Rev. Bras. Hematol. Hemoter. vol.38 número2

rev bras hematol hemoter. 2016;38(2):93–94

w w w . r b h h . o r g

Revista

Brasileira

de

Hematologia

e

Hemoterapia

Brazilian

Journal

of

Hematology

and

Hemotherapy

Scientific

Comment

Use

of

biomarkers

in

the

management

of

febrile

neutropenia

episodes

in

children

with

cancer

夽

Benigna

Maria

de

Oliveira

UniversidadeFederaldeMinasGerais(UFMG),BeloHorizonte,MG,Brazil

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Articlehistory:

Availableonline30December2015

Althoughthe diagnosis and treatment offebrile neutrope-niaepisodeshaveimprovedsignificantlyover thepasttwo decades,sepsisisstillamajorcauseofmortalityand morbid-ityinpatientsundergoingchemotherapyregimensthatcause intensive myelosuppression.1–4 _{Even in institutions where} early initiation of antibiotictherapy and advancesin sup-portive measures have significantly reduced the mortality associatedwithinfections,thereisgreatconcernaboutthe morbidityrelatedtothesecomplications.5 _{Other important} aspectstobeconsideredare thehighcostsassociatedwith treatmentand impairedquality of lifeofthe patients and theirfamily,attributabletotheneedforprolongedorrepeated hospitalizations.6

Therefore, it is extremely important to develop risk-stratificationmodelsthatcanpredictthefollowingconditions early,that is,atadmissionor within48hofevaluation:(1) childrenatlowriskfordevelopingsevereinfectionswhocan haveareducedintensityofantibiotictherapyand/orashorter hospitalstay;and(2)childrenathighriskofdeveloping com-plicationsanddeathwhoneedmoreaggressivetherapeutic measures.3,7

Althoughtheiruse iswell establishedinadultpatients, there is still no consensus on scores and strategies for predictingtheriskforinfectionandcomplicationsinchildren withcancerwhopresentwithfebrileneutropenia.7_Theuse

DOIoforiginalarticle:http://dx.doi.org/10.1016/j.bjhh.2015.08.011. 夽

SeepaperbyBarbosaetal.inRevBrasHematolHemoter.2015;37(6):395–9.

∗ _{Correspondingauthorat:DepartamentodePediatria,FaculdadedeMedicina,UniversidadeFederaldeMinasGerais(UFMG),Av.Alfredo} Balena,190,sala267,30130-100BeloHorizonte,MG,Brazil.

E-mailaddress:benigna@uol.com.br

ofreliableandreproduciblescoreswouldallowthe identifica-tionofpatientswhocouldbenefitfromthede-escalationof intravenousantibiotictherapytooraladministration,would helptoidentifythe besttimeforthis changeinprocedure, andwouldalsocontributetosafedecision-makingaboutthe placeoftreatment–hospitalorhome.3,7

Theresultsofresearchonthesepredictive models rein-force the importance of developing instruments designed forthepediatric population,includingparameters thatcan be easily measured. However, there is great variability in the methodsadopted for assessments, and they are often based onlyon clinical data, without sufficient discrimina-tory power.3,7,8 _{The elements used in the composition of} these scores include patient-related factors (such as age, typeofcancer,andstatusoftheunderlyingdisease), param-eters referring to the treatment followed, the presence of clinical complications (hemodynamic or respiratory insta-bility, high fever) and laboratory findings suggestive of myelosuppression.7,8

In order to move forward and define parameters for these predictive models,serum biomarker studiesseem to becomingmoreimportant.6,7 _{Thebiomarkersthataremost} frequentlyevaluated andappeartohaveagreater discrim-inatory power are the following: C-reactive protein (CRP), procalcitonin(PCT),interleukin6,andinterleukin8.6

http://dx.doi.org/10.1016/j.bjhh.2015.10.006

94

Inasystematicreviewandmeta-analysiscarriedout by Hauesleretal.,amarkedheterogeneitywasfoundamongthe 37studiesselectedwithregardtothediagnosisofthepatients included(hematologicmalignanciesorsolidtumors),the def-initionof febrile neutropenia,and the outcomes evaluated (severesepsis, severe inflammatoryresponse syndrome,or admissiontoanintensivecareunit).Thefindingsofthisstudy suggestagreaterdiscriminationpowerofPCTwhencompared toCRP.However,theseauthorsemphasizedthatthe hetero-geneityofthestudiescomplicatescomparisonsandprevented themfromreachingdefinitiveconclusions,whichlimitsthe clinicalapplicationoftheresults.6

Barbosaet al. conducteda study todetermine whether thelevelsofCD64,asurfacemarkerexpressedbyactivated neutrophils,couldbeusedasapredictorofpositivecultures inchildrenwithfebrileneutropeniaepisodes.Althoughthis biomarker has been considered promising in studies con-ductedwithadultsandnewborns,theresultsobtainedbythe BrazilianresearchersdidnotidentifyCD64asabiomarkerthat canbeusedtoidentifyfebrileneutropeniapatientswithahigh riskfordevelopingsevereinfections.Thelimitationsofthis studyaresimilartothosepreviouslydescribedinthe litera-ture,and,ashighlightedbytheresearchers,itisimportant to conduct a complementary investigation before reaching definitiveconclusions.9

Itisclearthatmanyquestionsneedtobeansweredbefore reachingaconsensusontheclinical relevanceof biomark-ersinthemanagementofchildrenwithfebrileneutropenia, eithertoguideimmediatemeasuresortoassistinthe moni-toringandevaluationoftheresponsetothetreatment.Despite promisingevidence,thereisstilltheneedforconsistentand reproduciblestudies tovalidate the use ofthese testsand demonstratethattheycanbecomplementarytoevaluations basedontraditionalclinicalcriteria.6,9

Conflicts

of

interest

Theauthordeclaresnoconflictsofinterest.

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