Utility of blood procalcitonin concentration in the management of cancer patients with infections

Diagnostic accuracy of procalcitonin in adult non-neutropenic cancer patients with suspected infection: a systematic review and meta-analysis

BACKGROUND

Procalcitonin (PCT) has garnered attention as a potential diagnostic biomarker for infection in cancer patients. We performed a systematic review and meta-analysis to evaluate the diagnostic accuracy of procalcitonin (PCT) and to compare it with C-reactive protein (CRP) in adult non-neutropenic cancer patients with suspected infection.

METHODS

A systematic literature search was performed in MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials to identify all relevant diagnostic accuracy studies. Original articles reporting the diagnostic accuracy of PCT for infection detection in adult patients with solid or hematological malignancies were included. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, area under the hierarchical summary receiver operator characteristic (HSROC) curve, and corresponding 95% confidence interval (CI) were calculated.

RESULTS

Seven studies were included in the meta-analysis. The pooled sensitivity and specificity of PCT were 60% (95% CI [45-74%]) and 78% (95% CI [69-86%]). The diagnostic odds ratio was estimated at 5.47 (95% CI [2.86-10.46]). Three studies compared the diagnostic accuracies of PCT and CRP. The pooled sensitivity and specificity values for PCT were 57% (95% CI [26-83%]) and 75% (95% CI [68-82%]), and those for CRP were 67% (95% CI [35-88%]) and 73% (95% CI [69-77%]). The pooled sensitivity and specificity of PCT and CRP did not differ significantly (p = 0.61 and p = 0.63). The diagnostic accuracy of PCT was similar to that of CRP as measured by the area under the HSROC curve (0.73, CI = 0.61-0.91 vs. 0.74, CI = 0.61-0.95, p = 0.93).

CONCLUSION

While elevated PCT levels can be indicative of potential infection, they should not be solely relied upon to exclude infection. We recommend not using the PCT test in isolation; Instead, it should be carefully interpreted in the context of clinical findings.

A retrospective cohort study of the effect of rapid versus delayed-result procalcitonin testing on antibiotic use at a community hospital

BACKGROUND

Procalcitonin is a serum biomarker used to distinguish bacterial infection from viral or noninfectious syndromes. Primary literature shows mixed data on use of procalcitonin for de-escalation of antimicrobials. Delays in test results of send-out procalcitonin assays may result in prolonged antimicrobial durations. It is unknown whether availability of rapid-result assays may shorten time to antibiotic de-escalation.

AIM

This retrospective, cohort study compared antibiotic durations of treatment between groups with rapid-result versus delayed send-out, procalcitonin test modality. This study was exempt from Ethics Committee Approval, as determined by the Institutional Review Board at the study site.

METHOD

Adult hospitalized patients were included if they had at least one procalcitonin test performed during the study period. The primary outcome compared mean duration of antimicrobial therapy between groups receiving a rapid-result procalcitonin test and a send-out test. Secondary outcomes included incidence of Clostridiodes difficile infection, mention of procalcitonin testing in the electronic medical record in reference to antimicrobial therapy decision making, and presence of comorbidities which affect procalcitonin levels independent of infection.

RESULTS

A total of 350 lab results were analyzed. The duration of antimicrobial treatment between groups was not statistically different with the median duration of treatment in the send-out group being 2.95 days compared to 3.35 in the rapid result group, p = 0.856. Patient comorbidities with potential to lead to a noninfectious elevation or falsely high level of procalcitonin were common.

CONCLUSION

Use of a rapid-result procalcitonin assay does not reduce hospital antimicrobial therapy duration as compared with send-out testing.

Predictive value of Leukocyte ImmunoTest (LIT™) in cancer patients: a prospective cohort study

Early diagnosis of cancer is crucial to initiate prompt treatment for better patient outcomes. The host immune function and its associated modulators are considered to be potential biomarkers for early cancer diagnosis. Immune and immune-checkpoint biomarkers have been reported to contribute to cancer development, while a high neutrophil-to-lymphocyte ratio has been shown to be associated with poor survival outcomes in a variety of cancers. One hundred sixty-one cancer patients were recruited to take a cost-effective novel Leukocyte ImmuneTest (LIT). LIT was measured to objectively determine the pre-treatment immune status of patients. The correlation between LIT and other conventional diagnostic markers or tumor-related variables was then investigated. Significant correlations between LIT and white blood cell count, smoking status, and tumor stage 4 were found. In addition, the LIT score significantly differentiated between malignant and benign tumors in this study population. Our work raises the possibility to use LIT for general screening surveillance before further costly specialized equipment is applied for cancer diagnosis.

The ability of inflammatory markers to recognize infection in cancer patients with fever at admission

Infection is one of the main causes of death in cancer patients. Accurate identification of fever caused by infection could avoid unnecessary antibiotic treatment and hospitalization. This study evaluated the diagnostic value of procalcitonin (PCT), C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-10 (IL-10), and other commonly used inflammatory markers in suspected infected adult cancer patients with fever, for better use of antibiotics. This research retrospective analyzed the clinical data of 102 adult cancer patients with fever and compared the serum levels of commonly used inflammatory markers for different fever reasons. Receiver-operating characteristic (ROC) curve and logistic regression analyses were performed. In adult cancer patients with fever, the serum PCT, CRP, IL-6, and IL-10 levels of infected patients were significantly higher than uninfected patients (median 1.19 ng/ml vs 0.14 ng/ml, 93.11 mg/l vs 56.55 mg/l, 123.74 pg/ml vs 47.35 pg/ml, 8.74 pg/ml vs 3.22 pg/ml; Mann-Whitney p = 0.000, p = 0.009, p = 0.004, p = 0.000, respectively). The ROC area under the curve(AUC) was 0.769 (95% confidence interval (CI) 0.681-0.857; p = 0.000) for PCT, 0.664 (95% CI 0.554-0.775; p = 0.009) for CRP, 0.681(95% CI 0.576-0.785; p = 0.004) for IL-6, and 0.731(95% CI 0.627-0.834; p = 0.000) for IL-10. PCT had specificity of 96.67% and positive predictive value (PPV) of 97.6%, when the cut-off value is set as 0.69 ng/ml. The serum IL-6 and IL-10 levels also had significant differences between the infected and uninfected cancer patients with advanced disease (median 128.92 pg/ml vs 36.40 pg/ml, 8.05 pg/ml vs 2.92 pg/ml; Mann-Whitney p = 0.003, p = 0.001, respectively). For the patients with neutropenia, IL-6 and IL-10 had higher AUC of 0.811 and 0.928, respectively. With a cut-off of 9.10 pg/ml, IL-10 had the highest sensitivity 83.33% and specificity 100%. In adult cancer patients, PCT had the best performance compared to CRP, IL-6, and IL-10 in differentiating infected from uninfected causes of fever, with high specificity and PPV. IL-6 and IL-10 might be useful in cancer patients with severe bloodstream infections and advanced disease. However, for patients with neutropenia, IL-10 might be more valuable than PCT in diagnosing infection.

Procalcitonin prognostic value in predicting mortality among adult patients with sepsis due to Gram-negative bacteria

BACKGROUND Sepsis is a leading cause of mortality and morbidity globally. Gram-negative bacteremia was reported to have a high risk of septic shock and poor prognosis. This study aimed to evaluate the role of procalcitonin in predicting mortality in patients with sepsis due to Gram-negative bacteria. METHODS This was a retrospective cohort study performed based on medical records and sepsis registry of Tropical and Infectious Disease Division, Department of Internal Medicine, Cipto Mangunkusumo Hospital. The inclusion criteria were patients aged ≥18 years diagnosed with sepsis due to Gram-negative bacteria based on blood culture on admission and hospitalized between March 2017 and October 2020. Data taken from medical records included subjects’ characteristics, laboratory parameters, and 28-day mortality outcomes during hospitalization. Receiver operating characteristic was used to determine the area under the curve (AUC) of procalcitonin and its accuracy. RESULTS A total of 128 patients were eligible. The cumulative survival of patients with Gram-negative bacteremia was 48.4% (standard error 0.96%). The AUC of procalcitonin to predict mortality was 0.45 (95% confidence interval 0.36–0.54). Escherichia coli was the predominant microorganism in blood culture (n = 38, 29.7%). CONCLUSIONS Procalcitonin has a poor performance in predicting mortality of patients with sepsis due to Gram-negative bacteria.

Application of Machine Learning for the Prediction of Etiological Types of Classic Fever of Unknown Origin

Background: The etiology of fever of unknown origin (FUO) is complex and remains a major challenge for clinicians. This study aims to investigate the distribution of the etiology of classic FUO and the differences in clinical indicators in patients with different etiologies of classic FUO and to establish a machine learning (ML) model based on clinical data. Methods: The clinical data and final diagnosis results of 527 patients with classic FUO admitted to 7 medical institutions in Chongqing from January 2012 to August 2021 and who met the classic FUO diagnostic criteria were collected. Three hundred seventy-three patients with final diagnosis were divided into 4 groups according to 4 different etiological types of classical FUO, and statistical analysis was carried out to screen out the indicators with statistical differences under different etiological types. On the basis of these indicators, five kinds of ML models, i.e., random forest (RF), support vector machine (SVM), Light Gradient Boosting Machine (LightGBM), artificial neural network (ANN), and naive Bayes (NB) models, were used to evaluate all datasets using 5-fold cross-validation, and the performance of the models were evaluated using micro-F1 scores. Results: The 373 patients were divided into the infectious disease group (n = 277), non-infectious inflammatory disease group (n = 51), neoplastic disease group (n = 31), and other diseases group (n = 14) according to 4 different etiological types. Another 154 patients were classified as undetermined group because the cause of fever was still unclear at discharge. There were significant differences in gender, age, and 18 other indicators among the four groups of patients with classic FUO with different etiological types (P < 0.05). The micro-F1 score for LightGBM was 75.8%, which was higher than that for the other four ML models, and the LightGBM prediction model had the best performance. Conclusions: Infectious diseases are still the main etiological type of classic FUO. Based on 18 statistically significant clinical indicators such as gender and age, we constructed and evaluated five ML models. LightGBM model has a good effect on predicting the etiological type of classic FUO, which will play a good auxiliary decision-making function.

Prognostic Value of Procalcitonin, C-Reactive Protein, and Lactate Levels in Emergency Evaluation of Cancer Patients with Suspected Infection

Simple Summary

Cancer patients are at increased risk of infections and related complications, including sepsis. We developed a scoring system for mortality prediction based on readily available clinical and laboratory data, including the quick sequential organ failure assessment (qSOFA) score, cancer subtype, and several laboratory markers (procalcitonin, C-reactive protein, lactate dehydrogenase, and albumin) that can be used in emergency departments for cancer patients with suspected infection. The prediction score, which stratifies patients into four different risk groups (from low risk to very high risk), achieved excellent performance in predicting 14-day mortality, with an area under the receiver operating characteristic curve value of 0.88 (95% confidence interval 0.85–0.91). The score was also effective in predicting intensive care unit admission and 30-day mortality.

Abstract

Cancer patients have increased risk of infections, and often present to emergency departments with infection-related problems where physicians must make decisions based on a snapshot of the patient’s condition. Although C-reactive protein, procalcitonin, and lactate are popular biomarkers of sepsis, their use in guiding emergency care of cancer patients with infections is unclear. Using these biomarkers, we created a prediction model for short-term mortality in cancer patients with suspected infection. We retrospectively analyzed all consecutive patients who visited the emergency department of MD Anderson Cancer Center between 1 April 2018 and 30 April 2019. A clinical decision model was developed using multiple logistic regression for various clinical and laboratory biomarkers; coefficients were used to generate a prediction score stratifying patients into four groups according to their 14-day mortality risk. The prediction score had an area under the receiver operating characteristic curve value of 0.88 (95% confidence interval 0.85–0.91) in predicting 14-day mortality. The prediction score also accurately predicted intensive care unit admission and 30-day mortality. Our simple new scoring system for mortality prediction, based on readily available clinical and laboratory data, including procalcitonin, C-reactive protein, and lactate, can be used in emergency departments for cancer patients with suspected infection.

The role of procalcitonin and presepsin in the septic febrile neutropenia in acute leukemia patients

BACKGROUND

The source of bacterial infection in neutropenic acute leukemia patients is detected in about 20-30% of cases. Bacterial cultures may require a long incubation period and risk false-positive and false- negative results. Therefore, biomarkers distinguishing septic febrile neutropenia from other etiologies in acute leukemia patients play the important role in patient assessment and treatment planning. This study aims to determine the role of procalcitonin (PCT) and presepsin (PSPN) in infectious complication in comparison to C-reactive protein (CRP) on the first and third day at the onset of febrile neutropenia in patients with acute leukemia.

METHODS

Between June 2018 and February 2019, 60 acute leukemia patients with febrile neutropenia receiving chemotherapy. The 41 acute myeloid leukemia patients and 19 acute lymphoblastic leukemia patients were recruited in this study. Their ages ranged from 14 to 65 years. PCT and PSPN were measured and were compared to CRP at the onset of febrile neutropenia and after 48 hours. 20 patients had a fever of unknown origin (FUO) and 40 patients had a bacterial infection.

FINDINGS

Our results showed that the values of these markers were higher in patients with infection than patients without. The area under the curve (AUC) of PCT were 0.931 and 0.813 on day one and three respectively, which was the best in determination of infection. The cut-off values of PCT were 1.27 and 1.23 ng/mL and the cut off values of PSPN were 1.75 and 2.9 μg/L in the successive days, their clinical sensitivities were high. PCT and PSPN were capable of distinguishing the cause of febrile neutropenia from the onset of infection and predicting its complications (p<0.05). The PSPN level couldn't differentiate gram-positive or gram-negative bacterial infection. Significant differences were found between the mean values of the PSPN during the successive days in all patients and patients with bacteremia. This study illustrated a weak positive correlation between PCT and Sequential Organ Failure Assessment (SOFA) score, the negligible correlation between CRP and SOFA score and no significant correlation between PSPN and SOFA score.

INTERPRETATION

PCT is an accurate biomarker in identifying infection in acute leukemia patients, its concentration is associated with the severity of bacterial sepsis. PSPN is superior to PCT for follow-up of patients.

Procalcitonin and C-Reactive Protein/Procalcitonin Ratio as Markers of Infection in Patients With Solid Tumors

Objectives: The roles of procalcitonin (PCT) and C-reactive protein (CRP) in febrile cancer patients is currently unclear. Our aim was to assess these in febrile patients with solid tumors and to identify cut-off values for ruling out infection.

Methods: We retrospectively evaluated patients with solid tumors admitted to hospital due to fever. They were divided into those with Fever with microbiologically documented infection (FMDI), Fever with clinically documented infection (FCDI) and Tumor-related fever (TRF). PCT and CRP levels were compared. Receiver-operating curves were plotted to define the best cut-off values for discriminating between infection-related and cancer-related fever.

Results: Between January 2015 to November 2018, 131 patients were recorded (mean age 68 years, 67% male, 86% with metastasis). Patients with FMDI or FCDI had significantly higher baseline levels of PCT and lower CRP/PCT than those with TRF. A PCT cut-off value of 0.52 ng/mL for discriminating between infection and cancer-associated fever yielded 75% sensitivity, 55% specificity, 77% positive predictive value (PPV), and 52% negative predictive value (NPV). A CRP/PCT ratio with a cut-off value of 95 showed 56% sensitivity, 70% specificity, 79% NPV, and 44% PPV.

Discussion: PCT is a sensitive marker of sepsis or localized infection in patients with solid tumors, but its specificity is poor. The CRP/PCT ratio improves specificity, thus providing a reliable means of ruling out infection for values above 95.

Circulating nuclear factor-kappa B mediates cancer-associated inflammation in human breast and colon cancer

BACKGROUND

Inflammation is recognized as a hallmark feature of cancer development and progression. The aim of our study was to investigate the significance of serum nuclear factor kappa-B (NF-κB) levels as a circulating marker in the monitoring of inflammation in breast and colon cancer; to show the relationship between NF-κB with inflammatory parameters as tumour necrosis factor-α (TNF-α), soluble TNF-related apoptosis-inducing ligand (sTRAIL), interleukin-6 (IL-6), pentraxin-3 (PTX-3), procalcitonin (PCT), and C-reactive protein (CRP) levels.

METHODS

Serum NF-κB, TNF-α, sTRAIL, IL-6, PTX-3, PCT, and serum CRP levels were measured using enzyme-linked immunosorbent assay (ELISA) in 40 patients with breast cancer, 40 patients with colon cancer and 30 healthy controls.

RESULTS

The serum NF-κB, TNF-α, IL-6, PTX-3, PCT, and serum CRP concentration was significantly higher, and the serum sTRAIL concentration was significantly lower in the patients with breast and colon cancer than in healthy controls. NF-κB was positively correlated with CRP and negatively correlated with sTRAIL.

CONCLUSIONS

These results suggest that increased NF-κB may decrease the clinical efficacy of sTRAIL in solid tumour cells. There is a relationship between inflammation and carcinogenesis so that the development of cancer occurs with chronic inflammation in breast and colon. The study results have shown that colon and breast cancer patients have increased systemic inflammation, as measured by increased circulating cytokines, and acute-phase proteins, or by abnormalities in circulating cells. NF-κB may combine with other markers of the systemic inflammatory response in prognostic scores in cancer. In addition to surgical resection of the tumour, and conventional radio and chemotherapy for cancer treatment, the use of sTRAIL or other agonists for cancer therapy appeared a new potential therapy.

Cabozantinib as the causative agent of high-grade fever in a patient with a background of metastatic clear cell renal cell carcinoma: a case report

Background

Fever, as an adverse event, is well documented in a wide array of drugs including multiple tyrosine kinase inhibitors however, it is not a previously well described consequence of the novel multi-targeted tyrosine kinase inhibitor, cabozantinib.

Case presentation

In this paper we document the first detailed review of high-grade fevers in a 54 year old male (Caucasian) with a background of metastatic clear cell renal cell carcinoma recently commenced on cabozantinib. After detailed investigation, we exclude infection and other common causes of fever as the causative agent and further, definitively resolve the recurrent fever by ceasing cabozantinib and starting a short course of oral corticosteroids.

Conclusions

We have demonstrated that cabozantinib should always be considered in the aetiology of high-grade fever in relevant patients. Further, we demonstrate that temporary cessation of cabozantinib and a course of short-term steroids can induce resolution of fever and allow for recommencement of cabozantinib safely thereafter.

Clinical Approach to the Patient in Critical State Following Immunotherapy and/or Stem Cell Transplantation: Guideline for the On-Call Physician

: The initial management of the hematology patient in a critical state is crucial and poses a great challenge both for the hematologist and the intensive care unit (ICU) physician. After years of clinical practice, there is still a delay in the proper recognition and treatment of critical situations, which leads to late admission to the ICU. There is a much-needed systematic ABC (Airway, Breathing, Circulation) approach for the patients being treated on the wards as well as in the high dependency units because the underlying hematological disorder, as well as disease-related complications, have an increasing frequency. Focusing on score-based decision-making on the wards (Modified Early Warning Score (MEWS), together with Quick Sofa score), active sepsis screening with inflammation markers (C-reactive protein, procalcitonin, and presepsin), and assessment of microcirculation, organ perfusion, and oxygen supply by using paraclinical parameters from the ICU setting (lactate, central venous oxygen saturation (ScVO2), and venous-to-arterial carbon dioxide difference), hematologists can manage the immediate critical patient and improve the overall outcome.

Hypogelsolinemia in Patients Diagnosed with Acute Myeloid Leukemia at Initial Stage of Sepsis

Background

Gelsolin (GSN) is an actin-binding and PIP₂/Ca²⁺-regulated protein found in the cytoplasm and blood plasma. Hypogelsolinemia occurs in a wide range of traumatic injuries and inflammatory reactions. We hypothesize that blood GSN levels will be altered in patients diagnosed with acute myeloid leukemia (AML) that develop sepsis, and assessment of GSN concentration will be a useful marker to determine their clinical outcome. To achieve this task, we evaluated the plasma gelsolin concentration in blood samples collected from patients diagnosed with acute myeloid leukemia (AML) at initial stages of sepsis.

Material/Methods

To assess if AML patients might be at risk of sepsis, a SOFA score was determined. Plasma gelsolin concentration was evaluated using an immunoblotting technique.

Results

We found that GSN concentration in the blood of the AML group with developing sepsis was significantly lower (32±41 μg/ml; p<0.05) compared to the AML group (65±35 μg/ml) and control group (176±37 μg/ml; p<0.001). Additionally, low gelsolin concentration in the blood of AML patients developing sepsis was associated with a high SOFA score. A decrease of GSN concentration in the blood of AML subjects with developing sepsis suggests that GSN level in blood reflects not only chronic inflammation stage associated with leukemia, but that GSN depletion also manifests the inflammation associated with sepsis development.

Conclusions

The results presented here suggest the possible utility of GSN evaluation for diagnostic purposes. Overall, these data support the that reversing plasma GSN deficiency might be a possible new strategy in sepsis treatment.

Defective Sphingolipids Metabolism and Tumor Associated Macrophages as the Possible Links Between Gaucher Disease and Blood Cancer Development

There is a rising number of evidence indicating the increased risk of cancer development in association with congenital metabolic errors. Although these diseases represent disorders of individual genes, they lead to the disruption of metabolic pathways resulting in metabolite accumulation or their deficiency. Gaucher disease (GD) is an autosomal recessive sphingolipidosis. It is a rare lysosomal storage disease. A strong correlation between GD and different types of cancers, such as multiple myeloma, leukemia, and hepatocellular carcinoma, has been reported. Common features for all types of GD include spleen and liver enlargement, cytopenia, and a variety of bone defects. Overall, the molecular bases leading to the association of GD and cancers are not clearly understood. Here, we describe the role of ceramides in GD, discuss the potential implications of immune cells activation and show how the disturbances in their metabolism might promote blood cancer development.

Plasma Gelsolin: Indicator of Inflammation and Its Potential as a Diagnostic Tool and Therapeutic Target

Gelsolin, an actin-depolymerizing protein expressed both in extracellular fluids and in the cytoplasm of a majority of human cells, has been recently implicated in a variety of both physiological and pathological processes. Its extracellular isoform, called plasma gelsolin (pGSN), is present in blood, cerebrospinal fluid, milk, urine, and other extracellular fluids. This isoform has been recognized as a potential biomarker of inflammatory-associated medical conditions, allowing for the prediction of illness severity, recovery, efficacy of treatment, and clinical outcome. A compelling number of animal studies also demonstrate a broad spectrum of beneficial effects mediated by gelsolin, suggesting therapeutic utility for extracellular recombinant gelsolin. In the review, we summarize the current data related to the potential of pGSN as an inflammatory predictor and therapeutic target, discuss gelsolin-mediated mechanisms of action, and highlight recent progress in the clinical use of pGSN.