GACETA MÉDICA DE MÉXICO

ORIGINAL ARTICLE

Chest tomography for COVID-19 screening in head and neck

cancer elective surgery. Is it enough?
Leonardo A. Barba-Valadez, José F. Gallegos-Hernández,* Ariadna L. Benítez-Martínez and
José A. Ábrego-Vásquez
Oncology Hospital, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico

Abstract

Introduction: Head and neck cancer patients are at high risk of SARS-CoV-2 infection; surgery in them involves risk for
patients, surgeons, health personnel, medical institutions and society, since it is associated with prolonged and inadvertent
production of aerosols and emergency procedures that facilitate the breach of protective measures by health personnel.
Objective: To find out if pulmonary tomographic findings are sufficient to preoperatively identify patients with COVID-19.
Methods: Retrospective, cross-sectional, analytical study of patients with cervical-facial neoplasms who were candidates for
surgery, preoperatively evaluated by simple chest computed tomography based on the CO-RADS classification. In CO-RADS
≥ 3 patients, surgery was suspended and PCR was performed using nasopharyngeal swab. Results: 322 patients were in-
cluded, all without COVID-19 symptoms. Tomography was positive in 35 (10.87%); in 30, nasopharyngeal swab was performed:
28 were negative and two were positive; none developed COVID-19 symptoms. Conclusions: Chest tomography is not use-
ful as the only preoperative screening procedure for COVID-19, since its findings are nonspecific, with a high rate of false-pos-
itive results. Clinical evaluation, with PCR and tomography, is the best form of preoperative screening.

KEYWORDS: Head and neck. Cancer. COVID-19. Screening. PCR. Tomography.

La tomografía de tórax para tamizaje de COVID-19 en cirugía electiva de cáncer de

cabeza y cuello. ¿Es suficiente?
Resumen

Introducción: Los pacientes con cáncer de cabeza y cuello tienen alto riesgo de infección por SARS-CoV-2; la cirugía en
ellos implica riesgo para pacientes, cirujanos, personal de salud, institución médica y sociedad, ya que se asocia a aeroso-
lización prolongada e inadvertida y a procedimientos de urgencia que facilitan la ruptura de las medidas de protección del
personal de salud. Objetivo: Conocer si los hallazgos tomográficos pulmonares son suficientes para identificar en forma
preoperatoria a los pacientes con COVID-19. Métodos: Estudio retrospectivo, transversal y analítico de pacientes con neo-
plasias cervicofaciales candidatos a cirugía, evaluados preoperatoriamente mediante tomografía axial computarizada simple
de tórax con base en la clasificación CO-RADS. En los pacientes CO-RADS ≥ 3 se suspendió la cirugía y se realizó PCR
por hisopado nasofaríngeo. Resultados: Se incluyeron 322 pacientes, todos sin síntomas de COVID-19. La tomografía fue
positiva en 35 (10.87 %); en 30 se efectuó hisopado nasofaríngeo: 28 fueron negativos y dos, positivos; ninguno desarrolló
síntomas de COVID-19. Conclusiones: La tomografía torácica no es útil como procedimiento único de tamizaje preopera-
torio de COVID-19, ya que sus hallazgos son inespecíficos, con tasa alta de resultados falsos-positivos. La evaluación clí-
nica, con PCR y tomografía es la mejor forma de pesquisa preoperatoria.

PALABRAS CLAVE: Cabeza y cuello. Cáncer. COVID-19. Pesquisa. PCR. Tomografía.

Correspondence: Date of reception: 04-07-2021 Gac Med Mex. 2022;158:36-40

*José F. Gallegos-Hernández Date of acceptance: 05-08-2021 Contents available at PubMed
E-mail: gal61@prodigy.net.mx DOI: 10.24875/GMM.M22000638 www.gacetamedicademexico.com
0016-3813/© 2021 Academia Nacional de Medicina de México, A.C.. Published by Permanyer. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

36
 Barba-Valadez LA et al.: COVID-19 preoperative screening
Introduction
The pandemic caused by the new type of coronavi-
rus, SARS-CoV-2, and global spread of severe acute
respiratory symptoms and associated pneumonia,
called COVID-19, have led to a rate of postoperative
pulmonary complications of 51.2%;1 44.4% of patients
require intensive care unit support, and reported mor-
tality is 38%. 2
Cancer patients are a group that is vulnerable to
SARS-COV-2 infection: their risk for developing se-
vere infection is 3.6 times higher,3-6 and case fatality
rate is double than that of the general non-oncology
population (5.6% vs. 2.3%).7
The rate of postoperative complications in COVID
patients is higher, even if they are asymptomatic,
which is why it is necessary to identify them in
order to avoid risks. For that purpose, various pro-
tocols have been created for pre-surgical screen-
ing during the COVID-19 pandemic in order for a
timely and accurate diagnostic approach to be
implemented. 8-12
Usually, patients with severe COVID-19 present with
unspecific symptoms such as fever, cough and dys-
pnea; however, there are others who may not exhibit
symptoms and remain that way.13,14 These patients can
be highly contagious, and it has therefore been sug-
gested that diagnostic screening for COVID-19 in pa-
tients who are candidates for a therapeutic procedure
should include nasopharyngeal swabbing with re-
al-time reverse transcriptase (RT-PCR) determination;
however, the results may not be immediately obtained
or the test itself may not be available.
Simple computed tomography (CT) of the chest is
easy to perform and can aid rapid diagnosis;
however, the results have been heterogeneous and
reported sensitivity is 68 to 98%, with specificity of
25 to 53%.15-19
In our setting, during the global COVID-19 pan-
demic, especially within the first year, based on in-
ternational recommendations, and given the routine
lack of PCR tests, we carried out SARS-CoV-2 in-
fection screening only with simple chest CT in as-
ymptomatic patients who were candidates for
cervical-facial surgery, 24 hours before the sched-
uled time for surgery. The purpose of the present
study was to evaluate the results obtained with this
diagnostic resource and to find out if it is sufficient
as screening method.
Methods
Between May 7, 2020, and January 7, 2021, all adult
patients scheduled for head and neck cancer surgery
at our institution underwent preoperative screening for
COVID-19 by simple chest CT 24 hours before the
scheduled time for surgery.
Prior to admission, patients were applied a quick
questionnaire on COVID-19 general symptoms. Those
who did not undergo the screening CT scan were ex-
cluded from the analysis. A retrospective, cross-sec-
tional, analytical study was carried out.
Baseline characteristics, CT findings reported by
the radiologist and perioperative results were extract-
ed from the electronic medical records.
In all chest CT scans that were performed, a stan-
dardized report form was used, based on the CO-
RADS score, created by the Dutch Radiological
Society, 20 which categorizes each scan into five
grades:
- CO-RADS 1, very low suspicion.
- CO-RADS 2, low suspicion.
- CO-RADS 3, indeterminate result.
- CO-RADS 4, high suspicion.
- CO-RADS 5, very high suspicion.
The CO-RADS score is based on the agreement of
the scan findings with typical radiological findings ob-
served in COVID-19. Patients with CO-RADS 3, 4 and
5 had their surgery suspended and underwent naso-
pharyngeal swab RT-PCR testing to determine the
presence of SARS-CoV-2. Based on the result of this
test and a new chest CT after quarantine, surgical
rescheduling was decided. Rescheduled patients had
to have at least one negative RT-PCR test and a new
CO-RADS 1 or 2 chest CT.
The proportion of patients with a RT-PCR positive
test result, the appearance of symptoms related to
COVID-19 after the chest CT, as well as the time
to perform a new chest CT and primary tumor sur-
gical resolution were determined. In the statistical
analysis, continuous variables were presented as
means ± standard deviation or medians. True pos-
itive (TP) findings were determined if images sug-
gestive of COVID-19 were observed on chest CT
and RT-PCR result was positive. Findings were
classified as false-positive (FP) if chest CT had
data consistent with COVID-19 and RT-PCR result
was negative.
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 Gaceta Médica de México. 2022;158

Tabla 1. Distribution of general characteristics of 35 patients with and none developed symptoms in the follow-up
data suspicious of COVID-19 according to pre-hospital chest CT
period.
Characteristic For surgical rescheduling, a new chest CT was car-
Age (years) 68 ± 14 ried out in 30 patients, with an average time period of
30.1 ± 17.2 days; the condition for authorizing surgery
n %
was having a CO-RADS score of 1 or 2, as well as a
Gender RT-PCR negative test result. All patients re-
Females 14 40
mained asymptomatic, even until the time of surgery
Males 21 60
rescheduling.
Comorbidities The two cases with RT-PCR positive results did not
Hypertension 21 60
Smoking 18 51.42 develop symptoms and had a new chest CT that was
Diabetes mellitus 17 48.51 negative for the disease and a new RT-PCR negative
Dyslipidemia 8 22.85 result, and thus surgery was finally carried out.
Hypothyroidism 6 17.14
Figure 2 shows the evolution of one of the cases.
Primary tumor Disease progression with tumor unresectability was
Skin non-melanoma 17 48.51
Thyroid gland 8 22.85
documented in two patients, and thus they were of-
Melanoma 6 17.14 fered radiotherapy; the remaining 28 patients
Oral cavity 3 8.57 underwent surgery, without subsequent respiratory
Larynx 1 2.85
complications, even in those with a previous RT-PCR
CT findings test positive result.
“Ground-glass” opacities 35 100
Interstitial thickening 28 80
Atelectasis 21 60 Discussion
Bronchiectasis 16 45.71
Consolidations 8 22.85
Other
Due to the aerosol-generation potential of cervi-
7 20
cal-facial surgery procedures, various guidelines
have recommended for it to be suspended and be
restricted to urgent cases. 20,21 To avoid delay in can-
cer treatment, screening of SARS-CoV-2-positive
Results asymptomatic cases has been proposed to be carried
out with RT-PCR and lung CT scan 24 hours before
During the study period, 322 patients who were surgery. 22
candidates for cervical-facial area elective surgery Chest CT has been suggested as a quick, effective
were included; all underwent preoperative chest CT, and safe method that allows early changes due to
with 287 (89.13%) being normal. SARS-CoV-2 infection to be identified, even in asymp-
In 35 patients (10.87%), chest CT was positive for tomatic patients, whereby risky procedures are avoid-
data suspicious of COVID-19 (CO-RADS 3 or higher); ed, without the need to wait several days for the PCR
general characteristics of these patients are shown in result. However, its sensitivity and specificity are
table 1, including a higher percentage of men and questioned, given that a high number of false positive
hypertension as the most common associated cases have been reported, especially during the pan-
comorbidity. demic. On the other hand, SARS-COV-2 infection de-
finitive diagnosis is carried out with nasopharyngeal
Non-melanoma skin cancer of the head and neck
swab RT-PCR test. It is considered to be highly spe-
area was the most common oncological condition,
cific, but its sensitivity has been reported to be low,
followed by thyroid cancer and melanoma.
ranging from 60 to 70%.8,9 False negative results en-
In 21 patients, chest CT was CO-RADS 4 or 5, and
tail serious clinical problems, and several negative
in 14, CO-RADS 3. In 30 patients, nasopharyngeal test results may be necessary in a single case in order
swab test was available seven days after the chest CT, to have confidence for ruling out the disease.
with 28 having a negative test result (false positives), Clinical evaluation with swab and imaging tests is
and two, positive (true positives) for SARS-CoV-2. probably the best form of preoperative screening;
A flowchart of the study is shown in figure 1. All emerging evidence suggests that preoperative chest
patients were asymptomatic at the time of chest CT CT alone does not contribute to the detection of
38
 Barba-Valadez LA et al.: COVID-19 preoperative screening

Consecutive patients programmed for head and neck surgery 322 patients
who underwent preoperative chest CT

287 patients with CO-RADS 1 or 2

Patients with chest CT findings related to COVID-19
35 patients

Chest CT result 14 patients 21 patients

CO-RADS 3 CO-RADS 4-5

RT-PCR result 10 patients 1 patient 16 patients 1 patient

negative RT-PCR positive RT-PCR negative RT-PCR positive RT-PCR

Figure 1. Flowchart of chest CT and RT-PCR results in patients with suspected COVID-19.

A Conclusion

The use of simple chest CT alone as preoperative

screening for COVID-19 in patients with head and
neck cancer is of little use, given the high rate of
false-positive results. RT-PCR, in combination with
clinical and tomographic evaluations, is probably the
B best preoperative screening method, as it has been
reported by other authors. 25,26

Acknowledgements

The authors thank Hilda Miranda Bravo, specialist

nurse and lymphedema therapist, for her support,
Figure 2. Preoperative chest CT of a 33-year-old asymptomatic woman enthusiasm, and professionalism, and who was a vic-
with thyroid cancer. A: Imaging findings evaluated as CO-RADS-5 in
tim of this terrible pandemic.
June 2020. B: Imaging findings evaluated as CO-RADS-1, 42 days
later.
Funding

COVID-19 in asymptomatic, isolated and tested sub-
jects, which is why it is not recommended for screen-
ing in elective cancer surgery. 23,24
In the present series, tomographic findings of
COVID-19 pneumonia were unspecific and similar to
those of other pulmonary infections, which is deduced
by the clinical evolution of those patients in whom
surgery was suspended. CT findings must be correlat-
ed with clinical evaluation and laboratory data; the
diagnosis is confirmed with RT-PCR. Simple chest CT
alone does not contribute to the diagnosis of COVID-19
infection in asymptomatic subjects, and it is therefore
not recommended for preoperative screening in the
setting of head and neck cancer.
This research did not receive any specific grant
from agencies of the public, commercial or non-profit
sectors.
Conflict of interests
The authors declare that they have no conflicts of
interest.
Ethical disclosures
Protection of human and animal subjects. The
authors declare that no experiments were performed
on humans or animals for this research.
39
 Gaceta Médica de México. 2022;158
Confidentiality of data. The authors declare that
they followed the protocols of their work center on the
publication of patient data.
Right to privacy and informed consent. The au-
thors declare that no patient data appear in this
article.
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