As of February 18, 2020, 112 patients with suspected COVID-19 admitted to our hospital. Of them, 98 cases have been confirmed COVID-19 via repeated swab testing and 1 death. Another 14 patients were excluded from COVID-19 (Fig. 1).
In total, 5 individuals have a history of malignancy, but only 4 cases received radiation therapy were included in this present study (Fig. 1), with a median age of 54 years (39–64 years). In them with 2 males and 2 females, 1 case was confirmed and 3 cases were excluded from COVID-19. Two patients with nasopharyngeal carcinoma had completed their concurrent chemoradiotherapy without any signs of tumor recurrence, whereas another 2 patients with advanced thoracic tumors present unsatisfactory outcomes to anti-tumor systematic therapies including palliative chemotherapy, radiotherapy, or target therapy et al.
The detailed description of 4 patients with suspected COVID-19 at admission was presented below (Table 1, Table 2):
Table 1
Clinical characteristics at admission and clinical outcomes
Characteristics | Patient 1 | Patient 2 | Patient 3 | Patient 4 |
Age, years | 53 | 55 | 64 | 39 |
Sex | male | female | female | Male |
Histopathology | esophageal SCC | lung adenocarcinoma | NPC | NPC |
TNM stage | T4aN2M1 | T4N3M1 | T3N2M0 | T2N2M0 |
Exposure history | N | N | Y | Y |
Comorbidities | gastric ulcer | N | sicca syndrome | hyperthyreosis |
PS | 3 | 3 | 1 | 0 |
Symptoms | | | | |
Fever | - | - | + | - |
Maximum temperature, ℃ | - | - | 39.5 | - |
Fatigue | + | + | - | - |
Cough | + | + | + | - |
Sputum | + | + | - | - |
Chest distress | + | + | - | - |
Myalgia | - | - | - | - |
Dyspnea | - | + | - | - |
hemoptysis | + | - | - | - |
Diarrhea | - | - | - | + |
Sore throat | - | - | - | - |
Vomiting after eating | + | - | - | - |
Headache | - | - | + | - |
TIME1(days) | 10 | 6 | 2 | 10 |
TIME2(months) | 12.6 | 13.6 | 5.2 | 77.9 |
Treatment | Tazocin + Moxifloxacin +Arbidol | Tazocin+ Methylprednisolone | Sulperazone + Arbidol +Thymosin α1 + Albumin injection | Resochin |
Outcomes | Transferred and discharged | Transferred and death | Transferred and discharged | discharged |
Note: SCC: squamous cell carcinoma; NPC: nasopharyngeal carcinoma; PS: performance score; TIME1: The time interval between the onset of initial symptoms and the first CT scan at admission; TIME2: The period between the onset of initial symptoms and the first CT scan at admission; Tazocin: Piperacillin-Tazobactam |
Table 2
Laboratory Findings at Admission
Parameter, unit, (normal value) | Patient 1 | Patient 2 | Patient 3 | Patient 3 |
WBC, ×109/L, (3.5–9.5) | 6.37 | 10.8↑ | 7.87 | 6.42 |
Neutrophil, ×109/L, (1.8–6.3) | 5.22 | 9.51↑ | 7.25↑ | 3.99 |
Hemoglobin/L, g/L, (130–175) | 124↓ | 138 | 119↓ | 144 |
Lymphocyte, ×109/L, (1.1–3.2) | 0.43↓ | 0.73↓ | 0.10↓ | 1.96 |
Platelet, ×109/L, (125–350) | 43↓ | 338 | 96↓ | 270 |
PT, s, (9.4–12.5) | 15.40↑ | 12 | 11.90 | 11.30 |
APTT, s, (25.1–36.5) | 27.60 | 26.80 | 30.30 | 31.80 |
INR, (0.8–1.15) | 1.34↑ | 1.11 | 1.03 | 0.98 |
D-dimer, mg/L, (0-243) | 1120↑ | 11535↑ | 482↑ | 46 |
CK, U/L, (39–308) | 183 | 67 | 29 | 141 |
CK–MB, U/L, (0–25) | 20.10 | 2.6 | 8.10 | 6.4 |
LDH, U/L, (120–250) | 259↑ | 721↑ | 153 | 153 |
ALT, U/L, (9–50) | 11.80 | 28.10 | 34.60 | 26.3 |
AST, U/L, (15–40) | 34.50 | 34.70 | 36.30 | 25.6 |
Total bilirubin, µmol/L, (3–24) | 41.44↑ | 4.7 | 10.10 | 5.42 |
BUN, mmol/L, (3.1-8.0) | 10.50↑ | 5.7 | 6.3 | 2.9↓ |
Creatinine, µmol/L, (57–111) | 82.80 | 65 | 90.30 | 74.9 |
CTNI, µg/mL, (0-0.0229) | ༜0.01 | ༜0.01 | ༜0.01 | ༜0.01 |
NT-BNP, pg/ml, (0-125) | 2160↑ | 641↑ | 208↑ | 29 |
PCT, ng/mL, (0-0.5) | 9.09↑ | ༜0.10 | 4.62↑ | ༜0.10 |
CRP, mg/L, (0.068-8.2) | 202.78↑ | 88.79↑ | 136.56↑ | ༜0.26 |
T lymphocyte subsets test | | | | |
CD4 + T cell, (550–1440) | NR | NR | 13↓ | 342↓ |
CD8 + T cell, (320–1250) | NR | NR | 39↓ | 245↓ |
CD4+/CD8+, (0.71–2.78) | NR | NR | 0.69↓ | 1.4 |
pathogenic examination | NR | Sputum cultures(-); Blood high throughput screening(-) | Escherichia coli (+) in blood culture; influenza A and B(-) | Influenza A and B (-) |
Swab nucleic acid tests of SARS-COV-2 * | Negative(3) | Negative(2) | Negative(5) | Positive |
Note: WBC: white blood cell; INR: International Normalized Ratio; PT: Prothrombin time; APTT: Activated partial thromboplastin time; CK: Creatine kinase; LDH: Lactate dehydrogenase; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BUN: Blood urea nitrogen; CTNI : Troponin I; NT-BNP: N-terminal-pro hormone brain-type natriuretic peptide; PCT: Procalcitonin; CRP: C-reactive Protein; NR: no report. *The numbers in the brackets represent the number times of swab tests. |
Patient 1
A 53-year-old male was admitted to the hospital with sputum production and cough of more than ten days duration and a little bit hemoptysis of two days duration on January 28, 2020. He also felt fatigued, chest distress, vomiting after eating, but no fever, neither from the infected area nor contact with infected peoples. The physical examination revealed coarse breath sounds during auscultation, and laboratory studies showed normal leukocyte, but lymphopenia and serious thrombocytopenia. Marked elevated concentrations of D-dimer, Procalcitonin (PCT), C-reactive protein (CRP), and N-terminal-pro hormone brain-type natriuretic peptide (NT-BNP) were observed at admission. In September 2016, Patient was diagnosed with middle and lower esophageal squamous cell carcinoma with multiple bone metastases staged with T4aN2M1 and began to receive palliative concurrent chemoradiotherapy on September 29, 2016. The radiotherapy dose using intensity-modulated radiation therapy (IMRT) for GTV (esophageal tumor lesions) was 49.4 Gy / 26Fr, and the paclitaxel/Carboplatin regimen concurrently was administered intravenously every three weeks for two cycles, then patients received palliative chemotherapy with paclitaxel monotherapy for only one cycle because of intolerance of side effects. On December 12, 2018, patients began to receive a second palliative concurrent chemoradiotherapy for recurrence lesions (GTV 44 Gy/22Fr plus nedaplatin), after that, regular reviews were performed.
Serial CT scans showed pericardial effusion, multiple enlarged lymph nodes in the mediastinum, scattered, multiple, similar round thin wall/no wall transparent areas (Fig. 2:A2, B2, C3), smooth or nodular interlobular septal thickening (Fig. 2:A1, B1), and multiple nodules in the dorsal segment of the lower lobe of both lungs with spotted calcifications and adjacent pleural thickening (Fig. 2:A2, A3). These above lung lesions were approximately the same as before. Compared with the previous CT scan 1 year before, chest CT images performed at the 10th day after symptom onset showed the following lung lesions obvious progressively, including patchy areas of consolidation co-existed with ground-glass opacities (Fig. 2:A3), or linear scarring with discrete consolidation (Fig. 2:A2), air bronchograms (Fig. 2:A1), and irregular intralobular or interlobular septal thickening (Fig. 2:A1, A2, A3) predominately in the lower lobes of both lungs adjacent to the mediastinum conforming completely to the irradiated area. These lesions suggest the possibility of RILI, interstitial pneumonia or viral pneumonia. After 3 days of anti-infective therapy with tazocin, moxifloxacin, and arbidol, combined with aggressive supportive care, follow-up CT demonstrated partial improvement (Fig. 2: B1) but primarily increment in the extent and density of lung lesions (Fig. 2: B2, B3), continued segmental consolidations and atelectasis were observed in the lower lobe of both lungs (Fig. 2: B3). Repeated three times of swab nucleic acid test for the COVID-19 were negative. Afterward, the patient was transferred to the department of oncology to continue treatment to reduce the burden of the frontier department.
Patient 2
A 55-year-old female was admitted to the hospital with dyspnea for 1 week and exacerbation for 1 day after more than 1-year targeted therapy for lung adenocarcinoma on January 23, 2020. Fatigue, chest distress, and sputum production with cough were also present. He had no fever, neither from the infected area, nor contact with infected peoples. The physical examination revealed disappeared breath sounds of the left lung during auscultation, and laboratory studies showed slightly elevated white blood cell and neutrophil, but lymphopenia. Elevated concentrations of D-dimer, CRP and NT-BNP were displayed at admission. Sputum culture examination revealed normal flora growth, neither Hemophilus influenza nor fungal growth. In April 2018, the patient was diagnosed with left lung adenocarcinoma with intrapulmonary metastases and multiple bone metastases staged with T4N3M1 and received palliative comprehensive treatment based on target therapy of EGFR inhibitor. On November 14, 2018, the patient began to receive palliative radiotherapy for C6-T2 vertebral metastasis (GTV 30 Gy/10Fr) and left supraclavicular metastatic lymph nodes(45 Gy/15Fr).
Compared with the previous CT scan ten months before, chest CT images performed on the 6th day after symptom onset showed enlarged mass with calcification in the left upper lobe and lung hilum with the maximum section of about 79mm*48 mm, and multiple mediastinal lymph node metastases. The boundary between them is obscure with atelectasis. Magnified irregular nodules scattered in both lungs. Metastatic tumors of the left pleura increased in the extent and quantity, so did the left pleural effusion and pericardial effusion (Fig. 3: A1, B1, C1), All these lung lesions indicated a progressive left central lung cancer after systematic therapy. There were bilateral diffused ground-glass opacities with partial consolidation (Fig. 3: B2), and a reticular pattern associated with bronchiectasis and intralobular or interlobular septal thickening (Fig. 3: B2), which indicated the possibility of viral pneumonia. After 9 days of anti-infective therapy with tazocin, combined with aggressive supportive care and glucocorticoid therapy(methylprednisolone), follow-up CT demonstrated continuous development in the scope and extent (Fig. 3:C1, C2). Repeated two times of swab nucleic acid test for the COVID-19 were negative, and blood high throughput screening for pathogenic microorganisms or viruses was also negative. The patient's disease continued to progress and died on February 6, 2020 in the department of oncology.
Patient 3
A 64-year-old woman who worked in Beijing presented to the hospital with a 1-day history of fever and cough on February 17, 2020. The maximum body temperature was 39.5 °C (103.1°F). She also had a little cough and headache. The patient traveled to Zhuhai and lived in her community where several patients were confirmed COVID-19. At admission, both lungs were clear on auscultation. Laboratory studies showed normal white blood cell and higher neutrophil, but serious lymphopenia. The concentrations of PCT and CRP increased significantly, and so did those of D-dimer and NT-BNP. The T lymphocyte subsets test showed a sharp drop in CD4 + and CD8 + T cell counts. Screening for influenza A and B were negative. In July 2019, the patient was diagnosed with nasopharyngeal carcinoma(T3N2M0) treated with definitive concurrent chemoradiotherapy followed by adjuvant chemotherapy. By September12, 2019, the patient received IMRT for nasopharyngeal tumor (GTVnx 70 Gy/33Fr), neck metastatic lymph nodes (GTVnd 66 Gy/33Fr) and lymphatic drainage of the neck (CTV 54 Gy/33Fr).
Chest CT images obtained on the second day after symptom onset showed there were minimal ground-glass opacities with partially rounded consolidation (Fig. 4: A1) in the apexes of both lungs, conforming completely to the irradiated area of low exposure. Multiple ill-defined patchy ground-glass opacities (Fig. 4: A2) were observed in the middle lobe of the right lung, considering the possibility of COVID-19 pneumonia. After 3 days of antiviral therapy with arbidol, antibiotic treatment with sulperazone, and supportive treatment with albumin injection et al, Follow-up CT demonstrated no obvious changes of lung lesions (Fig. 4: B1, B2). But the patient's symptoms improved significantly. Repeated four times of swab nucleic acid test for the COVID-19 were negative. Finally, blood culture suggested an Escherichia coli infection. Then the patient was transferred to the department of oncology.
Patient 4
A 39-year-old male was admitted to the hospital with a positive result of the swab nucleic acid test for COVID-19 a half of the day on February 14, 2020. The patient had transient diarrhea ten days ago and no other symptoms afterward. The patient traveled to Zhuhai from the infected area (Wuhan) and had close contact with the confirmed COVID-19 patient, his aunt. At admission, both lungs were clear on auscultation. Laboratory studies showed normal blood routine results. Screening for influenza A and B were negative. The T lymphocyte subsets test showed a slight drop in CD4 + and CD8 + T cell counts. In June 2013, the patient was diagnosed with nasopharyngeal carcinoma(T2N2M0) treated with radical concurrent chemoradiotherapy. By August 18, 2013, the patient received IMRT for GTVnx 70 Gy/33Fr, GTVnd 66 Gy/33Fr and CTV 54 Gy/33Fr.
Chest CT images obtained on the 10th day after symptom onset showed there were multiple ground-glass opacities of the lower lobes of both lungs peripherally and subpleurally (Fig. 5: A2); A few linear opacities presented in upper lobe lower lingual segment of the left lung (Fig. 5: A3) within the ionizing radiation area, indicative of radiation fibrosis. After 8 days of antiviral therapy with resochin and supportive treatment, Follow-up CT scans demonstrated significant improvement in the extent and density of the ground-glass opacities (Fig. 5: B2), but a new focal ground-glass opacity of the upper lobe of right lung appeared (Fig. 5: A1, B1). Treatment continued until the result of the swab test became negative.