LAUSR

Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) infection rapidly expanded and swiftly led to a public health crisis worldwide. Cancer patients infected by SARS-CoV-2 are at greater risk for severe illness and related death than general population, depending on primary malignancy, disease stage and type of treatment received [1–3]. Adrenal cortical carcinoma (ACC) is a rare endocrine malignancy which has several peculiarities compared to the other malignancies: (1) ACC may produces steroid hormones in over 50% of cases, (2) most ACC patients are treated long term with mitotane, an adrenolytic drug which requires steroid coverage; (3) ACC patients with advanced disease are often treated with mitotane associated to chemotherapy which leads to additional immunosuppression [4]. All these features place ACC patients potentially at high risk of SARS-CoV-2 infection and relevant complications. No data are up to now available on frequency and outcome of SARS-CoV-2 infection in ACC patients. The medical oncology of the Azienda Socio-Sanitaria Territoriale-Spedali Civili of Brescia is a referral center for ACC in Italy. It is located in Lombardy, the Italian region that recorded the highest number of people infected with the virus. This retrospective monocentric study was undertaken to provide data on whether ACC patients are at greater risk of contracting SARS-CoV-2 infection than patients with other malignancies and the general population, and whether the viral infection in ACC patients has a worse prognosis. During the Coronavirus disease (COVID-19) pandemic, 92 ACC patients were followed at the Brescia Oncology Unit. They were 36 (39.1%) males and 56 (60.9%) females, median age 55 years (range 23–83), of whom 49 (53.2%) patients have been radically operated and were free of disease. Twenty-three of them (46.9%) were on adjuvant mitotane therapy [5]. Among the 43 patients with metastatic disease, 25 (58.1%) were treated with mitotane, 18 (41.8%) were receiving chemotherapy+mitotane as follows: first line EDP (Etoposide, Doxorubicin, Cisplatin) [6] in 8 patients; second/third line therapies with temozolomide [7] in 5 patients (4%) and gemcitabine-capecitabine [8] in 5 patients (5%). Forty-seven patients (51.1%) were resident in Lombardy while the remaining 45 lived in the rest of Italy. Six ACC patients (6.5%) developed COVID-19 symptoms, five of them resident in Lombardy. The frequency of symptomatic SARS-CoV-2 infection in ACC patients living in Lombardy was as high as 10.9%. In the same period, 1163 cancer patients with breast, lung, gastrointestinal, head and neck, melanoma and sarcoma primary malignancies received antineoplastic therapies at the Brescia Oncology Unit, which consisted in chemotherapy (50.1%), immunotherapy (13.4%) and molecular target therapies (36.5%). Twenty-nine patients (2.5%) developed symptomatic SARS-CoV-2 infection and 8 of them (27.0%) died. As shown in Table 1, all ACC patients developing COVID-19 symptoms were receiving mitotane at a dose ranging between 0.5 and 6.0 g daily. Mitotane was prescribed in adjuvant setting in 5 patients, while it was administered in association with temozolomide, at the dose of 250 mg daily for 5 days every 28, in the remaining patient. In all patients, except one, serum mitotane levels were below the therapeutic range (14–20 mg/L) [9], due to These authors contributed equally: Deborah Cosentini, Salvatore Grisanti