A Missed Opportunity or Collateral Damage of Coronavirus Disease of 2019 ( COVID-19)?

Introduction: A round lesion of less than 3 cm in diameter in the lung is called a solitary pulmonary nodule and it is completely surrounded by pulmonary parenchyma and without other abnormality. After assessing the probability of malignancy, surveillance or biopsy modality is selected depending on patient values and preferences. The current pandemic has caused changes in patient preferences and in clinical guidelines for the follow-up of lung nodules . We report a case of an incidentally discovered cavitary pulmonary nodule in which decision making was affected by the Coronavirus Disease of 2019 (COVID-19) pandemic and led to worse outcomes. Case Presentation: 49 years old, never smoker, and otherwise healthy Hispanic female was initially seen in Emergency Room( ER) with chest pain and dry cough for a few days. She did not report any fever, weight loss, hemoptysis, and initial laboratory workup were within normal limits as well. A Computed Tomography Pulmonary Angiogram(CTPA) was done suggesting a 17mm size incidental cavitary nodule in the left upper lobe. Brock University's cancer prediction score was 31%. After discussing with the patient, it was decided to treat the patient with a course of antibiotics and to get a short-term Computed Tomography(CT) scan of the lungs in 3 months. Patient symptoms resolved in a couple of weeks and a follow CT chest showed no change in the nodule. Later, it was decided to get a follow-up CT chest in 6 months which was scheduled for April 2020 when COVID-19 numbers in New Jersey were high and rising. The patient decided to delay the CT. Later on, she presented to ER in November 2020 with a 2-week history of dry cough and 1 day of the history of minimal blood in sputum. CTPA done at that time showed enlargement of left upper lung nodule to 6 cm mass and moderate-sized pleural effusion was also seen on the left side. Pleural fluid cytology suggested the presence of cancer cells consistent with adenocarcinoma of the lung. Discussion: We have seen changes in clinical guidelines as well as patient preferences in the last few months in the follow-up of lung nodules. The COVID-19 pandemic has impacted cancer care resulting in delayed diagnoses and treatment. All healthcare systems should focus on rapidly innovating and reorganizing cancer services to ensure that patients continue to receive essential care while minimizing exposure to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection.