Vol.:(0123456789) 1 3 Journal of Neuro-Oncology (2020) 148:203–205 https://doi.org/10.1007/s11060-020-03496-7 LETTER TO THE EDITOR May we deliver neuro‑oncology in difcult times (e.g. COVID‑19)? Alessandro Perin 1,2  · Franco Servadei 3  · Francesco DiMeco 1,4,5  on behalf of the ‘Hub and Spoke’ Lombardy Neurosurgery Group Received: 8 April 2020 / Accepted: 9 April 2020 / Published online: 10 April 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020 Sir, Italy has been hit hard by COVID-19, ranking #2 after the USA when it comes to patients who have been infected by this virus. Surprisingly, in our country we are also seeing an extraordinarily high mortality rate 10.6% (https://bing.com/ covid retrieved on March 28th 2020—Fig. 1-top), which has not been explained yet, and may be partially related to the high percentage of elderly people in the Italian population or to the underrepresented fgure of the real COVID-19 posi- tive, yet asymptomatic patients/carriers. Hospitals workload has become hectic. This poses a threat to the everyday work of a neuro-oncology unit. The main limiting factor is represented by ICU’s, which are stuck, since ∼10% of the patients need intensive care at a certain point [1]. As neurosurgical oncology often demands for ICU admission in the early post-op, it is clear how such an epidemic can afect this neurosurgical subspecialty, on top of others. Besides, neuro-oncological patients may be immunocompromised, presenting the ethical dilemma of having them at the same hospital where COVID-19 patients are. As per the epidemic spreading curves (Fig. 1—middle) it is foreseeable that other countries may experience similar emergency situations in the near future. Lombardy is the Italian region which has been most heav- ily afected by this epidemic. The C. Besta Neurological Institute has a long-standing tradition as a national large- volume center mainly committed to neuro-oncology; it does not have an A&E Dept.; so far, we managed to keep it as a COVID-19-free hospital, enforcing a strict control policy for all admitted patients, relatives, and visitors. Because of these peculiar features, in an efort to preserve the availability of ICU beds for COVID-19 patients as much as possible, the C. Besta Institute has been designated as the regional cen- tralizing neurosurgery HUB for neuro-oncology [2], while all other Centers’ activity has been progressively quenched, according to a Hub and Spoke organizational scheme. This operative network became efective on March 16th, allowing SPOKE neurosurgical équipes from Lombardy to come to our Institute and to operate themselves on their patients. We provide them with the entire neuro-oncological infrastruc- ture, taking care of patients before admission (pre-op stud- ies), during hospitalization (including radiation and onco- logical therapy inpatient assessment, when appropriate), and at discharge (either home or rehab). In the frst three weeks of HUB implementation, despite the expected decrease of global activity as compared to normal times, we managed to take care of all the neuro-oncology patients that were referred to our Institute and deemed urgent (not amenable to be postponed). In particular, we have seen 159 brain tumor out-patients, operated on 67 patients (18 operated by SPOKE neurosurgical équipes at our Institute), and delivered in-hos- pital chemotherapy to 27 patients. Of course, the main chal- lenge was represented by maintaining the Hub as a COVID- 19-free Hospital. The algorithm that served to this purpose was based on a tight control of admissions, early recognition of any signs or symptoms of infection, and a rigid protection for any health professionals. More specifcally, all patients were deeply screened with body temperature, O 2 saturation, C-reactive protein, transamineses levels, complete cell blood count, chest radiography, pharyngeal SARS-CoV-2 swab, and a thorough interview. In case of SARS-CoV-2 positivity, surgical indication was re-discussed, based on some pre- liminary unpublished data (Fontanella et al.—manuscript in preparation), suggesting a higher risk of morbidity and lethality. So far, this new paradigm has worked smoothly, implementing a new way of close interaction via weekly teleconferences (Fig. 1—bottom). Neurosurgeons and * Francesco DiMeco francesco.dimeco@istituto-besta.it 1 Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy 2 Università Degli Studi Di Trieste, Trieste, Italy 3 Humanitas University and Research Hospital, Rozzano, Italy 4 Università Degli Studi Di Milano, Milan, Italy 5 Johns Hopkins University, Baltimore, MD, USA