Based on the findings of 2 case studies showing rapid development of COVID-19–associated pulmonary infiltrate in asymptomatic patients — as detected on chest computed tomography (CT) scans performed daily in association with radiotherapy (RT) — a call to action has been published by the Journal of Thoracic Oncology urging clinicians/researchers to submit clinical- and treatment-related data for any patient with cancer diagnosed with COVID-19 infection while undergoing daily RT with CT imaging.1

It is common practice for patients receiving either standard RT or stereotactic ablative radiotherapy (SABR)/stereotactic body RT (SBRT) to undergo daily chest CT imaging.  While these CT scans (eg, cone beam CT) are primarily used to properly align RT and are often of lower quality than conventional diagnostic CT scans, they do reveal “mild to severe pulmonary opacification, atelectasis, [and] effusions.”1

Other types of CT imaging used to locate tumor prior to RT delivery include CT-on-rails, which offers higher image quality.

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Patient case 1 involved a man aged 74 years with newly diagnosed lung adenocarcinoma characterized as T3N2M0 who was scheduled to receive therapeutic chemoRT with 3 cycles of platinum-based chemotherapy and 60 Gy of RT delivered over 30 fractions.2

While no pulmonary infiltrates were observed on daily cone beam CT scans of the chest through delivery of the first 7 RT fractions, “two ground-glass opacities (GGOs) with patchy consolidation were found, one in a subpleural location” on the cone beam CT scan performed in association with the eighth fraction delivered following a weekend, with infiltrate progression and development of an additional subdural GGO seen on cone beam CT performed prior to delivery of the next RT fraction. The patient, who had previously been asymptomatic for COVID-19 infection, first showed symptoms of the disease on the evening following delivery of the ninth RT fraction, and COVID-19 testing subsequently confirmed infection.2

Patient case 2 described a woman aged 63 years with recurrent lung adenocarcinoma in the left upper lung who was enrolled in a clinical trial evaluating the combination of SABR with the programmed cell death-1 (PD-1) inhibitor, nivolumab, in the setting of non-small cell lung cancer.3

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Although no sign of COVID-19 infection was observed on the initial CT simulation scan performed 20 days previously, and the patient was deemed to be at low-risk of COVID-19 infection based on the absence of associated signs and symptoms, CT-on-rails of the chest performed on scheduled day 1 of delivery of SABR revealed the presence of multiple GGOs of the lungs. Although the patient remained asymptomatic for COVID-19 infection, it was confirmed within 12 hours on RT-PCR testing.3

These 2 case reports have prompted a call for oncologists to “immediately consider adding review of daily CT image guidance for new infiltrates in any cancer patients where CT of the chest is being performed.”1 Also recommended was consideration of a new diagnosis of COVID-19 infection for any patient showing new pulmonary infiltrates on CT imaging performed as part of RT delivery, along with the timely administration of COVID-19 screening questions, COVID-19 testing, and the appropriate use of protective equipment.

Clinicians/researchers were also requested to rapidly submit deidentified data to the Journal of Thoracic Oncology for their patients diagnosed with biochemically confirmed COVID-19 infection while receiving daily RT with CT scan guidance by using the following link: COVID-10 and Radiotherapy. Data analyses and authorship of a subsequent publication would be shared by all participants.1


  1. Warren G, Adjei AA. A CALL FOR RAPID SUBMISSION OF DATA FOR AGGREGATE REVIEW: Can daily radiotherapy imaging be used as a potential screen for COVID-19? J Thorac Oncol [published online April 21, 2020]. doi: 10.1016/j.jtho.2020.04.006
  2. Suppli MH, Riisgaardde Blanck S, Elgaard T, et al. Early appearance of coronavirus disease 2019 associated pulmonary infiltrates during daily radiotherapy imaging for lung cancer. J Thorac Oncol [published online April 10, 2020]. doi: 10.1016/j.jtho.2020.04.004
  3. McGinnis GJ, Ning MS, Nitsch PL, et al. Rapid detection of asymptomatic COVID-19 by CT image-guidance for stereotactic ablative radiotherapy. J Thorac Oncol [published online April 17, 2020]. doi: 10.1016/j.jtho.2020.04.007