Clinical and Translational Oncology https://doi.org/10.1007/s12094-021-02634-5 RESEARCH ARTICLE Saving time in the radiotherapy procedures for COVID‑19 pneumonia treatment. A single‑institution experience M. Bonet1 · S. Vázquez1 · E. García1,2 · M. Visus3 · D. Jové3 · O. Ripol3 · C. Solé4 · L. Gutiérrez4 · J. L. Morales‑Rull4,2 · Á. Montero5 · M. Algara6 · M. Arenas7 · M. Mira1,2 Received: 26 March 2021 / Accepted: 29 April 2021 © Federación de Sociedades Españolas de Oncología (FESEO) 2021 Abstract Background The use of low dose radiotherapy (LD-RT) for the treatment of COVID-19 pneumonia is supported by biologi- cal rationale for its immunomodulatory effect. Some institutions have started to treat these patients showing encouraging results. To shorten procedure times is crucial for the comfort of symptomatic patients receiving respiratory support and to optimize institutional facilities. Patients and methods At our institution, LD-RT is offered to hospitalized patients with COVID-19 pneumonia and signs of early cytokine-released syndrome on behalf of a multicenter study. We designed a coordinated process flow starting from the patient transfer to the simulation CT-scan (first-step), to the end of the LD-RT treatment (last step). The times spent on each step of the process flow were evaluated. Results Mean age of treated patients was 83 (72–91) years-old. The timing parameters of the first 10 consecutive patients were analyzed. Except for the first (dummy run), patients were managed from the first to the last step in a median of 38 min (25–58, SD 10.67). The most time-consuming sub-process was the contouring of the treatment volumes and dosimetry. Conclusions LD-RT is not only an encouraging option for COVID-19 pneumonia patients, but a convenient and feasible procedure if performed in a coordinated way by reducing procedure times. Keywords Low-dose radiotherapy · COVID-19 · Pneumonia · Procedure times · Workflow Introduction At present there are many clinical trials on-going to assess the efficacy of different treatments for COVID-19 disease. * M. Bonet mabonet.lleida.ics@gencat.cat Low dose radiotherapy (LD-RT) has emerged as a promising option by reducing the inflammatory response in the lungs 1 Radiation Oncology Department, Hospital Universitari caused by SARS-CoV-2 pneumonia. As an institution, we Arnau de Vilanova, Av. Alcalde Rovira Roure, 80, are participating in the on-going multicenter clinical study 25198 Lleida, Spain IPACOVID (ClinicalTrials.gov Identifier: NCT04380818) 2 IRBLleida (Institut de Recerca Biomèdica de which is evaluating the efficacy of LD-RT as an adjunctive Lleida. Fundació Doctor Pifarré), Lleida, Spain treatment in interstitial pneumonia in patients with COVID- 3 Radiation Physics and Radioprotection Department, Hospital 19, to prevent patient progression to a critical state. Universitari Arnau de Vilanova, Lleida, Spain Since the start of the COVID-19 outbreak, few prospec- 4 Internal Medicine Department, Hospital Universitari Arnau tive cohort studies of patients treated with LD-RT have been de Vilanova, Lleida, Spain published. Results are encouraging though, and improve- 5 Radiation Oncology Department, Hospital Universitario HM ments in imaging and biomarkers are reported, leading to Sanchinarro, Madrid, Spain hospital discharges in less than 2 weeks and with no signifi- 6 Radiation Oncology Department, Parc de Salut Mar, cant acute toxicity [1–3]. In spite of these results, a recent Universitat Autònoma de Barcelona, Barcelona, Spain randomized doubled-blind study performed with critically 7 Radiation Oncology Department, Hospital Universitari Sant ill patients requiring mechanical ventilation, has failed to Joan de Reus, Universitat Rovira I VIrgili, Reus, Spain 13 Vol.:(0123456789) Clinical and Translational Oncology demonstrate improvements in clinical outcomes. However, The timing starting from the entrance of the patient into the on-going multicenter study IPACOVID is evaluating the the CT room for simulation to the delivery of the planned efficacy of LDRT in patients with SARS-CoV-2 pneumo- LD-RT was recorded and evaluated descriptively. nia with signs of early cytokine-released syndrome, which would be a more favorable clinical population. Results from the current clinical study have not been yet published [4]. The workflow While the main role of these studies is to evaluate the effi- cacy and safety of LD-RT, the feasibility and convenience of All patients were hospitalized and supported by the Internal the radiotherapy procedures in this context is also critical. In Medicine Department, where patients were proposed for the April 2020, close to the start of the pandemic outbreak, the study and signed the consent form. The next step was to Spanish Society of Radiation Oncology in collaboration with immediately contact the Radiation Oncology Department. the Spanish Ministry of Health wrote a document guiding Then, the workflow for LD-RT started and CT planning the management of cancer patients suffering from COVID- was scheduled in a safe time slot reserved for COVID-19 19 [5]. Some of these logistical recommendations were to patients. design a specific waiting room if possible and to locate these To optimize the workflow between the Internal Medi- patients at the end of the day to ensure a low flow of patients cine, Radiology, Radiation Physics and Radiation Oncol- and personnel. ogy Departments, one person was assigned to be in charge However, when treating non oncological COVID-19 of each unit. According to our clinical experience in onco- patients, there are some other considerations to be taken logic diseases, estimated times for each process/sub-process into account. Many of these patients are elderly and need rest were about 65 min in total. As the main concern of Internal while receiving respiratory support. Therefore, shortening Medicine Department was the time the patient was out of the the time spent on mobilizations and transfers is a priority hospitalization ward, we developed a theoretical framework. to avoid a clinical worsening. As recommended by our col- It has been based on the standard clinical practice of Radia- leagues from Internal Medicine, who are experts in the man- tion Therapy Departments in our country and agreed after a agement of COVID-19 disease, we have prioritized avoiding survey within the clinical and technical staff at our institu- unnecessary displacements and to ensure respiratory stabil- tion. A description of each process, the person in charge and ity for the patient. As a consequence, we developed some estimated duration is shown in Fig. 1. measures focusing on shortening, as far as possible, the stay of patients in our Department. Reducing waiting times during the LD-RT process needs The contouring and dosimetry sub‑process close collaboration with the different medical departments that are involved in the management of these patients. At our After the acquisition of the CT-scan, the critical structures institution, Internal Medicine, Radiology, Radiation Physics were created for dose calculation and positioning on the and the Radiation Oncology Departments are implied in the treatment facility (lungs, trachea, carina and bronchia). A management of COVID-19 pneumonia-related patients that template with those structures was pre-defined. The lung would benefit from a LD-RT. structure was drawn using automatic tools including all lung We designed a coordinated workflow between these tissue. Manual corrections of these volumes were performed departments aiming to minimize patient waiting times, depending on the extension of the pneumonia. The trachea improve convenience and optimize health-care facilities at was manually drawn from the lung apex to the bronchia. our institution. This structure was used as a reference for patient position- ing. Post-processing tools were used when needed. The PTV was created as an expansion of the lung struc- Patients and methods ture with an additional margin (of 5 mm in all axes except for the cranio-caudal direction where margins were of 10 mm) LD-RT is at present being offered to hospitalized patients as indicated per protocol (Fig. 2). Radiotherapy treatment with COVID-19 pneumonia on behalf of the on-going mul- was planned using an isocentric technique with two oppos- ticenter study IPACOVID (ClinicalTrials.gov identifier ing (AP/PA) 6 MV photon beams. To simplify the dosimet- NCT04380818) approved by the local Ethics Committee. ric sub-process, a template was created with the setup field Clinical details are depicted in the protocol. All patients and certain fixed parameters (such as beams configuration), had a proven SARS-CoV-2 infection and related pneumo- that was adjusted for each patient. The treatment volume was nia diagnosed by imaging, and also fit the inclusion criteria then fitted by adding a MLC with a margin of 10 mm. The for signs of early cytokine-released syndrome according to plan was normalized to the average dose and field weights the study. were also adjusted. 13 Clinical and Translational Oncology Fig. 1  Description of each process, person in charge and estimated times. RT radiotherapy, LD-RT low-dose radiotherapy The treatment delineating and dosimetry sub-process were progressively reduced. In addition, we learned that the use of the ‘pelvis’ The spaces were zoned to define “clean” and “dirty” areas. greyscale was more appropriate than the usual lung contour- The same two technicians that wore personal protective ing presents. Nevertheless, we experienced an unexpected equipment (PPE) to perform the CT-simulation (“dirty” per- computer network crash that affected the whole institution sonnel) were the same that positioned the patient in-room. delaying the download of CT images and contouring and A third technician and a Radiation Oncology physician dosimetry sub-process in the sixth patient. (“clean” personnel) were managing the console. An Internal None of the personnel involved in the treatment of these Medicine Physician (“dirty” personnel) was also present in patients has been infected by SARS-Cov-2. case patients had respiratory distress. A zone located at more than 2 m from the console was defined to place the “dirty” personnel while performing the treatment. Discussion In the context of an infectious disease such as COVID-19 Results there are three main points we consider to be crucial: first, time efficiency; second, patient convenience and third, The first ten patients were treated from 1st Feb 2021 to 24th patient safety during the process to avoid contagion among Feb 2021. Median age was 83 (72–91) years-old. health personnel. So, we describe an optimized and con- The whole process and sub-process times were recorded venient workflow based on the collaboration of four medical from all patients. Except for the first patient, where the time Departments at the same institution. spent was 58 min, the average treatment times were less than To achieve the first point it is necessary to limit the initially estimated. Patients were managed from the simula- extent of non‐value‐adding activities and to appoint a per- tion CT-scan (first-step) to the end of the LD-RT treatment son in charge of each sub process to improve throughput (last step) in a median of 38 min (25–58, SD 10.67). [6]. In addition, radiotherapy is a modality of treatment that As shown in Fig. 3, the most critical sub-process was needs several steps and where clinical practice workflows the contouring of volumes and dosimetry steps. After the should be highly standardized [7]. So, we can state that the dummy-run for the first patient, the times spent in the time reduction we achieved in the contouring process has 13 Clinical and Translational Oncology Fig. 2  a Treatment volumes in a patient with COVID-19 pneumonia. b LD-RT dosimetry of the same patient primarily been a consequence of the acquired experience Medicine, Radiology, Radiation Physics and the Radiation in automatic contouring and the use of templates (for struc- Oncology Departments is successful throughout all the dif- ture creation and beam configuration). The delimitation ferent tiers of health personnel implied. parameters that are usually used are inadequate due to the It is important to note that our patients were elderly with heterogeneous density of the lung tissue caused by pneumo- a mean age of 83 years-old. It has been suggested that older nia. Even though a manual correction is essential, this auto- patients would be enrolled in clinical trials for potential mation can greatly reduce the time spent in the contouring antiviral medications [8]. However, most of these hospital- sub process. Similarly in our practice, treatment planning is ized patients are close to a “therapeutic ceiling” and need a being customized from a single template with two opposing resting position to avoid worsening of COVID-19 respira- beams. Dose distribution is calculated and optimized using tory symptoms [9]. So it is important to avoid unnecessary the simulation CT, but with a basic configuration already displacements and to give them the highest comfort. All predefined. patients have received the standard of care protocolized in Shortening waiting times during the LD-RT process our center, which consists in administration of dexametha- needs close collaboration between the different medical sone, prophylactic enoxaparin and, tocilizumab in those departments involved as mentioned before. We are proud patients with elevated CRP and IL-6, and/or remdesivir in that at our institution, the collaboration between Internal patients with symptoms lesser than 7 days. It is important 13 Clinical and Translational Oncology Fig. 3  Whole process and sub-process times. Table: actions made to improve times in each sub-process to highlight that all patients with respiratory distress have Informed consent Informed consent was obtained from all individual received respiratory support with a high-flow nasal cannula participants included in the study. or non-invasive ventilation as an alternative to hospitaliza- tion in the Intensive Care Unit, associated with a worsening prognosis in this age group, especially when they undergo orotracheal intubation and mechanical ventilation. References Finally, it has recently been demonstrated that follow- ing preventive policies among health personnel COVID-19 1. Hess CB, Nasti TH, Dhere VR, Kleber TJ, Switchenko JM, Buch- wald ZS, et al. Immunomodulatory low-dose whole-lung radiation infections can be avoided [10]. 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