Use ‘careful judgment’ to determine optimal neuroendocrine tumor management in COVID-19
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Long-term treatment regimens for neuroendocrine neoplasms can be safely and temporarily delayed in the setting of life-threatening COVID-19-related symptoms, which should be “urgently treated,” according to new guidance.
“In viral pandemics, most specifically COVID-19, many patients with neuroendocrine neoplasms, including pheochromocytomas, paragangliomas and medullary thyroid carcinoma, may develop COVID-19 in a mild or severe form, or be concerned about the influence of viral infection relative to their tumor therapy,” Ruth Casey, PhD, consultant endocrinologist at Wolfson Diabetes and Endocrine Clinic and Cambridge University Hospital NHS Foundation Trust, United Kingdom, and colleagues wrote. “In general, newly presenting patients should be assessed, and patients recently receiving chemotherapy, targeted therapy or radionuclide therapy, or showing tumor growth, should be closely followed. For previously diagnosed patients, who have indolent disease, some delay in routine follow-up or treatment may not be problematic. However, patients developing acute secretory syndromes due to functional neuroendocrine neoplasms, pheochromocytomas and paragangliomas, will require prompt treatment.”
In guidance published in the European Journal of Endocrinology, Casey and colleagues wrote that neuroendocrine neoplasm multidisciplinary team meetings — taking advantage of videoconferencing when feasible — are “crucial” during a pandemic to ensure appropriate decision-making.
“For each case, the risk of the proposed intervention, diagnostic procedure or treatment should be weighed up against the risk of hospital attendance and COVID-19,” the researchers wrote.
The researchers outlined several recommendations for managing adults with neuroendocrine neoplasms during the COVID-19 pandemic:
- Utilize phone or video consultations for suitable patients when conducting clinical reviews; nonessential clinic consultations should be postponed.
- Cross-sectional imaging should be considered for patients with suspected disease progression, based on clinical symptoms, biochemistry or anticipated tumor biology.
- Routine surveillance in asymptomatic patients can be delayed when suspicion of disease progression is low.
- Somatostatin receptor imaging may be considered as an alternative to endoscopy-guided biopsy in certain cases for tumor management.
- Patients with neuroendocrine neoplasms and COVID-19 should receive venous thromboembolism prophylaxis in accordance with local protocols unless there is a significant contraindication.
- Treatment for neuroendocrine neoplasms should be withheld for patients on active therapy who develop COVID-19 with the exception of somatostatin analogues for symptomatic secretory tumors.
- Options for home administration of somatostatin analogues should be explored with patients and family members.
- Somatostatin analogues can be considered as a bridge to a postponed, curative surgery for asymptomatic patients with localized, well-differentiated and non-secretory neuroendocrine neoplasms.
The researchers also recommended that patients with neuroendocrine neoplasms and COVID-19 be recruited for a dedicated registry to better inform disease management.
“In patients with especially aggressive neuroendocrine neoplasms, a careful judgment should be made regarding the severity of any COVID-19 illness, tumor grade, and the immunosuppressant effects of any planned chemotherapy, immunotherapy, targeted therapy or related treatment,” the researchers wrote. “In other cases, especially patients with completely resected neuroendocrine neoplasms, or who are under surveillance for a genetic disorder, a telephone or delayed consultation may be in order, balancing the risk of a delay against that of the possible development of COVID-19.”
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