PMC:7224657 / 3992-10615 JSONTXT

{"target":"http://pubannotation.org/docs/sourcedb/PMC/sourceid/7224657","sourcedb":"PMC","sourceid":"7224657","source_url":"https://www.ncbi.nlm.nih.gov/pmc/7224657","text":"3 Discussion\nCe cas met en lumière la problématique actuelle des stratégies thérapeutiques oncologiques dans le cadre de la pandémie COVID-19. Les prises en charge chirurgicales qui se basaient jusqu’à lors sur l’opérabilité et la résécabilité des lésions tumorales chez une patiente donnée, se voient désormais assujetties d’un risque supplémentaire, le risque infectieux COVID-19. L’évolution fatale de notre patiente motive plusieurs axes de réflexion : Fallait-il maintenir cette intervention alors que l’épidémie faisait rage dans le Grand Est ? Quelles indications chirurgicales peuvent-être différer à l’avenir ? Quel dépistage pré-opératoire pour nos futures patientes ?\nConformément aux recommandations de l’ESGO et du CNGOF [1], [2], nous avons validé cette chirurgie de clôture au vu de l’opérabilité de la patiente, de sa bonne réponse clinico- biologique à la chimiothérapie néo-adjuvante, du nombre de cures réalisées, du faible risque de séjour post-opératoire en réanimation, et de l’absence de signes cliniques ou de notion de contact COVID-19, ne bénéficiant pas à l’époque de recommandations concernant le dépistage pré-opératoire systématique du COVID-19. Notre attitude s’est alors basée sur une évaluation scannographique poussée de l’étage sus-mésocolique. Au vu de son atteinte superficielle et de son accessibilité à une résection optimale, confirmée lors de l’exploration laparoscopique, l’intervention a été poursuivie par cœlioscopie, afin de réduire la morbidité du geste et la durée du séjour post-opératoire, action légitime au sein d’un centre fortement touché par le COVID-19 [3], [4]. Bien évidemment, les voies d’abord mini-invasives ne constituent pas aujourd’hui un standard de prise en charge du cancer de l’ovaire et doivent être réservées à des cas bien sélectionnés et réalisées par des équipes entraînées. La prise en charge opératoire a donc été strictement conforme à la stratégie thérapeutique pré-opératoire curative avec obtention finale d’un résidu tumoral nul. Ce sont l’infection au COVID-19 et l’insuffisance respiratoire qui en a résulté qui ont contraint l’équipe à décider collégialement de ne pas réaliser de prise en charge réanimatoire compte tenu de la crise sanitaire locale et de ses comorbidités. Afin de limiter le risque infectieux, différer l’intervention après épuisement de la vague épidémique aurait pu être une éventualité. Cependant ne pas opérer cette patiente, après six cures de chimiothérapie, serait revenu à lui proposer une abstention thérapeutique d’une durée absolument incertaine, au vu des fluctuations de l’épidémie et donc lui faire courir le risque difficilement estimable d’une progression tumorale.\nLe décès de cette patiente n’est pas un cas isolé. Une équipe de Wuhan décrit en effet un taux de mortalité à 15 jours post-opératoires de 20 % dû au COVID-19 dans une série de 34 patients asymptomatiques opérés, toutes chirurgies confondues [5]. Il s’agit d’un taux bien supérieur à ceux estimés habituellement. Le CNGOF fait également état de risque de complications respiratoires sévères liés au COVID-19 quatre à huit fois plus élevés chez les patientes atteintes de cancer et d’une majoration du risque de décès, ce d’autant plus qu’elles auront reçu une chimiothérapie ou une chirurgie dans les semaines qui précèdent [1]. Et un article de Liang et al. [6] démontre que les patients atteints d’un cancer sont plus susceptibles de développer une infection liée au COVID-19 en raison de l’immunodépression secondaire induite par le cancer, la chimiothérapie et la chirurgie ; et de présenter une forme sévère (39 % contre 8 %), notamment après chirurgie ou chimiothérapie (75 % contre 43 % des patients cancéreux n’ayant pas reçu de traitement récent). Il existe donc un probable impact de la dépression immunitaire post-opératoire et post-anesthésique dans l’apparition de formes sévères de COVID-19. Une chirurgie carcinologique programmée doit de ce fait être différée dès que possible par l’instauration première ou le prolongement d’une chimiothérapie. L’ESGO privilégie ainsi le report systématique des chirurgies d’intervalle [2]. La question est cependant plus difficile en ce qui concerne les chirurgies de clôtures, pour lesquelles le nombre complet de cure de chimiothérapie est déjà atteint. En effet, poursuivre une chimiothérapie sans arguments tangibles, comporte des risques, notamment des risques majorés d’infection, par exposition itérative au virus lors des aller-retours dans le service d’Oncologie et par altération de l’immunité consécutive à la déplétion de la réserve médullaire [2]. Comme le rapporte l’étude de Wang et al. [7] sur 138 patients testés COVID-19 positifs, 41 % des infections sont issues de contamination hospitalière. Il convient donc de reporter chaque intervention dès que possible et en cas d’épuisement des stratégies thérapeutiques alternatives (curatives ou d’attente), de la réaliser avec le plus de sécurité possible.\nAfin de mieux estimer le risque infectieux COVID-19, la SFAR [8] a édité des recommandations concernant le dépistage systématique pré-opératoire le 29/04/2020 et l’HCSP a défini des personnes à risque de formes graves de COVID-19, comme les patients de plus de 70 ans, atteints de cancers et obèses [9]. Il est désormais recommandé de rechercher des symptômes compatibles d’infection à SARS-CoV-2 à l’aide d’un questionnaire standardisé au moment de l’admission et 48-72 h avant l’intervention par appel téléphonique. Une PCR par frottis naso- pharyngée est réalisée 24 à 48 h avant la chirurgie. En cas de PCR négative chez un patient asymptomatique, l’intervention est maintenue. En cas de PCR positive et/ou de tableau clinique évocateur, l’intervention est reportée d’au moins 14 jours chez les patients immunocompétents et d’au moins 24 jours chez les patients immunodéprimés à compter de la disparition des symptômes. Il faut cependant rester vigilant concernant la fiabilité de la PCR par frottis naso- pharyngé, qui présente une faible sensibilité, avec un taux de faux négatifs estimé à 37 % [10]. En cas de doute ou de facteurs de risque, un scanner thoracique pourra également être réalisé. Les tests sanguins reposant sur la sérologie et la recherche d’anticorps sont actuellement à la phase d’étude et ne peuvent donc pas à ce jour être positionnés dans l’algorithme diagnostique. Même si un dépistage systématique pré-opératoire est légitime, il faut garder à l’esprit que ses modalités sont encore à définir et risquent de se modifier dans le temps selon l’évolution de nos connaissances du virus et des performances des différents tests de 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