3.2 Departmental COVID-19 dedicated procedures
Treatment scheduling was not modified and was followed our Institutional clinical practice: 6 weeks after surgery, 4 weeks after the last cycle of induction chemotherapy, within 4 weeks for exclusive radiation or concurrent chemoradiation).
The whole care path for HNC patients was re-planned according to temporal and special criteria, with the aim to maintain a safe working and treating environment. As previously detailed, patients were required to wear a surgical mask unless otherwise instructed by the personnel. A second surgical mask was provided to cover tracheotomies, if needed. A summary of dedicated procedures for HNC patients is provided inTable 1 .
Time management in the COVID-19 pandemic encompassed scheduling all computed-tomography (CT) simulation scans and RT delivery in dedicated slots. The rationale beyond these measures was to optimize room sanitization and to easily provide all involved healthcare professionals with PPE.
All treatments are performed with mouthpiece-assisted head and shoulder thermoplastics masks (FirmFit™ Thermoplastics Masks CIVCO Radiotherapy Corporate Office 2303, Iowa, United States of America), to minimize intra- and inter-fraction movements during treatment delivery. Due to our immobilization device of choice, it was not possible for patients to keep surgical masks during irradiation. For safety reasons, patients were instructed to wear their surgical mask until they were correctly positioned on treatment couch. Subsequently, they were invited to remove the surgical mask and to insert their personalized mouth bites. The thermoplastic mask could therefore be applied by the Radiation Therapist, who performed the standard set-up procedures. The temporary removal of surgical masks by the Radiation Therapist managing HNC patients’ set-up procedures were considered as a potential source of contamination, and an adequate PPE was provided accordingly (Figure 1 ).
Similarly, patients’ surgical masks were removed at least once per week during medical consultations for oral cavity examination and toxicity assessment. A consultation room was reserved exclusively for HNC patients, and sanitized at the end of every working day. Clinical evaluations during the RT treatment were regularly performed. Follow-up consultations were organized according to the general Department procedures detailed in Supplementary Materials . In detail, follow-up evaluations for HNC patients were organized in the form of telehealth surveillances, except for those requiring a physical and radiologic assessment of their gross tumor volume response following a curative-intent RT. In order to limit the accesses to our Institute, patients with no evidence of disease and good performance status were invited to stay at home and to reschedule their consultations.
All the above-mentioned procedures were progressively implemented according to pandemic development and in accordance with World Health Organization (WHO), National and recommendations and availability of Institutional resources17 While COVID-19 phase II started in Italy on May 4th 2020, these procedures are still applied in our Department while this work is being written (10th March).