Management of endocrine surgical disorders during COVID-19 pandemic: expert opinion for non-surgical options

Abstract

Purpose The COVID-19 pandemic brought unprecedented conditions for overall health care systems by restricting resources for non-COVID-19 patients. As the burden of the disease escalates, routine elective surgeries are being cancelled. The aim of this paper was to provide a guideline for management of endocrine surgical disorders during a pandemic. Methods We used Delphi method with a nine-scale Likert scale on two rounds of voting involving 64 experienced eminent surgeons and endocrinologists who had the necessary experience to provide insight on endocrine disorder management. All voting was done by email using a standard questionnaire. Results Overall, 37 recommendations were voted on. In two rounds, all recommendations reached an agreement and were either endorsed or rejected. Endorsed statements include dietary change in primary hyperparathyroidism, Cinacalcet treatment in secondary hyperparathyroidism, alpha-blocker administration for pheochromocytoma, methimazole ± β-blocker combination for Graves’ disease, and follow-up for fine-needle aspiration results of thyroid nodules indicated as Bethesda 3–4 cytological results and papillary microcarcinoma. Conclusion This survey summarizes expert opinion for the management of endocrine surgical conditions during unprecedented times when access to surgical treatment is severely disrupted. The statements are not applicable in circumstances in which surgical treatment is possible.

Management of Patients With Glucocorticoid-Related Diseases and COVID-19

“…Particular attention should be given to patients with ACC. Following the recommendations of endocrine surgeons (157,158), tumor resection should not be postponed. Mitotane treatment and antineoplastic therapies should be suspended in the case of severe manifestations of SARS-CoV-2, but the start of the treatment should not be postponed in the absence of any symptoms of COVID-19 (125,161).…”

“…Because of the aggressiveness of ACC, which shows a 5-year overall survival of about 15% in metastatic disease (stage IV according to the European Network for the Study of Adrenal Tumors classification) (156), surgical and medical treatment should not be delayed. Therefore, in cases of suspected/confirmed ACC, a complete en bloc resection (if possible) should be attempted (157,158).…”

Updated clinical management guidance during the COVID-19 pandemic: thyroid nodules and cancer

“…All the aforementioned cases should be prioritized for (total) thyroidectomy and lymph node neck dissection during the pandemic, always with precautions and risk/benefit assessment. A COVID-19 prevention protocol should be followed during surgery ( 25 , 26 ). Patients should also respect social distancing pre- and post-operatively, while avoiding visitors during hospitalization period is a sine qua non.…”

Charting the Unknown Association of COVID-19 with Thyroid Cancer, Focusing on Differentiated Thyroid Cancer: A Call for Caution

“…Postponement of surgery for 3–6 months and alternative treatment options are recommended for patients who are candidate for surgery due to a twice-confirmed result of FNA indicative of atypia/follicular lesion of undetermined significance (AUS/FLUS) (Bethesda 3), or Hürthle cell neoplasia/follicular neoplasia (Bethesda 4), or papillary microcarcinoma without pathological lymph nodes in the neck, or carcinoma without pathological lymph nodes in the neck. Such alternative treatment options are minimally invasive ablation techniques, including laser, microwave, or radiofrequency ablation, and active surveillance until the end of the pandemic [ 73 ].…”