RESULTS
In the study period, 52 patients were scheduled for surgery, of which 45
(86.5%) were “high risk” procedures for SARS-CoV-2 transmission.
Forty patients (76.9%) had mucosal pathology (e.g., malignant neoplasm,
infection, inflammation); 37 patients (71.1%) carried current diagnoses
of head and neck cancer, including mucosal and cutaneous malignancies.
Ten patients (19.2%) had a prior history of radiation to the head and
neck. There was no significant difference in the makeup of the groups
with and without discrepant results with regard to mucosal pathology,
current cancer diagnoses, or history of radiation (Table 2).
Forty-three (82.7%) patients had at least two preoperative tests
performed. A total of 102 tests were performed: 52 (51.0%) were for the
first preoperative test, and 43 (42.2%) were the second preoperative
test, when applicable. An additional seven tests were performed beyond
the two initial tests: 2 were for patients with 2 previously negative
tests, due to unrelated surgical delays; the remaining 5 were for
patients with conflicting results on the first two tests.
Of the 43 patients with more than one preoperative test, four patients
(9.3%) had discrepant results on the first two tests, with the clinical
implications for each discussed below (Table 3). One of these patients
left against medical advice and thus his true disease status is unknown.
For the remaining three out of forty-two patients (7.1%), repeat RT-PCR
testing was negative. They remained asymptomatic from COVID-19 official
symptomatology,20 and chest radiographs were clear
without signs of interstitial pneumonia. For two of these patients,
positive tests were re-reviewed by clinical pathologists, and tests were
found to have achieved positivity with titers that were borderline, just
over the cutoff values. All three of these patients were discussed by
multi-disciplinary teams including infectious disease specialists,
otolaryngologists, intensivists, pulmonologists, and pathologists, which
ultimately concluded that the positive test were false positives.
Assuming this determination is correct, and using prior and subsequent
negative RT-PCR, chest imaging and close follow up of clinical course as
the “gold standard” in the absence of a true gold standard test, the
calculated specificity of this test in asymptomatic patients in the
preoperative setting is 0.97.
Patient #1 – Late-March : A 60-year-old male with buccal
squamous cell carcinoma required composite oral cavity resection, neck
dissection, and free flap reconstruction. At the time of this patient’s
surgery, testing turnaround was at least 3 days. Four days prior to
scheduled surgery, the patient had a negative RT-PCR drawn as an
outpatient. On the morning of surgery, a second RT-PCR was drawn due to
a policy change requiring two tests before surgery. A positive result
was reported on postoperative day (POD) 3. Chest computed tomography
(CT) with contrast was normal. He was moved to a designated COVID-19
ward. A repeat RT-PCR was performed on POD 4 with a negative result
reported on POD 5, and the patient was transferred out the designated
ward. During that time, he remained asymptomatic with 2 normal chest
radiographs.6
Over the next month he developed no symptoms to suggest COVID-19 and
repeat a CT chest was negative.
Patient #2 – Mid-April: An 81-year-old female was transferred
for recurrent aspiration pneumonia. She had originally been treated for
oropharyngeal squamous cell carcinoma by definitive chemoradiation,
followed by salvage pharyngectomy and tongue base resection with neck
dissection, and radial forearm free flap reconstruction. Her
postoperative course after discharge had been complicated by a
nonfunctional larynx and recurrent aspiration pneumonias, with multiple
admissions to outside hospitals over several months. On her current
admission to an outside facility, the decision was made for transfer to
our hospital for narrow-field laryngectomy and pectoralis major flap as
treatment for recurrent aspiration. Prior to transfer, she had two
negative COVID-19 RT-PCR tests, and an additional negative test on the
day of arrival (hospital day 1) with plans for surgery on hospital day
3. On hospital day 2, a second RT-PCR was performed per departmental
protocol, and the result was positive. A third RT-PCR on the morning of
hospital day 3 was negative, however surgery was cancelled due to
discrepant results. Three additional tests were drawn between hospital
days 3 and 7, which were all negative. Multiple chest CTs were stable or
improved, although abnormal given her underlying history of recurrent
aspiration pneumonia over 6 months. Discussion with our clinical
pathologists revealed that the positive test was based on weakly
positive titers. Given the multiple repeat negative tests, this was
deemed a false positive, and surgery was performed on hospital day 7. As
a result of the positive test, surgery was delayed 4 days while the
patient remained an inpatient.
Patient #3 – Mid-to-late April: 63-year-old female with
melanoma of the cheek requiring wide local excision and sentinel lymph
node biopsy. Four days prior to scheduled surgery, an outpatient RT-PCR
was done and resulted positive. Immediate discussion with pathology
colleagues revealed a weakly positive titer, just above the level
necessary to be considered positive. The positive test had been
conducted at the affiliated institution, and the negative test was at
her primary hospital. One option discussed was to delay surgery for
three weeks anticipating possible development of COVID-19 symptoms.
However, with a negative CT chest for metastatic workup in the days
before surgery, the decision was to repeat two additional RT-PCR tests.
These were performed the following day and were both negative. The
patient was completely asymptomatic. Surgery proceeded with a three-day
delay. The process was quite stressful for the patient, whose surgery
was already delayed by several weeks due to the pandemic, and the
reconstructive plastic surgery team had to reschedule other surgeries to
accommodate the new schedule. Over the next three weeks she developed no
symptoms of any type, and repeat CT chest was normal.
Patient #4 – Early April: 20-year-old male with bilateral
pansinusitis complicated by unilateral orbital abscess and progressive
vision impairment with diffusely restricted extraocular movements and an
intraocular pressure of 41 mmHg. He was transferred from an outside
hospital without any testing or chest radiographs. On the day of
arrival, hospital day 1, RT-PCR was performed and was negative.
Intravenous antibiotics were instituted, and surgery was planned for
hospital day 4 to allow for preoperative COVID-19 testing. Since sinus
surgery was considered a high-risk procedure for SARS-CoV-2
transmission, a second RT-PCR was performed according to protocol and
unfortunately was positive. The patient remained asymptomatic other than
symptoms attributed to sinusitis and orbital abscess. Due to the
positive finding, surgery was delayed for further testing, and he was
transferred to a designated COVID-19 ward. Patient was uneasy about
being on this ward, and subsequently left against medical advice without
surgery on hospital day 5, refusing further workup. In telemedicine
follow-up three weeks later, he reported never having
coronavirus-associated symptoms; however, without additional workup his
true disease status is unknown. He has therefore been excluded from
statistical calculations related to the test. The patient reported that
his infection improved on oral antibiotics, and visual changes
normalized.