Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
Would you recommend a specific workup or change in management for patients with severe, persistent deficits from methotrexate leukoencephalopathy?
In my practice setting, I typically see this as delayed toxicity in adults that is not reversible. In the acute, and particularly pediatric settings, there may be some limited evidence for leucovorin, aminophylline, drugs that modulate NMDA neurotransmission, etc., but usually in adult patients, tre...
When would you consider additional testing for NUDT15 and other polymorphisms related to 6-MP/6-TG metabolism, if not guided by a study protocol?
My practice is to send a pharmacogenetic panel that includes TPMT and NUDT15 (as well as some other useful tidbits such as UGT1A! for Gilbert's syndrome) when patients with ALL are diagnosed. The cost-effectiveness of this strategy has been addressed, with different conclusions (van den Akker-van Ma...
When following current COG ALL protocols with the addition of two courses of blinatumomab to treatment for SR and HR patients, how frequently should surveillance bone marrow and MRD evaluations be performed?
With the caveat that I only treat adults, but the general concepts are similar:In our practice, we routinely do bone marrow exams with MRD assessment after the first cycle of blinatumomab. Assuming this shows no detectable disease, we typically will then perform the same before transitioning to main...
Do you use premedications (acetaminophen, diphenhydramine) before pRBC and plt transfusions to prevent febrile nonhemolytic transfusion reactions and allergic reactions?
I do not routinely premedicate patients. There is a recent meta-analysis that shows no benefit. I only premedicate those who have had a prior transfusion reaction. Old studies showed this was a common practice but those studies were performed before universal leukoreduction and other strategies aimi...
What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?
For any patient with fevers, I focus significantly on any symptoms that a patient might have, like headache, diarrhea, and sinus symptoms, and work up a differential diagnosis based on possible pathogens in this area. If I am not finding anything, I would obtain a CT chest/abd/pelvis, as both invasi...
How do you choose between blinatumomab and CAR-T cell therapy for relapsed or refractory pre B-ALL?
Many of the cellular therapy products are limited in indication which can help with making the decision, as well as the plan to go to transplant or not. Blinatumomab would have to be consolidated with HSCT while CAR-T can be curative in about 50% of patients without consolidative HSCT, which would b...
How do you approach prophylactic antibiotics in patients who continue to have recurrent neutropenic fever following chemotherapy for solid tumors despite chemotherapy dose reduction and growth factor support?
This has to be individualized to the patient. It depends on the length of neutropenia, previous infections, and local antibiotic resistance. If the patient develops neutropenic fever after every cycle of chemotherapy and no obvious nidus of infection has been identified, a trial of a fluoroquinolone...
Which patients with relapsed/refractory NHL are appropriate for pre-CAR-T bridging radiation therapy?
Before answering this important question, I think that we, as Radiation Oncologists, should give serious consideration to moving past the terminology of "bridging radiation therapy" and instead refer to it as "pre-CAR-T infusion radiation therapy." Bridging therapy was initially an apt name; we were...
When do you refer a patient with recurrent glioma for reoperation?
This question is a nuanced one that is dependent on many factors. When a patient has a recurrent glioma, the treatment options are generally re-resection, medical therapy (traditional chemotherapy or targeted agents, depending on the tumor), or radiation. Which treatment modality, or combination of ...
For which rituximab infusion reaction symptoms do you consider it safe to re-challenge in the office with adjusted rates and pre-medications?
When deciding whether it is safe to re-challenge with rituximab after an infusion reaction, the most important consideration is the type of reaction that the patient experienced. This will help to risk stratify and determine whether same day or future infusions of RTX should be used. Importantly, th...