Between 20 February to 20 April 2020, out of a total of 580 patients admitted in specialized ward for COVID-19 of Shariati hospital, 33 patients had a history of solid cancers (5.68%). Among these, 11 patients had a positive RT-PCR for SARS-CoV-2 and 22 patients had highly suggestive chest CT scan findings in favor of SARS-CoV-2 but negative RT-PCR. The mean age of the patients was 63.9 years, and 54.5% of the patients were males. Age and sex of the patients did not correlate with mortality (P-value = 0.312 and 0.22 respectively ). Demographic and clinical features of these patients are summarised in Table 1 .
Table 1
Demographic and laboratory data in the patients.
| Total n = 33 | Survived n = 17 | Un-survived n = 16 | P value |
Mean age ± SD | 63.9 ± 11.98 | 66.9 ± 12.8 | 60.7 ± 10.5 | > 0.05 |
Interval from fever onset to dyspnea onset (day) | 4.1 ± 4.1 | 4.69 ± 3.75 | 3 ± 4.86 | > 0.05 |
Symptoms and signs at on admission | | | | |
Fever | 20 (60.6) | 13 (76.5) | 7 (43.8) | > 0.05 |
Cough | 16 (48.5) | 9 (52.9) | 7 (43.8) | > 0.05 |
Serum Biomarkers | | | | |
Neutrophil × 109/L | 102.3 ± 7.8 | 72.1 ± 24.8 | 84.3 ± 6.8 | > 0.05 |
Lymphocyte × 109/L | 11.8 ± 10.3 | 13.8 ± 13 | 9.6 ± 5.8 | > 0.05 |
Platelet × 109/L | 176 ± 138 | 209 ± 152 | 140 ± 116 | > 0.05 |
Neutrophil-to-lymphocyte ratio (NLR) | 12.9 ± 11.7 | 10.9 ± 9.5 | 15 ± 13.7 | > 0.05 |
Lymphocyte-to-C-reactive protein ratio (LCR) | 42.9 ± 154.8 | 65.2 ± 214.8 | 19.3 ± 26.9 | > 0.05 |
Platelet-to-lymphocyte ratio (PLR) | 587.8 ± 1478.5 | 817.5 ± 2024.1 | 343.8 ± 412.1 | > 0.05 |
Serum Albumin (g/dL) | 3.2 ± 0.7 | 3.6 ± 0.5 | 2.9 ± 0.6 | 0.03 |
LDH (U/L) | 1487.5 ± 1392.8 | 932.3 ± 324.7 | 7170 ± 2077 | 0.016 |
ESR (mm/hr) | 69.1 ± 34.9 | 64.1 ± 34.5 | 131 ± 74.4 | > 0.05 |
CRP (mg/L) | 90.2 ± 58.7 | 97.6 ± 68.4 | 2220 ± 82.3 | > 0.05 |
Regarding to laboratory findings, blood count results, at the time of admission showed anemia (i.e. Hb < 12 mg/dl) in 26 (78.78%) patients, lymphocytopenia (absolute lymphocyte count < 1000/miroL ) in 23 (69.69%) and thrombocytopenia ( platelet count Less than 150000/microL ) in 14 ( 42.42% ) patients. Mean Neutrophil-to-lymphocyte ratio (NLR) was 12.9. Elevated erythrocyte sedimentation rate ( i.e. > 30 mm/hour) was found in 27 patients (81.81%), high C-reactive protein ( i.e. > 10 mg/L ) levels in 31 patients (93.93%), high levels of lactate dehydrogenase ( i.e. > 280 unit/L) in 30 patients (90.90%) and low levels of serum albumin ( i.e. < 3.5 g/dl ) in 29 patients (87.87%).
There was no difference in COVID-19 symptoms, lymphocytopenia, thrombocytopenia between survived and un-survived cancer patients. However, LDH level was significantly higher (7170 ± 2077 vs. 932.3 ± 324.7, P-value = 0.016) and also serum albumin was significantly lower in un-survived group (3.6 ± 0.5 vs. 2.9 ± 0.6 p-value = 0.03 ).
The mean length of hospitalization was 7.7 days (range 1.0–30.0) and the mean time from the symptoms onset to admission in COVID-19 unit was 4.34 days (range 0–14.0 days).
Mortality rate was significantly higher in 18 patients who received cytotoxic chemotherapy within the last 14 days (72% vs. 20%, P-value: 0.03) and they had also significantly shorter mean time from admission to death compared with 15 patients who undergone cancer treatment more than two weeks before their admission due to COVID-19 or not given cytotoxic chemotherapy within the last 14 days(5.62 ± 4.7 days vs18.5 ± 16.2 days P-value: 0.02).
In terms of developing complications, although sepsis was significantly higher in patients who received cytotoxic chemotherapy within the last 14 days (50% vs. 13% P-value: 0.026), occurrence of ARDS, AMI (acute myocardial infarction) and PTE were not significantly different between the two groups(P-value > 0.05)(Fig. 1).
The most frequent cancers were breast cancer (n = 6, 18.2%), colon cancer (n = 6, 18.2%) and gastric cancer (n = 6, 18.2%). Among them, five patients had a history of pulmonary metastasis (Table 2). Moreover, four patients (12.12%) had a primary diagnosis of lung cancer. Type of the cancer did not correlate with mortality (P-value = 0.5). However, the mortality rate was significantly higher in patients with a history of lung cancer or metastasis to lung compared to other types of cancer (77% vs. 37% P-value = 0.039).
Table 2
Clinical features in survivors vs. non-survivors
| Total n = 33 | Survivors n = 17 | Non-survivors n = 16 | P value |
Mean age ± SD | 63.9 ± 11.98 | 66.9 ± 12.8 | 60.7 ± 10.5 | > 0.05 |
Tumor diagnosis | | | | |
Lung cancer | 4 (12.1) | 2 (11.8) | 2 (11.8) | > 0.05 |
Breast cancer | 6 (18.2) | 3 (17.6) | 3 (18.8) | > 0.05 |
Cholangiocarcinoma | 1 (3) | 0 (0) | 1 (6.3) | > 0.05 |
Colon cancer | 6 (18.2) | 4 (23.5) | 2 (12.5) | > 0.05 |
Ovarian cancer | 3 (9.1) | 1 (5.9) | 2 (12.5) | > 0.05 |
Pancreas cancer | 2 (6.1) | 0 | 2 (12.5) | > 0.05 |
Prostate cancer | 3 (9.1) | 1 (5.9) | 2 (12.5) | > 0.05 |
Stomach cancer | 6 (18.2) | 5 (29.4) | 1 (6.3) | > 0.05 |
Testis cancer | 2 (6.1) | 1 (5.9) | 1 (6.3) | > 0.05 |
Tumor stage | | | | |
Stage I/II/III | 17 (51.5) | 14 (82.4) | 3 (18.8) | < 0.001 |
Stage IV | 16 (48.5) | 3 (17.6) | 13 (81.3) |
History of prior treatment | | | | > 0.05 |
Surgery a | 3 (9.1) | 2 (11.8) | 1 (6.3) | > 0.05 |
Chemo/Radiotherapy a | 26 (78.8) | 12 (70.6) | 14 (87.5) | > 0.05 |
Hormone Therapy a | 2 (6.1) | 2 (11.8) | 0 | > 0.05 |
Comorbidities | | | | |
Chronic cardiovascular and cerebrovascular disease (including hypertension and coronary heart disease) | 9 (27.3) | 3 (17.6) | 6 (37.5) | > 0.05 |
Diabetes | 8 (24.2) | 5 (29.4) | 3 (18.8) | > 0.05 |
Chronic pulmonary disease (including chronic obstructive pulmonary disease and asthma) | 5 (15.2) | 4 (23.5) | 1 (6.3) | > 0.05 |
Chronic liver disease (including chronic hepatitis B and cirrhosis) | 1 (3) | 0 (0) | 1 (6.3) | > 0.05 |
cytotoxic chemotherapy within the last 14 days | 18 (54.5) versus 15 (45.5) | 5 (29.4) versus 12 (70.6) | 13 (81.3) versus 3 (18.8) | 0.003 |
Symptoms and signs at on admission | | | | |
Fever | 20 (60.6) | 13 (76.5) | 7 (43.8) | > 0.05 |
Cough | 16 (48.5) | 9 (52.9) | 7 (43.8) | > 0.05 |
Fatigue | 15 (45.5) | 7 (41.2) | 8 (50) | > 0.05 |
Dyspnea | 30 (90.9) | 0 (0) | 13 (81.3) | > 0.05 |
Myalgia | 5 (15.2) | 3 (17.6) | 2 (12.5) | > 0.05 |
GI symptom | 11 (33.3) | 6 (35.3) | 5 (31.3) | > 0.05 |
Out of 33 cancer patients, in 16 cases (48.48%) the cancer was in stage IV, at the time of diagnosis. Among 16 patients with stage IV cancer, thirteen patients died, which was significantly higher compared to stage I-III cancer patients (81.3% vs 18.8% P-value < 0.001).
It should be noted that 5 patients (15.15%) developed COVID-19 during antitumour therapy in the hospital (nosocomial SARS-COV-2 infection), but none of them experienced mortality.
In addition to cancer, the most frequent coexisting chronic diseases were cardiovascular diseases (n = 9,27.3%) and diabetes mellitus (n = 8,24.2%). Associated comorbidities did not significantly increase mortality in this patient series (P-value > 0.05).
The most common symptoms on admission were dyspnea (n = 30, 90.9%), followed by fever (n = 20, 60.6%), dry cough (n = 16, 48.5%) and gastrointestinal symptoms (n = 11, 33.3%). The initiating symptom did not correlate with mortality (P-value > 0.05).
Out of the 33 hospitalized patients, 29 (87.9%) received oxygen therapy, 3 (9.1%) received non-invasive ventilation (NIV) and 16 (48.5%) patients received invasive ventilation (IV). The median duration of NIV and IV were 3 days (range 1.0–8.0) and 8 days (range 0.0–14.0), respectively. Fifteen patients (45.5%) were admitted in intensive care unit (ICU). The most common complication was acute respiratory distress syndrome (n = 9; 27.3%), followed by sepsis and septic shock (n = 11; 33%) and pulmonary thromboembolism (n = 1), respectively. In comparison of severe events between the patients who received cytotoxic chemotherapy within 14 days and other patients, sepsis and IV were significantly higher (Fig. 1). Hydroxychloroquine alone was administered in 5 patients and combined with antiviral agents such as lopinavir/ritonavir, ribavirin and oseltamivir in 28 patients. Corticosteroids were administered in 15 patients, mostly in whom suffered from severe events. A total of 17 (51.5%) patients were discharged from the hospital, with a mean hospital stay of 7.5 days (range 5.0–18.0) and 16 patients (48.8%) died with a mean interval of 7.33 days from admission to death.
In this study, there was no significant difference between the two groups of positive and negative SARS-CoV-2 RT-PCR regarding their sex, age, cancer type, mean Hb concentration, Platelet count, lymphocyte count, serum albumin level, ESR and CRP titer or other laboratory findings and also in terms of clinical symptoms and coexisting (Table 3).
Table 3
Comparison of characteristics of patients with positive or negative RT-PCR.
| Positive PCR(n = 11) | Negative PCR(n = 22) | P Value |
Age, years | 59.8 ± .16.9 | 65.9 ± .8.3 | > 0.05 |
Sex, n (%) | | | |
Male | 7 (63.6) | 11 (50) | > 0.05 |
Female | 4 (36.4) | 11 (50) |
Serum Biomarker | | | |
ESR | 66.8 ± 37.1 | 70.3 ± 34.6 | > 0.05 |
CRP | 73 ± 35.7 | 98.8 ± 66.4 | > 0.05 |
NLR | 13.5 ± 13.4 | 12.6 ± 11.1 | > 0.05 |
LCR | 98.9 ± 265.1 | 14.9 ± 23.8 | > 0.05 |
Albumin | 3.2 ± .65 | 3.3 ± .75 | > 0.05 |
LDH | 1586 ± 13 | 1438 ± 1455 | > 0.05 |
Admit to Death, days | 4.2 ± 2.6 | 8.4 ± 8.6 | > 0.05 |
Length of hospitalization, days | 5.45 ± 3.2 | 8.8 ± 6.9 | > 0.05 |
Symptom to hospital, day | 3.2 ± 4.3 | 4.9 ± 4.1 | > 0.05 |
Severe event, n (%) | | | |
ARDS | 1(9.1) | 8(36.4) | > 0.05 |
Sepsis | 2(18.2) | 9(40.9) | > 0.05 |
Invasive Ventilation | 4(36.4) | 12(54.5) | > 0.05 |
ICU Admission | 4(36.4) | 11(50) | > 0.05 |
Death | 4(36.4) | 12(54.5) | > 0.05 |
NLR: Neutrophil to Lymphocyte ratio, CRP: C - reactive protein, ESR: Erythrocyte Sedimentation Rate, LCR: Lymphocyte to CRP Ratio, PLR: Platelet count to Lymphocyte Ratio. ARDS, acute respiratory distress syndrome |
It was also shown that in terms of the mortality rate, there was no significant difference between the two groups of positive and negative SARS-CoV-2 RT-PCR (P-value = 0.3).