The Management of Glioblastomas during the SARS-CoV-19 Pandemic: A Narrative Overview

The SARS-CoV-2 pandemic and covid-19 diffusion are an international public health emergency. Patients with a history of cancer have a higher incidence of infection with severe acute respiratory syndrome–coronavirus 2 (SARS-CoV-2) and higher risk of severe COVID-19–associated events. Glioblastoma is considered to be among the most aggressive cancers,in this direction the value of treatment must be balanced with risks of exposure to infection, inducing immunosuppression and survival benefit. the objective of this review is to present all international consensus recommendation for the management of patients with glioblastoma (GBM) to inform clinical practice. During this pandemic crisis, careful patient selection that balances the risks and benefits of treatment is paramount to optimize the care of patients with glioblastoma in this setting.

Glioblastoma is considered to be among the most aggressive cancers,in this direction the value of treatment must be balanced with risks of exposure to infection, inducing immunosuppression and survival benefit. the objective of this review is to present all international consensus recommendation for the management of patients with glioblastoma (GBM) to inform clinical practice.

INTRODUCTION
The SARS-CoV-2 pandemic and covid-19 diffusion are an international public health emergency [1]. Patients with a history of cancer have a higher incidence of infection with severe acute respiratory syndromecoronavirus 2 (SARS-CoV-2) and higher risk of severe COVID-19-associated events [2]. Age is considered to be an important factor that considerably increases the risk of death linked to the Covid-19 pandemic [3,4], it should be noted here that the incidence of glioblastoma (GBM) is increasing in the elderly population.
Consequently, this pandemic poses an imminent and extraordinary threat to many adults with glioblastoma, and also to healthcare systems.
Since neuro-oncology patients with glioblastoma are a vulnerable patient group, the value of treatment must be balanced with risks of exposure to infection, inducing immunosuppression and survival benefit.
In this review, we present an international consensus recommendation for the management of patients with glioblastoma (GBM) to inform clinical practice.

NEUROSURGERY TREATMENT
The main prognostic factor for these patients' survival with GBM is the extent of resection of the tumor, and any delay in surgery may reduce the chances of successful treatment [7][8][9][10].
Given the high demand for intensive care during the pandemic, it is strongly recommended to identify patients who potentially need intensive care or a ventilator before the operation [11].
For the different surgical techniques used for glioblastoma, awake craniotomy is considered the gold standard for achieving maximum safe resection in patients with intracranial glioma.
This technique requires direct contact. between caregivers and patients during surgery, therefore, it is considered high risk during this pandemic [12].
for centers that do awake craniotomies, patients should undergo testing and isolation to confirm the absence of COVID-19 and allow them to undergo surgery as soon as possible.
For scheduled glioma surgery, all patients in China should undergo routine presurgical evaluation and "COVID-19 screening," which includes a chest computed tomographic scan and laboratory test for the novel coronavirus [13].

RADIO-CHEMOTHERAPY TREATMENT
Several recent studies recommend that for patients with glioblastoma, urgent surgery should be performed with 1 to 2 weeks of diagnosis, followed by adjuvant chemotherapy and radiation therapy according to established standards.
Radiation oncology centers should establish protocols to limit patients in waiting areas and provide masks for patients.
In cases where hypofractionated radiotherapy could be used to limit patient exposure, this should be considered [14]. during a radiotherapy session, the recommendations emphasize the wearing of surgical masks under the thermoplastic mask and a transparent disposable packaging must be applied to the immobilization devices [15].
For chemotherapy, the addition of TMZ to the initial treatment of GBM provided an Overall Survival (OS) benefit. This benefit is more pronounced in patients with a hypermethylated MGMT promoter [16]. However, haematologic toxicities are observed in these patients. Therefore, the potential long-term benefit of OS associated with the addition of TMZ should be carefully weighed against a potential risk of serious complications upon exposure to SARS-CoV-2 infection.
As per the British Neuro-Oncology Society (BNOS), it has been suggested to consider reducing the course and fraction of radiotherapy and chemotherapy if there is no significant worse prognosis. Moreover, For MGMT unmethylated glioblastoma patients, chemotherapy may be excluded; monitor patients for any deterioration. Oral therapy regimens are preferred, if possible, instead of Intravenous administration (IV) administration [17] , however , for those patients requiring infusions, patients should be appropriately separated with masks given.
Oncology establishments must establish an emergency plan for postive cases [18] , a recent review recommends for cases tested postive to Covid 19, the cancer treatment must be stopped until recovery and the risk-benefit ratio of the treatment must be evaluated for those patients with glioblastoma [17].

CONCLUSION
Decisions regarding the treatment of GBM and other high-grade gliomas are interdisciplinary as a standard of care, requiring a high level of expert knowledge.
During this pandemic crisis, careful patient selection that balances the risks and benefits of treatment is paramount to optimize the care of patients with glioblastoma in this setting.
To alleviate disruption in patient care, we believe that interdisciplinary meetings should continue using healthcare technologies like video conferencing, conference calls or other digital methods to maintain expert discussion between disciplines.