	0		0	1
	Yes	0	0	0	2		2 (R+S/S)	1 (CA)
O	No	1	0	1	0		1	1
	Yes	0	0	0	1		0

CA: Cancer; PO: Postoperative complication; ?: Unknown; RAD: Radiation enteritis; R: Regional; L: Local; S: Systemic; RT: Radiotherapy.

Table 6 Characteristics of liver and pancreatic cancer and performed surgeries

n (%)	Pancreas, n = 6		Liver, n = 6
Histology	Adenocarcinoma	4 (66.7) [1DCC]	Tumour type	CR metastasis	6 (100.0)
	Neuroendocrine	2 (33.3)		Other	0
Resectability (NCCN classification)	Resectable	3 (50.0)	Pre-COVID Extent of resection	Minor	2 (33.3)
	Borderline resectable (vein)	2 (33.3)		Major	3 (50.0)
	Borderline resectable (artery)	0		Extra major	1 (16.7)
	Locally advanced	1 (16.7)
Preoperative biliary drainage	0		0
Previous COVID	0		0
Neoadjuvant therapy	Long-course Chemo	1 (16.7)	4 (57.14)
	Short-course Chemo		1 (14.3)
	Radiochemotherapy	1 (16.7)
CRITCON level	0	3 (50)	4 (66.7)
	1	1 (16.7)	2 (33.3)
	2	2 (33.3)
Operative approach	Open	6 (100)	5 (83.3)
	MIS		1 (16.7)
Resection margin status	R0	3 (50.0)	4 (66.6)
	R1	3 (50.0) [2 NE]	1 (16.7)
	Imaging complete	0	1 (16.7)
Final staging	IB	2 (33.3)
	IIB	2 (33.3) [1DCC]
	III	2 (33.3) [2 NE]

NE: Neuroendocrine tumour; DCC: Distal cholangiocarcinoma; Chemo: Chemotherapy; MIS: Minimally invasive surgery; R0: No microscopic disease at margin; R1: Microscopic disease at margin; R2: Macroscopic disease at margin.

Table 7 Operated liver and pancreas cancer postoperative outcomes and stay

Pancreas and liver cancer, all results presented as n (%) unless specified			Pancreas, n = 6	Liver, n = 6
Overall complications	Mortality (CD V)		0 (0)	0 (0)
	Patients with complications		3 (50.0)	4 (66.7)
	Unplanned ICU admission (CD IV)		0	0
	Planned ICU admission		4 (66.7)	4 (66.7)
	Reintervention		1 (16.7) (III-A)	0
	Any major complication (CD III-V)		1 (16.7) III-A	0
	Acute kidney injury		2 (66.7)	2 (50.0)
	Ileus		1 (33.3)	1 (25.0)
	Bleeding requiring transfusion		0	1 (25.0)
	Superficial/Deep SSI		0	1 (25.0)
	Other		2 (66.7)1	0
HBP complications	Postoperative bleeding	No	6 (100)	6 (100)
	Bile leak	No	6 (100)	5 (83.3)
		Grade A	0	1 (16.7)
	Readmission with cholangitis		0	0
Pancreatic specific complications	Postoperative pancreatic fistula	No	6 (100)	-
Liver specific complications	Post-hepatectomy liver failure	No	-	3 (50.0)
		Grade A	-	2 (33.3)
		Grade B	-	1 (16.7)
		Grade C		0
	Length of stay (d)	Mean (SD)	8 (2.37)	6.33 (3.61)

¹Gastric empty delaying and peripheral catheter infection.

HBP: Hepato-Bilio-Pancreatic; CD: Clavien-dindo; SSI: Surgical site infection; ICU: Intensive care unit.

Table 8 Pancreatic carcinoma and breast cancer adjuvant therapies and oncological outcomes by definitive tumor-node-metastasis staging

		Pancreas carcinoma			Breast
		Chemo	Relapse	Death	Chemo	RT	HNT	Relapse
IA	No				5	1	2	9
	Yes				5	9	8	1 (S)
IB	No		1
	Yes	2	1	2 (CA/PANC)
IIA	No				0	1	0	3
	Yes				3	2	3	0
IIB	No		1	1
	Yes	1		0
IIIA	No							1
	Yes				1	1	1	0
IIIB	No				1	1	1	1
	Yes				1	1	1	1 (L)
IIIC	No
	Yes
IV	No
	Yes				1	1	1	1 (R+S)
O	No				2	0	2	3
	Yes				1	3	1	0

CA: Cancer; PANC: Pancreatitis; R: Regional; L: Local; S: Systemic; RT: Radiotherapy; HNT: Hormone-therapy; Chemo: Chemotherapy.

Table 9 Characteristics of gastric and oesophageal cancer and performed surgeries

Gastric and oesophageal cancer [n (%)]		Gastric, n = 7 (5 operated)	Oesophageal, n = 2
Final TNM staging	IB	1 (14.3)1
	I-E	1 (14.3)2
	IIA	2 (28.6), 13
	IIIA	1 (14.3)3
	IIIB		2 (100)
	IIIC	2 (28.6)
Location	Middle third		1 (50.0)
	Lower third – GEJ		1 (50.0)
	Proximal	2 (40.0)
	Distal	3 (60.0)
Histology	Adenocarcinoma	3 (60.0)	1 (50.0)
	Squamous cell		1 (50.0)
	Other	1 GIST (20.0) 1 lymphoma (20.0)
Neoadjuvant therapy	Long-course RT+CT		2
	Long-course CT	2 (40%)
Previous COVID		1 (20.0%)	0
CRITCON level	0	3 (60.0)	1 (50.0)
	1	1 (20.0)	1 (50.0)
	2	1 (20.0)
Urgency	Urgent/Expedited
	Elective
Operative approach	Open	1 (20.0)	2 (100.0)
	MIS	3 (60.0)	0
	MIS-open	1 (20.0)	0
Resection	R0	5 (100)	1 (50.0)
	R1	0	1 (50.0)
	R2	0	0

¹GIST patient.

²Lymphoma patient.

³1 non-operated patient.

GEJ: Gastro-oesophageal junction; RT: Radiotherapy; CT: Chemotherapy; MIS: Minimally invasive surgery; R0: No microscopic disease; R1: Microscopic disease; R2: Macroscopic disease at margin.

Table 10 Operated gastric and oesophageal cancer patient’s postoperative outcomes and hospital stay

Gastric and oesophageal cancer, all results presented as n (%) unless specified		Gastric, n = 5	Oesophagus, n = 2
Overall complications	Mortality (CD V)	0 (0)	1 (50.0)
	Patients with complications	1 (20.0)	2 (100.0)
	Unplanned critical care admission (CD IV)	0	0
	Planned ICU admission	2 (40.0)	2 (100.0)
	Reintervention (CD III)	0	1 (50.0) – IIIa (stent)
	Any major complication (CD III-V)	0	2 (100.0)
	Acute kidney injury		2 (100.0)
	Pulmonary embolism		1 (50.0)
	Septic shock		1 (50.0)
	Anastomotic leak		2 (100.0)
	Ileus		0
	Bleeding requiring transfusion	0	0
	Superficial/deep SSI	1 (20.0)	1 (50.0)
	Other	1 (20.0)1	1 (50.0)2
Length of stay (d)	Mean (SD)	8.4 (3.13)	14 (7.7)

¹Acute gastric retention (GIST patient).

²Pleural effusion.

CD: Clavien-dindo; ICU: Intensive care unit; SSI: Surgical site infection.

Table 11 Characteristics of breast cancer and performed surgeries

All results presented as n (%) unless specified		Breast, n = 20
Postoperative TNM staging	0	3 (15.0)
	IA	10 (50.0)
	IIA	3 (15.0)
	IIIA	1 (5.0)
	IIIB	2 (10.0)
	IV	1 (5.0)
Histology	Invasive carcinoma	19 (95.0)
	Ductal carcinoma in situ (high grade)	1 (5.0)
	Estrogen receptor (+/-)	15/5
	Progesteron receptor	11/9
	Her-2 (+/-)	3/16
	Nottingham prognostic index (N=19). [Mean/SD/Range]	3.65/1.11/ 2 - 6.60
	Oncotype score (N=7). [Mean/SD/Range]	48.86/23.53/10 - 80
Menopausal status1	Post/Pre-menopausal	15 (75.0)/4 (20.0)
Neoadjuvant therapies	Long-course chemotherapy	3 (15.0)
Previous COVID		1 (5.0)
CRITCON level	1	2 (10.0)
	2	10 (50.0)
	3	8 (40.0)
Resection	R0	17 (85.0)
	R1	2 (10.0)
	R2	1 (5.0)

¹1 patient not valuable (man).

R0: No microscopic disease; R1: Microscopic disease; R2: Macroscopic disease at margin; TNM: Tumor-node-metastasis.

Table 12 Comparison of colorectal cancer outcomes with the European Society of Coloproctology international audit and CovidSurg collaboration data

	Right colon			Left colon			Rectal
%	ESCP	CSURG	Ours	ESCP	CSURG	Ours	ESCP	CSURG	Ours
N	2225	724	15	989	367	13	2579	935	20
MIS	54.4	54.7	53.3	53.6	62.9	53.8	54.2	57.8	90
Open	36.5	41	33.3	36.8	29.7	38.4	35.8	38.0	5
Conv	9.1	4.3	13.3	9.6	7.4	7.7	10	4.2	5
ANAST	98.6	93.5	100	93.3	86.1	76.9	42.8	37.4	27.3
ANAST +DEF	0.3	1.4	0	1.8	5.7	0	33.5	35.4	45.451
End stoma	1.1	5.1	0	4.9	8.2	23.1	23.7	27.2	27.31
Leak	6.5	3.6	0	7.5	4.1	0	9.2	6.5	5; 12.52
Death	1.7	1.2	0	0.7	1.6	7.7	0.8	2.0	0

¹Excluded abdominoperineal resection patients.

²Considering only anastomosed patients. Data shown as % except first file.

1 patient with total colectomy in included in left colon (sigmoid cancer). MIS: Minimally invasive surgery; Conv: MIS-Conversion; ANAST: Anastomoses; DEF: Defunctioning stoma; ESCP: European society of coloproctology; CSURG: CovidSurg cancer study on colorectal surgery.