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\begin{document}

\title{Comment on: Viral infections in pediatric brain tumor patients treated
with targeted therapies}



\author[1]{Aimen Waqar Khan}%
\affil[1]{Jinnah Sindh Medical University}%


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  \date{May 27, 2024}


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Comment on: \textbf{Viral infections in pediatric brain tumor patients
treated with targeted therapies}

Aimen Waqar Khan

Department of Medicine, Jinnah Sindh Medical University, Karachi,
Pakistan

Dear Dr. Newburger,

We have read with great enthusiasm the article titled \textbf{Viral
infections in pediatric brain tumor patients treated with targeted
therapies} by Lisa Mayr et al {[}1{]}. We commend the authors' efforts
in collating epidemiologic data and investigating infectious outcomes
between pediatric patients being treated with targeted therapy versus
conventional therapies. It was a pleasure to read such a well-written
paper. We concur with the conclusion that patients receiving targeted
therapies are made more susceptible to developing viral infections than
those receiving conventional treatment. However, we would like to draw
attention to some key points regarding the study following a thorough
appraisal.

To begin with, the retrospective nature of the study adds several
unavoidable biases such as recollection bias and incorrect data
retrieval, which may have been mitigated had the investigators included
current cases at the time. The study is also limited in its
single-centered scope making it difficult to generalize the findings to
this particular pediatric demographic. Moreover, the comparison between
the two subsets of brain tumor patients is also subject to several
partialities. For instance, it is noted that those receiving targeted
therapies were managed in an outpatient setting and by extension,
exposed to greater environmental stressors than those being managed on
conventional chemotherapy. As a result, a greater proportion of
virological infections were reported in children receiving targeted
therapy than those being managed conventionally. Further, due to the
lack of available data correlating disease severity with treatment
option, the possibility that patients receiving conventional
chemotherapy simply had a lower disease grade than those on targeted
therapies and vice versa exists. Knowing this is pertinent as the body's
ability to fight off infections is greatly influenced by the grade of
cancer and hence degree of inflammation {[}2{]}. Next, it remains to be
seen what the baseline nutritional status of the participants was as
nutrition and metabolism are known to have a bearing on immune status
and hence infectious susceptibility {[}3{]}. Finally, the deduction that
patients treated with bevacizumab or mTOR (mechanistic target of
rapamycin) inhibitors suffered more infections than those treated with
other targeted therapeutic drugs cannot be made with certainty as not
enough patients were treated with drugs other than bevacizumab or mTOR
inhibitors for a fair and accurate comparison.

In conclusion, multi-centered prospective studies are required to better
lay claims regarding infectious outcomes and attention to potential
influencers of immunity must be given to minimize bias in future
studies.

\textbf{REFERENCES}

{[}1{]} Mayr L, Steinmaurer T, Weseslindtner L, Madlener S, Strassl R,
Gojo J, Azizi AA, Slavc I, Peyrl A. Viral infections in pediatric brain
tumor patients treated with targeted therapies. Pediatric blood \&
cancer. 2023 Jan;70(1):e30065.

{[}2{]} Hiam-Galvez KJ, Allen BM, Spitzer MH. Systemic immunity in
cancer. Nature reviews cancer. 2021 Jun;21(6):345-59.

{[}3{]} Alwarawrah Y, Kiernan K, MacIver NJ. Changes in nutritional
status impact immune cell metabolism and function. Frontiers in
immunology. 2018:1055.

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